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Old 13-05-2012, 06:44 PM   #1
gollygosh
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Default What stories do you tell

Educating patients about pain leads to metaphor, and story telling. Painful Yarns, helped me to understand that, and Mosely encourages to develop own stories. I have stories that I use frequently, and some evolve in the course of working with each patient. I am interested in what stories you tell. What works for you?

I’ll start it off with one of my recent favorites.

When the smoke alarm in our house was installed, it was set up to alert the hallway and the bedrooms associated with it. Unfortunately, it was also placed so that any kitchen activity resulting in any smoke—hot wok, burnt cookies, gravy spill resulted in the smoke alarm sounding.

When my daughter was 6 years old the fireman came to the school for fire protection week. He asked if their houses had smoke alarms. He asked what it meant when smoke alarm sounded. My daughter raised her hand, and replied, “It means it is time to get ready for supper.

This is good for a smile, and I use it to describe how alarms can be interpreted in different ways –context matters. I link this to pain as protective in response to real, or perceived threats, and getting on with the business of changing that context via DNM, simple contact, Feldenkreis type exercises, problem solving,..

Geralyn

Last edited by gollygosh; 13-05-2012 at 06:44 PM. Reason: spelling
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Old 13-05-2012, 08:59 PM   #2
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Good story GG!
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Old 14-05-2012, 07:49 AM   #3
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2 i use semiregularly

Pain is the flashing light on the dashboard of your car, it's telling you something will need attention and it's up to you if the attention is now or in the future. You can keep on driving with the flashing light and then find out later that the problem has arrived (I'm stuck at the side of the road with no gas), you can stop and work out why the flashing light is flashing (is it the gas light and i need to refuel? Is it the engine overheating and I need to stop or get water? Is it just faulty wiring to the light?), you can put a piece of tape over the flashing light and hope it means nothing ... until your car is a steaming mess on the side of the road. Then I point out 2 things - if you took your car to a garage and pointed at the flashing light and they tried to fix your light instead of working out what it meant (It's the gas light telling you you need gas) you'd conside them a bad mechanic. This is my dissuade against the 'the pain is in my shoulder so you must treat my shoulder' belief. And that if you took your car to a garage and pointed at the flashing light and the mechanic said they knew what it meant and then poured petrol over the gas indicator on your dashboard you'd consider them a bad mechanic. That's my dissuade of 'the problem is in my shoulder the solution is in my shoulder' belief.

While mechanical in nature it's a gentle step with certain clients from a familiar/mechanical/problem/injury content based analogies towards new/driver/process/injury context and addresses the 'You've come to me and this is why i'm not doing certain things that you may expect' scenarios.

The other one I use is how's your Pain cake tasting today. The sensations come in to the CNS like a whole bunch of ingredients for a cake, the spinal column and brain measure out the proportions and bake the cake and deliver it up to you to taste. It helps me lead into there is no pain in the sensations, it's just the mix that the brain has decided to bake up. Then I can lead into it the same cake tastes different depending on context (it tastes different if you brushed your teeth before hand or saw the baker hadn't washed their hands or it's from your child who has made their first independent batch of muffins etc.)

Thanks for the question, I'm always curious what other people say.

And yes, I once was that bad mechanic.
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Old 14-05-2012, 08:26 AM   #4
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Good stories from both GG and Mark.

I once used traffic lights to help a frustrated patient with 4 months of persistent pain and convinced her neck was the cause of her spinal and occasional sternal pain. She used to have her neck manipulated every fortnight which helped for several days, then returned. Her imaging was OK.

So I mentioned red (stop and investigate further), amber (something is happening) and green (all's well). I asked her which colour applied to her. She thought amber, followed by green, she hoped.
After a session of pain education and slump movements, she said it was a lot better, adding: "Next time I will be green!"

She was.

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Old 15-05-2012, 08:42 PM   #5
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http://mindblog.dericbownds.net/2012...s-iceberg.html

Came across this (in my blind wanderings through the internet desert) which I thought linked in nicely.

Last edited by Mark Hollis; 15-05-2012 at 08:43 PM. Reason: grammar/parenthesis
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Old 15-05-2012, 09:33 PM   #6
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Being a dad of both a four year old and two year old girls I often liken the treatment of pain to dealing with an angry/upset toddler. Patients might expect that we will be rough on their joints/muscles/whatever and forcefully correct something but I remind them of the angry/upset/cranky toddler. How do we calm down this angry toddler? We might want to yell at them but we know this won't help. Instead we cajole, trick and distract. We might offer to read Dora the explorer, a little bit of TV or a kiss from a puppy.

So your angry shoulder is a cranky toddler...lets let it watch some Dora.

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Old 15-05-2012, 10:00 PM   #7
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Default les sportifs

désolée, j'ai compris la question mais je ne peux répondre qu'en français
Lorsque j'ai des sportifs qui arrivent avec des douleurs quelquonques au point de ne plus pouvoir s'entraîner alors que l'échéance de la compétition arrive dans quelques jours...
Je leurs raconte ceci...
Quand j'étais plus jeune (hum j'ai 23 ans..), je m'étais entrainée pour réussir le marathon de paris. Mon corps et ma tête étaient prêts à fournir l'effort demandé. Au départ du marathon, je me suis foulée la cheville mais rien de grave. J'ai continué ma course. Au final 3h30 sans aucune douleur. Je suis arrivée à l'hotel ma cheville étaient bleue gonflée je ne pouvais plus marcher dessus. De plus, mon cardio m'avait brulé au 2 ème degré sous la poitrine. Et pourtant je n'ai rien ressenti pendant la course. Mais qu'est ce que j'ai souffert de ma cheville par la suite, et même sous la poitrine, rien qu'au frottement d'un vêtement.
Par contre un autre jour, à l'échauffement pour une compétition de natation, alors que je ne m'entrainais plus depuis quelques temps, un nageur m'a donné un coup dans la cuisse. J'ai du déclarer forfait car j'avais une douleur tellement forte qu'impossible de marcher ni de nager. La fin de compétition terminée je n'avais plus rien....
Est ce que j'ai répondu à la question ?
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Old 15-05-2012, 10:40 PM   #8
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Oui Zoolima, pile poil.
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" Toute douleur déchire ; mais ce qui la rend intolérable, c’est que celui qui la subit se sent séparé du monde ; partagée, elle cesse au moins d’être un exil. Ce n’est pas par délectation morose, par exhibitionnisme, par provocation que souvent les écrivains relatent des expériences affreuses ou désolantes : par le truchement des mots, ils les universalisent et ils permettent aux lecteurs de connaître, au fond de leurs malheurs individuels, les consolations de la fraternité. C’est à mon avis une des tâches essentielles de la littérature et ce qui la rend irremplaçable : surmonter cette solitude qui nous est commune à tous et qui cependant nous rend étrangers les uns aux autres. ''
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Old 15-05-2012, 10:59 PM   #9
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Parceque si j'ai bien compris Lorimer
Les exemples citées sont plus compréhensibles que si nous avons vécu cette expérience ou que nous avons soigné un patient avec cette expérience.
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Old 16-05-2012, 01:34 AM   #10
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Default Pain is a prison-- let's plan a jail break

I was speaking to a patient the other day who, between chronic pain and depression is pretty hard to deal with. He is having trouble understanding that I can't fix him. He sees limitations and no options. He dismisses suggestions as not likely to work. It's like this guy is imprisoned by his pain. As prison came to mind, I thought about the fact that prisoners have actually used things like dental floss, spoons, and toothbrushes as weapons, or as tools used in planning prison breaks. I pointed this out to him. Prisoners must have some shred of hope to plan their escape. They also need persistance, and creativity. After our chat, I had him lie on table--which felt very hard. I coached him through rotating and warming, and watched as he began to attend to the motion. As he reassesed, he noticed that something had changed, and the table was softer. Maybe he needed a prison metaphor, but it is the most positive vibes I've gotten from him.
I hope so.
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Old 27-01-2013, 08:39 AM   #11
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Here are my metaphors and stories. I am going to try to type it the way I explain to patients.

1. After reading Diane Jacobs' blog on HumanAntiGravitySuit regarding how she uses a picture of the nervous system to hook the patient to neuroscience, I have printed out something similar and explain to patients that our muscles, tendons, ligaments, organs, emotions, thoughts, and actions like stringed puppets performing a play. The nerves are the string and the brain is the puppet master. Pain and all of our actions are based on the puppet master which controls our body in the subconscious and automatic state. Yes there is conscious control, but parts of that are also automatic. I am going to focus your physical therapy on the puppet master and the strings to hopefully effect everything else. Then I try to explain about the skin as the container of our body and the strings go all the way to the skin. If the outer container cannot move, how can anything in it move?

2. If a patient is ticklish.... I like to share this one. Actually I like to share this one a lot. I start off with something like this: You know when a child is ticklish and you tickle them and tickle them and then stop to let them breath??? Then when you tell the child "I'm going to tickle you" and wiggle your fingers without even touching them, they start to giggle, protect their underarms and withdraw their body. The tickling sensation protects injury to the nerves under the arm. When they think they are going to get tickled, they start to laugh or become more ticklish. Pain is the same way. If you think that you will have pain with a specific activity or weather change, you will more likely have pain... Then I let them process that.... Also the more you tickle a child the more ticklish they get. Pain is the same way. Lastly, after a little more processing i state that the ticklish sensation is a protective mechanism. It protects the nerves under the arm. Pain is the same way. Pain is a protective mechanism telling you that there is an injury, potential injury, or it might be an incorrect . If my patient is a health care provider or wants more information, I will ask them to look up central sensitization.

3. Regarding neurotags: I like to ask patients this: Have you ever been somewhere, smelled something, or heard a song and it totally reminded you of a specific event or someone from the past? Pain is the same way. The brain connects everything that occurred during your initial injury, whether its a song, the time of year, your emotions, the weather and etc. Its like that song or movie that instantly reminds you of an ex-boyfriend or girlfriend. Pain is the same way and can turn on when any of the neurotags are stimulated.

4. Non-nociceptive pain: I use the the ticklish thing and the neuro tag example, as well as this one for patients who have bought in to the science of pain, but might need more metaphors. I will say something like... Did you know that pain doesn't have to have tissue injury? Have you ever seen on America's Funniest Homes Videos where you see a Father teaching his child how to swing a bat on a tee and you already know whats going to happen. Then boom!! a home run, smack right on the NUTS, the balls, the testicles, the family jewels...(well I don't really say it that way...hehe) and you can feel your gut and sometimes you actually grimmace...maybe even feel a little pain... Pain is the same way. The brain controls are pain through many mechanisms including memory, emotion, and all of our senses.


I also use the examples in Painful Yarns. I feel the best part of story telling is when patients finish the story for me or they share one of their own.

I hope my examples make sense. feed back is always appreciated.

Rex
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Old 07-02-2013, 09:27 PM   #12
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Today a woman I treated for persistant/resistant neck pain, jaw pain, headache, sat up, felt a lot better.

I told here she could keep it that way if she wanted, had her do some nice small slow moving in all sorts of planes. She asked, what about deep stretches? I said, what do you mean, deep stretches? She said, well, I usually take my neck as far as it will go and hold it there, to alleviate pain.
I said, well, I wouldn't recommend that.

I said, if you have a big ball of mixed yarn to try to sort out, if you pull hard on a loose strand, it usually makes a tighter mess.. but if you get into it and create more space, gently, you can usually take that loose end and thread it back through all the snarls and eventually free all the strands, one colour at a time, until you have a tidy bunch of rolled up yarn in a basket. So, movement is the same - close your eyes, feel your neck, move it small amounts, slowly so you can sense where it wants to go next, and let more space open itself up. Make sense?
She replied, yes.. it's not what I usually do though.. and I asked her, well, how did doing it your way work out for you? So far? And she replied, not so good... And I said, well, maybe trying it a different way might.
She agreed to try it the new way.

So, I call that the tangled-up yarn mess analogy.
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

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Old 09-02-2013, 08:47 PM   #13
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"So, movement is the same - close your eyes, feel your neck, move it small amounts, slowly so you can sense where it wants to go next, and let more space open itself up. Make sense? "

Absolutely. Great advice . If everyone with a neck problem did this before going asleep, they might discover the 'cosy spot' where the neck wants to be as you sleep, and morning problems might be lessened. Effective simplicity. Listen to the neck.
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Old 02-06-2013, 07:16 AM   #14
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I've rewritten this so many times and I think I am close to giving this to patients as a handout regarding pain. Its essentially common stories / metaphors that I share with patients. I typically mention peripheral and central sensitization during the initial evaluation. Then the rest is all up to the patient as when to discuss it.

I often find that I need a way to document what I discussed with patients. I can keep a copy of this handout in the chart to indicated pain education shared during treatment. This way I don't have to repeat things excessively, especially to those who are not ready to accept it.

If you like it, feel free to use it. You can call it the "Rex Fujiwara Pain Handout for Pain" if your patient likes movies like Dodge ball with Ben Stiller... hehe

If you don't like it, please give me feedback to improve it. There are a couple of kinks regarding fluidity with reading...but I can't seem to fix it.

Rex

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Old 02-06-2013, 01:36 PM   #15
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Hi Rex, that is a great effort.
I tend to think that providing a bit about how the pain of an injury or tissue occurs - example: Moseley's snake bite story - is important. I would bring in the brain very early on in the explanation. I tend to use visual analogies (visual illusions) as examples of how the brain brings us our perceptions, not just our senses.
Proving examples of the "learning" aspect of the nervous system WRT threat detection and response is part of that.

I usually ask them if they can come up with similar stories and examples - it often gives them that "oh, that's how that works!" moment.

So, I am not a hand-out giving person in general - although there are some people I have provide with the Diane-alphabet hand-out. (Somewhere on SS under the ABCDEFGHIJ handout tag).
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Old 02-06-2013, 02:35 PM   #16
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With a few modifications and additions I tell this story while I'm working.

This actually happened to me; at least, some of it - so I can tell it with ease.
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Old 02-06-2013, 07:00 PM   #17
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Bas


ahhhh... good point about the visual analogies.

Regarding bringing up the brain early in the rehab process. I used to go over it with a picture of the nervous system. I've been less successful with patient compliance and understanding. I have a lot of Spanish and Vietnamese speaking patients and use a translator using a dual headset on a telephone. Regardless of how clear I try to point out that pain is a neurological process, not just a psychological process, many of these patients tell the schedulers something like "Rex thinks the pain is all in my head" and are upset that I am not appreciating the tissue component. This is definitely a work in progress, I need to find a cultural connection....

I definitely need to add a perception component similar to Barrett's example. Time for some more changes. But I definitely want to keep it at one page.

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