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Likely, most people reading this have experienced some degree of lower back pain in their lives. Do you remember how your pain was described to you, or what you took away from meeting with your physiotherapist, chiropractor, or doctor? Were you inspired to exercise to help improve your pain, or did you leave the appointment feeling discouraged?

Dr. Peter Stilwell is a fourth year PhD in Health student, supervised by Dr. Katherine Harman (School of Physiotherapy) and Dr. Brenda Sabo (School of Nursing). He is researching how communication between patients with lower back pain and their clinicians can be improved for better outcomes.

Personal experience with pain

Dr. Stilwell spent a lot of his youth skateboarding, leading to his fair share of injuries and appointments with a variety of health practitioners. That sparked his interest in injury management, and wanted to find out why many pain patients didn’t exercise even when prescribed. He completed a Bachelor of Kinesiology at the University of Calgary, the Doctor of Chiropractic Program at the Canadian Memorial Chiropractic College then after clinical practice came to Dalhousie University to do a Masters in Rehab Research through the School of Physiotherapy, and a PhD in Health.

An enactive approach to pain

Part of Dr. Stilwell’s PhD research is a paper done with Dr. Harman titled ‘An enactive approach to pain: beyond the biopsychosocial model’.

Dr. Stilwell says he and Dr. Harman challenged the more traditional models, like the Biopsychosocial model, and built on them. The new pain model they propose brings in enactivism, which he says has been applied to depression and other mental health issues but hasn’t been applied to pain in a meaningful way.

“It’s very dynamic, it looks at the patient side but also the clinician side, how they interact together, and how that can shape pain for better or for worse. It provides a different route for explaining back pain in a way that’s saying, ‘it’s not all in your head, it’s about all of these things integrated together.’”

“We know that lower back pain is the number one cause of disability worldwide, so it doesn’t kill people, but it can contribute to a lot of suffering, lost work, and frustration. Eighty percent of people are going to experience back pain at one point in their lives. There are other more empowering ways to explain pain and shape a person’s path so they are doing more active things, coping with and ultimately reducing their pain.” - Dr. Peter Stilwell

Listen to Dr. Stilwell and Dr. Harman discuss their research! Podcasts: Clinical Athlete, Barbell Medicine

Dr. Stilwell explains that the biopsychosocial model was meant to be dynamic, looking at the biological aspects of pain (joints, discs), the psychological factors (a patient’s beliefs/expectations of their pain) and social factors (interaction between patients and the health care system), but somewhere along the line it started getting split up.

“People started saying if you can’t find the cause of a person’s pain through biological factors, it had to be psychological pain. Our model says that’s a false split. You can’t split them that way, they are all intertwined, and these are artificial circles that have been created.”

Hearing from patients and clinicians

Dr. Stilwell and Dr. Harman used their new framework to do a study; audio recording real clinical appointments between physiotherapists and chiropractors and their patients. After the appointments, they did individual interviews to find out why the clinician explained things the way they did, and how the patient interpreted it.

They found that certain explanations, such as “you’re 30 but you have the back of an 80 year old” could be really discouraging, and make patients feel like there was nothing they could do – decreasing the chances they would do the prescribed exercises which would help.

(Dr. Stilwell and his wife Christie Stilwell have been turning the metaphors given by patients and clinicians into art. This image represents back pain being like a fire, with subsequent descriptions of adding more water (proactive things) than gasoline (e.g.: sitting all day). Artist: Christie Stilwell)

Dr. Stilwell says one of the better explanations he heard was “motion is lotion”, which replaces the old saying “rest is best” and would hopefully motivate patients to exercise.

The teach-back technique is something Dr. Stilwell and Dr. Harman suggest clinicians try with their patients. With this technique, after giving a diagnosis or explanation pain, clinicians ask their patients how they would go home and explain their pain to their spouse/family/friends. If the patient interpreted the message differently than intended, this gives the clinician the chance to tweak their communication accordingly.

International reception

Since publishing their work, Dr. Stilwell and Dr. Harman have been invited to be guests on multiple international podcasts (Clinical Athlete, Barbell Medicine) to discuss their research, and they have heard from clinicians around the world.

“Clinical psychologists, physiotherapists, physicians and chiropractors are telling us this is helping guide how they talk and think about pain, and their potential impact on patients’ pain.”

Dr. Stilwell says there has been a lot of interest from the UK, US, and the Netherlands. To learn from leading scientists and philosophers, he recently attended a training program in Germany for PhD students interested in enactivism. His presentation on this research resulted in further interest from attendees from around the world.

After the research

Now that the study has wrapped up, Dr. Stilwell is taking the metaphors and explanations that were recorded and representing it in art pieces with the help of his wife who just started the PhD in Health program. He hopes to have a gallery showing and bring in the local clinicians involved in the study to see the results, so they can start conversations and clinicians will reflect on their communication style.

Dr. Stilwell plans to continue in this line of research in a post-doc. He says this research has radically changed how he views pain and how he would interact with patients, and he’s happy to hear clinicians are saying the same.