Oh Pain, Not So Simple...
By: Charmine Kay Bartlett
Pain had always been an enigma to me. It could debilitate all aspects of life when present. I find it as a form of disease looking inevitable sometimes, particularly with its reoccurrences despite interventions. It is true that the popular model of pathoanatomical or biomedical concept of pain experience was my fortress to clinical decision making for years. The Gate mechanism of pain by Melzack was a main framework. If physical therapy interventions coupled with imaging confirmatory bias, (which is still being practiced, sad to say) interplayed with no solid evidence of the linkage to pain and disability, patients would most likely be labeled as psychologically compromised. It is somewhat similar on the reverse i.e. when an imaging finding is not “normal, ” due to the profound details of the picture it represents, clinicians are quick to conclude an abnormality correlating readily to the patient’s pain experience. There is really no good relationship enabled between clinicians: MD, PT or psychologist etc. Each one would have their own way of paving through the puzzle, or say feeding each one’s ego. Thus, disastrous healthcare costs, economical burdens and unstructured optimistic outcomes for poor patients! But this is changing rapidly, only if insurance and healthcare companies would be on the same page with clinicians. Only if clinicians are given more of a time to independently decipher the individual patient’s pain experience, and only if the “financiers” would be a little more lenient with trusting the clinicians to do what they are trained for. Sentiments….
The pain neuromatrix e.g. cognitive functional approach by Dr. O’Sullivan and/or neurobiological / neurophysiological pain perception by Dr. Moseley, Dr. Butler, Dr. Louw etc. are not new but are currently gaining traction to understanding the heterogeneity of pain. However, it is true, understanding how the brain perceives pain now and overtime from interdependence of different components: physical, emotional, behavioral and psychosocial, I would still think understanding the basic biomechanical and pathoanatomical reasoning is still relevant in a sense for a clinician. Patients’ narratives may be repetitive or brutally say “boring” for a clinician, but listening instead of just hearing may substantially place pieces together, which could answer how/why/what patients need inorder to get relief. Most often, it is frustrating for clinicians to disregard (un/intentionally) patients’ perspective of their condition. This should not be the case. All of the above, chained as one, may lead into efficacious pain management! My opinion.
Clinical reasoning of a PT may be influenced by different approaches to pain management and classification systems/algorithms e.g. clinical practice guidelines, treatment based classifications etc., but it should not be bound within this context. Patient values, evidence based literature and clinician experience/expertise still bear the weight to a sound clinical decision. If a patient does not fit in a subgroup, reflecting back to the basics coupling with updated evidence may possibly create best intervention to a unique patient.
Medical screening is where a clinician begins the hands on. It is always important to determine if a patient belongs in the clinic or not. Red flags/yellow flags should be diligently recognized in the first place. PTs spend more time with a patient than any healthcare providers. Thus, vigilance to one patient at a time is good practice for a probability of more appropriate treatment or referral/consultation.
The concept of Pain Neuroscience Education is not new but it has been deemphasized from practice due to it being perceived by most in the profession as psychological profiling, which is not a forte of a PT. However, with emphasis on stress, fear, anxiety, depression and other psychosocial issues e.g. lifestyle/event being linked to recurrence or persistence of pain based on current researches and literatures, it makes sense to incorporate it in PT practice. The pain neuromatrix explains the changes that pain experience bring from stimulation of the dorsal horn (spinal cord) to somatosensory cortex (brain) wiring. It sounded like a huge concept for a non-medical person! But then, conceptualizing stories for patients to be more comprehensible analogous to the medical interpretation could help reset the wiring of the brain for that certain pain experience, and may lead into initiating a different pathway towards recovery. Theoretically or evidently, he said, she said… let’s find a consensus from here.
I concur that education (not only about pain) is integral to therapy but I also foresee barriers to making it successful with my geriatric patient population, which one way or another have decreased cognition due to dementia and/or has a psychosocial issue of being independent, that telling them what to do may cause difficulty with carryover. Yet, not always! Practicing resilience as an advocacy for my patient, may conceive a more positive consequence. That, I believe!
To be continued…