Low Tolerance!

We all have different tolerances to different things such as food, exercise, or how long we can put up with some people. Personally I have a very low tolerance for avocados, therapists who think they can release fascia, or those who take offence at everything they read on social media.

Our levels of tolerance both physical and psychological are due to many things such as our genetics, exposures, experiences, and even our education. Some people can tolerate exercise more than others simply because they do more of it, some people can tolerate mental stress more than others due to previous experiences with it, and some can tolerate other people better simple because they have been taught to.

However, it is clear that more of the human population are becoming more intolerant of more things such as race, gender, political views or differences in opinions! And many are also becoming more and more intolerant of any effort, exertion, difficulty or discomfort in their lives.

Our World Today

Most of us living in the modern developed world have a life of incredible convenience and comfort. A world where we have ample access to food, water, shelter, and wifi. A world where you have technology and gadgets to make your life easier and effortless. A world where you can buy a device to put your socks on in the morning, a duvet that makes your bed, or a machine that opens your jars. We don’t even have to go to the supermarket anymore to lift jars off shelves and carry them in a basket with home delivery and even unpacking services on demand.

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We are now living in a world where effort and exertion have mostly been removed, where any struggle or strain is considered unnecessary and often avoided. Don’t get me wrong, this modern-day lack of difficulty does has some amazing positives, I for one am not complaining about WiFi, my central heating, or my online grocery delivery service. But its the sheer amount and volume of convenience we have in our lives today that has its drawbacks.

One of these drawbacks I think is that we have lost sight of what is actually difficult, hard, or inconvenient. What we now consider challenging these days simply is not. Losing your wifi signal, missing a meal, or having to walk up the stairs because the elevator isn’t working are not really issues, yet our lifestyles and lack of exposure to them often make them feel so when we encounter them.

Pain Today

This I believe is no different with our experiences of pain or injury. Having a sore knee, an irritated shoulder, some low back pain, or a twisted ankle are not serious medical issues that need assessment, treatment or even to be worried about. Yet they often are by many, many people, for various reasons, the main one being again our modern convenient lifestyles and ease of access to healthcare! 

Most of our grandparents would not or could not see a doctor or therapist for such things, instead, they would have accepted that things hurt from time to time and they tend to ease on their own if they just ignore them and carry on. Unfortunately many have lost this stoical attitude, belief and trust in their bodies and its ability to look after itself and so seek assessment advice and treatment for things too often and too soon!

If we were to look back just a couple of generations we would see that many people would NOT seek medical attention for simple back, knee or shoulder pain. Of course this was for many due to less access, but I also think it was due to a difference in culture and attitude towards pain as well.

I often ask myself when I have a pain or an ache, what would my great grandad do… and most of the time it would be… ignore it and crack on!

But many now think that ALL pain and discomfort should be checked and treated immediately, and I think ALL of healthcare needs to do a better job changing this. I think a lot of things that hurt dont need assessment or treatment and instead need to be tolerated for a period of time until they improve on their own.

After 20+ years of working in healthcare I truly believe that trying to reduce and remove many pains too soon, too quickly, and too unnecessarily we are contributing to our population and society in becoming less and less tolerant and resilient to normal experiences of pain and discomfort.

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Now don’t get me wrong, I don’t think anyone in pain has to be happy about it! Pain is unpleasant, frustrating, and, well… just a pain in the arse! And I do understand that many in pain maybe confused and uncertain about why they have it, and if and when its going to go away, and so seeking some advice is perfectly natural. It just that many don’t need that pain to be removed or reduced with medications, massages, or any other treatments.

Instead healthcare professionals should be doing a better job at advising and reassuring those in pain carefully and compassionately that their pain is normal, safe and can be, and should be worked with rather than got rid of! However, this is not easy to do, and its not well rewarded or incentivised for many healthcare professionals to do, and so its often not done. Instead treatments that temporarily reduce or remove the pain are often recommended often unnecessarily!

A pain free life?

If you want your body to give you less pain in life, you simply cant abuse the crap out of and expect it to be happy. Unfortunately many people now think being healthy is easier in this easy modern convenient life we have. It’s not. Just the opposite in fact!

To be healthy these days there is still the same genetic lottery to get through first to avoid any disease or disability. But if you have got through this with good fortune then congratulations, but now the hard work begins.

To put this as clearly and simply as I can good health has to be earned with some hard work, self-control, and self discipline, and the inconvenient truth is that many painful conditions today are often consequences of our convenient lifestyles.

However, regardless, of why things hurt from time to time the key point I want to make is that often nothing needs to be ‘done’ for many episodes of pain other than reassuring the individual it’s not serious, it will ease with time, and they will not damage themselves if they feel some pain on movement and they should try to carry on as normally as possible.

Unfortunately, many healthcare professionals just don’t feel comfortable or able to tell people in pain this for either financial or egotistical reasons. Personally, I think many musculoskeletal conditions are over-treated with healthcare professionals pandering to patients while natural history makes them look good.

Frustrated

Please don’t think this is just me being a mean, grumpy uncaring old man, this is just me trying to be as open and honest as I can be after decades of trying to help people in pain. But my biggest frustration with this situation are the healthcare systems that are screwing things up royally.

There is no doubt that our modern healthcare services have improved hugely and helped humanity hugely by reducing disease and pathology and increasing survival rates and lifespans in many. But our healthcare systems have also inadvertently caused harm and detriment to many by making many in pain feel broken, fragile, less resilient and less tolerant to pain due to its over assessment and over treatment.

If you want some proof of these harms just go look at the BMJ global burden of disease studies where you will see how low back pain now consistently causes more disability and costs society far more than any other medical condition across the world, despite many so called advances in its assessment and treatment. Modern healthcare is just not helping people with many musculoskeletal pains or problems, in fact its making them worse!

In summary what healthcare is currently doing for musculoskeletal pain just isn’t working and something needs to change. Personally, I think this should start with more healthcare professionals recognising that they over assess and over treat it. And also more of us recognising and accepting that pain sucks but it is inevitable, but suffering is optional.

As always thanks for reading

Adam

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  1. “Personally, I think this needs to start with more healthcare professionals recognising that they over treat pain and many patients recognising that pain is inevitable, suffering is optional.” Adam, I think many people experiencing pain would not agree with you that their suffering is an “option”.

    • Hi John, sorry but I have to disagree, as someone who has experienced pain many many times for both short and long durations I can confidently say that mindset determines if you decide to suffer with it or not… Cheers Adam

      • Love this post, but I wonder if mindset isn’t the correct way to think about it because it implies it can be something so easy to change. I love the more philosophical side of things, because it ultimately informs how we think and thus approach health care. But if someone not only sees the world, but has shaped their entire life, meaning and defined their happiness based on a certain philosophy that doesn’t promote change or consideration of other viewpoints, their ‘mindset’ could be difficult to change.

        I see a lot of crossover with how we view happiness. Vox has a great article with researcher Carl Cederstrom that details the shift in philosophy, that I think correlates well with ultimately this change in ‘mindset’. That now we define our happiness as an individualistic pursuit based upon self actualization and improvement, which ends in ultimately, happiness as a right, not a privilege. Therefore, if happiness is seen a right, it can be easy to see how people define pain, an unpleasant sensation that can also limit our capabilities and ultimately what drives our sense of self and happiness, as a negative entity and ultimately exactly what you see and written about here Adam.

        https://www.vox.com/science-and-health/2018/9/4/17759590/happiness-fantasy-capitalism-culture-carl-cederstrom

        The addition to this is now we have technology that also drives us to skim read which ultimately affects our ability to read, comprehend and process new information and thus respond well when presented with new information, we’ve created the perfect storm.

        https://www.theguardian.com/commentisfree/2018/aug/25/skim-reading-new-normal-maryanne-wolf

      • Totally agree Adam I run a functional restoration program for people who are living with chronic pain for which physiotherapy has not helped. Just yesterday I had a patient tell me that although his pain remained at the same level he felt 90% improvement following treatment.

        The course is very much about education. We discuss pain mechanisms, body repair processes, pacing, lifestyle changes, psychological perception of pain, exercise benefits etc. Along with the education we run a gym session in the afternoon for good honest hard work and exercise.

        Now going back to this gentleman he has a very heavy manual job that he is now completing without issue. His words to me were that his pain was now a “background issue” it was still there but it didn’t bother him because he chose to focus on improvements such has improved flexibility, improved strength and endurance and a generally healthier lifestyle.

        Through reassurance, education and exercise this patient improved his quality of life and reduced his suffering without his pain changing at all.

        Now the likelihood is within 6 months of implementation of this way of thinking and living the patient will be pain free. Contrast this with a patient who is coddled and overdiagnosed that develops an external locus of control and makes no meaningful changes to their life. Now that is the type of patient that will report years of pain with no improvement despite receiving a lot of ‘treatment”.

    • Suffering is definitely optional. That’s the difference between the paraplegic who find gainful employment and continues on with their life and the “fibromyalgia” patient who goes on permanent disability/welfare and jumps from one health care provider to another trying to find the “miracle cure”.

      Same with at fault drivers vs. not at fault drivers when it comes to MVA’s. Majority of “chronic whiplash” patients are not at fault drivers while the at fault drivers just carry on with their lives.

      . Sullivan MJ, Adams H, Martel MO, Scott W, Wideman T. Catastrophizing and
      perceived injustice: risk factors for the transition to chronicity after whiplash injury.
      Spine (Phila Pa 1976). 2011 Dec 1;36(25 Suppl):S244-9

    • I am going to chime in here because this is an important opportunity for developing a sense of awareness that seems nearly absent in the formal orthodoxy promoted by PT. Adam, you are certainly entitled to your opinion, afterall this is your blog. On the issue of “suffering” and what constitutes this subjective experience, it is the same argument I hear when “pain” is substituted. The abysmal appreciation by biomechanists (most PTs) of psychological foundations of Self, personality, beliefs, and mental illness etc., prevents a more effective application of therapies. Just because you claim that you have experience in pain does not generalize beyond your shores; it is irrelevant to what suffering feels like for others in pain, whether physical or psychological. Few clinical psychologists would agree that one should just think positive thoughts and that would dispel the suffering of depression, for example. Its not about you. Its about the person suffering.

      • I can’t speak for Adam, but I don’t think he was saying to just gloss over suffering with positive messages. I read it as a call to society to reframe our way of thinking about “suffering” and pain. If I am in pain for whatever the reason, I can do 1 of 2 things. I can suffer because of it, or I can thrive despite it. The pain/discomfort/anxiety/etc might still be there, but the mindset is different and the latter keeps me moving forward. By moving forward, I may be able to eventually move past it. If I just allow myself to suffer, I may never get past it. This is NOT easy to do, but as therapists I think we can absolutely help people in educating them about what pain is, factors that can affect it, and how movement and mindset can help keep them moving forward.

    • Einstein – I fear the day technology will surpass our human interaction. The world will have a generation of idiots!

      Too much crap information easily available and too much good information stifled. Keep spreading the good word sir.

  2. Completely agree. As a physio working in australia i find the biggest barrier to this is financial. Musc physio in australia is almost completely in the private sector and i cant find a boss who wants to pay me to effectively educate and reassure people they arent broken. Very frustrating as this is what is needed with a majority of patients i see

    • Unfortunately most practices seem to primarily focus on retention rates with no intention on tracking patient outcomes

  3. Hi Adam,

    Thanks for continuing to promote your practical and common sense approach to pain management which empowers our patients and improves short and long term outcomes and which for those of us who use it is a no-brain option ! However, as common sense sometimes may not always be that common is still very noticeable how many physios (independent of age or experience) struggle with trusting exercise based rehab and still feel the need to over assess/treat or deliver manual techniques in order I think to feel like they have “fixed” the patient. Could it be insecurity on their part ? Or maybe the training pathway embeds in them the biomedical approach ? On a positive note I also believe that with the persistence of physios who use the active approach to rehab instead of passive alternatives that as we empower and educate our patients they may well become the channel through which the message flows to the wider population.

    Finally, keep up your great work as I think it is making a huge difference to our profession.

    Philip Phelan Physiotherapist Dublin

    Sent from my iPhone

    >

  4. Technology has given us everything we could ever want and at the same time it has stolen everything we ever needed

  5. “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

    Upton Sinclair

    Until the healthcare profession is not reimbursed for treating/overtreating nothing will change. I firmly believe if there were a billable code for an exorcism we would have continuing education , certifications, and in clinic seance’s.

  6. Thanks Adam, a good read. The world has gone totally insane. It’s all about the money, a fraction of the care is about efficacy, it is a complex interwoven hairy problem. Just off to my seance, Jane

  7. “Many think living pain-free is an automatic right. It’s not. It’s a privilege that has to be earned with hard work, self-control, and some discipline. If you want your body to look after you, you need to look after it. ”

    PREACH!!! ?? SO. VERY. TRUE.
    Self care, self care. ?

  8. I agree that we frequently overtreat pain. A motivated patient will generally get better regardless of what the physician does.

    “Medicine is the art of entertaining the patient while nature cures the disease.” -Voltaire

  9. Adam, your original post, and the comments of those who agree with you, support my view that health care professionals are inadvertently contributing to the stigma borne by those who experience persistent pain without discernible ongoing nociception.

    • I am unsure as to how or why you think my views here are contributing to the stigma of those in pain? I recognise only to well that many people in pain are treated terribly by both the modern health care system and many of those that work in it, I see it day in day out and its getting worse. I am actually trying to help change this by highlighting how society, media, technology, education is adding to the problem not helping it. I feel you have misinterpreted my point John.

      • Adam, have you considered that chronic pain sufferers may already be feeling inadequate because they cannot measure up to their own and/or their societies’ expectations? Feelings of shame, isolation and self-loathing can be their lot in life. I cannot agree with you that such suffering is “optional”.

      • Yes John, I have and I see it in people daily. However, my job is to turn that around and try and help them see how they can continue to function with pain, how pain shouldn’t define them or stop them doing want they want to do, and how suffering it is a choice.

      • John, unless pain is being inflicted under torture then everyone who has pain has a choice about choosing to suffer with it or cope with it. But this again is getting way of topic of what the blog was trying to discuss which is in my opinion our species is becoming less tolerant to pain… not about specific cases or individuals!

      • Adam, I have no way of assessing the truth of your opinion that “our species is becoming less tolerant to pain.” However, could it be that physical therapists (together with physicians) are becoming increasingly frustrated by their inability to relieve the pain of their patients? This would induce them to take on board the argument that you have presented, thereby shifting the blame away from themselves.

      • That’s a good point I hadn’t considered… I will do now! However I don’t treat Pain, I treat people! And I’m my opinion many people are becoming less tolerant and suffer to easily! But I do accept I am also perhaps becoming less tolerant too! Thanks for making me think a little harder! I need to go and have a lie down now!

  10. Good post and ideas.
    The point is if natural history could heal the problem so what is our rule? And in some patients they have some rest before PHysio why nat history did not do anything for them?
    And the last point is when a patient could releive by a thing immediatelly why we do not apply that? Why tell him ” you will be good in 4 weeks “.
    We have to believe and accept that ” peoole needs quick probl3m solving approch now but we have to learn them it is not always true for all MSK problems

  11. Great article again! I had this experience just the other day, as a sports massage therapist who is training as a physio and has been lucky enough to train under some brilliant physios (and some less so) I really support the need to give patients the right information to help them live life with or maybe without pain and for them to understand that their pain isn’t necessarily an injury. Now in my line of work I see many people who as a physio student I believe need strength work and a small can of man up but unfortunately until I am qualified it’s the massage life for me and that’s what they’ve come to me for. I do however offer them information about the true nature of pain and the likelihood of their problem self resolving where appropriate but I am constantly shocked by how many people just don’t want to hear it and want to come back for another massage (even when I’m basically telling them not to… Bank account doesn’t look great as a result!) I sometimes wonder if people seek validation from a health care professional in that their pain is justified and that they need a plaster and a lollipop but they’ll soldier on and low an behold it’s all better in a months time. Sorry for the rant but my question is.. When you’ve given them all the tools and information that will help them, how do you get them to buy into that?! It’s the bit that involves them putting in some effort on their own but in the long run saves them money and keeps them living their life working to a pain reduced/painless life but it seems as if they think that is as likely as seeing a purple unicorn dancing dancing with a lepricorn! How do you get them in board?!

  12. Thanks for yet another great post!

    We work hard on exactly this problem with pain management at a specialized hospital for neck- and back-related pain and disability (both specific and non- specific), and we see a lot of people with non-specific pain, that cant handle their own situation. We try to use for example CFT in our work, but sadly the health care system makes it hard to get to the bottom with peoples problems, before they are sent back out of the hospital.

    People need to be teached in understanding pain and pain management, instead of just going to the doctor and get drugs an MRI/CT scans for no reason.