Lorimer Moseley: How to Explain Pain

Pain researcher Lorimer Moseley covers two very important factors to consider as you communicate with your patients about their pain: information and empathy.

Yes, it’s a great question and we could spend a week on it—how to help patients under­stand pain. Maybe the caveat I would put in before I touch on that is that I started doing this when I first graduated as a physiotherapist. It was not intentionally, but noticing I could achieve more by explaining to people what’s wrong with them.

Most of that manifests by me explaining an ankle fracture, an ankle sprain or an anterior cruciate ligament reconstruction in a way that just hasn’t been explained to them before. It was remarkable how many people who had been to an anterior cruciate ligament reconstruction information session and still had no idea what actually happened. We tend to underestimate what our patients can understand. We have research to prove we do, actually.

The caveat, then, is I’ve practiced this a lot. I was really crap at it, and I’ve slowly gotten better; that’s why I want to remind you. Physical therapists, remember when you first felt a cervical spine? Do you remember that?

The patient lay in front of you and the clinical tutor had told you how to do it. This body is lying down and you’re feeling around and thinking to yourself, “Great, you’re the only person without a vertebra.”

You can’t feel anything. It’s been like that with explaining pain, but you start to develop strategies that work for you.

The things I rely on are engaging the patient, developing a relationship and a re­lationship that is trusting. I think it very much helps that I’m a physical therapist, as I’m meant to know about the body. It also probably helps that I’m a doctor. I’m not a medical doctor, but I’m called “Doctor.”

People will be referred to me as Profes­sor Moseley. In Australia, professor is more posh than doctor. I don’t know if that’s the same here. Patients come half expecting to get better because they’re seeing this guy who’s hard to get in to see. Those sorts of things really help, and you can play on that. I don’t think it’s a bad thing to play on that.

With engagement, for me, I tell stories and I try to slip information under the radar. But I think the most powerful mechanism I employ is almost a mindset mechanism: I no longer feel responsible for them getting better.

It makes it far more comfortable to say, “This is the fact, so I’ll tell you the facts.”

They’re guiding it to some extent, because they tell me what they want me to know. I no longer shirk at telling them something that’s true because I think it will offend them.

“It’s your call. Come back and see me if you want. I don’t care. I have lots of patients.”

I don’t really say that.

The other part of the mindset I can probably show better visually. This is hard for me to describe, but I feel like this is an important mechanism in the way I go about explaining pain.

During the whole time, I don’t feel like I’m across from the patient. I feel like I’m always standing next to the patient, as if trying to say, “We’re in this together, aren’t we?”

Does that make sense? Does that visual metaphor make sense? I feel like the whole time I want to remind the patient, “I believe you. We’re in it. I know this is horrible.”

Lock in with them. I don’t know if that really hits any chords.

I’m wondering if you might be dissatisfied with that answer, but there are particular strategies we use that might vary according to who’s using them.

I hope no one hears me saying it’s easy to give a different explanation of pain than what the patient heard from another medical professional. I completely understand and empathize with the problem of telling an apparently different story than someone who’s perceived to be more important and more powerful.

It’s hard when you get patients on board. Fantastic, they’re with you. They understand pain is complex and there are multiple inputs. They go to see the next clinician who might have a different qualification, who says, “I saw someone like this the other day. We’ll operate on that. We’ll take it out,” and then you’ve lost them.

That’s a problem and it’s difficult. This is a problem for physical therapists, which I presume most of you are. I think it’s a bigger problem here in the US than it is in Australia and in some parts of Europe. I don’t know the best way around this, except we have to spread the word.

It’s not only the physical therapists who are learning this information. There are doctors learning as well. You’ll all be encountering them now, who talk sensibly and who appreciate the multi-factorial nature of things.

But here you also have a system of fee-for-service arrangements, so the more you treat, the richer you get.

That seems a bit odd to me, but it means the barriers are really substantial. I don’t want to downplay that. We could do two days of an “explaining pain” course where we all go and share our strengths and weaknesses.

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