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.
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.
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.
Thank you for your post. I have read most of these references, i have attended and worked on NOI Group material with specialized instructors, as you know i am also an osteopath, i like to think i am open minded, i practice with as much evidence based information as possible, but i just cannot get my head around this. How does it work? How can we relieve pain? How can i teach my patients about this when i myself struggle with the concept? It is too different from everything i had ever learned, too scary to tell myself i can be in charge of my own aches and pain. How can anyone get their head around this? Talk about a change in paradigm! What i mean is… I also now have more questions than answers, how do you use this knowledge in your clinical practice?
good to hear from you and of course I know you’re an osteopath. I remember you from BCOM.
You asked a lot of good questions. Most of these questions are best answered by the people I have already linked to in the blog post. They all (especially NOI group) have a lot of good material that explains things on various levels in a much more eloquent, referenced way than I ever could. My explanations are a re-hashed version of their words.
As a resource to use both for your understanding and that of your patients I would point you to two of the links in the blog:
– Explain Pain (by Butler and Moseley) is fantastic.
– Greg Lehman’s free download. I highly recommended this.
I had slowly been moving towards the BSP model naturally after graduating. It makes much more sense to me than a purely biomechanical approach. However, I did get to a stage when I lurched too far into the whole ‘pain is in the brain’ idea and stopped looking at the physical component (read this by Adam Meakins for a nice take on this problem). I overlooked the ‘bio’ bit of BSP and just talked at people for the duration of the session once I had finished the assessment.
Some people I saw seemed to ‘get it’ with no problems and I had a few comments along the lines of people saying it made sense and that I had given them ‘permission’ to feel ok. In some cases that was pretty much all they needed, reassurance and advice on a graded return to movement (I wrote this which talks about this idea more).
Other people sort of understood. Most didn’t get it at all. They wanted a ‘structural’ reason for their pain and often someone to ‘fix’ that pain. This is a fairly common issue. Why? Not sure. Possibly due to:
– what many people are brought up with
– unhelpful (sometimes lazy) advice circulating in the media and on the internet
– vested interests
– it is taught this way in schools
– it is maintained by many practitioners
I still get the balance wrong but am slowly improving. After the case history I do an assessment, then try and combine the BSP elements. I try and talk while I am doing my manual therapy (mainly massage and mobs, I don’t manip much anymore) and then try and give homecare and exercises. I am trying to push exercises and homecare much more than manual therapy these days. It fits more with what I believe and what I am reading. The session is dictated by what the individual wants.
You mention it is ‘too scary too be in charge of your own aches and pains’. Yes, it can be daunting but empowerment (another buzz word I hope doesn’t go the same way as ‘holistic’) is important. Giving support to people to manage their own issues independently (but not in isolation!) is key to all elements of health. Where possible, we should be aiming to make people stronger and independent.
I still think manual therapy is a good thing to do and am ‘re-discovering’ it myself. I don’t regret sidelining it for a while, I think I learnt a lot through that process. MT has a place and can be effective. However, I have a lot of questions about the mechanisms commonly taught as to ‘why’ MT works.
Also, many people come to see and osteopath for MT. Not doing any (as I have occasionally done) can put them off. If that happens you lose any chance of trying to inform them of the BSP ideas, poor posture not being the same as pain, scans don’t always correlate with pain, the need for movement etc
It is a shift in thinking but one I think is worth doing. I wouldn’t jettison the ‘bio’ bit, I tried that with mixed results. Movement (rather than exercise per se) and education are the way forward with MT in a supporting role.
As for having more questions than answers, welcome to my daily headache! I have been working as a therapist for 16 years now, 10 of those as an osteopath and seem to have more questions than ever. I’m hoping this is a sigh of progress.
Hope this helps, please let me know if you have any more questions.