How do you choose your doctor? Perhaps you review the credentials and experience of local physicians. Maybe a friend’s recommendation sways you. Could Google reviews be the key? What about your doctor’s beliefs about pain?
According to recent research, a provider's belief about pain influences the treatments you receive.
As a physical therapist who conducts research and teaches, I am buried in research and constantly reflecting on my clinical practice. Unfortunately, I was not as diligent with my reflection before taking on my research and education roles. This led to many outdated treatment approaches for my patients.
Every provider starts with outdated mindsets as school, unfortunately, is always behind the research. It takes time and process to update the board examinations, which schools teach to. Even still, research suggests young clinicians are more clinically updated than experienced clinicians.
But what if a provider has a fixed mindset? What if they refuse to update their beliefs? This is the battle pain science researchers fight daily.
Changing beliefs about pain
My journey with pain science was akin to the five stages of grief:
Denial: Bullshit. There is no way pain actually works that way. Why would my school or previous doctors and therapists teach it differently? Are you telling me I was taught wrong my whole life?
Anger: Are you telling me I was taught wrong my whole life?!
Depression: Not only am I six figures in debt for an education riddled with misinformation, but I have also been telling my patients the wrong information all this time. I even told someone his spine was like a jelly donut, and therapy would push the jelly back in! (more on this popular analogy and my unfortunate use of it to come)
Bargaining: Perhaps I can blend the two models, and it won’t be a total waste. Surely there are some benefits of the previous education I received. It can’t all be a sunk cost, right?
Acceptance: Bring on the pain science. I’m ready to educate the hell out of people.
This happened roughly two years into my career. I wasn’t a pain science expert once I reached the ‘acceptance stage,’ but rather, I was ready to make adjustments to my clinical practice.
Experience is one of the most valuable teachers in life. It is how we build intuition, recognize patterns, expedite decisions, and progress the complexity of our minds. But experience alone is insufficient, even dangerous. Experience without a growth mindset causes providers to double down on outdated treatments, which may harm the patient.
Enter pain.
What treatments does your provider use?
Physical therapists who identify with a biomedical pain focus — relying on the concept that pain and disability are consequences of physical pathology — are more likely to use treatments such as specific back exercises, electrotherapy, soft tissue release, hydrotherapy, massage, lumbar supports, and acupuncture to treat chronic low back pain.
Yes, those treatments are not supported in research. Our backs are strong and robust. Research is clear that physical pathology — disc herniations, osteoarthritis, ligament tears, and muscle tears — are only a piece of the pain puzzle. Imaging often shows ‘damage’ without any pain and vice versa. The treatments listed above only provide small, short-term changes in pain, which are primarily placebo.
Instead, providers should operate with the biopsychosocial model of pain. Decades of research show pain is an experience that results from biological (e.g., tissue damage, genetics, etc.), phycological (e.g., mood, personality, etc.), and social factors (e.g., cultural, socioeconomic, etc.).
These providers are more likely to use physical-activity-based interventions, pain-coping skills training, and cognitive functional therapy. They emphasize the role of psychological and social factors in the development of pain, relying less on physical causes (posture) and treatments (lumbar support).
The treatments above are not exclusive to physical therapists. If you are trying to decide the mindset of a physician, pay attention to their treatment focus. Are they using medication, injections, or surgery to treat pain? Do they focus on ‘damage’ and rely on imaging reports? If so, find someone else.
When deciding on a provider, interview them. Our training, experience, values, and work environment all influence our treatment decisions. Many of those show up on a google search. No matter how impressive a resume is, outdated beliefs about pain lead to ineffective and potentially harmful treatments.
Pain is complex, and the research is evolving. Make sure your provider is keeping up.