Pain Schooled! #4 is now over. We are super privileged to have millennial hawker and fitness icon Walter Tay to join us as a guest at our chiropractic clinic.
Pain schooled! was founded to explore what it means to live in pain. We use research from pain science, that is how to approach pain from a biopsychosocial model, to deconstruct pain.
The plus side of running it as an open-format group workshop is that we all get to learn from each other. As a chiropractor, I get insights into how my current and past clients perceive pain and the treatment we offer.
Here are the seven things I learnt:
#1: Clients who saw me BEFORE I transitioned to an education-exercise practice couldn’t accurately explain the clinical rationale behind their recovery
Clients who worked with me while I was still operating as a multi-modality chiropractic clinic couldn’t explain their pain or their recovery. When questioned, they tend to use words like “alignment” – even though I have never used that in clinical practice – to describe their recovery process.
We don’t subscribe to the alignment model at Square One. You can read more about our position on posture and alignment at our text neck blog post.
We also do hear ex-clients attributing the success of their recovery to ‘muscle strengthening’. While we do indeed occasionally work on strength and conditioning, strength gain on its own is rarely the reason why a client achieves pain resolution. We wroteabout the specifics of what pain is and isn’t at our lower back pain treatment blog post.
For clarity, we work with clients in two specific areas:
- Musculoskeletal injury recovery or rehabilitation: For such cases, we work specifically to help a client recover from a current injury. Examples include hamstring tears, lower back strain/sprain. For more information about how this works, you can check out our case report on Kingsley Tay’s Achilles tendinitis session with us.
- Pain management: Most people still think of pain as symptom but we can’t emphasise enough that in cases of chronic lower back pain, it is a disease of its own. While people are trying to fight with the “tight muscles” or the “spinal misalignment”, why not deal with the pain itself? We deliver long-term pain solution because we don’t do any of the hocus pocus nonsense. You have pain, let us deal with the pain. (Yes, we often achieve this via exercise.)
Exercise as a pain solution is dramatically different from exercise for fitness or health. We often hear people telling us they have tried a self-direct exercise program and it didn’t work.
Well, that’s not surprising at all. Instagram rehab is not clinical rehabilitation.
Clients under our care after we transitioned to exercise, advice, and education were able to more accurately articulate why they experience pain and the clinical rationale behind their recovery. Hurry to education!
#2: Clients who achieve full recovery attributed their success to the process (not the treatments)
This is probably the most heartening comment.
We talk a lot about this. Focus on the process, not the outcome.
Exercising for pain relief* is not the same as exercising for strength gain where you have a specific 1RM goal or exercising for endurance sport where you are trying to race a marathon in record time.
Pain is a phenomenological experience. You either have it or you don’t.
That means you don’t necessarily see your pain decrease as you can squat more weight. Likewise, being able to do a perfect one leg squat doesn’t mean your knee pain will go away. These are outcomes that are focused on fitness-type goal.
You are pegging your pain outcomes to strength or function. But pain is more than that!
Quite often we do prescribe exercises like one leg bridges. The goal is not the strength gain or the being able to do them perfectly. The goal is to change your pain experience through movements and exercises. What we are interested in is to see how your pain exchange change as you do the exercises.
The strength and functional gains are of course good to have. But remember they are secondary to the pain goals.
Focus on the process. Doesn’t matter if you can’t do certain exercises well because that is irrelevant.
*Applies only to clients whom we are working with on pain management. Injury management is a different ballgame altogether
#3: Most clients agree working with Square One is a bilateral process
The clients who responded best under our care are those who have a good working relationship with us. This comes as no surprised. This is well documented in academic literature as therapeutic alliance or working alliance.
If you look up the meaning, the dictionary defined it as the relationship between a psychologist and a patient. Its usage today, however, applies to virtually all aspects to health care.
Therapeutic alliance refers to the positive social connection between a patient and a clinician. It is established through collaboration, communication, therapist empathy, and mutual respect. It is considered a core component of any therapeutic process and has a positive influence on treatment outcomes.
In 2018, a paper looking at the role of therapeutic alliance between physiotherapists and musculoskeletal pain (i.e. shoulder pain, neck pain) patients found strong therapeutic alliance to improve pain outcomes.
In 2017, a review of literature found therapeutic alliance to have benefits that may include increased adherence to exercise.
In 2015, an editorial looking at long term outcomes recommended that therapists have an ongoing relationship with each patient. The paper also suggest access to the therapist in the form online resources.
We 100% subscribe to building relationships with our clients and even prospective clients.
When it comes to online resources, there are no clinics of any kind that blogs as regularly as us. There are also no clinics in Singapore who write content that are high value and supported by high quality research.
To maintain a working relationship with all of our clients, they have direct access to me through WhatsApp.
Furthermore, we have a monthly Pain Schooled! workshop that is opened to our past clients as well.
We talk a lot about building relationships and, by extension, a community. The programs and initiatives we offer (i.e. free community clinic) reflect just that.
So, it’s super encouraging to hear clients bringing up the bilateral relationship they have with us. We believe in shared decision making, we believe in working with you, we go the extra mile for you to have a relationship with us. The result? Our patients get superior outcomes!
#4: The most challenging part to achieve recovery is commitment
This comes as no surprise. We are still working on this.
Let us be transparent here. There are clients who don’t respond to our care for various reasons. The most common reasons are:
- No availability within their current schedule to continue with treatment
- No time (or unwilling) to provide us with updates on their current progress
- No time, discipline, or commitment to do the exercises as prescribe
- No faith in the recovery process we offer (e.g. Google for exercises to supplement what is prescribed – yes, people do that)
- No faith in what we offer (and seek care from some one else)
- No time or effort in understanding to their pain, injury, or recovery
This is not a case of name and shame. These are real examples to why people don’t get better. I also think they are perfectly good reasons.
You might be thinking of seeking care with me because you woke up with the worst pain in your life. As of today, and perhaps the rest of the week, your top priority is to get rid of your pain.
Once the pain subsides to a more manageable level, your priority might change. You have work meetings to get too, you have weekly tennis games or runs to attend to, you have a date who needs your attention, you want to have fun and party.
These are perfectly good reasons. Priorities do change. We don’t see them as excuses.
In our intake form we ask how determined you are to get better and how confident you are of Square One getting you to your goals. Because we want to know how hard to push!
We don’t live with our head in the sand. At the end of the day, priority changes. Likewise, recovery/treatment outcomes change.
So there you go. The clients of Square One have spoken. Commitment is the most challenging aspect of achieving recovery.
p.s. As mentioned earlier, people do lose faith in what we offer. This means they choose to seek care elsewhere. This happens for a variety of reasons and most of the clients – unfortunately – are unwilling to share more.
We 100% respect your decision to take your recovery plans elsewhere. It is your prerogative to do so. We are comfortable with that.
#5: I “obliterated” one of my clients
In an un-moderated discussion among current clients about what it’s like working with Jesse, somebody mentioned brutal honesty.
In that context, of me (Jesse, the chiropractor) being realistic and overly truthful about what it takes to get better. In that if you are not ready to get better, come back later when you are.
From my perspective, there is a time and season for everything – including recovery. Like mentioned earlier, priorities change with time and life events. We 100% understand that.
This is also why we don’t do packages.
We don’t believe in running a business on the premise of tying our clients down with long, expensive packages. We believe in that you have the right to choose to come and when to not come.
A client who initially approached us for manual therapy, after our transition to a active recovery chiropractic clinic, said I “obliterated” him.
(That was his exact word. Harsh much.)
In the sense that I was sending him studies and blog posts about what we do now and what we no longer do, and also why what we do works. He added that it was almost like I didn’t want him as a client.
The truth is that I respected what he wanted. He was after a manual therapy service. I could in bad faith take his money and offered just that. But that is not us!
We believe in honesty and transparency. We also believe in educating prospective and current clients on what is the best clinical care based on the latest research. 100% bullshit free.
This is how you can achieve true informed decision making.
While we are fully capable of delivering manual therapy such as chiropractic adjustments or IASTM as a service, we choose not to. Because our position is clear: Manual therapy doesn’t work.
Just because you are willing to pay doesn’t mean we are willing to compromise our ethics to offer you a service that doesn’t give you long-term results.
Yes, we can do it. No, we politely decline to.
#6: Every client at some point referred to the prescribed exercises as “weird”
Our exercises change from visit to visit. Every client agree that they are weird. If you look at them closely, they are actually modified versions of very bread and butter exercises such as half squats, heel raises, leg raises, glut bridges, etc.
The reason they are weird it’s because you’ve never seen them before. And for good reason! These exercises are individualised to you as a person and your current presentation at the time of your visit.
We don’t believe in doing exercises for the sake of doing it or that it will just be “good for you”. We also don’t do one-size-fits-all.
Our exercises are prescribed with clinical intent. This means they address specific purposes and that you should see a tangible, observable outcome by the next visit.
This is the minimum we expect of our expertise. Of course you have a part to play in this as well.
Again, this is one of the reason why Instagram rehab doesn’t work.
Interesting enough, a client asked me today why are the exercises from week to week so different. There doesn’t seem to be a clear theme or progression.
From my perspective there is. I explained to the client that every exercise has its intent and purpose. Once you as a patient, have maximised its utility, there is no value in doing more of it. There are also times when we hit a “roadblock” where doing more of a specific exercise wouldn’t yield any better results. In this case, we might take a sidestep to work on other areas before revisiting that particular exercise again.
(Remember, process > outcomes!)
This is the beauty of rehabilitation. Everything has a part to play and, in good time, they come together to give you a full, perfect recovery.
Clinicians who choose to work with my test-retest and evidence-based approach are constantly on our feet thinking of what is the next best thing for you. It is a privilege and an amazing experience for us. It may seem weird and strange initially but trust us.
#7: There is a misconception that fitter and more athletic clients have better success rates
Some clients think athletic clients, particular those who are high performance athletes, get better than results than the average sedentary clients.
I would think so too but this is 100% not true!
Our best performing clients are individuals who are the type A corporate high flyers. They book an appointment, they make a decision to work out their neck pain or shoulder pain or lower back pain issue, and they commit to their recovery.
Most of these clients will take less than FOUR visits to achieve full recovery. (Not good for business at all!)
They come from different industries – directors at an international law firm, founders of international investment companies, F&B startups. You name it.
The bottom line, in our opinion, comes down to how determined you are to get better. It takes not just compliance to our exercise prescription, but also the hunger to understand your own pain and the willingness to take ownership of your pain experience.
So there you go, these are the seven take away lessons for me as a chiropractor at Square One Active Recovery.
You may think I know it all but there are plenty that we have to learn at Square One.
This is why we believe in a collaborative therapeutic relationship. We want you to come on board as a partner in your own pain management. We provide you with the skill set and education to achieve pain-free living. You provide the feedback to allow us to help you and prospective clients better.
Are you currently living in pain? Book an appointment with us today. Our chiropractic clinic is at 13A Bukit Pasoh Road. The nearest MRT is only two minutes away – Outram Park (Dorsett Hotel, Exit H). If you are coming by Tanjong Pagar, we are a five minute walk from 100AM Mall at Tras Street and Maxwell Hawker Centre via Duxton Plain Park.
Got a question? Drop us a message via our contact form below.