One of the most important questions that any good clinician should be asking in their first session with a chronic pain patient is; “what are your short- and long-term goals?” Generally, patients who present with acute symptoms will say things like:
“I just want to be out of pain.”
“I want to be able to train tomorrow.”
“I want to get back on the field asap!”
They have very short-term, tangible goals. Their lives have only been moderately impacted for a very small amount of time and there aren’t any lasting effects from their impairment. It’s all about getting them back to their normal lives as soon as possible - their usual training routine, sporting calendar, or just back to living life without pain.
For these patients, with low levels of impairment and generally good function, the desired outcomes are very clear and can often be achieved relatively simply. Some manual therapy, maybe some NSAIDs, exercise modifications or regressions, and a few follow up sessions to reintroduce movements and load, and they are on their merry way back to living their normal lives. The factors that contribute to levels of disability are often mostly related to the bio-physiology of the injury. “This hurts when I do this.” There may be some psychological aspects such as perception of pain or fear of movement and activity due to aggravation of symptoms, however these factors generally only have small contributions. Whilst these patients have the potential to develop into longer term chronic pain sufferers, the acute management patients have much simpler, achievable goals.
Working with complex, chronic pain sufferers is a completely different kettle of fish. Many times in clinic, when going through an initial assessment with these clients, I will often ask what the end game is - what do they want to get out of working together?
Some of the responses I’ve had over the years include:
“I just want to be able to play with kids again.”
“I need to be able to work again, to provide for my family.”
“I haven’t been able to enjoy anything for years because I am always in pain.”
“I’m depressed. I need to do something to get moving again.”
The goal posts have shifted, majorly. These patients are not after a quick solution to a small problem, they don’t have a bit of shoulder pain in a bench press that’s preventing them from hitting a PB. They don’t have a grade 1 hammy issue that’s keeping them off the field for 3 weeks.
Their quality of life is suffering. Their work quality, their ability to maintain and develop good relationships, their social life. Chronic injury and chronic pain become a much more complex issue than just physical pain, with some studies showing rates of comorbidity with depression as high as 35% .
For a lot of chronic pain sufferers, this isn’t the first time they have seen someone for their pain. Usually they have seen any number of GPs, physios, chiros, pain specialist and rehab specialists, and trialled a range of modalities including injections, exercise prescription, and psychologists.
So as a practitioner, how do I incorporate short and long term-goal setting into our sessions to try to get a result when nothing else has worked in the past?
1. Use the end goal and work backwards from there.
If the end goal is to be able to play with their kids, or get back to full-time work, let’s work our way backwards and implement specific steps to achieve that goal. These patients have been promised the world before, so it’s important to be realistic about achievable results and the time it may take to get there. If they have had low back pain for 5 years, it is unlikely that it will be resolved in a couple of sessions, but if we set-up a plan with smaller goals, the patient can see progress.
2. Set up a short-term goal that is function focussed, that can be achieved early.
Some form of pain is so deeply entrenched with chronic injury that patients often have a skewed view on it. They are always in pain and have been for so long, that asking them to describe the pain and quantify it can be confusing. Instead, I like to set up a short-term movement of strength goal that we can hit for a quick win, setting the patient up to focus more on what they can achieve, as opposed to what is limited. This can be something as simple as; “Let’s aim to go for a 10-minute walk twice this week” or; “We are going to try to do 3 sets of glute bridges every day just to see how your body copes with it”. Hitting an early win can help set-up a longer-term focus, which leads into point 3.
3. Trying to shift the focus from what we can’t do, to what we can.
Point 3 is a continuation of point 2. It is getting the patient to continually set-up their own progressive targets/goals, giving them something to work towards.
“Look at that, now you can do 10 goblet box squats pain free. Soon it will be 15.”
“15 minutes of walking without a break, awesome!”
“You kicked the ball with your son on the weekend? How good!”
If we can get a slow mental shift towards progression and not perfection, we can start to be less pain and disability focused, and more capacity focused.
Chronic injury can be very complex, and it often leaves people feeling hopeless, confused and like they will never feel better. It can be hard for some people to see how to get from point A to point Z. Setting up a simple but robust plan and giving people a clear direction can go a long way in helping tick through small wins and allow them to focus on going from A to B and then to C, and then trust that they can get themselves to point Z over time.
1. L.R.Miller, A. Cano. Comorbid chronic pain and depression: who is at risk? J Pain, 10 (2009), pp. 619-617.