I had an interesting medical experience in my role as a medico for the Melbourne Football Club aka the ”Demons’ in the AFL (Australian Rules Football) competition in 2007. One of the younger players developed difficulties breathing within a few minutes of the start of the game. Dr Andrew Daff and I were in attendance but I was the ‘first on’ medico for that day. I examined the player and was reasonably confident that he had a pneumothorax  which is air in the chest cavity between the wall and the lungs. This is a problem that does occasionally occur in contact sports as a result of trauma but Ricky (his name) told me he could not recall having had a knock at all. Ricky then steadily deteriorated to the point of losing consciousness which made me concerned that he had a life threatening spontaneous ‘tension pneumothorax’. I inserted a large cannula (needle tube) into his chest to release the air that was compressing his heart and stopping the flow of blood after which he rapidly regained consciousness and starting breathing easier again. After a short while the critical care ambulance officers that had been called arrived, praised the proceedings and took over his care. He subsequently was found to have congenital (born with) bullae (blisters) on his lungs that were dealt with surgically and he went on to have a reasonably long and successful football career with two football clubs. We have kept in contact with a special bond between us as a result of this experience.

(NB: they spelled my name wrong in this article! If you are going to have 15 minutes of fame in a lifetime wouldn’t it be nice if the spelling was right …?)

This event attracted considerable media attention because it was in the public eye and involved an AFL player. Realistically, such life saving activities occur regularly in ED, ambulance and other environments involving ‘regular’ people with no media hoo-ha. Nevertheless, I have to say that I did enjoy my ’15 minute of fame’ at the time. My elderly father (86 at the time) heard of this event. He is a devoutly religious Jewish man who has shown great tolerance to his son for not following him down the faith road. He quoted something from the Talmud to me on hearing of my much publicised experience. The Talmud (Hebrew for “study”) is one of the central works of the Jewish people. It is the record of rabbinic teachings that spans a period of about six hundred years, beginning in the first century C.E. (Common Era) and continuing through the sixth and seventh centuries C.E. My proud father stated the following:

“Saving one life is the same as saving the whole world”

The actual quote from the Talmud is a little more interesting and is the following:

“Whoever destroys a soul, it is considered as if he destroyed an entire world. And whoever saves a life, it is considered as if he saved an entire world.”

What an interesting concept for the medical profession to consider how importantly each and every interaction and opportunity to ‘change people’s lives can actually be perceived.

The segue to my current work in pain management is as follows:

In a previous blog I apologised for my past approach in my clinical practice where I ‘judged’ people in pain when they didn’t respond to my narrow-minded attempts to fix their structural problems alone. I stated that I obtain much greater satisfaction now than I ever did before, in my newer pain science prioritised practice.

Sure, I used to have what I thought were ‘wins’ previously but I left even these patients vulnerable to future problems with their pain issues by reinforcing in their minds that pain and structural tissue damage are reliably linked. I didn’t know any better. When I ‘win’ now I provide people with the knowledge and skills to ‘save’ and protect them on a long term basis. In addition to that, I am also seeing patients in chronic (persistent) and amplified pain make remarkable turnarounds on a regular basis. These patients never really benefited meaningfully from my previous methods. And all this is done safely.

I feel like I ‘save the entire world’ quite frequently these days. Instead of returning home after a consulting session in which I struggled to objectively see consistency of outcomes, I return home frequently buoyed by the meaningful improvements made; many of which even still surprise me in their extent. I had a particularly good example of this the other day when a smiling, young lady of 26 years of age turned up in my waiting room just last week. But the story didn’t start there …

This lady was referred to me approximately 6 months earlier. Without going into laborious detail, and mindful of privacy issues, her pain was fairly wide but centred around one of her hip regions. There was no specific injury and her pain had been there for several years and was severe, constant and very easily aggravated. She had had to cease many normal activities including part of her studies, and her life was profoundly affected. She had been managed in the standard manner before seeing me and arrived with an abundance of previously advised ‘diagnoses’ eg: a “slipping sacroiliac joint”, “tension in the glute”, “psoas strain” and “nerve pain”. There was recent focus on the hip joint itself and an expectation that, as a sports medicine doctor, I would be providing her with magical injections to ‘fix’ her. She was quite desperate to rid herself of the pain which was completely understandable. The problem was that her pain did not fit at all well with a ‘fixable’ structural contributor and she did not know that there was any other explanation for pain apart from injured and damaged body structures.

I advised her that I was not comfortable performing a potentially harmful intervention for a pain presentation that did not make sense unless a pain science based perspective was considered. I asked her to consider this perspective, gave her an introduction to it and asked her to visit my ‘pain literacy’ website.

She had already had investigations of her lower back and sacroiliac joint (which were thankfully normal) but prior to seeing me a MRI scan of her hip had also been organised. I told her I would follow this up when available to make sure that there was no ‘red flag’ diagnosis and that all other changes would have to be considered and explained very carefully.

When scans are done in non-traumatic pain, and especially persistent pain the results that are obtained fit into three categories. They can be ‘normal’ which should be reassuring, but people in pain sometimes find this frustrating and not reassuring at all. They can very, very rarely show a ‘red flag’ diagnosis eg: infection or cancer, which is clearly important, but is RARE. The vast majority fit into the ‘there is something there’ category. The great majority of these changes are also seen abundantly in people with NO pain or minimal pain. This means to the logical observer who understands pain that just because there is pain and there is a ‘change’ the two things are NOT necessarily related. For others, these discovered changes present lucrative ‘targets’ for interventions that have no evidence of direct effectiveness but do have potential direct (and indirect pain perpetuating) harms.

In a typical unwittingly alarmist manner her obtained hip scan report stated the following –

“Right moderate cam lesion which disposes to cam-type femoroacetabular impingement. There is an associated superior and anterosuperior labral tear present …”

Even if you are not medical, this sounds bad doesn’t it?

In the interests of reducing the already considerable size of this blog I won’t explain these findings in detail. Google search this and you will mostly see the scary explanatory stuff based on the opinions of those intent on ‘fixing’. You will also find a small body of data that suggests this is not a big deal at all but merely a relatively recent ‘fad-equivalent’ diagnosis to justify interventions including hip surgeries in many people, while possibly producing real benefits in only a few (this group is described in the next paragraph).

Groan …! After getting this result I knew I would have be working uphill to try to explain to someone searching for a fixable ’cause’ for pain that this sounds horrific but is seen not uncommonly even in younger people with no symptoms. Furthermore, from a mechanical perspective it should only produce a protective pain response if kicking a football or hurdling or similar ie: loading the hip in a highly bent / flexed position. It was not an explanation for constant, unrelenting and very easily aggravated, persistent, non-adaptive pain. My notes indicated that her hip was not particularly restricted or irritable when examined slowly and carefully and with some distraction by chatting and asking questions at the same time.

This young lady lived quite far away and so when I obtained the hip scan result I communicated my concerns via a few emails and a direct conversation with her referring physiotherapist.

There was some engagement but then radio silence; I never heard or saw this young lady again … until she turned up in my office about 6 months later wearing a smile.

She (and her physio) ‘bought in’ to the pain science prioritised perspective provided, but I never knew it, and her pain improved. She had even gone surfing and surprised herself at how OK she felt! She has resumed her studies. We discussed her current improved state, she thanked me and I thanked her right back! What a beautiful smile and what a contrast to the desperate, upset person in pain who I met about 6 months previously. She tells me that she still has pain episodes and these can be amplified and severe. I have advised that this is most likely due to a longstanding sensitised pain processing system with many well-intentioned but unhelpful contributing inputs over a three year period. However, I am confident she is on the best and safest path to her best recovery and she seems keen to continue in this direction.

There was one more important component to her recovery and ability to get her life back. She told me that at some stage she met someone about her age who had hip pain, had a similar scan, injections and at least one hip arthroscopy procedure to try to ‘fix’ the damage. His pain had worsened and he was on daily morphine with more surgery planned; even possibly hip replacement surgery at his young age. The problematic ‘carrots’ discussed in the previous blog in this series incentivising her to seek interventional treatment were dealt a blow with this information and this helped her ‘buy in’ to the safe and empowering pain science based perspective and a fresh rehab program.

This case also reminded me of a contrasting and scarily typical case review I performed in my job doing such case reviews for motor accident and worker’s compensation patients. It was a case involving a 38 year old lady who had a relatively low intensity ‘rear ended’ motor car accident but felt hip pain afterwards. To cut a VERY, VERY long horror story short this person’s pain has persisted beyond about six surgeries, perceived short term benefits (weak placebo?) and at some point extended similarly to her other hip with similar management. Her scan results of both hips were almost identical to my young lady as was her pain presentation. On each surgical occasion she gained more scarring and minimal real beneficial change despite amplified claims made by her hopeful surgeon who is a highly credentialled hip joint specialist. At her relatively young age her clever surgeons (she was sent for a second opinion and had her last surgery from another surgeon) are doing more extensive ‘reconstructive’ surgery using tendon grafts etc, simply because her pain won’t go away (in a compensable – ‘there is someone to blame’ context). This patient was never given a pain science based explanation; instead her many structural diagnoses have been repeatedly speculated and offered as ‘expert opinion’.

Quite apart from the completely unbalanced surgical viewpoints based on discovered scan changes that wouldn’t have raised my concern, it is of interest to see what this person’s specialised physiotherapist was telling her. This is presented via this direct quote as I couldn’t paraphrase something this absurd if I tried –

“… After initial assessment it became obvious there was a deep damage to the musculature of both her hips … internal damage to both the attachments of a number of muscles which has led to a co-ordinated dysfunction between them … micro synchronisation problems … shock damage as per automobile accident leading to femoral head dislocation on a functional basis …”

I shudder to think what the future holds for this poor lady based on such dangerous, nocebo-effect inducing nonsense and other standard ‘fixing’ attempts. Her past is lamentable and her present is appalling.

It is important as a privileged health practitioner to do what it takes to ‘save the entire world’.

Many of us, without necessarily realising it, are doing the opposite and perhaps even ‘destroying the entire world’.

Is ignorance an excuse?

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. View all posts by kalfried