This topic contains 4 replies, has 2 voices, and was last updated by 
Carl Nottoli, DC June 7, 2018 at 7:44 am.
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Brandon Cohen DC, CSCS
Any best practices on communication with patient’s who have a strong psychosocial component to their pain who don’t/won’t recognize it?
I have one who has been very challenging. History and exam point strongly to psychosocial. Other commentary strongly indicate it. She is older, so the ROF was full of soft language as she has adhesion and degeneration, but not enough to explain fully what’s going on. Palliative/provocative is all wrong as well.
I have asked a lot of questions about the origin of pain, life situtations of when it began, but she cannot connect any of the dots for me. I’ve asked these questions and probably some others.
What was going on in your life 10 years ago when this started?
Have you had any life changes when this whole thing started?
You mentioned that you moved 12 years ago, how was that process? Leaving friends for years can be difficult.
How are your current stress levels?
What do you do for yourself? What do you do daily/weekly that makes you happy?
We have made some reasonable improvement on her adhesion, but her chief complaint symptoms have continued to be variable. Thanks, y’all.
Christopher Stepien
As someone with significant social issues (LOL), I have thoughts.
The first part is that the more present, compassionate, and non-judgemental you are when she’s seeing you, the more likely she is to share “what’s really” bothering her.
It takes more time, but asking open-ended caring questions when you notice anything subtly emotion, like “Tell me, X, what’s really going on?” While staring at them in the eyes and not budging (even for minutes) is a surprisingly powerful tactic to get people to open up.
While way outside of our scope, I will ask people about their parental relationships or traumas. I’m often surprised by how many are never asked deep questions and how the simple release of answering that deep question allows people to acknowledge, consciously, their own emotional baggage.
I have more thoughts, but I’ll stop here. <3
Adam Holen D.C.
Have you heard of pain science? They’re pretty big into phrasing #wordsmatter. She prob just needs to PR on deadlift, squat, and bench.
But on a serious note, I’d probably just refer out if things aren’t adding up. If it’s in her head, it doesn’t add up, and results are variable I’d save face and get her to a professional (non-pain pseudoscience). How exactly to go about that is a conversation I have yet to have on coaching, so don’t have much to offer there.
Brandon Cohen DC, CSCS
Thanks for the feedback. My main concern is that I don’t believe she recognizes that there is something else going on besides her pain. We are nearing the end of treatment for what I can help with, and want to get her to the right place effectively.
Carl Nottoli, DC
Voice those concerns directly. You have treated all relevant MSK problems that are fixable and if there’s not any other MSK structural pathology present it’s not MSK.
This highly suggests psychosocial overlay or other non-MSK pathology. Make sure you lay out the facts simply and with the concerns you have mentioned. This patient doesn’t need further conservative care. Ask them to contact you when they’ve made the appointment with another provider so you can stay up to date with their progress.
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