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Applying Problem Solving Skills to Chronic Pain

chiropractic treatment, fast results
“The idea that patients who appear to improve in the first treatment session will do well longer term is not supported by the literature.” Source: Musculoskeletal Science and Practice

When it comes to recovery from chronic pain or injury, we have an expectation that we should feel better with each visit.

However, research tells us that feeling better after chiropractic treatment doesn’t mean you are going to get better faster. In short, how you are feeling alone is does not indicate recovery success.

This is where the confusion comes: How do you separate feeling better from actually being better?

How do patients know they are in fact recovering and not being taken on ride for their money?

Exploring an effective problem-solving process

pisa scores, singapore education, problem solving
B-S-J-Z refers to the four Chinese provinces (Beijing, Shanghai, Jiangsu and Zhejiang) that took the PISA. Source: Business World

Most people in Singapore are exceptional at problem solving.

As Jamus Lim pointed out in his General Election 2020 campaign, our PISA scores puts us at the top of the world when it comes to education.

Most of you are leaders at work. If you are not, you are probably involved in some form of decision-making one way or another.

You are familiar with making problems go away.

So much so that you probably intuitively do it without considering what are the steps involved.

What are the 8 steps to problem solving?

When it comes to your aches and pain, your symptom management shouldn’t be any different.

Because we don’t really take a systematic approach when self-managing our chronic pain, let’s take this opportunity to visit University of Iowa’s 8 step problem-solving process:

1. Identify the problem
2. Clarify the problem
3. Define your goals
4. Identify the root cause of the problem
5. Develop action plan
6. Execute action plan
7. Evaluate the results
8. Continuously improve

Steps 1 & 2: We are off to an easy start

chronic pain, pain solutions

When most clients come to see me, they are pretty good with articulating what the problem is.

The problem is easily identified and, with some encouragement and prompting, most pain sufferers will be able to provide a lot of details about their complaint.

Bear in mind that problems or barriers to recovery can include things that are outside of your pain experience.

For instance:

• Motivation or commitment to recovery
• Time management
• Personal finances
• Social, family, or peer support

In considering your problems or barriers to a good recovery, it is always useful to think outside of the box.

If you think about it, whatever you previously thought of did not give you the results you desire. This is a good opportunity to self-reflect on what you may have missed.

Step 3 is where most, if not all, clients would struggle with
smart goals, goal clarification, chiropractor singapore
Take an hour to work through what is really important to you. Once you figured out what it is you are after, set some tangible goals that you can start working towards. Source: VComply

I use the SMART goals criteria at my practice with all of my clients.

I highly encourage you to use the same guide to work out what you truly want to achieve with seeking treatment.

There is research to suggest that people with clarity of goals achieve better results. This is true for both therapy and also work performance.

There is no other way to say this: goal setting is always worth your time.

Even if you are looking to self-manage your own pain, it is a good idea to have clarity of what you are trying to achieve.

Often people don’t feel better because their goals change too quickly or they forgot what their goals were. For this week they may working on their neck ache from sitting at a computer but just last week they may be working on the neck pain they are getting from their weekly HIIT classes.

That’s not to say that you cannot have two goals. You totally can!

If that’s the case, you want to be mindful that achieving just one of those goals — being able to sit at the computer without neck ache alone — is progress.

Patients who are excessively problem-focused also tend to forget the good things that happen during recovery.

Just yesterday, I asked a client how close is he from attaining his goals.

He sheepishly smiled and replied, “I have forgotten the goals I have set.”

In this case, it is totally okay because we have gone through the goal setting process and I did record them down in my notes.

You see, it is with these goals that we are able to do an assessment on how far we have come and how close we are from your goals.

When in the problem talk head space, it’s very easy to miss the forest for the tree.

This is why clarity is important.

P.S. It’s definitely a good idea to also understand what type of change (technical vs adaptive) you are working with. You cannot solve a problem in the long-term without some form of change.

An infographic from a study published in Lancet to reveal the outcomes and benefits that are desired by patients living with depression. While we may all experience chronic pain, our symptom experience can be completely different from one person to another.

Most clients would share that their goal is to be pain-free. While I appreciate that being pain-free is indeed the ultimate goal for most chronic pain sufferers seeking treatment, the nuances of being pain-free can be striking different from individual to individual.

I have worked with clients looking to be “pain-free” so they can start their weight loss program, increase work productivity, improve sleep quality, save their marriage, or boost their daily moods.

Working with some one whose marriage is at an all-time low because of their pain experience is dramatically different from some one who is trying to increase their work performance so they can be the next CEO at their company.

While I don’t think any research has been conducted to investigate the outcomes chronic pain sufferers are looking for, the study just published in The Lancet reminds us that people living with depression do not just want to be sadness-free.

This is overly reductionistic.

If you are thinking you want to seek treatment because you want to be pain-free, perhaps take a few moments to dig deeper to consider what made you decide to seek treatment now?

To get you started, these are some questions adapted from the study that you can ask yourself:

• What is the most difficult aspect of chronic pain to live with or endure?
• For you personally, what may improve with treatment?
• What prompted you to seek out a chiropractor or physiotherapist?
• What may make you consider yourself as recovered?

Step 4: Finding root causes DOES not apply to musculoskeletal pain or injury management
chiropractor singapore, pain management, root cause
When it comes to effective pain solutions and finding true freedom from pain, we no longer take a root cause approach. The cup analogy is the best evidence approach to being pain-free.

I’ve blogged about why working from a problem-based approach will lead to poorer treatment outcomes. There is plenty of good data to support that!

If you really want to work on “root cause”, think of them as contributors or stressors instead. Note: plural.

In other words, what are the things that will make your symptom experience worse?

It’s important to know that what is making your pain worse is NOT the same as what is causing your symptoms.

If you were to cut your foot while trekking and only notice the pain when you take a shower, the running water is aggravating or initiating your pain experience. However, the running water is NOT the cause of your pain.

You may then decide to take your affected foot out of the running water and you would feel better immediately.

problem solving, post hoc ergo propter hoc
Post hoc ergo propter hoc: A fallacy all of us a guilty of. We often mistake a cause-and-effect relationship between two events just because one happened after another. I feel less pain after an adjustment → I am in recovery.

Some chiropractors or physiotherapists will misleadingly sell this ‘feeling better immediately after treatment’ as addressing the root cause.

However, from this example, it should be clear that feeling better alone doesn’t indicate what the root cause is or address it!

What makes your pain hurt or doesn’t hurt tells us exactly just that – what makes your pain hurt vs doesn’t hurt. We refer to this as contributing or aggravating factors.

Furthermore, it’s impossible separate root causes from contributing factors. It is super important that you do understand how pain works and that singular root causes don’t exist because pain is a complex, multifactorial experience.

There is just too much that goes into a pain experience for us to be able to tease out a single cause.

Steps 5, 6 & 7: Let the action begin

Very few chiropractors and physiotherapists in Singapore actually work with patients on an action plan. It’s kinda unfortunate.

For most parts, health professionals will dictate what is best for the patient and provide the appropriate treatment.

My question for them is, appropriate for whom?

what is coaching, coaching vs mentoring

This is why I take a coaching-based approach to managing chronic pain. The clients whom I work with are equal stakeholders. We share control of the recovery process and co-construct long-term pain solutions.

Arguably, having ownership of your pain solution is the only way you can get genuine long-term results.

The upside to a coaching-based approach is clear. But don’t misunderstand that to be an easy process. For most parts, clients find this a hard change.

So I am going to address steps 5 to 7 together because I think they exist within a continuum.

Of course the starting point is an action plan. This should be largely based on the goals you have set for yourself. In some cases, the chiropractor or physiotherapist may have an input because the goals may be a little too big for a start.

collaborative healthcare, coaching
It is true that I am the chiropractor and I know what it takes to diagnose and treat chronic pain. This makes me the subject matter expert. Here is what most people forget, YOU are the expert of your own life. It is impossible for anyone to achieve meaningful pain outcomes without actively collaborating with you.

Again, we co-construct the pain solution together. Both you and I have some say in how recovery should look for you.

It is true that for the first two to three visits, the chiropractor or physiotherapist may have a larger say. This is because part of my job is to keep you safe through recovery. I cannot afford to allow you to do whatever you want without first understanding how your body will respond. You can use this opportunity/period of treatment to understand load management.

After the first couple of sessions, I would have clarity to how your body responds to exercises/treatment. This is really steps 5 to 7 happening at the same time. We decide on an action plan, you execute the action plan between sessions, and we will evaluate the results during the follow ups.

It is super important to know that this is a test-retest period.

We are testing a variety of exercises (could be physical or even non-physical) to see how your body responses.

This means you could feel worse. And that is totally okay.

Super, super important to get on board with this because it’s more important to know for sure how your body responds and to stick to a process than to set an action plan based on how you are feeling or assumptions of what the root cause is.

If you have had other treatments that delivered underwhelming results, it’s probably because they didn’t have a test-retest process.

process over outcomes, results driven

Most healthcare professionals would (literally) eyeball the problem or perhaps prod your body around to see where’s a good place for a chiropractic adjustment, stretch, or massage.

Some would take x-rays to “find the problem”. However, research doesn’t support that x-rays improve clinical outcomes. Ironically, imaging has been well demonstrated to worsen pain outcomes.

If your pain management specialist is not tracking your progression beyond a “how’s your pain today” question, you should 100% seek a second opinion.

Can you imagine if school or university graduation examinations come down to a single “how’s your competency today” question?

We intuitively utilise test-retest strategies in everyday life.

From how much sugar to cut out of a cake recipe to how much seasoning you use in your instant ramen, we apply the test-retest principles.

Why would you not do the same thing for your recovery?

Step 8: The reason people pay a premium for Square One Active Recovery

I am immensely passionate about continuous improvement. Both for myself and also my clients.

This is what my clients pay for — a viable long-term solution that genuinely makes my own services redundant to them.

You can read more about what my clients have to say about my fees.

I also care a lot about empowerment. That at some stage my clients need to be able to drive their own recovery AND manage their risk of re-injury.

Why do you think I blog so much?

It’s because education a huge part of the recovery puzzle. For some of you, recovery is an easy change (i.e. know-do cycle).

All you need is a little evidence-based information to push you along.

I mean, come on, there’s so much broscience and fake news out there. Just Google posture or running causes “wear and tear“, you will get tons of opinion pieces without any credibly citations. For the lack of a better way to put it, it’s all junk science.

With the wrong information, you are of course not going to get better.

Sometimes recovery can begin with doing less of the things that do not work.

Choose process over feelings (or outcomes)

chronic pain, chiropractor singapore, solution-focused
We think that injury and pain are a direct correlation. I feel less pain, therefore I am getting better. Well, not quite. In normal healing vs. pain (left), the pain subsides BEFORE tissue healing is complete. Just think of the last time you cut yourself, the pain usually stops before the tissue healing is complete. In chronic cases (right), the tissues actually heal first but the pain levels remain elevated. This is why adequate pain management is tricky. Source: British Journal of Sports Medicine

It’s understandable that people follow how they feel when it comes to choosing their own recovery for chronic pain.

My opinion is that that is the worst approach to managing your pain.

When it comes to other areas of our lives, we tend to be more intuitive with focusing on the tasks and the processes rather than just the outcomes.

If we look at weight loss, most of us are capable of starving ourselves for a week or two.

However, we know that that is not sustainable. So, when it comes to making our excess weight go away, we develop a strategy that looks into the long term.

Instead of aiming for a dramatic reduction in weight, we can focus on improving our relationships with our food, being mind of our diet/energy intake, rethink our physical activity levels/energy output.

We don’t give up after a week of taking the stairs because there are no results.

In fact, we are likely to shy away from weight loss strategies that promise immediate, dramatic results. Virtually all of us would be familiar with yo-yo dieting that comes with fad diets.

We want to avoid that because we know it doesn’t benefit us in the long run.

May I invite you to adopt the same mindset when it comes to working with chronic pain?

achieve mastery, small steps, success coach

May I invite you to look into the long-term and focus on creating sustainable change?

May I invite you to choose the process over the outcomes?

I know it is frustrating when you pain always comes back. I also know it is frustrating when everybody promises results but you don’t seem to be seeing any of it.

It’s a tough situation to be in. I empathised with you.

While there’s a lot about pain management that we still don’t understand, there’s also so much that we already know but chiropractors, medical doctors, and even surgeons are not talking about.

If you are sick of receiving mediocre pain treatments and you would like to give my evidence-based solution-focused approach a shot, book in an appointment with me via the form below to discover the difference the right care can make.


Frustrated by the lack of results-driven and ethical chiropractic clinics in Singapore, Chiropractor Jesse Cai found Square One Active Recovery to deliver meaningful and sustainable pain solutions.

Our goal? To make our own services redundant to you.

*We do not offer temporary pain relief such as chiropractic adjustments, dry needling, or any form of soft tissue therapy.