You Can’t Treat What You Don’t Understand: The Case for Listening in Pain Rehab

The Power of Listening in Pain Care

There is broad appreciation of how important good listening (and the time to do it) is when it comes to treating persistent pain. Mark Kargela, physiotherapist, clinical assistant professor & host of the modern pain podcast, wrote in a post well worth reading in full on LinkedIn 'The key was to shut up, listen, and give the patient's narrative space.' In a similar vein, in answer to an audience question about which is the most useful intervention you use at the SIRPA conference, Dr Sarah Hadfield responded 'Listening, first of all...'.

Dumbo's third cousin, twice removed

Clinicians Interrupt Too Soon (And Too Often)

We clinicians could sometimes do better when it comes to listening. 60% of the time, physiotherapists interrupt the people they have just asked a question, taking on average just under 30 seconds to do so (Chester et al., 2014). Across a range of settings our medical colleagues are much quicker to the cut off, averaging 12 seconds (Singh Ospina et al., 2018), although, to be fair, doctors tend to be under greater time pressure.

Tight on Time

Time will forever be a limiting factor. For GP's with full caseloads, there are often literally not enough hours in the day. Whether one has 4 minutes or 45 minutes for each encounter, it is a case of doing the best possible with the time available. If there is a lot to hear, sometimes the best use of an initial appointment is listening, with treatment initiated in the second visit.

Why Listen?

Listening is particularly critical in persistent pain treatment, not only for developing a good therapeutic rapport, which emerging research suggests positively affects treatment outcomes (Kinney et al., 2020), but also because each person's presentation is so complex and unique that optimal treatment is necessarily a collaborative endeavour between the person in pain and the person treating, as highlighted by Dr. Deepak Ravindran in his SIRPA talk in May.

If you have met someone living with persistent pain, you have met one person living with persistent pain.

Listening is essential because cookie cutter treatments are not effective.

This is why evidence based practice should be about more than decisions being made by the person receiving care, as outlined in the Sicily statement (Dawes et al., 2005). In this limited conceptualisation, the person receiving care makes the ultimate decision on treatment after being provided with options by the experienced clinician, who in turn has an understanding of the evidence base.

EBP

What this framework lacks is the explicit recognition that the person receiving care has the keys, through their unique lived experience, to unlock the best possible care for them. These insights are available to the person seeking treatment alone. That is why clinician listening is essential.

It is not enough for the person receiving care to make the decision about treatment.

They must also inform the treatment.

References

Chester, E. C., Robinson, N. C., & Roberts, L. C. (2014). Opening clinical encounters in an adult musculoskeletal setting. Manual therapy, 19(4), 306–310. https://doi.org/10.1016/j.math.2014.03.011

Dawes, M., Summerskill, W., Glasziou, P., Cartabellotta, A., Martin, J., Hopayian, K., Porzsolt, F., Burls, A., Osborne, J., & Second International Conference of Evidence-Based Health Care Teachers and Developers (2005). Sicily statement on evidence-based practice. BMC medical education, 5(1), 1. https://doi.org/10.1186/1472-6920-5-1

Kinney, M., Seider, J., Beaty, A. F., Coughlin, K., Dyal, M., & Clewley, D. (2020). The impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: A systematic review of the literature. Physiotherapy theory and practice, 36(8), 886–898. https://doi.org/10.1080/09593985.2018.1516015

Singh Ospina, N., Phillips, K. A., Rodriguez-Gutierrez, R., Castaneda-Guarderas, A., Gionfriddo, M. R., Branda, M. E., & Montori, V. M. (2019). Eliciting the Patient's Agenda- Secondary Analysis of Recorded Clinical Encounters. Journal of general internal medicine, 34(1), 36–40. https://doi.org/10.1007/s11606-018-4540-5

Second image: What is evidence-based practice? - BDA