Transcript

Bart Van Buchem (00:01)
Hello and welcome to a brand new episode of the pain podcast from Le Pub Scientifique. My name is Bart van Buchem. I'm a pain specialist, physiotherapist and co-founder of Le Pub Scientifique and with me, Tim Beames, founder of Le Pub Scientifique and expert in residence. Thank you, Tim. And yeah, we've got a, we found out we've got a nice topic for today's and something that we title as

From frustration to flourishing, helping patients navigate pain setbacks. So we're going to talk about mainly about setbacks, I reckon. ⁓ that's something that happens and occurring all the time. ⁓ and they're inevitable, inevitable in chronic pain recovery journeys in my view. And, ⁓ we try to help patients to reframe these setbacks, not as failures, but as part of the process. So easily said are to be done.

Tim Beames (00:59)
Totally, totally.

Bart Van Buchem (01:00)
⁓

so, so we're going to just briefly on this, ⁓ episode for the next 30 minutes, we were going to talk about things that may reframing the idea of, of, ⁓ a setback, how language is involved, how you can do things actually to taking this as a learning opportunity, ⁓ putting it together for your patients to sort of move on forward again, even after a setback is well,

The thing that, that strikes me that people say, ⁓ I have to start all over again. I'm back to the, to the start or the beginning. And it's the motivation that is basically to zero. And you can, you can understand that, right. But, ⁓ we all know as a clinicians that, that this is part of the journey. ⁓ although it's a tough one, it's a really tough one, but, ⁓ one to crunch. So Tim.

Tim Beames (01:56)
Yeah.

Bart Van Buchem (01:58)
Where we should start? I've got a few questions that came to my mind and maybe there's something to start. So let's start with the idea of the reframing. Like the word setback could be problematic in itself because it sounds so awful negative. Although it is negative in a way. If you're in the situation, I couldn't agree more. But any thoughts on that?

Tim Beames (02:11)
That's a rubbish word.

Yeah.

Yeah, well, look, that's a great place to start, isn't it? Because it's probably in people's minds and but you can't go back for a start, can you? Although you will hear it, I just want to be back to my old self or whatever. So there is that sort of frame of reference. But but you're not going back. We're always we're constantly on this journey, aren't we? ⁓ And but one, yeah, one thing I'm I'm thinking about is

how easily derailed people can be. And that's not blaming anybody. You put and you invest time and effort, cetera, money perhaps into your recovery and you experience these blips, flare ups, whatever you wanna call it. And you can totally understand why someone just goes, whoof, loses heart and

You know, it's really, really challenging. And we talk about being derailed. You know, you're kind of on this path, you're on this journey, then boom, and then it just completely shoves you off that path. And it's not just that you'll have increases in pain, but there's a massive emotional cost to it. People can, and when you're in those moments as well, all those

strategies that you've been developing and then positive mindset that you're growing and what have you. It's inevitably, it is challenged and they are really difficult moments. They are the moments when you, I think most often need skills, some support to be able to help you in those moments. yeah, setbacks, rubbish word. We talk about this in

graded motor imagery, we talk about learning opportunities. And I would say that if we can sort of reframe it more as that, it's a learning opportunity and it's a natural part of a recovery process as well, that you're gonna have these moments.

Bart Van Buchem (04:37)
Is there a relationship between you think succeeding a succeeding in the process of recovery versus whether people do not or do have setbacks?

Tim Beames (04:52)
⁓ Yes, I mean, what are you are we thinking about the research? Are we thinking pragmatically as well?

Bart Van Buchem (04:59)
Well,

there must, there's probably, there is some research on, on, on setbacks. What I've found really interesting is when you see these research articles and trials that have included 200 patients and there is a dropout. It's very normal to have a dropout. So does that means these people had a setback and they weren't able to sort of get back on the, on the real?

Or is it, I think it's a, it's something that probably the clinician has to be very skillful to do to keep people on board. Because it's a risk of dropout. And is this something you can reflect in the research and from your experience in the clinic? I'm just, my reflection will be if people do not have a setback at all, I'm a bit worried during the process as they might not have the opportunity.

Tim Beames (05:47)
you

Bart Van Buchem (05:53)
to see how it might work, not necessarily inducing a setback obviously, but you can see the risks that involve the people who not have had these learning opportunities, especially if they come from a very chronic pain state and do well on recovery.

Tim Beames (06:12)
Yeah, know. So interesting sort of way of looking at it is, is yeah, being a bit concerned that they haven't had, ⁓ yeah, these learning opportunities. I look, I mean, the research out there on flare ups, for instance, demonstrates that there is a positive prognostic value in monitoring and understanding flare ups. as flare ups gets, less in terms of the frequency, the intensity, the time that they're around, that it looks like it's prognostic of

people recovering. And I share that with my patients. And, and partly because I'm wanting to prepare them that it will happen that there will be flare ups. And also that that might be something that we see as value in that you're doing the right things and keep on going, you know, you might not have this amazing magic pill that goes right pain be gone, but

By committing to a process, you will start to see a steady shift and change in the journey and the pattern. And patterns are interesting from a pain point of view, because everybody has a slightly different one, that someone's recurring pattern might be over several months, for instance. In fact, it's only just popped into my mind, but I had a conversation with someone yesterday. And they were saying, isn't it interesting that

This is coming up a year almost to the day of the last time that I was struggling. And it's like, wow, what an observation. So is there something, and we had a discussion about is there or isn't there something in the sort of time of the year and what's going on in the life. quite simply, I don't know, but it is interesting to think of it like that as well.

Bart Van Buchem (08:03)
Yeah. So you basically say, well, that implies that as there should be a meaning for it, there's some, there might be some reason, but, I, if I understand it correctly, that you, you discussing it with an open mind, right? So we don't know, but let's figure out what, it might mean. And if it's a year after the date, is that, how does that relate? Although it's hard to have any, there's an, and is one that's the safety, guess, ⁓ which

allow you to speculate in a way, but if the patient is happy to say, the 1st of March is going to be terrible day. Well, as long as it's every day of the year is too terrible. I guess there is this marathon. It's interesting.

Tim Beames (08:50)
Do you,

I'm gonna jump in, but do you know the story of ⁓ Engel, so the biopsychosocial model, and he predicted his death and illness around his brother and his dad dying with cardiovascular diseases in and around the time. And he noticed he was unwell at a particular time of the year. And he pretty much predicted, I can't remember how closely he predicted, but I think it was within a couple of days he predicted.

Bart Van Buchem (09:02)
Wow, yeah.

Tim Beames (09:17)
I'm going to die of a cardiovascular event on this day. And it was, it was absolutely accurate.

Bart Van Buchem (09:23)
wow.

Tim Beames (09:25)
So thinking of holistic

understanding of there's some,

Bart Van Buchem (09:29)
Well, yeah, yeah.

Well, it's interesting to go back to his work for sure. I think his work has been widely misinterpreted because of the lack of understanding and the real reading it. So I would encourage you to go back to George Engel's work. It's been quite accessible. I find it quite easy to read. there are a few, I don't know the titles by the back of my mind right now, but there will be, there's definitely something that is more close to what he

essentially said, this, ⁓ everything together and then making this assumption of your death is quite interesting. think patients do, does granite pain do this all the time in a way. So they predict I'm going to have a setback after this exercise or after this specific, ⁓ activity. I'm sort of tend to challenge that.

a bit, whether why would it be that activity? Or why would it be that thing? Because there's so many other things that might influence and how many times it actually did go fine or well. You don't, don't count them in. Do you think it's like, ⁓ setbacks it's about

really, ⁓ trying to get this understanding of the broader idea of what's really going on to basically shift the idea of everything is going wrong. And this is what I did wrong. And this is, I should have done this to something more broader view, like a more, I would say a more accurate view, basically correcting them. Do you think a setback is correcting the ideas or the understanding of the setback as a part of the reframing?

Tim Beames (11:21)
Yeah, yes. Yeah, I mean, essentially, yeah, we've got as humans, typically a sort of negativity bias within all those predictions. and if and if our previous experiences have been fairly negative, including, you know, pain and what have you, then it's understandable that that's even, you know, fueled even further. So and it's a big part, certainly, it's a big part of what I do. I think it's a big part of what you do as well, that we

Bart Van Buchem (11:50)
Yeah. Putting

it into perspective, basically is that, yeah. Well, there's a risk, right? There's a risk of putting something in perspective because you're challenging the idea. So I think this is, I'm in a setback now. Are you saying putting a setback in perspective because of the reasons or the meaning of it? It's a, it's it's a tricky part in my view. Any, any thoughts on that, that process where?

Tim Beames (11:52)
Yeah, putting into perspective.

Yeah.

Bart Van Buchem (12:17)
how you would go about this in a patient, for example, that has this massive setback had it before, and probably blaming a very specific activity that is inevitable ⁓ as part of the reason.

Tim Beames (12:35)
Yeah, yeah. Yeah. Well,

as you're saying that there's a few like in the moment, things as well. So if someone is experiencing a big flare up in symptoms, there's also navigating that right now and ⁓ creating some safety and and that includes things like validating where they're at and ⁓ and perhaps yes, that perhaps it is important sometimes to understand the associations that

potentially move them closer towards that. And that's where pain neurophysiology education comes in, doesn't it? It's just understanding self and how we respond in certain situations. So yeah, there are elements of sort of feeding the here and the now and something that we know about, ⁓ you know, big

flare ups is that it completely shifts your ability to be able to problem solve as well. So people really struggle, they might have navigated life pretty well, and then the flare up comes about and then it's almost like they're struggling to be able to use all the skills that they had before. And that's a fairly typical feature of a couple of different pain conditions. we as clinicians have quite an I think, quite an important role at those times.

Bart Van Buchem (13:47)
Yeah.

Yeah, absolutely. I just mentioned that you switch from Setback to Flare Up.

Yeah! What's that? Got unconsciously.

Tim Beames (14:05)
Yeah. ⁓ yeah. I mean, I suppose that's what I'm thinking about with a a a setback.

Yeah, I just think a setback is just a rubbish word as well. But in my parlance and the sorts of words that my patients are using, we typically typically call it a flare up. Yeah.

Bart Van Buchem (14:24)
Yeah, which might be for some people, although I'm not sure whether people choose to be, it's a setback because this is how it feels, depending on the situation or the context, probably not challenged that too much. You could propose a different definition or a different thing. What I wanted to challenge here, so ⁓ I had a question in my mind, something like that.

expecting to ask, so what are the triggers for Setback? Which is, I think that's even that question implies that there is something, but I think we agree in a chronic condition. We're also struggling with, there are so many reasons that it could be the bilby in the bathtub, right? That would be the Aussies were saying the bilby in the bath. There's an English, ⁓ saying probably what would be similar.

Tim Beames (15:15)
the straw that broke the camel's back.

Bart Van Buchem (15:18)
Yes,

exactly. Yeah. Yeah. They're Dutch. Every, every language has its own, but if that's the case, then talking about triggers might be problematic in itself. Would you think of avoiding finding a trigger at some stage, or do you feel like ⁓ labeling, listing all the triggers, potential triggers and what it, and then

So what?

Tim Beames (15:49)
think it depends on the individual. So if you're doing a sort of problem based reasoning approach, a cognitive behavioral approach, for some people that can be really effective. So figuring out what the, you know, things are that more likely to move them towards that setback and flare up and what are the things that move them away. I think that that can be really helpful for some for some

where there is perhaps an over fixation on the problem already, then figuring a more solution focused approach out might be more effective. yeah, and I have a variety of different, I'm pretty certain that you're gonna have this as well. I have a variety of different ways that I do this where we're thinking about balance or optimizing health and wellbeing or.

or we literally have a sort of more methodical way of structuring what's the day and the week and activities might look like. I stole something from Louie Gifford years and years ago, which is basically an individualized way of creating a graded exposure approach where you can learn. ⁓ if people have been on my courses, you'll have heard the no way will be fine scale and, ⁓ and, you pick something.

an activity that someone's struggling with and you figure out not just the amount that they can do, but you look at how it feels, how they respond, you think about how you set it up to succeed and how you come down from it as well. so then you're creating strategies within activities as well to make you most likely to experience some success.

And I think the drip, drip, drip effect of successes is an important part of a recovery process from flare ups. need to get some sense that what you're doing and what you're committing to is effective enough for you to continue that process. Because the balance there is drip, drip, drip of small successes when you've got these mega things that are the setbacks and the flare ups.

and what have you. So, yeah.

Bart Van Buchem (18:13)
Yeah, it's an interesting, because I think you put it down nicely here where there you could have a focus on a problem solving focus. You could go like solution focus. And the last one, maybe somehow like a more constructivism focus, which basically gonna re frame the idea of what it basically is. And there may be nothing that has been attributed to the problem.

⁓ a reason why, and I would, ⁓ I would love to, sort of move a little bit further when, when there is, this is my, my, my reflection, just right. So when problem solving a solution focus also validates the idea there is something. And I can see many patients who always blame important activities, like taking my kids to school.

doing my work. ⁓ let's say things that you would, would consider to be inevitable in life are blamed for. So I do too much walking. ⁓ if I go do an exercise and I love to do exercise, but it always flares up with these exercises. So a solution focus will be so well do a little bit less or

prevent doing it or doing something with a different mindset, but it also validates the idea that it is actually a problem. But what if it means like we said before, it's, it's the question, right? It's, it's absolutely not sure that an activity is to be blamed because there's so many times then that the activity is not provoking it because it's the, the one thing that

takes the blame for everything. It's, it's probably not helpful. So reconstructing or even challenge the meaning of it. And the flare up as part of a disease as, as it happens with many diseases, chronic diseases, they do have their like waves, right? It goes up and down like rheumatid arthritis, for example, is not a flat line. And

I can see even in people, even your energy, your daily energy, you're going to blame yourself for having energy. What did you do wrong? I did a lot and didn't rest very well. So what is it up for now? So I probably have to focus on doing a bit more, did you something, did you did something wrong? No, you did life, right? And sometimes I feel like going solution or problem solving sort of, ⁓ like to an old school cognitive behavior or therapeutic approach, just change it by not doing it. And.

Probably. that's one of one of the things that I've seen a lot and I'm really keen to hear your thoughts on it. ⁓ that people are trying to, starting to avoid the things retract from life because the easiest way is not doing it. If you find out, that's a problem. So let's do it less or less frequently. And then it's, ⁓ it, it, it basically it's a downward spiral. So I was having thinking like the risks of.

Tim Beames (21:16)
Yeah.

Bart Van Buchem (21:30)
going this direction of basically adjusting life to these flare ups.

Tim Beames (21:38)
Yeah, yeah, yeah. Yeah. Well, there's there's avoiders. And it's understandable that if you don't want to be in pain, you avoid doing the thing that caused you pain. I think great, well done, you found a strategy. But unfortunately, what we see is that often spirals down and down and down. So you can do less and less and less. And we have the other side as well, don't we? We have the endures who just push on through and, and the middle way is not the sexiest way.

It's not the obvious because you've tried your, in essence, you've tried that sort of right, wrong, yes, no, black, white approach. And then suddenly you're having to try something that is more nuanced and more complex. I've forgotten what your question was now, but that's what I was thinking about when I was there.

Bart Van Buchem (22:22)
No,

the risk of avoiding as a part of the, as a result from the strategy, let's problem solving and solution focus. well, let's do a little bit less. Let's pace your recovery or let's pace your activities, for example. Basically it means winding down, which because it's never gone up. let's, let's increase your activity level right now when you're in a Flora. It's very unlikely.

Tim Beames (22:31)
Okay, yeah.

Yeah, yeah. ⁓

Yeah. ⁓

Bart Van Buchem (22:50)
But the risk of where it starts to be avoiding or have to be cautious about these strategies, because even people who, like you said, are pushing the boundaries can be and become avoiders at some point.

Tim Beames (23:05)
Yeah. Yeah. Yeah. Well, look, I see a lot of men with pelvic pain and things like sitting, going to the toilet, et cetera, are the activities that are most likely to cause pain and flare up. So, and they are literally unavoidable, although people will try and stand for most of their day or lie or stand for most of their day. And, but then you're still going to have to do your toileting as well. So yeah, that is something that is completely unavoidable.

which is an example that teaches us, I think, more about how we can change the context of that activity instead of just avoid it. What could we do it? How could we do it differently? And I was mentioning before about setting things up, not just in the moment of the activity, but how do you lead to that activity? And then also bringing yourself back down from the activity. I think our important

elements for some people, so that there's more likely to be a success or ease in that activity than there usually is. Just coming to the flare ups, and we've chatted about this in the past, but I mean, that's something for me to spend some time with my patients talking about is to have those strategies for when you are actually in the setback and the flare up.

So we call it a toolbox, your flare up toolbox. And some people it's a literal box, some people it's a metaphorical box, but essentially it's a list of instructions. It might include certain things like mantras or tea bags or a hot pack or whatever it is. There's some things that this is what I do when I'm in the flare up. I've already pre-decided that these are my strategies that help me normally to

Bart Van Buchem (24:36)
Hmm

Tim Beames (25:02)
create some ease and I'm going to commit to what I have already pre-planned and having that plan in place can in itself provide some safety. I know what to do if things are problematic, but also when they arise, then we have some evidence then of, you know, these are the tools and actually I got through this perhaps.

10 % better than I would have done without that or actually, you know, it passed relatively quickly compared to normally. so having those, the preparation in there can be a really helpful process as well. I was having a chat actually, I've worked with a guy for maybe, I think maybe a couple of years now, but we were talking about his flare ups and he was saying how,

Bart Van Buchem (25:32)
Hmm.

Tim Beames (25:58)
You know, now he's got, he's almost like there's so much learnt. This is what I do when I'm in this situation. He can predict when there's like little sort of signs coming up in his body. He knows when actually this is, these are the signs that say I'm doing too much. And I know to just put into place some of those strategies that I always have. so instead of it getting to that.

flare up or set that level, he's got these like predictors and the predictors in him, I can't remember exactly what they were, but you hear people say things like, mouth goes dry or I start to feel a bit queasy or I get a little headache in front of my head or whatever it might be. It isn't necessarily their pain or their main symptoms coming on, but their little clues and that...

awareness, that sort of embodied awareness is a phenomenal piece for then into the future. So someone has that then, then into the future, I think they are mega well equipped. It takes time to get there.

Bart Van Buchem (27:07)
Yeah, yeah, exactly. that's the pre, yeah.

that's sort of finding some, some indication, or at least some signs that may, you start using the toolbox. All right. So let's move it to the other side.

Tim Beames (27:21)
Yeah. Why wait until

it's really bad to do this stuff that calms things down? Why not do it beforehand? It's a bit like, you know, your house is on fire, so I'll start throwing some water on it. Why not put some precautions in place before the fire even starts? So, yeah.

Bart Van Buchem (27:25)
Of course.

Actually, it's quite certain that it will happen at some point. There will be flare ups. I think that's something that's a very honest, right? So why would it just disappear at some point? Even people in migraine. So we have had some very good sessions with Bernhard Taxer as a migraine specialist. Amazing how sort of the strategies that comes and it is very much on these early signs and symptoms and act on these.

and it's very helpful in managing because the truth is there will be another migraine attack at some point. So there's no way, ⁓ it's not an unlikely event. I just wanted to move it sort of, ⁓ the way around. So, so when this is like the pre's like the early signs, but there's also this time when people say, well, how long this is going to take. So I'm in a flare up. ⁓ and there is this uncertainty. Now I'm really interesting to hear some thoughts from you about.

this managing uncertainty in terms of how long this is going to last.

Tim Beames (28:43)
Well, it's so variable for everybody, isn't it? Because I've had people where it's been several months of, you know, things have been mega and then thankfully it's more usually a day or two. And then sometimes for some it's hours, but yeah, more likely to be a day or two. But yeah, it can be more than that. It is so challenging.

Bart Van Buchem (28:46)
Yes, yeah, yeah.

Tim Beames (29:10)
when you're in it, and I've got a couple of people that really come to mind here where their flare ups are so massive, you know, the system's just going bonkers because of whatever's been going on in life at that time. And being able to sort of navigate those moments, particularly when things have been going relatively well. And then that difference.

Bart Van Buchem (29:35)
Mmm.

Tim Beames (29:38)
between relatively well and those setbacks is really, really big. It really does sort of magnify how challenging those times are. So yeah, I mean, that's again, where I think having a good relationship with your patients comes in really, like, so, so important here. And also not just you, but having that structure within support in the family and work and

and what have you outside of there. ⁓

Bart Van Buchem (30:10)
Yeah. Yeah. And it needs some very, you have to be quite skillful in your communication to be not saying, well, it's going to be all right in a week or so. Because that's gonna, they're going to pin you down on that to exactly the hour. I've found that

Tim Beames (30:23)
Yeah.

That's

where, you know, having that pre-built plan, you know, pre-agreed structure, if you want, for when things are bad, this is what we do. But that takes a bit of time to get to. And I have sort of fairly ⁓ distinct, in my head, I'm sort of reasoning categories, if you want, but sort of stages of recovery. And the first one is how do we calm things down? How do we create stability? How do we just create a sense of safety?

And that might in itself take some time for people. And as you're developing that, you might have multiple periods of times where you have setbacks or flare ups.

Bart Van Buchem (31:08)
absolutely.

Yeah. Yeah. That's, ⁓ it's probably another episode on, on challenging and managing uncertainty and expectations. ⁓ as a part of that, and not just, just a teaser of what I've found really, really helpful is the step-by-step approach. And, ⁓ it sort of came from my like personal experience when things are seems to be, ⁓ seems to never end. You have to stick with the plan.

And it's the step-by-step approach that's good. let's stick it together. This is what we can do now. We cannot be there in the next 10 steps. so putting, getting people back to here and now. And I found that in my clinical work, very helpful and people would, would understand that it, but it's the wish you just want to know. It would satisfy or relieve or reassure you massively. But if there's no reassurance available at that stage, we don't know. You have to go. So what's your next step?

What is it you're going to do next today here when you move yourself from the clinic to home? What's the next thing? And what's the next thing? So step by step, which would be highly interesting. we'll be at least as good for, managing that moment. And secondly, when people are actually do well after a flare up, not just taking it for granted. And I think this could be adding to your toolbox again, right? So when you use these reflections to.

Basically upgrade or update your toolbox and, formalizing it, writing it down. think we should writing things down in a clinic, even if people are not really writers, they might need to draw it or they need something to sort of get themselves their heads around. Because in a flare up, you're not thinking like you would think without the flare up. It's my experience. Even simple things can be very hard. So.

Tim Beames (32:40)
really.

Hmm.

Bart Van Buchem (33:05)
Basically saying, well, I love the idea of the toolbox. I think that will be a takeaway. The problem solving solution focus, meaning challenge, the meaning of it, and managing uncertainty and expectations as part of the flare up. that's not the one off. That's a whole process, right? It's, it's a key part of this. So yeah, I love it. ⁓

Tim Beames (33:30)
And there's reframing,

I know we're coming to the end of the episode, but there's reframing what that flare up is, because a lot of people, that's harm and badness and what have you. And if we reframe pain as a, if you want ⁓ a useful, helpful, perhaps protective feature of the experience of the human being, we could explore, you know, what are we needing to protect?

at this time and if that is the case, how do we offer a sense of security and safety and support and all of those things move someone, not rapidly, but move someone towards a sense of safety and well-being.

Bart Van Buchem (33:58)
Absolutely.

Absolutely.

Yeah. Yeah. And some of the episodes that will be upcoming will be about these topics for sure. ⁓ this, is the direction we want to take from here, ⁓ of these detailed, but very potent variables in the clinic that happens every day with every patient. And, ⁓ we trying to help you guys, ⁓ as we are trying to help ourselves.

All right. ⁓ we're going to wrap this up. so I think we did some of a summary. and, I'm really keen to make sure, have a look at our website as the variety of material that's there. ⁓ and we'll be explicitly helping you to challenge these, these, ⁓ these problems you will face in the clinic because we have them. We, we face them and we're trying to manage them, learning from each other.

because that's the only way of moving forward. We've all experienced when we had conversations with some of the LePub members and I want to say hi to everyone who we met in Epic Leon and before I was a couple of weeks ago in Melbourne, met some lovely people to ⁓ chat about what we think are the challenges and looking forward to hear you guys. ⁓

of your so, so this is one of these. Well, this topic obviously came from someone we spoke spoke to. I wasn't sure who it was again, but I will definitely leave it in the in the notes or somewhere. The thanks to the person who brought this up. So ⁓ thank you for listening. Looking forward for the next episode, Tim, because there's a whole massive list of things ⁓ we'd love to chat about.

Tim Beames (36:06)
Brilliant. Yeah. And if you like what you hear, please, please, please share it. We just want to just boost that knowledge and understanding and help that we can, we can provide. yeah, huge thanks everyone.

Bart Van Buchem (36:17)
Totally.

Thank you. Bye bye.