Álvaro Pinteño, pain expert: ‘For a physical therapist, the most difficult thing is to do nothing and explain why’

Álvaro Pinteño, 30, says that he too suffers from chronic pain, a problem that affects nearly 20% of all people. His experience helped him to understand how the phenomenon’s complexity — which involves both social and psychological contributing factors that go well beyond the physical origin of suffering — must be a part of the equation when it comes to the search for cures.

In his recently published book ¡J*der, cómo duele! (F*ck, That Hurts!), Pinteño offers a guide to better understanding pain through his personal experiences as both a health professional and patient, taking readers down a path that avoids simplistic explanations and clear-cut solutions.

During an in-person interview carried in Madrid, he recognizes how social media tempted him to offer the kind of advice that has proven so popular online.

“The less you know, the more confident you appear,” says Pinteño, who is convinced that “the most appealing messages, and the ones that people repeat the most, are the simplest ones.”

Nowadays, he offers a much more nuanced interpretation that references many scientific studies and culminates in a message of hope. Although it’s not easy, it is possible to get rid of chronic pain — or at least, learn to live a full life while experiencing it.

Question. What do we least understand about pain?

Answer. A person thinks that if something hurts, there has to be an organic reason behind it. In the majority of cases, that will be true, especially with more acute pain, but when pain is more chronic and persistent, and imaging tests don’t give us the answers we’re looking for, we start thinking that there might be another serious cause or something else that is being overlooked. And so begins the medical journey, with false diagnoses and treatments that do not take into account previous failed solutions, in which every health professional thinks they will do better than the ones who came before, and that they will find a solution.

But when it comes to chronic pain, it’s more about understanding what it isn’t — reaching knowledge through subtraction, by identifying what not to do. Often, the patient thinks that something is wrong with their body, but frequently, it has more to do with the body adapting to the environment in which the person exists — an environment that reinforces many dysfunctional pain-coping behaviors. That’s what we treat in our practice.

Q. A very common perception of physical therapists’ work is that they give massages to alleviate pain. What is a physical therapist’s real job?

A. What we do is help patients to actively deal with the problem that is producing pain. We give tools for them to know what they have to do when they are in pain, when they have a relapse. So that they know that in many cases, within 48 to 72 hours, the pain often disappears on its own, that they have that security and that cognitive flexibility to be able to live with pain and improve their quality of life.

Q. Sometimes placebo treatments are given so that a person feels like they’ve received care, because they won’t be happy if they don’t receive anything.

A. There’s a very important concept, particularly when it comes to patients living with chronic pain, which is misdiagnosis. You encounter patients who come to their consultation with a folder full of records, and the purpose of a diagnosis is to provide an explanation and offer reassurance and hope. I encourage taking the necessary time to go through all the reports that a patient has and discard those that no longer serve their purpose. There comes a point when patients begin to identify with their diagnosis label, and that becomes disabling. Their identity becomes that of a suffering body.

For a physical therapist, the most difficult thing is to do nothing and explain why. It’s hard to be the first person to suggest not continuing on with failed solutions, even if the patient asks for them, and to have that uncomfortable conversation about all those reports and how we’re going to bring a new focus to the situation. Nowadays, my patients usually know what they’re coming in for, but at first, I had to get over my fear of losing patients by having that conversation.

Q. Nowadays, there are many more ways to obtain information through all kinds of tests and many more treatments available. Is that a good thing?

A. We thought that with the advance of technology and the increase in knowledge we would have better treatments, but what has grown is iatrogenesis [harm caused by medical treatment], overdiagnosis, and naïve overtreatment. Medicalization has not led people to have less pain, and has sometimes even led to addiction issues, as is the case with opioids.

Q. How can that be remedied?

A. Everything starts with a good clinical history, a proper assessment of the case, looking at the psychosocial factors that influence it — including the experience of pain, where you hurt, how it hurts, and what the characteristics of that pain are. What beliefs, emotions and thoughts are related to the pain and how it affects you when you move. Often, we think that we can’t begin to work without a “why,” when really, once serious pathology is ruled out, the important thing is not the why, but rather, how the problem is functioning. With that information, I try to make sure that the patient has an idea of what is happening. There is an inevitable tension between individual and collective responsibility.

Q. It’s been said that there are healthy amounts of pain.

A. Nowadays, we’re losing the ability to experience healthy amounts of pain, because we have immediate solutions for practically everything. If we are hungry, we order food, we can watch any movie we want instantly, and at the slightest hint of discomfort, we can take medication. It’s also because we’re constantly expected to produce — we can’t afford to feel unwell, because if we take a sick leave, we risk being fired. Today, the moment a symptom appears, we turn to Dr. Google and self-medicate.

Pain is not a problem that is exclusive to the individual. You have a certain responsibility about what happens in your life, but there is also a collective responsibility. There are some burdens in life for which there is no medication or treatment, and pain can sometimes be related to one’s environment or to psychosocial factors that are not in the purview of a physical therapist.

Q. What do you think would have to change within physical therapy?

A. We have a problem with iatrogenesis, there are studies that say that it is the third most common cause of death in the United States. We treat many consequences that could have been avoided.

There are studies in which 79% of psychiatrists from a sample say that they would not take the medication they prescribe to their patients and would prefer a more conservative approach. Incentives in the healthcare system push us to intervene, even when it is not necessary. For years, I overtreated patients with invasive therapies that I would not use on myself, and many colleagues privately admit to doing the same. The fundamental principle must be first, do no harm. We should be more careful.

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