Managing Chronic Pain Beyond Hands-On Chiropractic 

Pain is defined by the International Association for the Study of Pain (IASP), as the “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (Merskey & Bogduk, 1994, p. 210).  According to Bond and Simpson (2006), clinical aspects of pain can be classified into acute and chronic pain. Acute pain is common and is the consequence of tissue destruction caused by stimuli including trauma, inflammation or tumour. This pain is useful as it draws the attention of the sufferer to the injured site, triggering behaviour designed to address or relieve pain as quickly as possible. On the other hand, chronic pain is pain that remains for at least 6 months and is often strongly associated with physical disability and deemed to be “useless” as it usually doesn’t indicate tissue damage hence no subsequent activation of healing mechanism. This is developing into a major public health issue globally and require ongoing evaluation to determine the ideal approaches for its prevention and management. It was reported that 41% of the society in both developed and developing countries suffer from chronic pain which is a huge financial burden to the countries (Tsang et al., 2008). Multiple studies (Ruddock, Sallis, Ness & Perry, 2016; Furlan, Giraldo, Baskwill, Irvin & Imamura, 2015) have shown that chiropractic treatments including spinal manipulation and soft tissue therapy are effective for treating pain but mostly in the short-term only. As chronic pain becomes epidemic, chiropractors need to move beyond focusing on solely providing hands-on chiropractic treatment to patients, and emphasize on approaches that incorporate physical, emotional, psychosocial and healthy lifestyle changes to manage patients with chronic pain (Gliedt, Schneider, Evans, King & Eubanks, 2017).

According to Bond & Simpson (2006), since chronic pain can trigger negative emotions and behaviour patterns like anxiety or fear, it is crucial that the practitioner displays empathy when dealing with chronic pain patients, so that the patients feel understood and heard. Moreover, Gleichgerrcht & Decety (2013) defined clinical empathy as the ability of a practitioner to understand his patients’ suffering, communicating to confirm that perception with the patient, then proceeding to make the effort to help them. Effective communication is of key importance in any therapeutic efforts between a doctor and a patient. It has been studied that good communication between the two parties help to regulate emotions of patients and the delivery of medical information, allowing the doctor to better determine the patient’s needs and expectations (Ha & Longnecker, 2010). Following that, Ha and Longnecker also reported that patients are more receptive to good communication in terms of satisfactory levels with their care, as they are also more likely to share important information that helps the accuracy of their diagnosis, not to mention subsequently adhering to advice and treatment that was prescribed by their doctors as they trust them, thus being able to achieve better health outcomes. The therapeutic effects can potentially already begin in the first encounter between the doctor and patient, during the history taking session by an expression of empathy by the doctor. 

However, as stated by Pollak and Ashton-James (2018), it may be challenging to communicate empathy properly when it comes to patients with chronic pain. Firstly, practitioners may not easily identify patient’s negative emotions, particularly when constant interaction with distressed patients can lead to compassion fatigue (Sorenson, Bolic, Wright & Hamilton, 2016). This can happen where practitioners become apathetic to patients’ suffering. Pollak and Ashton-James emphasized that practitioners must constantly remember to put themselves in their patients’ shoes in order to understand what they are going through and express empathy effectively. Once an empathic opportunity is identified, the next challenge for practitioners is to ensure their empathic response is appropriate so that it is not reinforcing patients’ pain-catastrophizing beliefs, which is strongly associated with disabilities related to chronic pain. The subsequent challenge for practitioners is when patients are conveying strong emotions and there is an apparent possibility of them losing control and dwelling in their distressed state. In this case, it is suggested that practitioners deliver empathy using “buried” empathic statements rather than “unburied” ones, where practitioners acknowledge the suffering of patients but redirect their focus elsewhere, for example, how they could play a part in taking charge of their pain or health. Ultimately, empathy needs to be personalised to the needs of the patients and is crucial as it is evident that empathic communication yields more accurate diagnoses, thus playing a role in more effective treatment (Halpern, 2014).

In addition to empathy, another factor that greatly influences clinical outcomes of chronic pain patients is the choice of words that are utilised by chiropractors in the doctor-patient encounters. As mentioned by Gliedt et al. (2017), practitioners should be consciously mindful of the words they choose when communicating with patients, especially when they deliver and explain the diagnosis to their patients, and when discussing about the management of their problems. Some practices provide extremely detailed reports of findings where they stress on pathoanatomical diagnoses or use language that is associated with pain and disability. Examples of this include the explanation that the “bone is out of place”, “subluxation”, or describing patients’ condition by referring to the “phases of spinal degeneration”, thus convincing the patients that they need to be routinely corrected, and being put under indefinite maintenance or treatment plans where they receive passive therapies like spinal manipulations and soft tissue therapy. Gliedt et al. stated although practitioners may have good intentions of informing patients about the non-threatening nature of their pain and encourage them to manage via self-care approaches, this may instead instill negative beliefs and behavior where patients’ self-efficacy is decreased and their fear or anxiety amplified, promoting their dependence on the chiropractor. While fear is acknowledged to be a potential strong motivator to increase patients’ compliance with care (Peters, Ruiter & Kok, 2013), this practice is often deemed unethical and have been reported by Gliedt et al. to give more negative effects to their behaviours. This particularly affects those with low self-esteem or self-confidence, feeding into their fears and negative emotions, and once again, reinforcing their catastrophising beliefs. This negative style of communication is said to be less effective in encouraging patients to change or make modifications for their health as it can reinforce the fear-avoidance model of pain in chronic pain patients. This is described by Gliedt et al. where patients are afraid that a certain movement or physical activity may bring on or exacerbate their pain, therefore choosing to avoid those activities, leading to withdrawal from society and decrease in their physical function, producing negative emotions which further intensifies their pain and disability. 

Therefore, an approach where clinicians convey positive messages to patients is highly recommended, in order to improve clinical outcomes for chronic pain patients. Howick et al. (2018) found that positive communication was consistent in decreasing pain and anxiety although in small amounts. Furthermore, they also found that positive communication improved the physical function of patients, resulting in a higher satisfaction of care and quality of life. These points highlight the importance of positive communication as compared to negative or fear-inducing messages when it comes to delivering the diagnosis to chronic pain patients and the discussion of management plans of their conditions. In addition to choosing the right words, the body language of the practitioner also plays a huge role when communicating with patients (Halpern, 2014). 

Moving on, once practitioners has figured out the patients’ problems, delivered the diagnosis and treatment, their responsibilities do not end there. Pain education have been shown to provide clinical improvements in pain, disability and function of chronic pain patients, as found in multiple studies (Moseley & Butler, 2015; Louw, Zimney, Puentedura & Diener, 2016; Louw, Diener, Butler & Puentedura, 2011). Explaining Pain (EP) is a series of educational interventions introduced by Butler and Moseley (2013), with the goal to modify patients’ perception of the biological processes underpinning pain as a strategy to reduce pain. One of the key ideas in EP is that pain is normal, and its purpose is to alert an individual that the body needs to be protected, and therefore serves as one of our protective systems. The level of pain depends on the brain’s perception of levels of harm and the possible benefits of protective behaviour, which may or may not be the accurate harm level or true benefits. The next key idea in EP is the biology of pain, explaining that nerves or nociceptors in the body have mechanical, thermal and chemical sensors that send signals to the brain via the spinal cord when sufficient ‘danger’ stimulus is detected. The brain then decides whether the body is truly in danger and whether it needs to generate protective responses such as pain in that body part. Furthermore, it was also mentioned that these ‘danger’ sensors and the transmission system have adjustable sensitivities. Persisting pain will cause the neural networks of the brain and response to become more sensitive, resulting in a larger effect on pain and the protective mechanisms. These are all important concepts that should be conveyed by practitioners to patients in helping them understand pain as a therapeutic effort to reduce their pain. 

However, there may be a challenge posed in delivering this information to patients if they have existing pain related beliefs. Butler and Moseley (2013) also mentioned that EP is about “conceptual change” which was defined as “a field of education that explores the process of change in our understanding of a phenomenon in the presence of existing knowledge” (p.103). In general, it is easier to teach a concept if he has little or no existing knowledge of it as he is less likely to reject the idea. Conflicting knowledge can lead to resistance to change due to different beliefs. How a practitioner can start this conceptual change is by encouraging patients to identify DIMs (Danger in Me) or SIMs (Safety in Me) in their lives, which could range from activities they take part in, the things they say or hear, to the people they interact with. Examples of DIMs could include what they understand from their x-ray report or what they believe from the news on TV. On the other hand, examples of SIMs include setting health goals, getting help from a good clinician and support from friends and family. When a patient’s brain assumes that there are more DIMs than SIMs, they will feel pain. With the knowledge of the biological process of pain, DIMs could be turned into SIMs, thus improving their pain. It is vital for clinicians to present information about pain while making sure the patients understand by undertaking strategies like using props and printed materials appropriately in a suitable context.

In conclusion, chiropractors should not only focus on delivering hands-on chiropractic treatments that are considered passive therapy, including spinal manipulations and soft tissue therapy. They should incorporate a more biopsychosocial approach, especially when it comes to managing patients with chronic pain. This can include displaying empathy during the interaction with the patients from the first encounter with them, so that they feel understood and heard, which is vital to establish a good and trusting therapeutic relationship. It is also important to continue empathizing with them in the following interactions with them, but in a skillful and effective manner, without causing a negative effect on patients’ emotions and pain belief. Next, practitioners should be aware of the words they use when communicating with patients regarding their diagnosis and treatment plans. This is to avoid reinforcing the fear-avoidance model of pain, where the fears and negative emotions of patients are amplified, which could result in increased pain and disability. Lastly, when the time is right, patients should be educated about the pain biology so they understand that pain is normal and does not necessarily mean their painful body part is in harm. These patient-centred communication skills are vital in managing patients. Unfortunately, it has been reported that chiropractic students have limited training in this aspect (Muddle, O’Malley & Stupans, 2019). These patient-centred communication skills, along with the existing skills of hands-on therapy that chiropractors utilise, could help achieve a more desirable clinical outcome for patients in the long term, especially for those who are suffering from chronic pain.