As I am a physiotherapist, I will begin this blog with topics that I am equipped to discuss. This is the run sheet for the first year of my blog. If this seems like something you might be interested in, stay tuned:
- Pathologising of pain.
- Payment paradox; placebo, nocebo and physiotherapy.
- The state of the union; who are we and where are we going?
- Mobility, stability and strength; the great debate.
- How much have movement screens done for you lately?
- Aesthetics and the damage done.
- Manual therapy; dinosaur or lungfish?
- I have no qualms in sticking you.
- Ditch the plinth bro.
- Specialisation and titling; where is the profession leading us?
- Triple M and evidence based practice; gurus, senseis, and the average physio.
- Open letter to the APA.
Setting the tone
I will deliver more about myself in upcoming blogs and explain more about the specific context from which my particular viewpoints are formed. I will state at the outset, however, that I deal with the ‘painful person’ every day, just as many of you do. This is my job, my bread and butter; we treat pain first and foremost. My constant pondering has lead me to the important question;
“Am I part of the problem?”
Pain and its evolution
This is not the forum for elaborating on the evolution and subsequent description of various physiological, neurophysiological, behavioural and social aspects to the pain picture. And I won’t. Suffice to say, there is a plethora of reading on the subject (1-5).
From Descartes almost 400 years ago, through to Melzack and Wall of the 1960s and even to the current pioneers in the field of pain science like Lorimer Moseley, Michael Sullivan and the Neuro Orthopaedic Institute (NOI) group, I don’t think anyone has argued that pain works. Pain is essential to survival. Pain behaviour and the communication of these sensations will increase our chances of survival, not only as individuals but as a species. Further, the human being’s ability to empathise with another who is experiencing pain is an enduring reminder of the really quite altruistic aspects of society as a whole. We all recognise somebody in pain, and will all lend a hand to comfort; more often than not this hand is in digital form nowadays.
But what is it about pain that you have a problem with?
While most types of pain result in a loss of Quality of Life, I am particularly concerned about the tidal wave of Years Lived (or Lost?) with/to Disability (YLDs) due to musculoskeletal conditions that we seem to be experiencing. Low back pain is a notable inclusion into musculoskeletal disorders by most definitions (alongside arthritic conditions and osteoporosis). Low back pain is placed by The Global Burden of Diseases study as ranked first for disease burden within Australia and New Zealand from 1990 through to 2010 (6). AIHW places musculoskeletal problems 2nd and low back pain as 3rd in disease burden in 2011; let’s call a spade a spade and hand the ‘pain’ we (health professsionals) deal with the number two spot (7). In essence, for people that continue to live, pain is really only eclipsed by mental illness. And I think the mental health community and its advocates have done something incredibly insightful that we, in the health field, have yet to do.
So what? Pain is a big issue, that’s why there are so many of us.
To expand; I think ‘us’ as a health professional collective may have a lot more to answer for than we would care to admit.
“Am I part of the problem?”
I think about this all the time. What exactly is the simple act of my interaction (let alone intervention) with this patient doing to the global system? As you might see, in the next post, I will explain a little more about why I’m in a luxurious position to seriously consider this thought. I want to make it clear that I am not taking the moral high ground here, I’m simply in a lucky position and have thus far experienced, first-hand, multiple different contexts of care. I am going to address the elephant; hello elephant.
There is an industry devoted to treating pain, and you’re telling me that by doing my job I’m adding to a global burden?
Well yes, I am.
F**$ you pal, and the horse you rode in on.
Understandable. To extrapolate, let us consider the Global Disease Burden study; if an industry was devoted to managing a certain phenomenon, doesn’t it seem logical that in 20 years that particular industry could have made a certain impact? But then again why would we want low back pain to come off the number one and/or two spots? Yes, before you mention it, I do also consider an ageing, more obese, less active population and an improved management of other chronic health conditions to confound these results. I still contend, however, this argument is valid and the answer may be subtler than just blaming it on fat people not moving around; there may be a subversive, pervasive force at play that is not yet fully realised. What exactly is the social value of pain in today’s world, in the Darwinian sense? Has the original utility of pain (to ensure survival of our species) attenuated somewhat due to the myriad of things the sufferer can get/buy/take/seek out? Pain is no longer associated with survival as closely as it once was. The modern mavericks for pain science have given us a lot of fantastic understanding, and I have to demonstrate my bias here; I think physiotherapists do the best job of incorporating this into practice than any other health professional out there. But therein lies the crux of my argument; does it make the impact on a population level that is required to reduce a global burden such as this? I don’t have an answer, but I do have a few points that may address the issue:
1. Change the response to pain and the behaviour of an industry devoted to it.
Do we need to start to change our own response to the everyday back patient that walks in the door? Does pain need to become the by-product and not the main intervention source for all professionals working in the musculoskeletal realm? Again, I think physiotherapists do the most by way of instilling confidence, focusing on function and restoring ability where disability may flourish instead, but as an industry do we need to start shifting our perceptions? Accuracy of language and appropriate use of resources is needed on a population level to make the impact that is necessary. We would need to recognise, and one day appropriately deal with, those people that may propogate pain throughout the population, essentially returning pockets of the population back to ‘pain-normal’. The STarT Back group out of the UK (Keele University) have made good headway in this regards, by way of stratifying the number of sessions given to patients according to psychosocial and behavioural response to an episode. In a fairly robust randomised control trial, a structured approach such as this was shown to result in greater mean health benefit (in Quality Adjusted Life Years) and fewer work days lost because of back pain (Hills et al 2011) (8, 9).
2. Normalising pain, like a similar push in the mental health realm, may mean social reinforcements to pain behaviour may also change.
With this, starting young is the key; again I don’t have many answers for this, but this is where it must start. We have all come across family units with a long history of chronic pain; children in these units have been indoctrinated and don’t have a choice in what vaues they will ascribe to pain. These family units theoretically skew a population into ‘pain-positive’ rather than ‘pain-normal’. A social environment that opens a discussion on why moving and living through pain (from musculoskeletal sources) is a normal process may have the ability to change the current context of pain. A top down approach with public education would potentially be necessary in this regard. I’m not, in any way, comparing pain to smoking, but public campaigns worked to change societal behaviours around this. Surely a measured public campaign from Governmental sources (instead of any one particular professional body) may eventually be a logical place to start?
So in conclusion, I don’t foresee a changing of the physiology of pain in the human being. Pain still works, it keeps us alive. What happens when you pathologise something so much, however, is that it becomes a problem. For ALL of us. Yes, it means more business for us in the future, but at what cost for society en mass? I foresee that to tackle this global issue, a perception shift is needed.
Here’s a link to a song that will soothe the cerebral synapses, or potentially anger them further.. If against all odds you stuck in until the end of the post.. Enjoy this banger, go on, you deserve it.. https://www.youtube.com/watch?v=mVR10CD2Alk