Friday, June 07, 2013

Melzack and Katz, Pain. Part 6g, History of Pain continued

The paper, Pain

Part 1 First two sentences Part 2 Pain is personal Also Pain is Personal addendum., Neurotags! Pain is Personal, Always.

Part 3a Pain is more than sensation: Backdrop Part 3b Pain is not receptor stimulation Part 3c: Pain depends on everything ever experienced by an individual

Part 4: Pain is a multidimensional experience across time

Part 5: Pain and purpose

Part 6a: Descartes and his era; Part 6b: History of pain - what’s in “Ref 4”?; Part 6c: History of pain, Ref 4, cont.. : There is no pain matrix, only a neuromatrix; Part 6d: History of Pain: Final takedown Part 6e: Pattern theories in the history of pain Part 6f: Evaluation of pain theories

At last, we return to the paper itself. [Thank you, both of you who read this blog, for hanging in there while I meandered through Reference 4.]

The section called A BRIEF HISTORY OF PAIN mainly is a cautionary tale, in my opinion, about the danger of basing all your pain research on only anatomical conceptualization.
"This rigid anatomy of pain in the 1950s led to attempts to treat severe chronic pain by a variety of neurosurgical lesions. Descartes’ specificity theory, then, determined the ‘facts’ as they were known up to the middle of the 20th century, and even determined therapy... The psychological experience of pain, therefore, was virtually equated with peripheral injury. In the 1950s, there was no room for psychological contributions to pain, such as attention, past experience, anxiety, depression, and the meaning of the situation. Instead, pain experience was held to be proportional to peripheral injury or pathology."
Melzack and Katz are talking about medical therapy, of course, but that is what physical therapy has always been attached to - a bio medical model of pain. Only lately has this started to change in any noticeable way. 

"Patients who suffered back pain without presenting signs of organic disease were often labeled as psychologically disturbed and sent to psychiatrists."  
Well, there is still a lot of this going on, depending where you live and work. 

Fortunately, things are turning around. Every so often now, one comes across a paper which emphasizes that non-specific effects of treatment are more useful to patients than any direct effects. I will be reading this one, as soon as I can get my eyes on it: check out the news story from just a couple days ago:  Physiotherapy patient interaction a key ingredient to pain reduction,  research says.  

 Jorge Fuentes holding a spine model in his hands. 

Jorge Fuentes PhD research in Alberta showed; 
"how a physiotherapist interacts with a patient verbally, through eye contact, body language and listening skills is almost as important as the treatment itself."

There were a total of 117 people, all with chronic low back pain,  in four groups:

Group 1: 
5 minutes of PT interaction, limited eye contact, didn't engage the patient, gave them some electrotherapy.

Group 2:
PT stayed with patient the whole 30 minute time, strong communication back and forth, same electrotherapy.

Group 3: 
Same as Group 1, but electrotherapy was not plugged in.

Group 4: 
Same as group 2, but electrotherapy was not plugged in.

Results? Group 2 did best, and group 4 came in second. Electrotherapy is just a ritual - it "works" whether it's plugged in or not, as long as the therapist also is interacting with a patient in a way that supports his or her nervous system's recovery. (Jason Silvernail and I wrote a letter about this, way back when.)

Is anyone surprised? The results (according to the news story, at least) included clinically significant decrease in pain scores and increased pain threshold. I.e., recovery from pain felt in the back likely has nothing much to do with any of the anatomy inside the back - only the nervous system's opinion about its "back", held in some neurotag of the "back" connected to everything else in somebody's life. 

So, it's interesting that in the picture, Fuentes holds a spine model in his hands, reddened disc bulge visible. I don't know why. Maybe he plans to toss it in the trash. Maybe it was a clever idea the photographer had, and nobody protested. See Paul Ingraham's piece on Scary Spine Models.

Models like this are iconic, actually. Sort of like crucifixes in churches. No manual therapy office is complete without one. Even mine.
I would hasten to add, however, that I performed a complete bulge-ectomy on the plastic skeleton that hangs in my office.  I took off every molecule of red disc bulge with fingernail clippers. It's clean now. You'd never know it ever had a disc bulge on it. Much better to remove the disc bulge on the icon - this helps them be removed from patients neurotags a lot easier. 

I remember David Butler, hollering as if way off in the distance, on an online forum, at least a decade ago, 

"We don't treat anatomy - we treat physiology!"


Please note (both of you) that I will be unable to blog over the weekend about this endlessly riveting paper, as I am busy teaching a workshop in lovely San Jose. I'll be back Tuesday or Wednesday. 


Malc said...

Both of us in our 000's Love it!! :)

Unknown said...

There are three of us.
Great blog! Love it.

steffens, martijn said...

great stuff..