Heather has persistent left shoulder pain that arose for no reason. At first, it was there only when she lifted her arm overhead. Over a number of months, it slowly worsened even though she did her best to follow guidance from her doctor to stay active and try different anti-inflammatories and pain medications. When she started to lose more movement and the pain flared up even more, she saw a physio. The pain was always better after physio, and she improved a little, but her insurance coverage didn’t support her continuing. A few months later, the pain became constant, and a year later it is disrupting her sleep, making it hard to focus at work and zapping her usually positive outlook on the world and life.
You and Heather make a pain care plan that includes the Pain Care Aware movement guidelines. She is pleased to try this because it is so different from her usual approach of ignoring her body and mind as best as she can when there is pain or anything uncomfortable. She is also excited to try something that we learned from people in pain rather than a ‘scientific’ fix.
When Heather comes back to see you the third time, she shows you that she is following your advice well, and then says, “Even these small movements you are telling me to do are making me worse.”
You check in to make certain that she understands the key concepts needed to gain success with the movement guidelines when working with someone whose protective mechanisms are easily amplified by movement. You recognise that she has the right knowledge and she has the right approach, but this approach is not working. Not only that, Heather is losing confidence in her ability to have any influence over movement or pain, and her hope is waning.
How might you respond?
Is it possible that motion is not lotion in this situation, or that movement isn’t always part of the solution?
Let’s consider this experience as common in people with persisting pain. There are times when the individual’s protective mechanisms are so dialed up that even the most gentle movement performed while keeping breath, body, and mind calm can intensify the pain. The answer for her might be to gain more skill in calming down these protective mechanisms before working on increasing activity. It might be to use imagined movements, graded motor imagery, or for Heather to first spend time every day watching others move their shoulder with ease, before she tries imagined movements or gentle exercises.
The nuances here include that recovering ease of movement might require individuals to gain skill in self-regulation first or concurrently with changing the activity plan; and that we can decrease protective mechanism activity by limiting movement intensity, frequency, and resistance but also by practising imagined movement before we physically move the body. Just as Olympic athletes rehearse their sport in their minds when they are injured so that they have a quicker return to sport, we can include different forms of visualization and imagery as part of normal pain care practices.
Clients can learn different visualization or kinesthetic imagery strategies, combining them, or even grading their nervous system sensory-motor activity in order to regain ease of movement, change protective mechanisms, and change the pain itself.
When we can show Heather that there is another way to recover movement, this can provide realistic hope. Her experience of being able to influence pain and pain-related disability are important factors in a pain care aware plan.
In other words, we can use the mind to change the body, just as we can use the body to change the mind. Both science and lived experiences provide guidance in how to help when our usual approaches are not moving our clients toward their goals.
How will you interact with the next client who tells you or shows you that “Even these small movements are making me worse.”