The patient, a chronic pain patient with multiple sites of dysfunction, is attending her first appointment. We are performing a seated exercise, working on dissociating foot and ankle, and in doing so, stimulating the reflex activity driven from the sole of the foot through the to the pelvis.
The patient begins to groan, and she gasps that the exercise is creating pain around the outside of her hip and buttock. She grasps it with a grimace and contorts her body away from it.
- Stop immediately because you believe that no exercise should be painful. (Patient and therapist become passive)
- Exhort the patient to continue, because the sensation she is experiencing is just an output of her brain and that she must learn to tolerate these sensations and strengthen despite them. (Therapist becomes dominant, patient becomes submissive)
- Knowing that this partial weight bearing position is not in itself provocative, question the patient further to first clarify the nature and site of the pain, and in this case, reframe the patient’s experience by exhibiting delight that she has awakened her hip and pelvic muscles, a wonderful achievement. (Therapist/patient dynamic becomes collaborative).
It will be of no surprise to you that I chose option 3. Reframing the patient experience gave me the opportunity to prime the next effort. Priming allows for a change in emotional association with the activity and with it, a change in context for the sensations experienced. In this case, I further explained the link between foot and pelvis, and how this was ideal for the purposes of improving her weight bearing. The result? On the next set, the patient settled into exploring whether the sensation was in fact a pain sensation, or just a sensation that was unfamiliar. It turned out that it was just a new sensation, but that she was accustomed to interpreting any new sensation as pain. Our priming created space for her to interrupt her habitual reaction and examine the situation from a new viewpoint.
When we then moved into a standing task next, she was able to identify a similar feeling around her hip and buttock area, but instead of aversion behavior, she noted how surprising it was that performing a simple weight acceptance task could work so many muscles. No fear. No catastrophising. Just interest.
It usually isn’t all the whizzy new techniques that make the difference. It is managing the patient/therapist interaction to establish a collaborative, exploratory, two way process. It so frequently isn’t what you do but how you do it that holds the magic.