This Feature Friday post is one of my favorites. It is a patient story involving the application of pain neuroscience education in an acute care setting written to ISPI faculty member Kory Zimney. Please take a read – it will brighten up your Friday. Remember, what we do as PTs is important and can make a difference in someone’s life!
My name is Peter Drinkwine.
I’ve been debating on whether to share an experience I’ve had since taking a TNE course with you, trying to decide what value it would add to anything in the PT world. I figured it wouldn’t hurt to share it with you and the ISPI team regardless. I’ve only been a PT for a little over two years and have been very interested in pain education since I was a first year PT student. I work in an acute care hospital with a diverse number of units in which I work on day to day (ortho, neuro, trauma, cardiac, surgical, medical, ICU, oncology, burn, and behavioral health), and also share working in the emergency department with one other PT. I have already had many very unique experiences as a PT, but one sticks out above all of the others and I’d like to share it.
Not long after taking the TNE course, I was working covering the behavioral health unit. PT was consulted for a patient with chronic low back pain by the attending physician. This patient was admitted to the BH unit due to an intentional drug overdose and suicide attempt. This patient had made her way through the ICU, medical floor, and then transferred to the BH unit once medically stable. This is obviously an extremely unfortunate situation, but an all too familiar one as mental health and drug abuse is a growing problem throughout the country.
The first time I approached this patient she was laying in bed crying, nearly in the fetal position. I asked the patient if right then was a good time to talk with her, and she asked if I could return later, that her pain was too much currently. She obviously was not ready for PT at that time, and I wasn’t sure if she would be ready in this time of her life for PT at all. I approached the patient this way was because I remembered from the TNE course that you had told us not all patients are ready to hear what we, as PTs, may have to say – pain education has a time and a place, and should be uniquely tailored to each individual. I returned later that day and the patient was up on the unit and was agreeable to at least just talking with me.
She was a very pleasant person but was also in a very dark and fragile place in her life. I asked the patient about herself, her story, her pain, and sat and listened before trying to push my ideas and education on her as I feel we may tend to do as the eager PTs wanting to help people. The patient had back pain for many years now – she knew the exact date of her initial injury, which was very curious and told me that this pain was obviously making a significant impact in her life and something that she focused on and dwelled on often. Since then she had lived with constant low back pain with some radicular pain, flaring up at times and calming down at others but persistent nevertheless. She had tried many medications, injections, had multiple imaging studies completed (an MRI was done during her hospital stay with nothing but mild degenerative changes expected for age), and at one point years ago had tried PT which consisted mostly of traction, modalities, and a few stretches, none of which were effective for her. Recently, the patient had a greatly increased amount of stress in her life, which she willingly divulged while I sat there and listened, all relating to family, finances, job, and her chronic pain. She reported that her pain was continuing to worsen and that the other stressors in her life had become too much for her to handle. She was having significant difficulties ambulating when in the hospital and around the BH unit due to her back and leg pain. While I listened, she told me that her worsening pain was what had push her to the point of intentional overdose, as she couldn’t stand living with her worsening chronic pain anymore.
After listening to the patient’s story, I then asked if she was willing to undergo a PT examination as I wanted to see if I could help her. She agreed, and I completed a thorough examination to assure that the patient had no red flag symptoms. This way I could assure the patient that there was nothing seriously wrong or concerning with her spine, as you also made sure to discuss with us during the TNE course. The exam was benign with the exception of a positive slump test which did indeed correlate with her radicular pain and resulted in decreased knee extension and some hypersensitivity around her lumbar spine. She also ambulated with a moderately antalgic gait. It was then I asked the patient if I could take a few minutes to explain how pain worked to her. This was such a simple yet very effective approach I had learned from you in the TNE course and has become extremely valuable as I continue to practice PT. I then proceeded to discuss the more basic concepts of pain neuroscience using TNE – how nerves work, how pain works, how pain is a protective mechanism, how the nervous system becomes sensitive, etc. etc. This was my first time provide true “Therapeutic Neuroscience Education” after taking the course and having the formal training. As I said earlier, I have been very interested in pain education for years but had never had any formal training until that point. To be perfectly honest, when talking with this patient I felt like a babbling idiot. My brain was racing with ideas on what the appropriate education would be, I was trying to remember all the details of each TNE story, trying to figure out ways this patient could use graded activity appropriately, and I was just simply quite nervous. I talked for what felt like 30 minutes straight, but in reality was probably only 5-10 minutes or so. She had questions which I answered to the best of my abilities and generally appeared receptive of the education but there was no “ah-ha” moment I could tell. I gave her only three things to work on – a nerve glide, one core exercise, and educated the patient on the importance of completing an aerobic exercise program. Luckily, our BH unit has access to some general exercise equipment for the patients to use so I encouraged the patient to try walking or use a seated bike for five minutes at a time, multiple times a day. I thanked her for her time and informed her we would follow up while she was still on the unit.
I had the ability to return to check in with the patient a few days later. When I went onto the unit the patient was not in her room, she was up walking the unit. She smiled when she saw me – a smile I will not soon forget. I asked the patient how she was doing, how she has been since I last saw her. She reported that she was feeling much better. She had taken my advice and had been walking, completing her exercises, and had thought about everything we had talked about during our previous session. Her chronic pain, which had previously been consistently around 8/10 (even during my evaluation), was now down to a 2/10 and she was not relying on her opioid medications anymore but able to use more over the counter medications such as Tylenol. She was able to complete full knee extension during her slump test. She reported her mood felt much better too. I asked the patient if she had any questions about what we had talked about last time, and she said that she did not, that everything we had talked about made sense to her the more she thought about it. She stated that she actually had mentioned what we had talked about regarding her pain during the family assessment she had completed over the weekend (this is a special meeting unique to the BH unit where a specialized staff member meets with the patient and his/her family to help with family dynamics and what resources are needed for a safe discharge, and to provide any counseling needed). We reviewed her exercise program and I recommended she follow up in outpatient PT, as she was doing so much better she was going to discharge the next day. She was very grateful and thanked me, with happy tears. Again, I thanked her for her time and the opportunity to work with her.
I thought this was a success because I had helped this patient decrease her pain and walk better. However, I remembered that the patient had said she mentioned our discussion on pain during the family assessment which peaked my curiosity. I went into the EMR to begin to document my note and decided to see if there was any mention about the patient’s PT session. This was when I realized I may have helped this patient more than I could have ever known. A portion of the family assessment note read as follows (one sentence was taken out to maintain HIPAA otherwise word for word):
“She said that she also has experienced an important paradigm shift since her PT discussed with her how nerves and pain work. She learned how stretching and exercise will actually decrease her pain, and this made her hopeful, she said. She explained that it has been a lengthy journey with opioids and benzos, but she said she is convinced she can put those behind her.”
I was dumbfounded. As PTs we are taught to teach patients about how nerves and pain work, and how stretching and exercise will decrease pain – this is essentially the basis of the PNE. I couldn’t believe what I had read. When talking with the patient, I felt like I screwed up – like a babbling idiot as I said. Clearly something went well though. Not only did the patient listen and understand what we discussed and the pain education I had provided, but it gave her hope – hope that she can regain control of her life let alone her pain. Of course, this patient’s recovery was not simply due to PT alone. In this specific setting the psychiatrists, psych nurses, therapists, social workers, occupational therapists, and, apparently, the PTs are all on the same team to help these people. What I find most interesting though, is that it was another provider who noted that the education I had given and the time I had spent with this patient caused a “paradigm shift” in this patient’s beliefs and life.
This has been my proudest moment as a PT. To give someone hope who was in the middle of the worst time of her life, who had tried to end her life, was a gift to me that I could have never imagined. I guess the purpose of this story, why I wanted to share it, was to encourage others to put themselves out there and take that first step to providing pain education. This is a very unique and specific example no doubt, but shows the serious role and impact that we as PTs can have in our patients’ lives. The research clearly shows that pain neuroscience education is effective, and I’m sure many therapists realize that this is becoming an essential part of the rehabilitation world (or perhaps just my bias?). However, it can be extremely intimidating to put yourself out there as a PT and take that first step out of your comfort zone to provide pain education to help patients address the very sensitive issues which surround chronic pain. Despite my interest in pain neuroscience for years (as a student and a professional), I was hesitant to try and provide formal pain education to this patient because it was something uncomfortable for me, something I had never truly done before. I am glad I took that first step, forced myself out of my comfort zone, as it turned out the be the best thing I have ever done and, as the patient reported, provided someone with hope for a positive future. I would encourage anyone who may be nervous, scared, or just hasn’t taken that first step to providing pain education to do so because you never know the impact you may have on a patient’s life and their hope for a better tomorrow.
I would be more than happy for any feedback from you and/or your colleagues and want to help spread the word about the importance of pain education. I really just wanted you and ISPI to know this story because it not only provided the patient with hope but made a profound impact in my life and how I treat my patients. I am utterly grateful for the education, recommendations, and insight you provided during the TNE course. I have already submitted an application for one of the TPS cohorts for 2019 and cannot wait to eventually hear back and hopefully start furthering my education even more in pain neuroscience.
Sorry for the very long message but I truly appreciate your time and the work you do for our profession.
Peter Drinkwine, PT, DPT