Recently I found myself helping a young person with long-standing, incredible pain behaviour which led me to find a sense of balance between a very mild version of the ‘hard medicine’ approach and my personal take on the graded exposure model. In other words, I really had to adopt my approach and involve the biopsychosocial model even more than I usually would due to the complexity of the persons presentation.
I have seen quite a few of these types of presentations over the years, including one in the not-so-distant past that involved a quite-so-distant family member. What is quite remarkable is that in the week I found out the ‘family client’ had not progressed well since deciding to go it alone I got a call from a very worried parent to help with this child with a very similar issue. In fact, I had only just read the ‘family client’ notes the morning of the call and the whole clinical approach I took with them was in the forefront of my mind. This really helped me decide what to do, what style to go with the young person and just as important what method would be best with the parents. I decided to say “yes, I can help”.
I will detail some of the presentations I learned over a couple of visits briefly here for early scope and perspective:
- 12 years of age
- Arrived on two crutches, non-weight bearing on right
- Very anxious and nervous ++
- Two years on crutches intermittently (but basically consistently)
- X-ray, MRI etc all clear throughout
- Pain 10/10 on weightbearing and palpation – sole of foot, centrally, flexor digitorum brevis area
- No issues whatsoever on range of movement, strength and standard and ‘special’ tests of knee, foot and ankle apart from above
- No neural issues from outset
- Extreme & vocal pain when lying prone and foot being very slightly mobilized in non-weight bearing. This did not repeat under same pressure with good oul’ distraction chats about football
- Extreme & vocal pain when attempting to do any level of weight bearing even standing on foot. The timing of pain did not match when pressure was on area of discomfort described
- No incident or mechanism of injury, initially gradual onset after but then very suddenly progressed to 10/10 pain
- Likes X-box, has become really isolated from friends, starting secondary school in September parents a long time struggling between ‘soft approach’ and ‘come on there is nothing wrong’
- Has a much younger only sibling
- Refusing to leave house, cycle or engage with anyone not deemed essential
Pain Is Complex
One important thing to mention is it is essential to trust your knowledge, experience and judgement to decide ‘is it safe to start graded exposure?’ before commencing but even more important is to be acutely and consistently aware that pain is a very complex bodily function and just because a person may not have any structural damage whatsoever does not mean that after a certain period, they don’t in fact feel the pain they initially described for any number of complex reasons. And no, this does not mean they are making it up. Pain like this is multifaceted, difficult for some people to believe yet alone understand, but can without a doubt be present for the person themselves.
Understanding a Patient in Pain
As I said, the key for me here was deciding for myself that there was no musculoskeletal reason to not begin to attempt progress while always keeping the biopsychosocial element of this case at the forefront of my mind. I decided to focus on ‘emotional intelligence’ and to show the young person I understand how you feel and I will help you find a way to improve this. It was time to listen, acknowledge, support and believe this young person. Finally, after all this time choose and implement a positive way forward. Figure out why this may be happening psychologically and attempt to address this concurrently e.g. when suitable try again to get friends involved in forms of outdoor activity
I decided to use positivity, humor, communication, confidence, trickery, connection and fun & joyful rehabilitation time that fully acknowledged the young persons position but more importantly showed a way out. This is one of handful of cases where I didn’t create ‘goals’ I said we will go as slow as you like. There was no advantage to pressure here.
I met and discussed with the parents alone first what I thought was our best route as I could explain in detail the psychological reasons these things can happen and discuss options to help this going forward. Then I met the the parents and young person together where I could discuss in more detail the physical elements that can happen which was now or route out. You are finally acknowledging this person but showing them there is a pretty good way out of this and back to a better lifestyle. Blatantly “get on with it” isn’t working and neither is other healthcare professionals stating “there is nothing wrong here”.
I described how after somewhat seemingly innocuous incidents many people can experience ‘hyperalgesia’ and ‘allodynia’. I believed this was a perfect route as it can sound and be very scientific in nature which reaffirms the person but can also be described very easily to people who have not been exposed to the intricacies of them previously in layman’s terms which is also helpful in cases like this, as you tend to get an ‘oh yeah’ response. In other words, you are stating that these can certainly be painful, but are no good to us, serve us no benefit in the long term and are useless and maladaptive. Most importantly you can change the picture quicker than you believe with the right approach to these types of issues. Understanding reduces the threat. I constantly used a combination of scientific and normalizing vocabulary. I showed them a cause, the effect of this, a diagnosis and finally for them all, even I bet subconsciously for the young person, a way out. Most importantly I was constantly positive in my communication “wow, that is some going in one week” to give them confidence in their progress.
Managing Beliefs and Personalities
This can be difficult but very rewarding work. You have to manage many different beliefs and personalities. You have numerous doctors, specialists and surgeons billing, injecting, medicating and proposed operating. This was after the ‘just get on with it, the Mri is clear’ approach of course. Should these people not spot an issue when they see it and try help find a way out? I would have thought that is their only job. Meanwhile a child was on crutches for 2 years, has lost contact almost all their friends, is about to go to secondary school with no mobility and at the risk of seeming over the top their school and life path was being changed and the parents are lost.
Helping You Get Your Life Back
Not anymore. After 2 years on crutches, we are 3 weeks in. This young person is now cycling 20-30 mins 4-5 days a week. They are walking crutch free. Most importantly, they are back outside and playing with friends. Not there yet but on the road!
I also found out they had seen two psychologists who, through no fault of their own, could not help break down the wall. This is a major problem with all forms of mental health in our country that may be for another blog, day or year but stigma around mental health and mental health support is innate in us, and many, in that having a problem and seeking help shows vulnerability and weakness. Of course, this then feeds down to young adolescents who are experiencing body changes, anxiety, social media matters, bullying, popularity challenges, body shame, sexuality, the list is endless. This person was never going to progress in a psychologist’s office in my opinion. To them it would show weakness and expose possibly no true issue in many people’s eyes. However, a small bit of support and acknowledgment goes a long way.