Qualified & Practising: The Diary of a Junior Physiotherapist [S1E6] - The Chronic Pain Enigma

by Nikki Anderton





In this blog series, Nikki is taking over to tell us about her experience as a newly qualified physio and to describe the joys, fears and challenges she meets along the way. She'll also share her tips which might be useful to some of you too!



ew year, new rotation - I have now moved to community rehab. Whilst feeling sad to have left my previous team, I am excited to take on a new challenge. Yet, the familiar fears and anxieties I have felt at the start of my first rotation and placements have revisited me, this time accompanied by a sensation of feeling slightly out of my depth (!).

Whilst the routine waiting list appears never ending with clients waiting on average 12 weeks to be allocated a physiotherapist (perhaps reflecting the pressures the NHS is currently facing), the handful of clients I have picked up somehow seem to overwhelm me. Upon reading over their referrals before arranging initial assessments, I can’t help but notice a bit of a common theme: Chronic Pain.

For me, these words are overwhelming and I am unable to place a finger on why.


Of course, as with any new rotation or job, it is normal to feel a little overwhelmed. Everything is new - the processes, the types of patients. I finished my last rotation feeling more confident in my abilities as a Physiotherapist, so why do I now feel so out of my depth?

Perhaps, because in one way, I am. Looking back at my time as a student, I never had any true experience to chronic pain. My five week placements did not seem long enough to follow any patient suffering with chronic pain through to the end of their treatment meaning I only had limited exposure.

At University, chronic pain was a topic we briefly touched on - I think we had one ‘What is pain?’ lecture where we differentiated theoretically, between acute versus chronic symptoms and the science behind pain, but when you are faced with a patient who has suffered for years, it is a whole different ball game. As a qualified physiotherapist, I can’t help but feel a little cheated by my lack of experience.


A snapshot into my first day on the job …


I visited a Turkish lady in her late 50s referred with chronic back pain. The initial assessment revealed that over the years she had become less and less active because she was experiencing increased amounts of pain. It was now a struggle for her to complete her activities of daily living such as climbing up the stairs, walking to the bathroom and preparing her meals. The assessment further revealed that her mood was low and she had gained a lot of weight over the past few years.

My next client was a lady who had Rheumatoid Arthritis and Lupus, however her back pain was her main complaint. The assessment uncovered that she no longer accessed the community and was also low in mood. It became apparent that she had always been a strong matriarchal figure in her family and was used to others relying on her, not having to rely on others. Over the years, this lady seemed to have exhausted most options available to her - hydrotherapy, the Pain Clinic, various pain medications and TENS machines, but still, her chronic pain remains.

It appears that for both of these clients, they have become increasingly inactive, their mood is low and their pain seems to have taken control of them.

As well as their pain, both patients divulged a number of complex issues that they were also dealing with and I soon realised how the BioPsychoSocial Model, which was a core learning objective in most University essays, must be considered in their treatment.

Take case study two for example. This lady’s arthritis is the biological diagnosis that she labels herself with and attributes a lot of her back pain to. Psychologically, she is low in mood and this is possibly because socially, she cannot access the community anymore, complete her housework or prepare her meals. Her locus of control has shifted to an external one and all of these different aspects have a role in a vicious cycle of disability. It becomes difficult to know which one should to be addressed primarily.


So, what do the guidelines say?



In the recent publication of low back pain guidance from NICE, exercise is recommended as a key intervention which offers leading opportunities for the physiotherapy profession. I believe that physiotherapists should also pride themselves on the abundance of other skills that they develop when training and throughout their career. On top of exercise, we have knowledge about behaviour change, the management of long-term conditions and we are uniquely positioned to facilitate the management of pain and to signpost patients to appropriate services.  

The guidance suggests using risk stratification such as the STarT Back risk assessment tool in order to inform your person-centred management. From this, it can be attained whether someone may be more appropriate for self-management support and education or whether they may need a psychological approach as well as exercise. It is important to know that acupuncture and electrotherapy are no longer recommended in the NICE guidelines for chronic back pain and sciatica!


“CSP Pain Myth Busters”

The CSP outline 4 myths about lower back pain which I have found useful to refer to and use as education tools with clients in the community. These common myths need to be busted as supported by the latest evidence (CSP, 2016).

Myth #1 : Moving will make my back pain worse.

Myth #2 : I should avoid exercise, especially weight training.

Myth #3 : A scan will show me exactly what is wrong.

Myth #4 : Pain equals damage.




How do I begin to assist my clients with chronic pain?


Firstly, I admit that my weekly supervisions have been my saving grace! When feeling overwhelmed, do not be afraid to approach your supervisor and talk things through. They are more experienced and have no doubt faced similar challenges before. Draw on their expertise and they can guide you through various treatment paths.

Write a problem list. After information gathering in the initial assessment, the picture the client has painted can seem rather daunting. Take things back down to basics and break the information down.

Goal set! SMART goals have never seemed so important and relevant when treating clients with chronic pain, especially in the community. Ask the client what do they want to be able to do again, making the goal as specific as possible. This will help both you and the client see (hopefully) positive changes in their function and ability.


With about two fifths of the UK population living with chronic pain (The British Pain Society, 2016), I can’t help but wonder whether I am alone with my lack of awareness on the topic? Reflecting back on my studies and exposure on placements, I feel as though students should be more prepared on this topic for when they qualify. Yet, perhaps it is the complex nature of chronic pain that poses challenges as to how it is taught and that actually, hands on experiential learning is the best way of developing knowledge on the subject. In which case, chronic pain will remain to be one of the toughest challenges newly qualified physiotherapists will tackle!


Further reading


A unified theory of healthcare - how it all links together (Part I: sleep deprivation, mental and physical health)

In this series, Andrew will look at current common approaches to managing pain and illness in our healthcare system. With the example of sleep deprivation, he’ll show how some factors still misunderstood and often ignored can lead to worsening health and poorer outcomes in some patients. He’ll also look into ways to improve rehabilitation of such patients by stepping away from some of our current health care beliefs. Read more ››



Nikki Anderton

About the author

Nikki Anderton

Nikki is a newly-qualified physiotherapist with a previous degree in Human Communication Sciences, currently working in a busy university hospital in East London. She was the first ever to sign up to one of our seminars when we started back in 2015; now a year down the line, she's our first ever resident blogger! Expect to see (and read) more of her very soon!