Education in rehab - WTF does it mean.....?

Education, education, education. How often do you hear this term in relation to modern MSK practice?

Sorry, I got that wrong. Education & exercise, Education & exercise, Education & exercise : )

All the bloody time is the simple answer!

But education, just like exercise, suffers from the issue that we talk about it in very general terms but have little in the way of actual frameworks for application. Every guideline going seems to point towards these as core treatments but often without any real direction. I can see why therapists fall back on more traditional perspectives faced with uncertainty.

So education about what? When? How? To who? The usual questions come out when we unpick it a bit. Education has been hijacked by PAIN education over the last few years but in reality its formed a backbone of MSK practice…..well forever. Education is something I talk about in class A LOT, but I do feel people are like hurry up and get to the REAL treatment Ben, i'm getting bored over here.

Is education seen as PROPER treatment? I am not convinced yet.

People ALWAYS have wanted information

This is nothing new!

How often have you had someone come in and say “My back pain has been going on a little bit longer than usual and I thought I had better have it checked out”. We know back pain, as an example, can last for 2-6 weeks and its perfectly normal for this to happen. But if someone has only ever had the problem before for a few days it’s probably a bit worrying and they want to know what is going on to decrease the worry that can flourish in stressful situations.

People definitely come to see us to get rid of their pain, but they also want to understand their problem, the implications and know how to manage it as well.

Louis Gifford highlighted a few things that is fairly universal amongst people. What is it? How long will it last? What can we do about it? Another question I get asked regularly is “Can I still do….”. People still want to do things but not to make the problem worse but often get scared into reducing activities rather than receive knowledge to sensibly manage them.

Education or knowledge transfer?

We use the term education, but for me that can conjures up images of stern teachers in front of naughty school kids and does not really reflect what we often do with people. Maybe it is really about helping someone make coherent sense of the issue, decreasing the uncertainty and danger around the problem and providing paths forward. This is more of a partnership perspective that incorporates knowledge transfer than traditional didactic models of teaching. So maybe knowledge transfer or sense making is a better term?

What can we ‘educate’ about?

So many things is the simple answer!

What is it?

Probably the most important thing that people want is a diagnosis. If we know what it is we can effectively treat it right? Er…maybe as we know in so many MSK issues that is simply not possible from a structural perspective. In the absence of this we need a positive & coherent narrative around the problem. That could include pain ed but information about pain does not need to dominate.

“Cases of nonspecific musculoskeletal pain where, although the source of the pain is unclear, diagnostic imaging is not indicated, and the pain may not always be completely alleviated with treatment. In such cases, concrete, clear, and consistent information can help the recovery process, even in the absence of a specific diagnosis” Carroll et al 2016

How long will it take?

Prognosis and the factors that influence it can be really helpful with often unclear diagnosis like back, knee or shoulder pain. Setting realistic expectations is important as well. Too high and it can lead to disappointment when they are not reached, too low and the motivation to engage in the process can limit the outcomes.

What can I do about it?

Health and lifestyle, exercise, activity and self management are all areas that we can help people with. Helping people to effectively create management plans is sorely missing IMO. Again perhaps this is not seen as treatment?

What does the person want to know?

For really effective transfer of knowledge maybe taking the time to find out what the person WANTS to know is important. Just throwing out information might lead to important questions remaining unanswered. There are so many questions that people have that we may not have considered or we feel are not important. If they are important to the person they should be important to us!

“What concerns you the most about your problem?”

“Do you have any major concerns you would like to talk to me about?”

“Whats your biggest fear about this?”

"What’s the most important question I can answer for you today?"

Context

It needs to make “biological and biographical sense” as my friend Joletta Belton would say. This was the great failing of pain education IMO, it does not automatically integrate with the person story, it’s like talking to a stranger in a pub when they are telling you about their life story and you are being talked AT without he conversation ever relating to YOU. A friend that just talks about themselves is another example, you just want to get the hell out of there, or . So make sure your knowledge transfer actually fits the person and their story in a way that relates.

Failure

Maybe this is why some of the things we expect to be helpful don’t succeed? Without a knowledge of what to do, why they are doing it and how it is going to help, exercise, as an example, does not relate to the person and their problem?

Lots of my failures (professional ones : ) may have come from not aligning in terms of treatment philosophy with the person I am working with. My vision of what to do does not match theirs and in part that might stem from my inability or failure to ‘educate’ about the what, why’s and how’s.