The importance of connection when treating chronic pain

This blog post was written by Tori Etheridge and was originally published in PABC. Tori is a Rehabilitation Supervisor at the Surrey Neuroplasticity Clinic – Heuro Treatment Center.


Working with individuals who have persistent pain, for many practitioners, can seem demanding and overwhelming. There is a large range in presentation of persistent pain, and sometimes, these individuals’ needs are not able to be met in a typical fast-paced clinic environment. In their constant pursuit for answers, these patients can also feel as though they are lost in a sea of healthcare professionals, and may not gain any further understanding of how to manage their pain.

Paradoxically, the information they do receive could compromise their self-confidence leading to patterns of avoidance, isolation and withdrawal. Having an open mind to explore the complexities of their pain experience is essential. Below are a few things to consider when working with patients with persistent pain.

Taking the time with these patients to explore their history, thoughts and beliefs can often lead the therapist down a good path to help the patient. Rather than listening only for a potential diagnosis, consider listening to be able to understand their pain and to understand the impact their pain has had on their life. Use this opportunity to provide validation of their experience and build a therapeutic alliance.

Their story is key for understanding how they got where they are. Listen carefully and ask questions through a biopsychosocial focus. Ask open-ended questions that require them to reflect and explain what their understanding is of their pain, tailoring the questions to the person sitting in front of you. It is here you can gain knowledge about their beliefs, expectations, fears and other factors which may have a role in maintaining their pain. Some questions that can be helpful to ask those with persistent pain are:

  • What have you been told is going on with you?
  • How do you feel about what you have been told?
  • What do you think is going on?
  • What else is going on in your life?
  • What is something that you would like to do again that you have stopped because of your pain?
  • Do you think it is safe for you to participate in exercise?
  • Is there anything else you would like to tell me about your current situation or pain?

When providing education, consider how your language can impact their beliefs and understanding of their pain. Ask yourself if what you are saying could lead to more or less fear of movement. Use your current knowledge of pain to help their story make sense to them. This should be a two-way conversation, not just a regurgitation of “explain pain” (Explain Pain, Butler and Moseley). Consider discussing the heightened sensitivity of the nervous system, dysfunctional modulators of pain, sensory hypersensitivity, protective responses and other social and psychological factors that can influence pain.

Be honest, and discuss expectations and realistic timelines for change. Patients are vulnerable to falling into a dependent role where they rely on you to manage their pain. We should be facilitators in their care. Work to empower your patients to take control and give them the tools they need to manage their pain. Avoid promoting passive treatments that lack clinical research to support their efficacy.

These individuals should be encouraged to actively participate in self management and have ownership over their rehabilitation. Teach them how to advocate for themselves, how to educate others about their pain, and be honest with their healthcare providers. Provide opportunities to experience pain reduction in the clinic; calming strategies such as relaxation, breathing and visualization can positively influence pain. Movement and manual therapies can provide novel inputs to modulate pain and reinforce the benefits of activity. Teaching patients how to recognise protective responses and how to change them can be powerful and give a sense of control. For example, are they holding their breath, tensing up, bracing or moving awkwardly? These strategies can reinforce that our nervous system can change.

Build confidence to move. Help patients build the confidence to load the tissues and coach them to manage the protective buffer of their nervous system. Encourage them to move and educate how hurt does not always mean new harm. Encourage them to move mindfully and slowly as they attempt new exercises, versus with high caution. Educate about the difference of challenging the
pain versus pushing through the pain and ignoring it. Discuss flare ups and teach them pacing strategies to help avoid them. Explain how pain will increase slightly when they go to move, but that this is safe and expected. We need to teach them how to find a balance between the extremes of inactivity and over activity.

During physiotherapy sessions, frustrations and emotions often come out, and this should not scare us. Some may shy away from conversations around this, but if you don’t ask questions, who will? To quote Peter O’Sullivan, Professor of Musculoskeletal Physiotherapy at Curtain University in Perth, Australia, “We need to treat the emotional consequences of their disability that arise when they can no longer do the things in life that give them meaning.” We need to be comfortable asking about depression, anxiety, PTSD, trauma and other emotions. Explaining the role of emotions in chronic pain and linking the mind and body are key. We need to open the door, and if you find your patient needs more advanced skills, then we refer on appropriately.

A special thank you to the Pain Science Division (PSD) Executive Team and a few PSD members for their feedback on this article.