The Pallbearer

[Barrett Dorko]

It’s been a quiet week in Cuyahoga Falls…

Manny’s shoulder and arm and lower back hurt pretty much as they did a few years ago when I saw him the first time. But until a few weeks ago he had felt fine. Then he began having a great deal of pain, especially at night. A visit to his doctor revealed more tenderness and restricted motion than even Manny knew he had and when offered therapy he chose to see me again.

In Ubiquity – The Science of History…Or Why The World Is Simpler Than We Think Mark Buchanan writes a great deal about the problems inherent to any prediction when you’re talking about complex systems. He demonstrates this by pointing out that virtually all past events are explained from perspectives that are more convenient that anything else. There are simply too many factors to take into account and, being human, we settle for those few easiest for us to remember and imagine are most important.

“I’ve been thinking about it and I’m almost sure this happened when I had to carry that casket down those stairs,” said Manny. He went on to explain how he’d consoled his old friend on the untimely death of his son and then looked for a place beside the casket. At the last moment a cousin of the deceased told him to move to the front end and the descent began. “I felt the strain,” said Manny, “but the family was all standing around and I didn’t want to say anything. I was really stupid to do that, and now I’m paying for it”

Buchanan looks at every study of causation related to our understanding of history and then makes this clear: “The surprising conclusion is this – even the greatest of events have no special or exceptional causes.”

Think about that. And then think about all the time spent trying to discover the answer to the question your patients so often ask: “What exactly did I do to get like this? Please tell me so that I don’t do it again.” If causes are far too numerous to consider fully and if complex systems are often massively altered by tiny bits of stimulation (chaos theory states that they are), why do we try so hard to find the single thing responsible for what we see today?

Frederic Nietzsche spoke of this quest in the 19th century: “To trace something unknown back to something known is alleviating, soothing, and gratifying and moreover a feeling of power.” Clearly, the desire to know, or, at least, imagine that we do, often overwhelms our reason. On top of that, our love of story, especially one with coherence and structure drives us toward an explanation that isn’t relevant to any sort of care, but it sounds good. Heroes and villains are an added bonus.

I let Manny tell his story and I listened carefully. And then I said, “You shouldn’t blame yourself for this. Where we end up isn’t entirely up to us. You told me your friend’s son weighed over 300 pounds and attended that big Greek Orthodox Church downtown. What if he’d watched his weight and worshiped in that little non-denominational storefront place up on Cuyahoga Falls Avenue?”

Manny grew quiet and I sensed a shift within him. It was exactly what I’d been waiting for.

“Now,” I said, “let’s see if we can’t find your way out of this.”

[Jana OT]

Well said. I frequently have had similar experiences when may patients are admitted to our hospital after not heading their physician's guidelines for home bedrest. Or the elderly woman I met who attempted to move a pool table for her neighbor, unaware of the tremendous weight of the average pool table. I also find myself listening to their stories as they seem to feel a need to share and then gently taking their hand or placing a hand on their shoulder and prolem solving with them how we will manage from here. I have also found myself at times lost in that inner drive you speak of to find an explanation only to finally take a deep breathe and realize it really doesn't matter. I will add Buchanan to my reading list.

[Luke Rickards]

The latest edition of IJOM has just been released on Medline and I have been enjoying an article by Bogduk that reminded my of this post.

Bogduk seconds Barrett's approach with Manny regarding the laying of blame-
It has become convenient for some practitioners to blame the onset of back pain or its persistence on psychosocial factors, and to use the literature on risk factors as circumstantial evidence of this. This practice, however, is more a reflection of the practitioners than the patients. They use the psychosocial explanation in order to rationalise their inability either to formulate a biomedical diagnosis or to offer effective management. There is no evidence that psychological factors cause back pain or its persistence. There is no credible, biological model by which they might do so.

I've also attached a Viewpoint on this paper that has some relevant comments - The underlying thinking is that most episodes of low back pain in most people resolve uneventfully, and we can’t objectively identify any particular pathological differences in those who don’t recover. Thus, the concern is reversed - it’s not so much a matter of what’s happened to patients but why do some not recover as expected?care is required to ensure consistent, positive messages - what you say can undo what you do.

Luke

(I couldn't upload them. I'll send it to Bernard)

[nari]

Do we, as a profession, tend to lay the blame on an event (or two?) that has happened in the patient's life? I wouldn't have thought so...but the patient certainly wants to know and hopes to avoid circumstances where pain may occur again.

If the patient has been in a car accident and has a sore neck, then maybe the accident was a contributing factor. So may have been umpteen falls in the past, his job, his football...maybe all was well until the sandpile shifted; (to quote a phrase Laurence Gonzales uses in his book Deep Survival on another thread) a tiny shift in a potentially unstable structure.

I don't know of anyone who would tell a patient directly that X was the reason that Y has happened...but maybe I'm wrong. PTs blaming psychosocial factors alone for causing sudden traumatic pain is something else that I would expect never to happen.. but doctors tend to resort to anxiety and stress being prime reasons for a deterioration in health if there is nothing evident in tests.
Am I missing something here?


Nari

[Barrett Dorko]

Luke,

I really appreciate the quote from Bogduk. I am always asked, "Don't you think stress causes or at least contributes to pain?" The questioner is often someone who looks extremely hopeful that I will not become even more insensitive to their long-held belief that physical pain is often a direct consequence of unhappiness. They cling to this theory like grim death.

I can speak at this moment of Sam Keen's quote, "Stress means you're living someone else's life" and often begin to see some understanding appear in their expression. I extend this to not living our own physical lives and add that the philosopher John Searle felt that pain was the result of "plans thwarted and hopes dashed." To this I can add the concept of adaptive potential and point out that our tolerance for pain's origin (mechanical deformation for instance) can easily lower in the face of stressful situations.

I usually lose their interest somewhere about my mentioning Searle - but not always.

Nari,

When patients say, "Tell me what caused this so that I don't do it again" I ask them about being lost in a forest and how they got there isn't important at that point. They agree that what they're doing to stay there is more important and that finding the path out is what therapy must be about.

[Jon Newman]

I do think there is a difference between the onset of back pain and the clinical report of back pain. The latter, I would argue, is influenced by negative affect which might be why statements like "what you say can undo what you do" might be true.

[nari]

Jon, I agree; there is a difference.

Someone with back pain (or pain elsewhere in the bony structures) can adopt a 'wait and see' attitude and stay away from medical model practitioners. Usually, it gets better. However, anxiety about its possible persistence will drive them to a doctor (or PT). This anxiety is often increased, along with the pain, by tests which show degeneration, bits floating around, strange shapes and curves.
What is said by the clinician at that time counts a great deal towards resolution or not.
I have operated, or tried to, on the principle for a long time that " what we say can undo what we do". I also think a lot of PTs believe in that principle as well - the point of my previous post. Most of the time we are trying to undo what doctors have said to the patient.

Nari

[Jon Newman]

Thanks Nari,

I agree with your comments about "wait and see" although I'm torn about it. That is, most folks don't go rushing to their MD with each new ache and yet they get better. Here's where I'm torn. Perhaps it is during this interim that people develop unhelpful thoughts/behaviors. Early intervention may be helpful although it has its obvious drawbacks. Education for all (think public health campaign), as it pertains to pain, seems to be the smartest and may avoid the drawbacks of requiring "early intervention".

Is anxiety, fear or other negative affect the manifestation of lowered thresholds and tolerances or the cause of them? I'm ill-equiped to answer that with the type of authority worth listening to though I am fascinated by it. In the mean time I suppose it shouldn't matter so much as long as one is able to reset those thresholds and tolerances or reduce the deformation in the nervous system (as mentioned already by Barrett) or both in a way that relieves pain.

[nari]

It seems true that the concept of fear, anxiety and negativism is rather complex in the effect on pain. Chicken and egg stuff. It also seems true that education on pain can negate these effects. (Butler, Moseley, et al).

People who avoid doctors like the plague - and there are many, mostly males - seem to manage joint and other problems quite well unless they are competitive athletes or something like that. I've come across dozens, as we all have, who took the 'wait and see' stance and simply got on with life. They reported all was well down the track.

One thing amongst many which David Butler emphasised in his course was the fact that negative thoughts (gloom, doom, fear, anxiety..) were the strongest indicator for development of chronic pain. So my take is that someone with a painful spinal bit either thinks 'it will only get worse, so I had better do something about it' or: 'if I ignore it, it will go away'. Both situations can work out well.

Miseducation on pain is a classic example of undoing what we do with what is said. It still persists - don't bend over, don't reach up, sit straight, do a zillion core stability exercises, don't push pain, stop doing this....

What is the person left with other than fear avoidance and boring exercises?
I think of Louis Gifford's very wise 'pink flags'; list what a patient can do, not what they can't in the evaluation. From that point of view, I can readily appreciate Barrett's 'end of evaluation' if all it does is 'can'ts'.

It's complex but I think there is light in the tunnel - hopefully not a train.

Nari

[bernard]

Hi All,

Here is the files sent by Luke (you forgot a valid file extension).

[Luke Rickards]

Nari,

You make good points about the instillment or persistance of fear, and Bogduk addresses this in the article (thanks Bernard) Avoidance behaviour is based on experience, memory, cognitions and beliefs. It is largely the experience of patients that attempting activities aggravates their pain.
I find that one of the most potent effects of SC is that because the movement is both unplanned and surprising, any fear-based cognitions surrounding the direction it might take are bypassed (so to speak). Before they know it, people find themselves in a motion or postion that they believed would result in uncomfortable pain, but for some reason is now not painful (or not very painful). Challenging beliefs at this instant usually proves very productive.

Luke

[Barrett Dorko]

Luke,

What you describe has been my experience of a patient's ideomotion many thousands of times. Though I am careful not to claim that spontaneous corrective movement is not necessarily painless or painful, I would agree that one of the surprises common to its pursuit is the ease, power, precision and unexpectedly painless nature of its manifestation.

If only people would allow it - especially therapists who know how painful a choreographed may become but perscribe it anyway. When I bring it to their attention they all agree that improvisational dance is painless yet they never recommend it.