Introduction to Jason’s Pain Handouts

In my opinion, patient handouts and education are an important part of our rehabilitation process.
My approach to patient education and handouts has evolved over time, and I hope yours will as well.
After all, we should be changing our approaches and reasoning with new evidence. Dr. Adriaan Louw
was quoted in a physical therapy conference as saying “Why do people come see us in pain, and leave
as experts in biomechanics?” Why indeed, since when the evidence shifts, our explanations should as
well. We should be moving away from connective tissue structural explanations and towards more
neurophysiological concepts of sensitivity for better accuracy. In addition to accuracy, handouts and
education strike a balance between simplifying material for understanding, without leaving out key
elements or misrepresenting the facts. Here are some introductory thoughts for the use of these
handouts.
Education needs to be closely linked to the treatment approach. That is, the education you
provide should naturally support the treatment you are providing. The connection between why patients
hurt and why the therapy is helping needs to be very clear and straightforward. It needs to provide them
an explanation for their symptoms in a way that is scientifically accurate, practically useful both now and
in the future, and reflective of their direct personal experience while under your care. Trying to convince
someone of an alternate way to understand their condition before providing them some kind of progress
or change is rarely useful – you need credibility and you need some evidence for a different model from
the patient’s point of view first. So I save most all my education and explanations for later in the first or
second visit after we have some progress under our belt.
Education needs to be simple and straightforward. We often underestimate our patients’ ability to
understand things, so we shouldn’t shy away from explaining, but we need to ensure our education
serves the patient’s needs and not our own. It’s not an opportunity to show how smart or educated we
are, it’s an opportunity to set the patient up for success both now and for any similar future troubles they
might have. To achieve this, simple and direct approaches are better than complicated and detailed ones.
Balancing this simplicity is a desire to not cut so much detail away that we mislead either ourselves or our
patients. We need to be aware of a few levels of detail we can get into for each key concept and tailor
that to the patient’s needs, prior knowledge, and interest.

The ‘Understanding Mechanical Pain’ handout is probably the most popular of the group, and I
expanded it into two parts. Please take the time to read Louis Gifford’s critique of the concept of
mechanical diagnosis and mechanical pain, “Centralisation, Part 1: Mechanical pain, mechanical
diagnosis and the Wrasse bite” also. It’s important to understand the strongest possible version of a
critique of our ideas – and Mr Gifford surely provided us much to think about that should give us pause in
using the term ‘mechanical pain’ too freely. The best audience for this is a patient with a significant
component of nociceptive pain - those with a presentation suggesting that central sensitization is primary
may not connect with many of the explanations here.
The ‘Watering the Grass’ handout helps patients understand the concept of dosage of exercise
and the time it takes for physiologic change to manifest. Over time I have moved away from sets and
repetitions and rigid rules about exercise therapy and moved toward time based goals and a good self-
assessment process for patients to help them do enough therapy to get better. Teaching patients that
sensations of stiffness, difficulty in moving and muscular tightness are signals from the body can connect
it closely to familiar feelings of increased hunger and thirst and provide a window into self-assessment
and management that puts the locus of control squarely with the patient and not the practitioner.
In “The Three Stages of Recovery from Pain” I attempt to help people see their pain and
protective responses as a normal part of their body’s response that they can put in context of other
problems they have had and as a necessary step toward resolving their pain. These stages help people
see that their protective responses as not only normal, but carrying important information about their
body’s response to threat.

I hope you will find these pain handouts well balanced and supportive of your clinical
management of patients.

by Jason Silvernail DPT, DSc