Blog 10: ‘I feel your pain’

What a lovely, empathic statement.

It just isn’t true.

No one can truly feel anyone else’s pain. Even those who are so empathic that they feel pain while considering other’s experiences, don’t ACTUALLY feel the OTHER person’s pain. They feel their own pain. Not even this poor fellow, written up in the paper recently, who is seriously in the wrong job:

(clicking on it makes it easier to read)

docfeel

The extraordinarily emergent phenomenon which is the brain’s protective pain response is a totally unique and individual experience.

In order to be able to categorise people in pain, standard question asking methods are employed and taught in medical school and as in any communication there are the usual interpretative and language constraints:

  1. Where is your pain?
  2. Please describe your pain?
  3. What makes it worse?
  4. What makes it better?
  5. What is it out of 10 at best and at worst?
  6. etc…

An array of pain descriptors and variables are then recorded and the pain is categorised into our neat little diagnostic ‘thought boxes’ eg: burning = nerve pain etc …

At this point it may be worth reading my blog on ‘> 50 shades of grey in pain’ to see how much of a problem this linear process can become unless we keep our minds widely open.

Now that my mind is receptive to the kaleidoscopic and subjective world of pain, I find the varied descriptors that are used utterly fascinating and I record them verbatim. They would merit a publication on their own! I keep hearing new descriptors and many don’t fit easily into our standard pigeon holes. And almost all vary with the passage of time.

Given my more recently gained awareness of placebo’s horrible twin brother – NOCEBO, these days I avoid ‘leading the witness’. For example I no longer use suggestive questions such as “do you have any leg pain?” when patients come in with back pain. It is amazing how often that symptom develops after being repeatedly asked the question!!

In the standard, medical-school-taught diagnostic process, a physical examination usually follows which is thought of as being a reliable addition to this process. What a shame that there is such a poor level of inter-observer reliability in these findings unless ‘red flag’ (ie: truly nasty) underlying conditions are present. In persistent pain, it is the exception to find documented findings in consistent agreement. My professional travels have convinced me that there is little value in this part of the process in a serious number of pain presentations.

And then investigations are done and we SEE things.

Just like you can’t feel someone else’s pain, you certainly cannot SEE pain.

Descriptions such as ‘painful arthritis’ are a major conundrum. This type of common phrase implies that the ‘arthritis’ or degeneration in the body is painful. Given that pain can exist commonly even in the absence of injury or degeneration, and considering that the vast majority of degenerative ‘arthritis’ is painless, seeing the two together does NOT automatically mean that one is causing the other.

Don’t believe me? Go have a full body scan.

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This entire diagnostic process has become accepted as valid via a ‘back flow’ effect. ie: if a treatment creates a desired outcome by being directed towards our ‘diagnosis’ then we were correct and the process is valid from the beginning. And so we keep pigeon-holing our patients using the outcome of their treatment as the ‘gold standard’.

A ‘gold standard’ is vital in medical research as it is the part of the process that is thought to be the most robust, reliable and reproducible. If that bit is correct then other parts of the process can be judged more reliably.

Hmmmm ….. but what if is incorrect and unreliable? What does that mean for the whole process?

We were taught that the diagnostic process was in this order –

HISTORY

Examination

Investigation.

The reason for this order was that the greatest weight should be on the story being consistent and making sense, and less on the examination as this is recognised as more subjective. The least weight of importance was on the investigation component. We were taught idioms such as:

“Only order an investigation if it alters your management”

and

“Treat the patient, not the x-ray (ie: the scan, these days)”.

I understand from discussions with medical students that these are still being taught, along with the good old Hippocratic – “FIRST, DO NO HARM”.

The worrying trend is how many patient records and specialist letters either start with the reported investigation finding AS THE DIAGNOSIS FOR PAIN (!!!!) or prioritise it highly in the ‘diagnosis’. This seems to be the case independent of the discordance of the patient’s pain and the possibility (? probability) of pain and structure having nothing to do with each other (blog number one). Near enough seems to be well and truly good enough. This process more often than not reflects the ‘end game’ of the practitioner rather than anything objective, and reminds me therefore of the metaphor of hammering a square ‘pain’ peg into a round hole.

Squarepeg

 

The emphasis is on structural changes in regions of pain which leads to regular comments that indicate that people seem to think they can ‘SEE’ pain.

And this process then becomes a common ‘pain catch 22’ in vulnerable patients because of the brain’s pain equation (ie: safety vs danger). Many patients believe experts without realising that the process is essentially just educated, process driven speculation; not hard scientific fact. This is a major problem when a pain literacy deficient view is the only explanation that is offered.

There is an abundance of such examples but a very recent personal one was a conversation with an orthopaedic surgeon who was proposing the usual knee arthroscopy and menisectomy (cutting away the ‘torn’ cartilage) for a compensable patient in his 50s who had persistent pain and the usual contextual issues. I am not going to detail why this was a very bad idea based on the individual circumstances. I am not going to elaborate on the poor relationship between such findings in knees and pain. I am not going to highlight again the evidence that such a procedure is of potential harm and very questionable effectiveness. The interesting thing about this conversation was that this eminent surgeon, who stated his credentials including his teaching status, also advised me that he was able to judge by appearance alone (ie: SEE) which meniscal ‘tears’  were painful and which were not. And that is what he taught his students. I don’t think I bothered to extend that conversation too much further; I simply wondered whether this surgeon and his students would perform well on a pain literacy assessment.

NB: The provided example above is problematic in knee pain; I won’t elaborate here on how much of a problem ‘seeing pain’ is in spinal pain and no one has really looked at most other body regions yet.

Furthermore,  when such procedures like knee arthroscopies are performed and are either ineffective or result in temporary perceived benefit, the seeds are sown for further intervention on the basis of what is SEEN. This following sort of comment is almost invariably made in such situations:

“… During surgery he had a large meniscal tear … however he also had significantly more arthritis than I had anticipated … I have explained that I expect this to continue to become worse and that  ultimately what will be required is a knee replacement …”

This common, nocebo-laden, ‘I can see pain’ comment assumes a linear relationship between what is SEEN, pain levels and management outcomes.

Hmmmm …. really??

So most with visible arthritis will inevitably get non-adaptive pain needing further surgery? I don’t think so. My 95 year old dad wasn’t told that and is doing just fine without any artificial orthopaedic assistance.

But more will have pain and perceive they require such treatment if they believe it to be true. That is the nocebo effect in unfettered action in everyday ‘expert’ clinical practice.

It is amazing how effective the exact opposite message can be in ‘arthritis’ if what is SEEN is downplayed, rather than upgraded.

As alluded to above, comments such as the one exampled assume that the intervention response is the ‘gold standard’ by which the whole diagnostic process is validated backwards to the very beginning.

What a shame that these ‘gold standard’ responses are so questionable if subjected to PROPER scientific analysis via well structured placebo ie: ‘fake’  surgery / intervention comparisons.

(NB: Prof Ian Harris’ new publication should be compulsory reading regarding our  dangerously loose and self serving scientific standards:

Harris

Even in this EXCELLENT publication, the ‘back flow’ effects which are likely involved in pathways to persistent pain in vulnerable people are not reflected upon; only the immediate outcome problems are considered. That task may be my job.)

What a shame it is also then that such a large number  of uncomplicated hip and knee replacements result in little or no significant pain relief.

So if the ‘gold standards’ are not true gold after all, it pretty much calls into question the whole paradigm right from the start of the process.

What is worse, this largely flawed process itself is full of information which feeds into the danger part of the brain’s pain equation perpetuating pain in vulnerable people.

Back to the drawing board??

Not necessarily.

At the risk of cliche overkill, it is not necessarily the case that the baby has to be thrown out with the bath water.

I have altered something very simply in my clinical practice. All I am doing in current times is changing the order of things. Instead of targeting structure first via investigations and interventions, once I am satisfied that I have considered ‘red flags’ clinically (the nasties eg: cancer etc), I introduce proper pain literacy FIRST and attempt to ‘calm the farm’ (sorry – another cliche). This is applied together with appropriate medication if required, and early ‘normalisation’ strategies. I tell people we can always attend to the other stuff later if needed; but not at the beginning.

I am aware that other early intervention programs have shown limited benefits. However, please factor in that my version of early intervention is via comprehensive pain literacy. As explained in my other website information this includes understanding pain neuroscientifically and includes VITAL information on the significant limitations of current management and funding models, neuroplasticity processes and placebo / nocebo responses. Patients in pain have a right to know these things before it is too late.

The anecdotal results in early injury / pain presentations have been spectacular and it is my intention to study this further and more formally.

But, please consider that this is a SAFE and INEXPENSIVE management pathway and as a result the onus of requirement of infallible proof is not necessarily as strong as if I was wielding a scalpel, or for that matter an absurd quantity of morphine, or a spinal stimulator device.

I could give many great case examples but this blog has gone on much longer than I intended already. Perhaps a sequel will be in order at some stage.

I am not investigating much and rarely referring to surgeons et al these days.

But then, I don’t have a compulsion to either feel or SEE someone else’s pain in order to help them. I just need to understand it.

 

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PS: I was accused by the orthopaedic surgeon referred to in the conversation in the blog above  of being “biased“.

I was also accused previously by a very eminent spinal surgeon of being an “idealogue” and not accepting ‘best available evidence in spinal surgery’ (how bizarre is that last bit of his comment?!).

I plead guilty on both counts.

Yet, strangely the accused is both guilty and innocent at the same time.

 

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Published by

kalfried

I attained Fellowship of the Australian College of Sports Physicians in 1995 and have gained extensive experience in this field both before and after that milestone. I worked for five years in the Victorian snowfields, before joining the Melbourne Football Club (AFL) in the mid 1990's. I was a medical officer there for a total of 15 years with Dr Andrew Daff, as well as another 2 years with the Collingwood Football Club in the VFL. I was appointed as the AFL Australian International Rules team doctor in 2011 and 2013. I have also supported other elite sporting teams including the Australian Diamonds netball team in 2012. My main current appointment is with the TAC and WorkSafe as a medical advisor on the Clinical Panel and on various projects, and I am also an Independent Medical Examiner. In addition to general sports medicine I have developed a particular interest in the neuroscience of pain, the potential to 'de-sensitise' persistent pain, the biopsychosocial management model and exercise & conditioning prescription.

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