A manuscript has just recently been submitted for publication with my contribution and collaboration. I have always been more of a coal face worker, basing my writings on my observations, supported by science and various references, but using a persuasive, metaphorical style. This was my first prolonged exposure to publishing in an academic style together with other co-authors. The manuscript is about helpful and unhelpful models of management of patients with injuries that have happened in the workplace ie: in a compensation context. From other blogs, I think it may be obvious by now that this is a particular interest area of mine. The only explanation that currently makes sense for the different outcomes in injuries in different contexts is via the available pain science.
I was honoured and privileged to be involved with five other authors who are highly credentialled and respected people in their fields and who I hold in great esteem. All authors were from backgrounds highly relevant to the important messages conveyed in the manuscript.
And so my Star Wars-esque spaceship landed on Planet Academia for my first visit.
What an interesting experience from another perspective.
Basically, Planet Academia is a place where, the indigenous (let’s call them –>) ‘academians‘ impose high standards and will only write anything that is robustly researched unless clearly stated otherwise. That is a very good thing. Any sneaky effort by me to insert some persuasive, metaphorical styling to my contribution was dealt with mercilessly (I now have repeated nightmares where I see those dreaded tracking cross outs), reminding me that this was a serious piece and not just another blog.
The writing standard was carefully worded and stringently referenced. The current editing process before publication is of a similarly meticulous standard.
My concern after this experience is based on my belief that there is desperate need for meaningful change in pain conceptualisation and the management model being used which is not the one strongly in play. Every day that passes condemns more vulnerables to steep downhill pathways that encourage undeserved persistent pain outcomes because of this model. Little meaningful progress is being made despite many similar highly robust academian publications over many years supporting such change. This is largely because this is there is another prevailing ‘first in, best dressed’ paradigm that is strongly in play and, for many reasons, highly resistant to change.
There are others on the planet pushing their own research barrows who care little for the uncompromising restrictions which the indigenous academians impose upon themselves and collaborators like me. Let’s call this rather large countering group on the planet – the ‘quasi-academians’. They are non-indigenous to the planet and the publications produced by this group, either subtly or overtly, provide thinly supported, yet influential, messages that support and perpetuate the prevailing, flawed paradigm.
So, to explain using one of my metaphors, if the sky on a regular day looks blue, indigenous academians will only write that it looks blue if numerous high level studies have been conducted to provide strong evidence for that statement. The problem with that is that there are also studies out there from the quasi-academians supporting that the sky is yellow, green, purple etc. But the sky IS blue! Just look at it.
Essentially, it doesn’t matter how obvious the problem is, nor how terrible the actual outcomes are. If you are an academian you can’t push your argument for safe change too strongly or persuasively, but need to stick to strict academian dialect in any communication.
For various ‘real world’ reasons in reference to pain, which will be elaborated upon below, that may not always be possible, and so the existing faulty, but more strongly driven paradigm continues its messy, unchecked progress. It is therefore the quasi-academians, who are mostly in control, pushing poor quality evidence more aggressively to suit their end game and perpetuating the existing ‘norm’.
In response, all academian statements that are based on observing the problems that are caused by such poor ‘evidence’ from these sources have to be diluted and stated carefully so as to avoid criticism of being unfounded or too persuasive in style. This happens to the point where the final publication can actually sometimes say very little, or just go unnoticed altogether. Meanwhile, opposing quasi-academian voices are nowhere near as concerned about how their conclusions are critiqued and are happy to believe their own quasi-science, push it and act on it; no matter how directly or indirectly harmful.
And so it seems to me that academic entropy* is created.
*Entropy is a borrowed thermodynamic term which refers to an overall lack of order or predictability and a gradual decline into disorder.
This is a big problem which the indigenous inhabitants of Planet Academia may be insufficiently aware is weakening the core structure of their planet.
Please recognise that I vigorously support the sincere scientific methods of the academians of Planet Academia; it is just that I can’t help considering that the Planet is smoldering as the indigenous inhabitants are playing a violin concerto.
And so this may be yet another catch 22 in the field of pain management which is relevant to research supporting meaningful paradigm change. The question is how to maintain research and publication standards supporting such much needed change while simultaneously being persuasive in creating an actual real world outcome, including effectively addressing the poor standards of others. These poor standards produce publications that are very much easier to digest, and therefore more influential. There is importance and integrity in maintaining standards but from a strategic, game-changing point of view, there are also significant consequences in ‘losing’.
I note that this recognition of poor research standards is being addressed by some academians, but wonder if this will be enough to strategically turn the tide:
It is just worth considering the limitations of current methods in battling poor quasi-academian ‘science’ and achieving true, badly needed change.
Is there relevance to pain literacy in all this? Absolutely!
As stated above, there has already been a huge volume of written material over many decades in Planet Academia of the importance of the biopsychosocial model in determining optimal outcomes with pain neuroscience at its core. Despite this, the practical uptake of this model has been very poor at all levels and the standard, faulty biomedical model management paradigm continues unabated. Pain science literacy levels, crucial to building solid foundations for pain management, remain perilously low in patients as well as health practitioners.
Despite this and in parallel, the therapeutic community has simultaneously made an uncomfortable transition to reliance on what is quoted as ‘best available evidence’. This term is used to justify potentially hazardous interventions and treatments with highly dubious effectiveness (1). This approach has advanced alarmingly due to many reasons including stakeholder profits and is amply supplied with material by the quasi-academians. It does not reflect the ‘null hypothesis’ requirement in science (demanded by true academians) that dictates that it is only when multiple attempts have failed to disprove a proposition that it becomes reasonable, yet still subject to scrutiny. Albert Einstein has been quoted as saying that “No amount of experimentation can ever prove me right; a single experiment can prove me wrong.” The true scientific process is relentless, not accepting.
In pain, the pendulum has swung very far to the end of the biomodel / structurally obsessed management spectrum on the momentum of various stakeholder interests, cognitive dissonance (2), poor quality evidence masquerading as science and convenient expediency. This pendulum swing has extended further being incentivised by insurer systems based on their trust in expert advice given, but with eyes closed to the type and trajectory of the outcomes being achieved.
An example of this is spinal fusion surgery for persistent back pain in general. Building on this example, and illustrating one of the messages of this blog well, is the manner in which spinal disc replacement funding was achieved via Medicare in Australia in recent times using the highly questionable model of fusion surgery as the comparator (3). The recommendation was for funding approval despite acknowledgement of the limitations associated with the fusion surgery comparator and despite noting the significant post-operative narcotic usage rates in overseas studies. This conclusion relied rather unscientifically on the expert opinion of three eminent surgeons that simply stated in opposing this inconvenient evidence that ‘this was not what was observed in Australia’. A subsequent Cochrane review opined contrarily (4) while not considering such geographic qualifications. This harmful procedure, and its older brother of spinal fusion surgery for pain, both continue to attract insurer funding despite copious research questioning the outcomes.
Given where the pendulum currently sits in prioritising a biomedical model approach to injury management and how wide and entrenched this simplistic conceptualisation of pain is, it is therefore predictably difficult to study the effects of a significant paradigm shift to where the pendulum should be swinging, ie: far enough to the other, biopsychosocial side, in current times. The pain literacy message is a ‘hard sell’ currently, to patients and, more significantly, to their treating health professionals themselves. A recent study illustrates this well (5). Conclusions were reached based on a study including pain education while still reporting the following crucial limitation of the study – “The internal validity and the compliance of the clinicians are difficult to assess. Only 50% of the patients were able to report specific content of the sessions which may indicate uncertainty in the providers’ compliance to the manual.”
So inevitably, optimal pain science literacy effects will be difficult to achieve, let alone study, and no doubt this will lead to continued support for the current management model in the absence of convincing, alternative, academic evidence of sufficient standard to satisfy academian requirements.
Hence, there will predictably continue to be no real change.
However, please consider the following from a logical +/- ‘persuasive’ perspective:
Should it not be considered a basic right for people in pain to obtain consistent, accurate information and education (this clearly includes optimal pain literacy) on which to base their many important and potentially life changing decisions?
Given the fragility of the neuroplastic pathways that are capable of cascading adversely after nocebo inducing thoughts are allowed to enter regarding perceived (but most often groundless) structural frailties, should it not be considered a priority to alter this common critical point in pathways to avert needless chronic pain outcomes?
Are health professionals not duty bound to avoid ‘harm’ and manage patients as the entire, complex people that they are rather than consider, simplistically, that technology has all the answers?
Is it not reasonable to consider that funding pathways should incentivise optimal outcome pathways and dis-incentivise others?
Given the described ‘pendulum-related’ difficulties in researching alternative management pathways, the alternative cannot be to continue to endorse and incentivise the prevailing biomodel management paradigm, pushed by the quasi-academians, that has been discredited not by just one ‘experiment’, but by many.
Let’s hope the indigenous academians figure out a strategic solution without lowering their own standards, so that academic entropy can be reversed. Then their planet can thrive in the way that it should, with flow on benefits to other regional planets.
- O’Connell NE, Moseley GL, McAuley JH, Wand BM, Herbert RD. Interpreting Effectiveness Evidence in Pain: Short Tour of Contemporary Issues. Phys Ther 2015;95(8):1087–94.
- McLeod SA. Cognitive Dissonance. 2014. Available from: http://www.simplypsychology.org/cognitive-dissonance.html
- Review of interim funded service: Artificial intervertebral disc replacement – lumbar. MSAC application 1090.1. Available from: http://www.msac.gov.au/internet/msac/publishing.nsf/content/BCDDBBD4F1F258DACA2576870083B3A1/$File/1090.1-Assessment-Report.pdf
- Jacobs W, Van der Gaag NA, Tuschel A, de Kleuver M, Peul W, Verbout AJ, et al. Total disc replacement for chronic back pain in the presence of disc degeneration. Cochrane database Syst Rev. 2012 Jan;9:CD008326.
- 1. Werner EL, Storheim K, Løchting I, Wisløff T, Grotle M. Cognitive Patient Education for Low Back Pain in Primary Care. Spine (Phila Pa 1976). 2016 Mar;41(6):455–62.