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Un-Noceboing a friend or trainee

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  • Un-Noceboing a friend or trainee

    How do you go about un-noceboing someone? I have a friend who was told by her chiropractor that she can’t squat or deadlift with a barbell because her pelvis is tilted and her hips are out of alignment. She also mentioned that she’s in pain “85% of the time, even when she’s just sitting down.” I also had a personal training client over the summer who complained about all kinds of little aches and pains throughout our time together. She would complain about her hips when we squatted, her back when we deadlifted, her shoulders when we pressed, etc. It seemed like there was always something. She had no self efficacy and would go to the chiropractor weekly to “fix” her pain. This kind of stuff makes me so mad, because these people let their pain define them and don’t believe they have the capacity to change it on their own. My question is, how do you go about helping people who have been lead down this path of being told that they are in pain because they are out of alignment or that they can’t do something because it will make their pain worse?

    Thank you in advance for your response.

  • #2

    This is a very complex topic and one dealt with daily in clinics everywhere. Living and practicing near the creation of chiropractic (yes it was created by a snake oil salesman in Davenport, Iowa) its a daily challenge. See below:

    Samuel Homola is a retired chiropractor who has been expressing his views about the benefits of appropriate use of spinal manipulation (as opposed to use of such treatment based on chiropractic subluxation theory) since publication of his book Bonesetting, Chiropractic, and Cultism in 1963. He retired from private practice in 1998. His 15 published books include Inside Chiropractic, published by Prometheus Books in 1999.

    “A lot of the things that we have to spend time dispelling in our practice are myths that patients come in with” Chiropractor, Dr. Shawn Thistle [B.Kin (Hons...

    There are a couple options:
    1. Avoid the issue:

    It doesn't sound as if your friend and client have asked for YOUR help. They are placing their trust in someone else. Its unfortunate and sad to stand by watching people seek out mis-informed dogma. This scenario has a few outcomes.

    Outcome 1: They improve and feel better. Not because of the "treatment" but more likely from regression to the mean and the normal outcome for musculoskeletal pain is improvement.
    Outcome 2: They hit rock bottom or hopefully they recognize this is not working. Outcome 2 provides an opening (potentially) to slowly provide information or recommendations to seek care from a more informed and up to date healthcare providers.

    2. Address the issue:

    Tread lightly, slowly, compassionately, empathetically.... Provide breadcrumbs of information. Information that refutes dogma and pseudoscience. Here are some options:

    "have you seen this video?"

    This is a great, easy to follow video about chronic pain. It helps you understand what current research has been saying about chronic pain - thats its not a ...

    "Did you see this video on low back pain?"

    Check out our new website, Dr. Mike for new videos! Dr. Mike Evans is founder of the Hea...

    "It sounds like all the core stability stuff isn't what we once thought"

    Peter discusses cognitive functional therapy and the myth of "core stability" in relation to chronic low back pain.Listen to Professor O'Sullivan discuss thi...

    "Did you see this video about x-rays and MRI's???"

    Concerned about your medical imaging findings? Studies show that abnormal findings, such as on x-rays, MRIs, and ultrasound scans may actually be normal in t...

    Remember this is a complex topic. Health care seeking behavior is also something to keep in mind
    Background The global burden of low back pain is growing rapidly, accompanied by increasing rates of associated healthcare utilization. Health seeking behavior (HSB) has been suggested as a mediator of healthcare utilization. The aims of this study were to: 1) develop a proxy HSB measure based on healthcare consumption patterns prior to initial consultation for spinal pain, and 2) examine associations between the proxy HSB measure and future healthcare utilization in a population of patients with spine disorders. Methods A cohort of 1,691 patients seeking care for spinal pain at a single military hospital were included. Cluster analyses were performed for the identification of a proxy HSB measure. Logistic regression was used to identify the predictive capacity of HSB on eight different general and spine-related high healthcare utilization (upper 25%) outcomes variables. Results The strongest proxy measure of HSB was prior primary care provider visits. In unadjusted models, HSB predicted healthcare utilization across all eight general and spine-related outcome variables. After adjusting for covariates, HSB still predicted general and spine-related healthcare utilization for most variables including total medical visits (OR = 2.48, 95%CI 1.09,3.11), total medical costs (OR = 2.72, 95%CI 2.16,3.41), and low back pain-specific costs (OR = 1.31, 95%CI 1.00,1.70). Conclusion Health seeking behavior prior to initial consultation for spine pain was related to healthcare utilization after consultation for spine pain. HSB may be an important variable to consider when developing an individualized care plan and considering the prognosis of a patient.

    Good luck and all the best!


    • #3
      Unfortunately, if there were a simple answer to this our jobs would be much easier. There is a reductionist phrase thrown around in rehabilitation (I use it myself) that the two proven things to get someone better are education an exercise. When someone has been told a lot of nonsense sense related to the second of those two, we are essentially left with the first. In some aspects this makes it easier as we only have one variable to work with, in others it becomes a sales job of how to initiate exercise.

      The easiest answer when it comes to reducing the nocebo of exercise is to start framing it around "movements" instead of "exercises." I've joked for a long time that if I told my mother she needs to exercise it would fall on deaf ears, but making her understand the need to continue to be able to get up the stairs, in and out of the house is another issue. It sounds like you have a personal training back ground which can work against you in these situations as it is "easy" for you to see what to do, but for her it can be damn near impossible. Especially when she's been told it is impossible by another practitioner. THAT ONE TRICK (sorry, I couldn't help myself) that I often begin with is a discussion around increasing "x." I.e. if you can sit for 30 minutes without pain and we get to 45 that is a win, if it hurts 85% of the time when you are sitting down, if we get that to 50% that is big progress. I'm clear that when symptoms come on, often they can be the same intensity, but if we can decrease the frequency of episodes that is progress. The operative word in both instances is framing the situation through progression instead of regression.

      If we can get a patient/client to start chalking up some wins, we can start gaining their trust. Right now she has been told (and it sounds like trusts) a practitioner who told her she could not and should not accomplish any worthwhile goals. I would start by asking her what both her short and long term goals actually are then discuss ways in which you could possibly work together to achieve those goals. It is easy to see people in cases such as this as "these people," but if you want to change minds you have to move it to "we people." If all people had the capacity to change on their own we would be out of jobs. Our goal is to guide the path, not push the cart for them. To this example though, your friend thinks the cart is loaded to the brim (because of the bullshit stacked in it from this practitioner), your first job in getting rid of the nocebo is just showing them the cart can be moved.


      • #4
        Originally posted by Derek Miles
        To this example though, your friend thinks the cart is loaded to the brim (because of the bullshit stacked in it from this practitioner), your first job in getting rid of the nocebo is just showing them the cart can be moved.
        On that theme, here's an old Zen story: A university professor went to visit a famous Zen master. While the master quietly served tea, the professor talked about Zen. The master poured the visitor's cup to the brim, and then kept pouring. The professor watched the overflowing cup until he could no longer restrain himself. "It's full! No more will go in!" the professor blurted. "This is you," the master replied, "How can I show you Zen unless you first empty your cup."