Basic Course about the method of Somatosensory Pain Rehabilitation - Montreal 2023 (PART I)
Tamara SOGOMONIAN and Marie-An HOANG[1]
Thursday September 28th, 2023 — Institut de Tourisme et d’Hôtellerie du Québec
9h00, Day 4 of CSTP Certification — Montréal, Québec, Canada
Twenty-seven occupational therapists and one physical therapist technician have gathered at the ITHQ in Montreal, seated at circular tables with our chairs turned towards the large screen at the front of the room. It is the third day of the course about the method of Somatosensory Pain Rehabilitation (SPR) and the third day of our final clinical placement in the completion of our Masters in Sciences (Applied) in Occupational Therapy at McGill University. By this third day, we are now equipped with the newfound knowledge of how to evaluate and to provide interventions with those living with neuropathic pain - reduced sensitivity to touch (on day 1) and touch-evoked pain (on day 2). The first two days of the course followed a similar schedule. In the morning, we learned about the neurophysiology and etiology of different types of neuropathic pain, followed by the evaluations and interventions of such conditions; while the afternoons were dedicated to apply their theory into practice.
The room is filled with enthusiasm that has yet to wane since the beginning of the course. On this third day, there seems to be more excitement and eagerness to be introduced to more “complex” neuropathic conditions by our clinical supervisor, Claude. Expecting the third and fourth day to proceed as the first two days, participants have their notebooks and pens, ready to take notes.
Instead, Claude starts the day by reading:
« Nous sommes enfermés dans une prison et une voix nous dit : « Sors. » Nous répondons : « Impossible, la porte est verrouillée » et la voix nous dit : « Oui, mais elle est verrouillée de l’intérieur, regarde et ouvre ». Ce sont nos représentations qui nous enferment. Nous vivons plus dans l’échafaudage de nos représentations que dans la réalité objective. Le Réel, lui, n’a ni porte, ni fenêtre, il est l’infini de l’infini des possibles. » (Singer, 2001)
We’re confined in prison and a voice tells us: “Get out.” We answer: “Impossible, the door is locked”, and the voice tells us: “Yes, but it’s locked from the inside, look and open it” It’s our representations that lock us in. We are living more in the scaffolds of our representations than in objective reality. The Real, on the other hand, has neither door nor window; it is the infinity of the infinity of possibilities.
The room falls silent.
Reflections
We are introduced to the experiences of those (surviving?) living with pain. As occupational therapy students venturing to Fribourg to complete our last clinical internship, we are shown, through the text above, a glimpse of a reality that is not our own, but of those who we seek to “understand”, and most importantly, listen to.
The prison that which we speak of is not only a bodily prison, but one that can encompass the mind, spirit, and soul. This prison of pain blinds the prisoner of its exit and places them in a reality that is not shared or understood by others. This prison dissociates the prisoner from their Past Self (a person), the Current Self (a prisoner), and therefore, questions the possibility of a Future Self.
Despite its power, this prison is invisible to those outside of it. So, who knows best? The blinded prisoner or the ones outside it? How does one tell another to “get out” of a reality that is not shared or understood? How can therapists help guide the trajectory a patient with pain, when the immediate answer is “Impossible, the door is locked”?
~ ~ ~
Although the day continues with theory on neuropathic conditions, many interesting discussions arise. From the commonly used biomedical approach, to a newfound focus on patients’ experiences with neuropathic pain, discussions emphasized the consideration brought to the positioning of healthcare providers within therapeutic relationships. The course instructors sway between providing concrete answers on how to evaluate and treat neuropathic conditions, such as spontaneous neuralgia and Complex Regional Pain Syndrome (CRPS) while providing insight of their own experience of working with patients. Frequently alternating between these two topics conveys that, despite being knowledgeable about the theoretical aspects of somatosensory rehabilitation of neuropathic pain, providing concrete answers and solutions for specific situations will not necessarily apply to others’ patients. It is simply impossible to teach a course that will provide solutions to each patient’s unique experience living with neuropathic pain. Instead, the course instructors provide insightful prompts that encourage the group to reflect on how they view pain and how they position themselves when working with patients living with neuropathic pain.
Clinical Placement’s Week 2 — Somatosensory Rehabilitation Centre
Welcoming Room — Freiburg, Switzerland
Claude shares that our role as healthcare professionals is to:
« Accompagner les patient·s…ce que j’offre [à mes patient·es], c’est ma présence. »
“Accompany the patient…what I offer [to patients] is my presence.”
(see leidmotief, p. 130: Hillesum, 1943)
On the first day of our clinical placement in Fribourg, we are welcomed into the clinic where we meet a seating area that resembles more of a living room. A living room with different types of chairs that bask in the sunlight coming through the large windows and surround a table with books and papers. This is the welcoming room. Books are available for patients to flip through whilst waiting for their appointment.
« La chronicité de la douleur est une altération radicale de la narration de soi […] Il n’y a ni sens ni non-sens à la douleur ou une épreuve personnelle, elle est là et appelle la réplique de l’individu. S’il réussit à lui donner une signification, il la supporte mieux. Lui seul est comptable de l’histoire de sa douleur. La capacité de symboliser est de prime abord mise à mal par la douleur. Pour l’atténuer, il importe de la traduire en mots, de la résorber dans l’histoire qu’elle contenait et qui ne pouvait pas encore exprimer. Ou dans ce qu’il en imagine car il n’y a pas ici de récit juste mais juste des récits. […] Une telle médecine, technicienne, considère la relation comme secondaire puisque la vérité du symptôme ne sortira pas de la bouche du patient mais des examens. (…) Le patient est réduit à sa pathologie, ses propos, ses commentaires sur ses troubles, ses hypothèses sur leur origine sont perçues comme des obstacles ou du temps perdu. » (Le Breton, 2017)
The chronicity of pain is a radical alteration of self-narration. [...] Pain inherently holds no sense or nonsense, nor does it represent a personal challenge; it is simply there and calls one’s response. If one, however, is able to give pain meaning, one bears it better. The individual is solely accountable for the history of their pain. The ability to symbolize pain is first undermined by it. To relieve pain, it is important to translate it into words, slowly making pain disappear into its spoken story that one was initially unable to express. Or in what they imagine of pain, for there is no right story here, only stories. […] This kind of technocratic medicine considers the relationship to be secondary, since the truth of the symptom will not come from the patient’s mouth, but from the tests. (…) The patient is reduced to their pathology, and what they say, comment on their disorders, or hypotheses about their origins, are perceived as obstacles or a waste of time.
Reflections
Perhaps it is not about questioning the patient with negative medical test results and denying the presence of the prison of pain around and in them, but rather attempting to speak the same language as the patient to better understand what the prison looks like and feels like on their day to day. And through words, through articulation, describe an exit from the prison of pain, partial or complete. Speaking the patient’s language, affirming their lived experiences within a reality that is unseen to the therapist and other outsiders, can make the patient’s reality less bleak. Despite not being in the prison of pain with the patient, “being near” them, offering our presence and believing such prison is existent yet finite, represents the beginning of the therapeutic journey.
“Being near” can hold different meanings. A few examples of “being near” is being present during sessions, providing attention and listening to not only what the person is saying, but also not saying. This also includes how is the prison of pain described: is it with rage, through whispers, with indifference? Has there been a shift in the room?
“Being near” can mean providing silence, as an act of honesty, rather than a distant, generic, therapeutic response such as “I understand”, because, do we actually understand? Can we understand pain that makes no sense to the patient?
“Being near” is an attempt to speak the patient’s language. When the patient is able to speak their language in the therapeutic room with their healthcare provider, it can represent a significant relief from feelings of alienation, invalidation, and neglect.
~ ~ ~
« Êtes-vous prêt·es à désapprendre ? » Are you ready to unlearn?
-Claude asks us with a quizzical brow.
Unlearning previous ways of understanding, saying, and doing during therapeutic sessions is necessary in the context of neuropathic pain. Introducing patients to resources such as the Somatosensory Pain Rehab which includes patient testimonials and experiences of pain can be a source of relief (that others may be going through something similar) and encouragement (that the status of prisoner can be temporary).
During therapeutic sessions, when therapists ask the patient about their social support, some may share that such support is difficult to find, as other do not understand let alone recognize their experience of pain. For this reason, a printed sheet of Neuropathic Pain: Myth or reality? (Spicher, 2017) is given to both the patient, their social circle who struggle to recognize or imagine what the patient is going through. By providing a brief, lay synthesis of the patient’s condition, their reality may be better acknowledged by their surroundings, alleviating feelings of alienation, invalidation and neglect.
Following such reflections, the Basic Course about the method of SPR aims to introduce clinicians to the identification, assessment, treatment, and rehabilitation of eight neuropathic pain conditions. Having to apply the theory learned in the course with patients in Fribourg has been a tumultuous yet reassuring learning experience. With so much theoretical and practical knowledge that must be covered within the Basic Course, it is only natural to expect that we can simply apply what we learned in the course with our patients in Fribourg.
As written on the first page of the chapter on pain in the manual, pain is not a singular experience (Spicher et al., 2020). Instead, pain encompasses a set of complexities and nuances unique to each patient we encounter. How can we, as future healthcare providers, possibly become experts at pain when pain is experienced differently by everyone. We are indeed well equipped with knowledge and solutions that allow us support our patients. However, clinical education often presents such knowledge and solutions as a “one size fits all” approach. We are taught that a list of evaluations and interventions for a list of conditions. It is then up to us, once in the field, to adapt such evaluations and interventions to our patients. However, what remains lost upon us is the concept of self-reflection and “patients as experts of their own experiences.” How have our perceptions and understandings of pain influence the way we behave and act with our patients living with neuropathic pain? Walking out of the four-day Basic Course, we had told ourselves that we would review the eight different neuropathic pain conditions along with their evaluation and intervention. A day before starting our clinical placement at the Somatosensory Rehabilitation Centre in Fribourg, we huddled ourselves into our room and dug our heads into our textbooks and notebooks to practice the evaluation and interventions methods. And yet, after individually having a session with a patient living with neuropathic pain on the first day, we quickly realized:
No course can possibly provide one singular answer or a solution to the exiting prisons of pain.
Every patient is different, and every session is different. While being healthcare professionals, a sense of apprehension to navigating uncertainty with patients may always be present, that may also be part of the therapeutic journey.
« Accueillir les patient·s comme iels sont et non pas comme vous souhaitez qu’iels soient. »
“Welcoming patients as they are, and not as how you want them to be.” C.J. S.
~ ~ ~
~ More reflections following the Swiss clinical internship to be revealed in Somatosens Pain Rehab 21(1) ~
References
Le Breton, D. (2017). TENIR Douleur chronique et réinvention de soi. Paris : Métailié
Singer, C. (2001). Où cours-tu ? Ne sais-tu pas que le ciel est en toi ? Paris : Albin Michel
Spicher, C. (2017). Douleurs neuropathiques : NON, ce n’est pas dans la tête ! Tribune de Genève, 15 (une page). Téléchargeable (24/10/2023): https://www.neuropain.ch/sites/default/files/e-news/e-news_somatosens_rehab_14_2.pdf#page=32
Translated as: Spicher, C.J. (2017). Neuropathic Pain: Myth or reality? e-News Somatosens Rehab, 14(2), 88-89. Available (10/24/2023): https://www.neuropain.ch/sites/default/files/e-news/e-news_somatosens_rehab_14_2.pdf#page=47
Spicher, C., Barquet, O., Quintal, I., Vittaz, M. & de Andrade Melo Knaut, S. (2020). Douleurs neuropathiques : évaluation clinique & rééducation sensitive (4e édition) – Préface : F. Moutet. Montpellier, Paris : Sauramps Médical, 379 pages.
[1] MSc(A) Occupational Therapists, CSTP®, School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, Québec, Canada
