Writing pain

In my other life I’m an osteopath (think badly dressed chiropractor). I regularly see people with bad backs (1). In the book Lieutenant Franklin hurts his back (have I mentioned recently I’ve written a book?).

Before you read on, please be aware that this is more of an opinion piece on pain science rather than a fully referenced document. It’s also longer than the previous blogs. It does tie in with Lieutenant Franklin, Dr. Swann and the other characters and it doesn’t take a huge leap to see why pain science became part of the plot.

• there’s a ‘story arc,’ which is helped by Lieutenant Franklin’s injury.
• I’ve been advised to ‘write about what you know about’. (2)
• the current ideas as to why things may hurt are important to understand.
• one of the themes of the book is myths vs science.

What would happen if a government treated anything non-scientific like alcohol in 1920s America?

I’ve tried to explore this idea in the story. I’ve also attempted to present some current concepts about pain without being too preachy, heavy-handed or ‘ranty’. Given that pain is a great leveler, I think it’s useful if people in pain have an idea of what may be happening. I don’t believe I’ve detracted from the plot too much but I’ve pulled into the mix some concepts in manual therapy which are now being challenged. Keeping it simple, they essentially they boil down to:

In the red corner (“You shouldn’t use that colour, it’s inflammatory and associated with danger. You’re influencing your reader already.”)

• The bio-mechanical model of pain
• Passive therapy
• Posture and movement patterns being directly correlated with pain (they aren’t). (3)
• The idea of ‘pain nerves’ (they don’t exist) and tissue damage being solely responsible for pain (it isn’t). (4)
• A therapist doing something TO a patient.
• Encouraging dependence.

Vs.

In the blue corner (I think you can guess by now which model I prefer).

• The bio-psycho-social model of pain
• Active therapy and empowerment of the patient with a focus on psycho social elements as well as (not instead of) biomechanics.
• The idea that tissue damage is not always solely responsible or needed for pain. Pain is real but it is a perception; an output of the nervous system not an input. (5)
• A therapist doing something FOR the patient.
• Encouraging independence.

Some of the above may be dismissed as semantics but language is important (says the man trying to write a book). In my next post I’ll teach your grandmother how to suck eggs (see this by Matt Low and this by Martin Bonnevie-Svendsen on Adam Meakins’ superb Sports Physio site on the role of language in therapy).

Our knowledge and assumptions need to be challenged.

There are a lot of grey areas in therapy which are sometimes glossed over or avoided by practitioners. This can be for various reasons, some more benign than others. I don’t think there are many therapists deliberately setting out to mislead patients (though I have met a few I wonder about) but I think there are questions that need to be asked.

Is ‘experience’ a synonym for ‘bias’?

Facing up to questions is not always easy when your career has been built upon a certain set of beliefs, you identify with these beliefs and your income is riding on them. But if you are so insecure that you can’t deal with sensible questioning then you need a new job. You could consider becoming a cult leader charging exorbitant fees in pursuit of enlightenment or a guru selling a ‘new’ treatment or exercise regime (read this by Bret Contreras). We should have moved on from judging a technique’s efficacy on its age, how esoteric or holistic it seems, or purely on the basis that the ‘father’ of the profession had a long white beard. (If that continues, in a few years we’ll have health policy being dictated by ageing hipsters. Or Santa).

Massage makes most people feel good

Partly due to the bio-psycho-social model, my thoughts on what I’m actually doing as a therapist have changed over the years. With these changes have come more questions than answers (I’m hoping this is a sign of progress). These views may change again, though it’ll be easier for me if they don’t.

For the record, I believe that manual therapy is a ‘good thing’. I think it merits a supportive/ adjunctive role in dealing with pain and physical issues. This role still applies even if its efficacy is more due to psychological/ neurological reasons than mechanical. I don’t see this or the placebo effect as negative. The caveat with this is that we need to be honest about what we are doing, what we do and don’t know and open about the limitations. Just like with medicines, a short-term dose is usually ok, long-term treatment should be avoided if possible (unless the massage is just for ‘TLC’).

I’m biased. I use manual therapy in my job. I also teach other people ‘how’ to massage. This means I may not be as impartial as I should be when talking about it, no matter how much I try.

Confused yet?

For a very accessible intro into the bio-psycho-social model of pain, see these links:

Understanding pain: What to do about it in less than 5 minutes? (An animation).

Why things hurt. (A short, humorous TedX Adelaide talk by Professor Lorimer Moseley).

Explain Pain ebook by Lorimer Moseley and David Butler. Not free but HIGHLY RECOMMENDED! (And I hope I haven’t just blatantly plagiarised the book in this blog.)

How does this relate to Lieutenant Franklin, Nascimento, Dr. Swann, Orr and the Rukan bone-setter? In a few months I hope you’ll be able to find out for yourself. The feedback from beta readers is trickling in and I’m cautiously optimistic.

* * *

(1) Not bad backs, PEOPLE with a bad back. Big difference. Backs, whether ‘bad’ or ‘good’, usually have a person attached to them and that person has a brain and a nervous system. A person’s beliefs and expectations are probably more important in pain management than any physical treatment.

(2) I am by no means an expert in this field but I have had experience of dealing with it from both sides of the fence. Anyone who claims to be an expert deserves a respectful grilling. After all, if they’re an expert they should be able to answer the questions (yet should we trust someone who claims to have all the answers?).

(3) There is also a small section on sitting and posture in the book, which has survived the editing so far. In future I may address this in more detail in a blog. For now I’ll simply say that I think a lack of movement is more relevant than sitting itself. When assessed in isolation, ‘poor’ posture is not the same thing as, nor predictive of, pain. See this by Ped Carnicero (have I got your name right?) and this by Todd Hargrove.

(4) Pain nerves don’t exist. Nociceptive nerves exist but these are more like ‘possible problem’ nerves (‘Apollo 13 nerves’) rather than pain nerves. They do not transmit pain, just a warning that something may not be ok. Pain can exist without nociceptive activity.

(5) These are not my descriptions. If anyone can point me in the direction of who said this initially, I will happily reference them.