Problems with Pain
Introduction:
Dealing with pain is no minor problem, and it is a problem of personal, national, and international proportions. Chronic back pain is the most common cause of permanent long-term disability worldwide. In the U.S. alone, approximately half of the population is in a state of pain from all sources, and between 20-40% involve lower back pain. The costs are staggering, with economic impact estimates ranging from between $200 billion in direct medical costs and $800 billion in total costs annually.
It is no wonder that so much of our health care system is oriented toward pain relief, and so perplexing to observe that with so many professions addressing it, the numbers continue to rise. It is also perplexing that with so many different diagnostic and treatment models for pain, not one of them has popped-out as a cure-all answer. The major causal factor is age; the older we get, the more likely it is that we accumulate various pain-related injuries and illnesses. But, effective treatments remain elusive. While it makes sense to observe pain from a population perspective for public health purposes, devising treatments based on population models has its limitations.
Fragmentation & Reductionism:
While we all have our physical, cognitive, and social commonalities, you are highly unique. Your life experiences, present circumstances, and needs are like no one else's. You, as a naturally "round peg", should not be forced into anyone else's "square hole"; even though that is how most research is conducted, how most practitioners are educated and trained, and how most clinical health care practices operate.
You are already a wholly integrated human being, not just an agglomeration of parts and isolated subsystems. But, in our society, we have an institutional health care system that is structured on a high level of fragmentation. Sometimes, that is a good thing. If you need a hip joint replaced, an orthopedic surgeon who specializes in hips is definitely the way to go. But the specialization model breaks down when the parts needing attention are not easily identified, or when the problem involves networks of parts and their relationships on multiple levels.
Fragmentation into parts is hardly the case in terms of the actual unified physical body; where molecules, genes, cells, tissues, organs, systems, and the whole body interact within a complex hierarchy of levels (think of a ladder; with the very small at the bottom, working upward). Each level is comprised of "parts" from the level below, while having unique properties greater than just the sum of its parts. For instance, various cells make up tissues, which act in more complex ways than the cells themselves. This hierarchical relation of new qualities is known as "emergence". Emergence happens at each step up the ladder. In turn, each level can influence levels below, or "downward causation".
Compare this holistic hierarchical model with that of conventional medicine, where the primary focus is on the diagnoses and treatments of isolated parts. This is "reductionism", which is appropriate for certain issues (e.g., surgeries for local tissue damage, drugs which target specific metabolic dysfunctions), yet do not address emerging symptoms at higher levels (e.g., referred pain; chronic fatigue; cognitive and emotional dysfunctions; strength, balance, and coordination problems; or various drug reactions).
Beyond Holism:
While each one of us has these parts and levels, we are also unique in our life histories, ongoing health conditions, personalities, relationships, leisure activities, and work and home environments. Total health care, if it is to be properly addressed, must not only address the complexities of each individual's bodily hierarchies (i.e., "holism"), but must also address one's mental, physical, and social environments and resources in context (e.g., one's self-efficacy, agency, physical demands, functional capacities, daily activities, work stressors, familial/relationship supports, etc.)(i.e., "integration"). What is vitally important is the uniqueness with which we engage with the world, and how that is managed toward an optimum of physical, cognitive, and emotional health. We are, throughout our lives, an experiential composite of our memories, our ongoing sensory inputs, our physical, mental, and emotional states, our behaviors, and our environments. We are always changing, and always in motion. Each one of us is not just a frozen "snapshot" of fragmented parts and levels, nor even just a "whole' body, but a "complex dynamic system" integrated by action, reaction, and engagement.
In order to live a resourceful and fulfilling life, we must thrive, not just survive. Life is challenging enough when things are going well; and when we encounter the inevitable illnesses, injuries, insults, and other distractions and stressors; we learn that taking the time to heal and recuperate is essential. For simple daily fatigue, a "power nap" may suffice. Sometimes we need a few days or weeks to recover from a common cold, a stubbed toe, or a minor strain. Other issues, like major surgeries, may take a few months. We can accept these conditions, with the understanding that our health will recover. And then there is chronic pain, which is an entirely different beast. It can be confusing, time-consuming, activity-limiting, frustrating, anxiety-producing, exhausting, depressing, and isolating; and it gets in the way of much of what makes living worthwhile. Chronic pain is the primary health-related reason for job loss and disability worldwide; and nearly half of us has it, at least to some degree.
Pain Problems:
Medical care in the U.S. is based on single event reporting, single diagnostic findings, and conventional treatment protocols. Unfortunately, this model of care is often inefficient and ineffective in managing and treating chronic, recurrent, or complex conditions. Reliance on drug therapies include many unwanted consequences, including risks of organ damage and addiction.
Chronic pain is experienced in a variety of ways. It may have certain qualities, such as burning, aching, soreness, or tenderness to the touch. It may be constant, it may reoccur with no apparent stimulus, or it might involve episodes of short to long durations. It may change its qualities and intensities over the course of the day (e.g., morning stiffness, late day fatigue). Pain may occur in obvious places, like the stubbed toe; or quite commonly it may radiate or refer to other locations, making it difficult to diagnose or treat (e.g., spinal pain, fibromyalgia). And, above all, it is subjective; you have the experience alone.
Your medical health care providers, lacking direct objective signs (e.g., pulse or blood pressure), rely on your symptom descriptions (e.g., qualities, pain levels) and behavioral signs (e.g., postural anomalies, gait and range-of-motion dysfunctions, guarding reactions to touch or movement, affect [such as facial or vocal expressions]); and other tests, depending on their diagnostic protocols and specializations.
Medical providers diagnose primarily for "acute" (i.e., new) pain, given their education, training, and insurance reimbursement guidelines. Unfortunately, their education and training is especially lacking for chronic or complex pain conditions. Your primary care physician likely has a couple of hours (if that!) of medical education on the subject of chronic or complex pain, and, given the brevity of your time together (8-10 minutes of direct total contact), will take very little time to decide on a course of action. I highly recommend Jerome Groopman's book, How doctors think, which elaborates on the disconnect between doctors and patients in the primary care setting. Groopman points out that many medical physicians take under 30 seconds after initial contact to decide on a diagnosis! This illustrates a major structural problem with our health care system: requiring primary physicians to see more patients in decreasing time allotments. With increased time demands for routine documentation and insurance reimbursements, time for patients to explain their symptoms fully and for doctors to perform adequate tests diminishes.
Most pain goes unreported. We diminish it ("It's nothing, really"), we wait it out, we learn to "live with it", and often self-medicate; yet 85% of all pain reported to medical professionals will not receive a definitive medical diagnosis! "Non-specific" (meaning no source of pain can be identified) pain is one of the most common conditions leading to permanent job loss and long-term disability worldwide (ahead of heart disease, cancers, and diabetes), yet its effective treatment remains elusive for modern conventional medicine and the "complementary and alternative medicine" (CAM) communities. More than a few physicians, general practitioners and specialists alike, have told me that chronic pain, especially "non-specific" pain, is the most frustrating condition to address and the hardest to manage in their practices. The same opinion reverberates throughout the professional literature. What is missing is simple: chronic pain is vastly different and much more complex than a single-case episode of acute pain. More levels of the physical and environmental hierarchy are involved, and additional perspectives and approaches are necessary.
Steps to Nowhere?:
For presentations of pain, physicians employ conservative one-size-fits-all "step-therapy" protocols, which are driven more by medical traditions and insurance industry demands to limit reimbursements than more effective and judicious case management practices. The first step-therapy response to acute (i.e., new) pain: tell you to rest (but move!), recommend over-the-counter analgesics, suggest cold and hot packs, and try to assure you that most pain episodes resolve themselves. This conservative approach is based on a "common wisdom" that 90% of all pain will resolve without additional intervention (I take great exception to this, as does much of the neuroscience research community!). Each new episode of pain is treated as unrelated to any previous occurrence, which is standard practice in medicine (i.e., one visit, one problem, one diagnosis, one treatment). If you're lucky, the pain will subside - for a time. One assumption attached to this "wisdom" is that if the pain has gone away (or is at least subsiding), the underlying source of that pain has also gone away; which is easy to assert if there is no "known" cause in the first place!
Unfortunately, with each incident, there are reactive changes in muscles, nerves, and stress hormones; some of which can take only minutes to occur, others taking hours, days, or weeks. These changes become much more complex in consecutive or concurrent injuries, and can include further emergent systemic reactions that occur over days, weeks, and months. This is called "compensation"; and it can build up, layer upon layer, in very complex "somatosensory-motor" patterns, which are the multi-level central nervous system (CNS; i.e., brain and spinal cord) changes regulating your pain sensations (inputs) and your muscular tensions and coordinated movement functions (outputs). The mechanism of neuronal pattern changes in the CNS is referred to as "plasticity". While a single acute local injury (e.g., the stubbed toe) may not initiate long-term neural plastic changes; severe, consecutive, or chronic injuries to weight-bearing (e.g., spines, hips, legs, and feet) and other heavily-used structures (e.g., shoulders) are much more likely to result in major and complex neural and postural changes; all of which are implicated in the development and maintenance of chronic pain and impaired movement. Even a stubbed toe may have vastly different effects on individuals who spend much of their time sitting compared to those who are on their feet all day.
You may have problems moving parts of your body in areas that weren't a problem before, and are linked to even more discomfort elsewhere. These range-of-motion problems are not limited to specific locations, and can result in dysfunctional movement patterns throughout the body; some more noticeable than others. For example, months (or years, even decades!) after a back strain injury, one knee may wobble, while your calf muscles ache on the opposite side; or perhaps your hand feels numb from a seemingly unconnected episodic "minor" headache. You may have pain in your upper back or neck, trouble moving your neck, or chronic tension headaches, but you haven't ever had a neck injury. Or you may have had a whiplash injury in an automobile collision years ago, and cannot understand why your middle or lower back hurts, or why you have jaw stiffness or eye strain. And it can get much more complicated if you also have other structural, neurological, or endocrinological changes (e.g., the "chronic fatigue"-inducing hypothalamic/pituitary/adrenal "stress response syndrome"); especially from consecutive incidents over the time scales of months to years. These patterns can build up without triggering your threshold for pain. In other words, you may think that you are simply feeling fatigued and your back is stiff just because you are "getting older"; until one day you bend over to lift something up, whether it's a grocery bag or a pen that's fallen to the floor, and you experience incapacitating pain lasting days or weeks.
These complexities are rarely addressed by conventional medical diagnostics; and if and when they are, it may take many years and many doctors later. Unfortunately, this is all too typical: looking in the wrong places, not looking in all the right places, and squandering valuable time and resources with one-size-fits-all step-therapies that do not match for injury type differences, individual contextual differences, or time-related factors.
Let's back up a bit to examine the next steps in the medical model for acute pain that is not subsiding. Basically, it a repeat of the conservative "let's-wait-and-see" approach; the next "step". You may be told to "give it more time", increase the over-the-counter pain medications, and receive a prescription for global muscle relaxants, which have their own unwanted side-effects, such as chronic fatigue and declines in cognitive reasoning, concentration, and memory. You may also be referred to a radiology unit to screen for an underlying structural lesion (e.g., a fracture, cyst, or torn ligament); starting with x-rays, and may also include costlier scans, such as MRIs and CTs. Of course, you can expect more delays, and frequently hidden costs (e.g., co-pays and deductibles).
If you have a major lesion, surgery may be indicated; but there are problems with relying on radiological findings, especially with back pain. Here is a major conundrum from the research literature: While 70% - 90% of individuals with low-back pain show no spinal pathologies on these scans (including x-ray, MRI and CT), another 70% of people with no pain have demonstrated pathologies! If you are considering surgery, please take extra care, study the relevant information, ask lots of questions, and talk out your options with a trusted friend or family member. Multiple surgical opinions could be life-saving, as long-term outcomes from spinal surgery may range from full recovery to permanent chronic pain and disability. I have known dozens of people who rushed into surgery for the wrong reasons, and have life-long regrets and intractable pain.
Lingering Pain:
Weeks have gone by, and you are now in the "sub-acute" stage; and still experiencing pain and/or movement deficits. The next step under the conventional medical model is physical therapy (PT), which consists primarily of passive therapies, movement education, and exercises. Passive therapies (e.g., hot packs, ultrasound, TENS) applied to painful sites are non-invasive and quite safe, but of highly questionable long-term therapeutic value (i.e., often superficial, ineffective, or marginally useful; based on the chronic pain research literature and client feedback).
Timing is the critical factor here. One of the major problems with targeting peripheral pain sites after the acute stage is that pain and movement restrictions may be amplified and maintained by, and originating from, plastic changes and emergent properties in the central nervous system (CNS) (i.e., "central" pain). To review: dynamic changes in the CNS occur over time after injury, and layered compensation patterns become more complex and harder (or impossible) to change with methods targeting too few (or simply the wrong) parts and levels. For example, targeted treatment to tissues and biomechanical sub-systems may increase range-of-motion and local strength in isolated joints and muscles, yet not address emergent effects at a higher level in the physical hierarchy, such as regional movement compensation patterns, dexterity, and coordination. In other words, treatments which are considered "reasonable and necessary" under the medical model and insurance reimbursement guidelines may result in unintended or unforeseen consequences that the current model cannot describe, explain, or treat (e.g., generalized or referred pain, early onset or chronic fatigue, or cognitive problems with concentration or memory). Another common problem with PT is that individuals in pain often find many exercises (a core modality of PT) much too painful to perform, and dropping out of research studies and clinical therapy is common. The conventional wisdom is that the pain will only respond to exercise, which puts the patient in a paradox; not being able to exercise, when mismatched treatment modalities and exercise are the only options offered. If you are spending lots of time at PT, especially repeated rounds of it, but getting no effective relief, why continue? While PT is effective for many conditions, it comes up short for chronic pain; as its goal is to address pain as a symptom, not its underlying cause.
As time goes on, conventional treatments have less impact, and whatever gains that have occurred reach a plateau; where no further improvement is evident. Once people realize that their practitioners are using ineffective tools to help them, they move on. For medical practitioners and their allied-health cohorts, concepts and clinical practices are both dictated and constrained by their education, disciplinary traditions and protocols, and insurance reimbursement schedules; which are often incoherent, incomplete, and far behind current research in neuroscience.
Institutional constraints often result in stagnation and retard innovative clinical advances. In other words, they need a better and more up-to-date toolkit; a new set of strategic treatment approaches and techniques - a shift in paradigms. Something substantial is missing from the conventional treatment model; how to re-regulate the CNS to both reduce pain and make everyday movement and exercise possible, without triggering more pain and reactive tension patterns. To cite the famous quote by psychologist Abraham Maslow: "I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail." Clearly, new tools and perspectives are needed.
A Chronic Condition:
Due to the rapidly increasing population of chronically-disabled people, a rapidly growing medical sub-specialty, "physical medicine and rehabilitation" (PMR), is the next, and usually the final, conventional case management destination for individuals in chronic pain; offering more exercise, more surgical options, more drugs (oral or injected "pain killers", steroids, and global muscle relaxants). Among the newest institutions are "pain centers", which are being run by PMR medical specialists (physiatrists) and psychologists, combining cognitively-based counseling ("mindfulness" and cognitive-behavioral therapy [CBT]; which are the latest in one-size-fits-all trends these days), all of which focus on coping mechanisms over chronic physiological pain reduction. These services and centers are often for-profit (and very expensive), with mixed short-term results, absent any long-term tracking results, and are often excluded from any insurance reimbursements. Many programs include non-scientific "alternative therapies", and the exclusive, high-end facilities may resemble "celebrity" detox centers more than healthcare clinics. In my opinion, while these operations may make an improvement in centralizing pain-related case management (i.e., administrative) functions, they are still offering only marginally-effective conventional approaches and "popular" interventions for much more cost than is necessary.
Drug options:
The drug problem is now well known, as opioids, which were once liberally prescribed and considered safe, have resulted in widespread dependence, addiction, cognitive, emotional, and personality changes, and dangerous interactions with other drugs, especially anti-depressants. Overdose deaths are at epidemic proportions. People who are in chronic pain may get their only relief from opioids, and they are in a major bind if they are denied renewals for the only drugs that keep them functioning. When opioids are withdrawn from individuals who depend on them, suicide rates increase. Even over-the-counter (OTC) drugs pose dangers of severe and irreversible organ damage. Most self-medication is with alcohol, which poses enough problems on its own, and highly increases risks for severe complications and death when mixed with other powerful medications. Many individuals are also on multiple medications for other conditions, which, when combined with pain medications, may be highly toxic. The medical use of marijuana offers a viable, and much safer, option for pain, with fewer contraindications; although its legal status for use is still restricted in many states and at the federal level. Early reports indicate that many medical marijuana users have reduced or eliminated their dependence on opioids and other medications for chronic pain and stress-related conditions, particularly anxiety, depression, and PTSD. And of course, there are many people who choose to keep all drug use to an absolute minimum, or completely out of their lives, if possible.
CAM options:
Complementary and Alternative Medicine (CAM) has become a popular addition or option to conventional medicine over the last few decades, although it can be difficult to categorize particular therapists as belonging to CAM or conventional medicine's "allied" professions. Primary care physicians will have M.D. (Doctor of Medicine) or D.O. (Doctor of Osteopathy) degrees. Physician's assistants (PAs), nurses (RNs, LPNs) nurse practitioners (NPs), physical therapists (PTs), occupational therapists (OTs), medical technologists (MTs), various specialty technicians (e.g., in radiology and ophthalmology), are usually understood as "allied". Recently, NPs have been elevated to Primary Care Provider (PCP) status, under the supervision of MDs or DOs. But how do we even categorize, never mind evaluate the effectiveness of: chiropractic (DCs), naturopathy (NDs), massage therapy, neuromuscular therapy (NMT), strength training, acupuncture, yoga, trigger-point therapy, meditation, "mindfulness", cognitive-behavioral therapy (CBT), hypnotherapy, phototherapy, dry-needling, bio-feedback, EMDR, NLP, reiki, ayurvedism, nutritional supplementation, homeopathy, and the long list of other body/mind practices found in "alternative health" directories? Here is a quick answer to the question of categories: If the conventional medical establishment regularly uses specialists trained under the "medical model" as part of its service provisions, it is "allied". If not "allied", but based on science, it's "complementary". If it's not scientifically-based, it's "alternative". And, some of these approaches are hybrids.
So, how do we understand which of these CAM approaches, with or without conventional medicine, alone or in combination, can effectively address and treat chronic, recurrent, or episodic pain? How do we know what is useful, or even critical, for our individual needs? And most importantly, where do we invest our time and money in order to get the best outcomes?
All of these CAM therapies have a certain appeal to individuals with different cultural values systems and personal beliefs, and may be chosen more by subjective expectations and popularity than an objective effective "fit" to individual needs. Most of them are reductionistic, and only deal with limited parts and isolated procedures; too small a scope to address complex problems. Some claim, even in their written materials, that their therapies are scientifically based, when they are clearly not. Most CAM therapies have major problems with their logical core constructs, confusing applications, overt or implied claims to unsubstantiated global therapeutic outcomes (another version of "one-size-fits-all"), and poor or absent basic reliability and validity standards. Many are, or are historically, based on "vitalism," "essentialism," or "entelechy," where biological operations are replaced by metaphysics or supernatural "energies"; long ago debunked and abandoned by serious researchers. Many claiming global and long-term effective results have demonstrated only very limited and short-term effects; similar to common placebo results. And, regrettably, some of them are utterly illogical and nonsensical.
It is impossible to say that all CAM therapies are either effective or ineffective, as each has wildly different foundational presuppositions and approaches. Some can be marginally useful for some aspects of pain, but the absence of long-term effects and poor results in clinical research (if there is any research at all!) leaves a lot to be desired. The appeal and motivation to engage in any therapy is, again, personal and individual. Some of my clients absolutely refuse to see medical doctors and their allied cohorts for pain, as they have been repeatedly unsatisfied, have had iatrogenic effects (i.e., therapy made the situation worse) and have seen many different CAM therapists. Others, especially those with backgrounds in medicine or the biological sciences, consider most CAM therapies as outright quackery, potentially dangerous, and a complete waste of time and money. Most people have limited exposure to different health delivery models, and may stumble onto a particular model or practitioner due to personal referrals or matches with other pre-existing beliefs that have little or nothing to do with their own individual physiological needs.
Summary:
Where conventional and CAM (Complementary and Alternative Medicine) approaches yield poor, limited, or short-term results, a new model is required. First of all, a review of existing therapeutic approaches is needed to determine what does and does not work for particular individuals in the context of the real world, not just in the clinic. As each discipline is isolated from the next (from founding concepts, formal education and training, research designs and methodologies, and clinical protocols), most practitioners are severely limited in formulating clinical options when their own affiliative and institutional biases are challenged.
These widespread limitations of both overgeneralization of one's perspective, and the blanket rejection of other points-of-view, often yields a "more-of-the-same" approach to therapy. So, no matter if you have been getting drug therapy, exercise instruction, chiropractic adjustments, acupuncture sessions, or other interventions (this list is endless!), you may have reached a plateau in that therapy's effectiveness; and you may be better off with a different approach. Of course, you may be spending years chasing down your options without expert guidance. One answer, I believe, is contained in the comprehensive and multi-perspectival approach to rehabilitation case management for chronic pain and its relationship to the central nervous system, which I have been developing through years of rigorous study and clinical experience.
The subject of pain is obviously not simple, and I have attempted to present some major issues which impede progress in the area of clinical treatment for chronic, recurrent, and episodic somatosensory pain and related movement disorders. One of the biggest problems is the chasm between the past half-century of basic biological and physiological research and its translation into reliable and effective somatic therapies. A similar problem exists in the domains of psychological, social, and environmental factors; where common (so-called, "reasonable and necessary") provisions and relationships between individuals and their providers are based on severely outdated conceptions. In the U.S.A., private insurance interests put profits ahead of major innovations, and traditional disciplinary biases maintain fragmentation over individual experiential and practical needs. These factors alone result in structural mismatches and delays in treatment which may result in increases in chronic intractable pain and long-term disability.
There are reasons to be skeptical of the current state of treatment offerings, and individuals have valid reasons to be confused and frustrated. However, there have been repeated calls in the professional literature over the past 25 years for early access to comprehensive, systemic, and individualized client-centered case management services and treatments based on a composite of biological, psychological, social, and environmental considerations. There are enough problems to demonstrate a need for a shift in paradigms, where the focus is first and foremost on the needs and long-term outcomes for individuals in pain, and many of whom are at unnecessary risk for long-term disability. The current system puts political, economic, institutional, disciplinary, and academic stakeholders in more powerful positions over individual outcomes. This has to change.
In the meantime, I have developed a client-centered case management approach that is qualitatively and structurally different from the currently available conventional, complementary, and alternative approaches. In addition, I have identified and formalized a clinical treatment approach to non-specific pain, which is based on decades of scientific advances in basic and experimental research into pain and its relationship with movement. Please go to the next page, "How I Can Help" for a different approach.
Introduction:
Dealing with pain is no minor problem, and it is a problem of personal, national, and international proportions. Chronic back pain is the most common cause of permanent long-term disability worldwide. In the U.S. alone, approximately half of the population is in a state of pain from all sources, and between 20-40% involve lower back pain. The costs are staggering, with economic impact estimates ranging from between $200 billion in direct medical costs and $800 billion in total costs annually.
It is no wonder that so much of our health care system is oriented toward pain relief, and so perplexing to observe that with so many professions addressing it, the numbers continue to rise. It is also perplexing that with so many different diagnostic and treatment models for pain, not one of them has popped-out as a cure-all answer. The major causal factor is age; the older we get, the more likely it is that we accumulate various pain-related injuries and illnesses. But, effective treatments remain elusive. While it makes sense to observe pain from a population perspective for public health purposes, devising treatments based on population models has its limitations.
Fragmentation & Reductionism:
While we all have our physical, cognitive, and social commonalities, you are highly unique. Your life experiences, present circumstances, and needs are like no one else's. You, as a naturally "round peg", should not be forced into anyone else's "square hole"; even though that is how most research is conducted, how most practitioners are educated and trained, and how most clinical health care practices operate.
You are already a wholly integrated human being, not just an agglomeration of parts and isolated subsystems. But, in our society, we have an institutional health care system that is structured on a high level of fragmentation. Sometimes, that is a good thing. If you need a hip joint replaced, an orthopedic surgeon who specializes in hips is definitely the way to go. But the specialization model breaks down when the parts needing attention are not easily identified, or when the problem involves networks of parts and their relationships on multiple levels.
Fragmentation into parts is hardly the case in terms of the actual unified physical body; where molecules, genes, cells, tissues, organs, systems, and the whole body interact within a complex hierarchy of levels (think of a ladder; with the very small at the bottom, working upward). Each level is comprised of "parts" from the level below, while having unique properties greater than just the sum of its parts. For instance, various cells make up tissues, which act in more complex ways than the cells themselves. This hierarchical relation of new qualities is known as "emergence". Emergence happens at each step up the ladder. In turn, each level can influence levels below, or "downward causation".
Compare this holistic hierarchical model with that of conventional medicine, where the primary focus is on the diagnoses and treatments of isolated parts. This is "reductionism", which is appropriate for certain issues (e.g., surgeries for local tissue damage, drugs which target specific metabolic dysfunctions), yet do not address emerging symptoms at higher levels (e.g., referred pain; chronic fatigue; cognitive and emotional dysfunctions; strength, balance, and coordination problems; or various drug reactions).
Beyond Holism:
While each one of us has these parts and levels, we are also unique in our life histories, ongoing health conditions, personalities, relationships, leisure activities, and work and home environments. Total health care, if it is to be properly addressed, must not only address the complexities of each individual's bodily hierarchies (i.e., "holism"), but must also address one's mental, physical, and social environments and resources in context (e.g., one's self-efficacy, agency, physical demands, functional capacities, daily activities, work stressors, familial/relationship supports, etc.)(i.e., "integration"). What is vitally important is the uniqueness with which we engage with the world, and how that is managed toward an optimum of physical, cognitive, and emotional health. We are, throughout our lives, an experiential composite of our memories, our ongoing sensory inputs, our physical, mental, and emotional states, our behaviors, and our environments. We are always changing, and always in motion. Each one of us is not just a frozen "snapshot" of fragmented parts and levels, nor even just a "whole' body, but a "complex dynamic system" integrated by action, reaction, and engagement.
In order to live a resourceful and fulfilling life, we must thrive, not just survive. Life is challenging enough when things are going well; and when we encounter the inevitable illnesses, injuries, insults, and other distractions and stressors; we learn that taking the time to heal and recuperate is essential. For simple daily fatigue, a "power nap" may suffice. Sometimes we need a few days or weeks to recover from a common cold, a stubbed toe, or a minor strain. Other issues, like major surgeries, may take a few months. We can accept these conditions, with the understanding that our health will recover. And then there is chronic pain, which is an entirely different beast. It can be confusing, time-consuming, activity-limiting, frustrating, anxiety-producing, exhausting, depressing, and isolating; and it gets in the way of much of what makes living worthwhile. Chronic pain is the primary health-related reason for job loss and disability worldwide; and nearly half of us has it, at least to some degree.
Pain Problems:
Medical care in the U.S. is based on single event reporting, single diagnostic findings, and conventional treatment protocols. Unfortunately, this model of care is often inefficient and ineffective in managing and treating chronic, recurrent, or complex conditions. Reliance on drug therapies include many unwanted consequences, including risks of organ damage and addiction.
Chronic pain is experienced in a variety of ways. It may have certain qualities, such as burning, aching, soreness, or tenderness to the touch. It may be constant, it may reoccur with no apparent stimulus, or it might involve episodes of short to long durations. It may change its qualities and intensities over the course of the day (e.g., morning stiffness, late day fatigue). Pain may occur in obvious places, like the stubbed toe; or quite commonly it may radiate or refer to other locations, making it difficult to diagnose or treat (e.g., spinal pain, fibromyalgia). And, above all, it is subjective; you have the experience alone.
Your medical health care providers, lacking direct objective signs (e.g., pulse or blood pressure), rely on your symptom descriptions (e.g., qualities, pain levels) and behavioral signs (e.g., postural anomalies, gait and range-of-motion dysfunctions, guarding reactions to touch or movement, affect [such as facial or vocal expressions]); and other tests, depending on their diagnostic protocols and specializations.
Medical providers diagnose primarily for "acute" (i.e., new) pain, given their education, training, and insurance reimbursement guidelines. Unfortunately, their education and training is especially lacking for chronic or complex pain conditions. Your primary care physician likely has a couple of hours (if that!) of medical education on the subject of chronic or complex pain, and, given the brevity of your time together (8-10 minutes of direct total contact), will take very little time to decide on a course of action. I highly recommend Jerome Groopman's book, How doctors think, which elaborates on the disconnect between doctors and patients in the primary care setting. Groopman points out that many medical physicians take under 30 seconds after initial contact to decide on a diagnosis! This illustrates a major structural problem with our health care system: requiring primary physicians to see more patients in decreasing time allotments. With increased time demands for routine documentation and insurance reimbursements, time for patients to explain their symptoms fully and for doctors to perform adequate tests diminishes.
Most pain goes unreported. We diminish it ("It's nothing, really"), we wait it out, we learn to "live with it", and often self-medicate; yet 85% of all pain reported to medical professionals will not receive a definitive medical diagnosis! "Non-specific" (meaning no source of pain can be identified) pain is one of the most common conditions leading to permanent job loss and long-term disability worldwide (ahead of heart disease, cancers, and diabetes), yet its effective treatment remains elusive for modern conventional medicine and the "complementary and alternative medicine" (CAM) communities. More than a few physicians, general practitioners and specialists alike, have told me that chronic pain, especially "non-specific" pain, is the most frustrating condition to address and the hardest to manage in their practices. The same opinion reverberates throughout the professional literature. What is missing is simple: chronic pain is vastly different and much more complex than a single-case episode of acute pain. More levels of the physical and environmental hierarchy are involved, and additional perspectives and approaches are necessary.
Steps to Nowhere?:
For presentations of pain, physicians employ conservative one-size-fits-all "step-therapy" protocols, which are driven more by medical traditions and insurance industry demands to limit reimbursements than more effective and judicious case management practices. The first step-therapy response to acute (i.e., new) pain: tell you to rest (but move!), recommend over-the-counter analgesics, suggest cold and hot packs, and try to assure you that most pain episodes resolve themselves. This conservative approach is based on a "common wisdom" that 90% of all pain will resolve without additional intervention (I take great exception to this, as does much of the neuroscience research community!). Each new episode of pain is treated as unrelated to any previous occurrence, which is standard practice in medicine (i.e., one visit, one problem, one diagnosis, one treatment). If you're lucky, the pain will subside - for a time. One assumption attached to this "wisdom" is that if the pain has gone away (or is at least subsiding), the underlying source of that pain has also gone away; which is easy to assert if there is no "known" cause in the first place!
Unfortunately, with each incident, there are reactive changes in muscles, nerves, and stress hormones; some of which can take only minutes to occur, others taking hours, days, or weeks. These changes become much more complex in consecutive or concurrent injuries, and can include further emergent systemic reactions that occur over days, weeks, and months. This is called "compensation"; and it can build up, layer upon layer, in very complex "somatosensory-motor" patterns, which are the multi-level central nervous system (CNS; i.e., brain and spinal cord) changes regulating your pain sensations (inputs) and your muscular tensions and coordinated movement functions (outputs). The mechanism of neuronal pattern changes in the CNS is referred to as "plasticity". While a single acute local injury (e.g., the stubbed toe) may not initiate long-term neural plastic changes; severe, consecutive, or chronic injuries to weight-bearing (e.g., spines, hips, legs, and feet) and other heavily-used structures (e.g., shoulders) are much more likely to result in major and complex neural and postural changes; all of which are implicated in the development and maintenance of chronic pain and impaired movement. Even a stubbed toe may have vastly different effects on individuals who spend much of their time sitting compared to those who are on their feet all day.
You may have problems moving parts of your body in areas that weren't a problem before, and are linked to even more discomfort elsewhere. These range-of-motion problems are not limited to specific locations, and can result in dysfunctional movement patterns throughout the body; some more noticeable than others. For example, months (or years, even decades!) after a back strain injury, one knee may wobble, while your calf muscles ache on the opposite side; or perhaps your hand feels numb from a seemingly unconnected episodic "minor" headache. You may have pain in your upper back or neck, trouble moving your neck, or chronic tension headaches, but you haven't ever had a neck injury. Or you may have had a whiplash injury in an automobile collision years ago, and cannot understand why your middle or lower back hurts, or why you have jaw stiffness or eye strain. And it can get much more complicated if you also have other structural, neurological, or endocrinological changes (e.g., the "chronic fatigue"-inducing hypothalamic/pituitary/adrenal "stress response syndrome"); especially from consecutive incidents over the time scales of months to years. These patterns can build up without triggering your threshold for pain. In other words, you may think that you are simply feeling fatigued and your back is stiff just because you are "getting older"; until one day you bend over to lift something up, whether it's a grocery bag or a pen that's fallen to the floor, and you experience incapacitating pain lasting days or weeks.
These complexities are rarely addressed by conventional medical diagnostics; and if and when they are, it may take many years and many doctors later. Unfortunately, this is all too typical: looking in the wrong places, not looking in all the right places, and squandering valuable time and resources with one-size-fits-all step-therapies that do not match for injury type differences, individual contextual differences, or time-related factors.
Let's back up a bit to examine the next steps in the medical model for acute pain that is not subsiding. Basically, it a repeat of the conservative "let's-wait-and-see" approach; the next "step". You may be told to "give it more time", increase the over-the-counter pain medications, and receive a prescription for global muscle relaxants, which have their own unwanted side-effects, such as chronic fatigue and declines in cognitive reasoning, concentration, and memory. You may also be referred to a radiology unit to screen for an underlying structural lesion (e.g., a fracture, cyst, or torn ligament); starting with x-rays, and may also include costlier scans, such as MRIs and CTs. Of course, you can expect more delays, and frequently hidden costs (e.g., co-pays and deductibles).
If you have a major lesion, surgery may be indicated; but there are problems with relying on radiological findings, especially with back pain. Here is a major conundrum from the research literature: While 70% - 90% of individuals with low-back pain show no spinal pathologies on these scans (including x-ray, MRI and CT), another 70% of people with no pain have demonstrated pathologies! If you are considering surgery, please take extra care, study the relevant information, ask lots of questions, and talk out your options with a trusted friend or family member. Multiple surgical opinions could be life-saving, as long-term outcomes from spinal surgery may range from full recovery to permanent chronic pain and disability. I have known dozens of people who rushed into surgery for the wrong reasons, and have life-long regrets and intractable pain.
Lingering Pain:
Weeks have gone by, and you are now in the "sub-acute" stage; and still experiencing pain and/or movement deficits. The next step under the conventional medical model is physical therapy (PT), which consists primarily of passive therapies, movement education, and exercises. Passive therapies (e.g., hot packs, ultrasound, TENS) applied to painful sites are non-invasive and quite safe, but of highly questionable long-term therapeutic value (i.e., often superficial, ineffective, or marginally useful; based on the chronic pain research literature and client feedback).
Timing is the critical factor here. One of the major problems with targeting peripheral pain sites after the acute stage is that pain and movement restrictions may be amplified and maintained by, and originating from, plastic changes and emergent properties in the central nervous system (CNS) (i.e., "central" pain). To review: dynamic changes in the CNS occur over time after injury, and layered compensation patterns become more complex and harder (or impossible) to change with methods targeting too few (or simply the wrong) parts and levels. For example, targeted treatment to tissues and biomechanical sub-systems may increase range-of-motion and local strength in isolated joints and muscles, yet not address emergent effects at a higher level in the physical hierarchy, such as regional movement compensation patterns, dexterity, and coordination. In other words, treatments which are considered "reasonable and necessary" under the medical model and insurance reimbursement guidelines may result in unintended or unforeseen consequences that the current model cannot describe, explain, or treat (e.g., generalized or referred pain, early onset or chronic fatigue, or cognitive problems with concentration or memory). Another common problem with PT is that individuals in pain often find many exercises (a core modality of PT) much too painful to perform, and dropping out of research studies and clinical therapy is common. The conventional wisdom is that the pain will only respond to exercise, which puts the patient in a paradox; not being able to exercise, when mismatched treatment modalities and exercise are the only options offered. If you are spending lots of time at PT, especially repeated rounds of it, but getting no effective relief, why continue? While PT is effective for many conditions, it comes up short for chronic pain; as its goal is to address pain as a symptom, not its underlying cause.
As time goes on, conventional treatments have less impact, and whatever gains that have occurred reach a plateau; where no further improvement is evident. Once people realize that their practitioners are using ineffective tools to help them, they move on. For medical practitioners and their allied-health cohorts, concepts and clinical practices are both dictated and constrained by their education, disciplinary traditions and protocols, and insurance reimbursement schedules; which are often incoherent, incomplete, and far behind current research in neuroscience.
Institutional constraints often result in stagnation and retard innovative clinical advances. In other words, they need a better and more up-to-date toolkit; a new set of strategic treatment approaches and techniques - a shift in paradigms. Something substantial is missing from the conventional treatment model; how to re-regulate the CNS to both reduce pain and make everyday movement and exercise possible, without triggering more pain and reactive tension patterns. To cite the famous quote by psychologist Abraham Maslow: "I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail." Clearly, new tools and perspectives are needed.
A Chronic Condition:
Due to the rapidly increasing population of chronically-disabled people, a rapidly growing medical sub-specialty, "physical medicine and rehabilitation" (PMR), is the next, and usually the final, conventional case management destination for individuals in chronic pain; offering more exercise, more surgical options, more drugs (oral or injected "pain killers", steroids, and global muscle relaxants). Among the newest institutions are "pain centers", which are being run by PMR medical specialists (physiatrists) and psychologists, combining cognitively-based counseling ("mindfulness" and cognitive-behavioral therapy [CBT]; which are the latest in one-size-fits-all trends these days), all of which focus on coping mechanisms over chronic physiological pain reduction. These services and centers are often for-profit (and very expensive), with mixed short-term results, absent any long-term tracking results, and are often excluded from any insurance reimbursements. Many programs include non-scientific "alternative therapies", and the exclusive, high-end facilities may resemble "celebrity" detox centers more than healthcare clinics. In my opinion, while these operations may make an improvement in centralizing pain-related case management (i.e., administrative) functions, they are still offering only marginally-effective conventional approaches and "popular" interventions for much more cost than is necessary.
Drug options:
The drug problem is now well known, as opioids, which were once liberally prescribed and considered safe, have resulted in widespread dependence, addiction, cognitive, emotional, and personality changes, and dangerous interactions with other drugs, especially anti-depressants. Overdose deaths are at epidemic proportions. People who are in chronic pain may get their only relief from opioids, and they are in a major bind if they are denied renewals for the only drugs that keep them functioning. When opioids are withdrawn from individuals who depend on them, suicide rates increase. Even over-the-counter (OTC) drugs pose dangers of severe and irreversible organ damage. Most self-medication is with alcohol, which poses enough problems on its own, and highly increases risks for severe complications and death when mixed with other powerful medications. Many individuals are also on multiple medications for other conditions, which, when combined with pain medications, may be highly toxic. The medical use of marijuana offers a viable, and much safer, option for pain, with fewer contraindications; although its legal status for use is still restricted in many states and at the federal level. Early reports indicate that many medical marijuana users have reduced or eliminated their dependence on opioids and other medications for chronic pain and stress-related conditions, particularly anxiety, depression, and PTSD. And of course, there are many people who choose to keep all drug use to an absolute minimum, or completely out of their lives, if possible.
CAM options:
Complementary and Alternative Medicine (CAM) has become a popular addition or option to conventional medicine over the last few decades, although it can be difficult to categorize particular therapists as belonging to CAM or conventional medicine's "allied" professions. Primary care physicians will have M.D. (Doctor of Medicine) or D.O. (Doctor of Osteopathy) degrees. Physician's assistants (PAs), nurses (RNs, LPNs) nurse practitioners (NPs), physical therapists (PTs), occupational therapists (OTs), medical technologists (MTs), various specialty technicians (e.g., in radiology and ophthalmology), are usually understood as "allied". Recently, NPs have been elevated to Primary Care Provider (PCP) status, under the supervision of MDs or DOs. But how do we even categorize, never mind evaluate the effectiveness of: chiropractic (DCs), naturopathy (NDs), massage therapy, neuromuscular therapy (NMT), strength training, acupuncture, yoga, trigger-point therapy, meditation, "mindfulness", cognitive-behavioral therapy (CBT), hypnotherapy, phototherapy, dry-needling, bio-feedback, EMDR, NLP, reiki, ayurvedism, nutritional supplementation, homeopathy, and the long list of other body/mind practices found in "alternative health" directories? Here is a quick answer to the question of categories: If the conventional medical establishment regularly uses specialists trained under the "medical model" as part of its service provisions, it is "allied". If not "allied", but based on science, it's "complementary". If it's not scientifically-based, it's "alternative". And, some of these approaches are hybrids.
So, how do we understand which of these CAM approaches, with or without conventional medicine, alone or in combination, can effectively address and treat chronic, recurrent, or episodic pain? How do we know what is useful, or even critical, for our individual needs? And most importantly, where do we invest our time and money in order to get the best outcomes?
All of these CAM therapies have a certain appeal to individuals with different cultural values systems and personal beliefs, and may be chosen more by subjective expectations and popularity than an objective effective "fit" to individual needs. Most of them are reductionistic, and only deal with limited parts and isolated procedures; too small a scope to address complex problems. Some claim, even in their written materials, that their therapies are scientifically based, when they are clearly not. Most CAM therapies have major problems with their logical core constructs, confusing applications, overt or implied claims to unsubstantiated global therapeutic outcomes (another version of "one-size-fits-all"), and poor or absent basic reliability and validity standards. Many are, or are historically, based on "vitalism," "essentialism," or "entelechy," where biological operations are replaced by metaphysics or supernatural "energies"; long ago debunked and abandoned by serious researchers. Many claiming global and long-term effective results have demonstrated only very limited and short-term effects; similar to common placebo results. And, regrettably, some of them are utterly illogical and nonsensical.
It is impossible to say that all CAM therapies are either effective or ineffective, as each has wildly different foundational presuppositions and approaches. Some can be marginally useful for some aspects of pain, but the absence of long-term effects and poor results in clinical research (if there is any research at all!) leaves a lot to be desired. The appeal and motivation to engage in any therapy is, again, personal and individual. Some of my clients absolutely refuse to see medical doctors and their allied cohorts for pain, as they have been repeatedly unsatisfied, have had iatrogenic effects (i.e., therapy made the situation worse) and have seen many different CAM therapists. Others, especially those with backgrounds in medicine or the biological sciences, consider most CAM therapies as outright quackery, potentially dangerous, and a complete waste of time and money. Most people have limited exposure to different health delivery models, and may stumble onto a particular model or practitioner due to personal referrals or matches with other pre-existing beliefs that have little or nothing to do with their own individual physiological needs.
Summary:
Where conventional and CAM (Complementary and Alternative Medicine) approaches yield poor, limited, or short-term results, a new model is required. First of all, a review of existing therapeutic approaches is needed to determine what does and does not work for particular individuals in the context of the real world, not just in the clinic. As each discipline is isolated from the next (from founding concepts, formal education and training, research designs and methodologies, and clinical protocols), most practitioners are severely limited in formulating clinical options when their own affiliative and institutional biases are challenged.
These widespread limitations of both overgeneralization of one's perspective, and the blanket rejection of other points-of-view, often yields a "more-of-the-same" approach to therapy. So, no matter if you have been getting drug therapy, exercise instruction, chiropractic adjustments, acupuncture sessions, or other interventions (this list is endless!), you may have reached a plateau in that therapy's effectiveness; and you may be better off with a different approach. Of course, you may be spending years chasing down your options without expert guidance. One answer, I believe, is contained in the comprehensive and multi-perspectival approach to rehabilitation case management for chronic pain and its relationship to the central nervous system, which I have been developing through years of rigorous study and clinical experience.
The subject of pain is obviously not simple, and I have attempted to present some major issues which impede progress in the area of clinical treatment for chronic, recurrent, and episodic somatosensory pain and related movement disorders. One of the biggest problems is the chasm between the past half-century of basic biological and physiological research and its translation into reliable and effective somatic therapies. A similar problem exists in the domains of psychological, social, and environmental factors; where common (so-called, "reasonable and necessary") provisions and relationships between individuals and their providers are based on severely outdated conceptions. In the U.S.A., private insurance interests put profits ahead of major innovations, and traditional disciplinary biases maintain fragmentation over individual experiential and practical needs. These factors alone result in structural mismatches and delays in treatment which may result in increases in chronic intractable pain and long-term disability.
There are reasons to be skeptical of the current state of treatment offerings, and individuals have valid reasons to be confused and frustrated. However, there have been repeated calls in the professional literature over the past 25 years for early access to comprehensive, systemic, and individualized client-centered case management services and treatments based on a composite of biological, psychological, social, and environmental considerations. There are enough problems to demonstrate a need for a shift in paradigms, where the focus is first and foremost on the needs and long-term outcomes for individuals in pain, and many of whom are at unnecessary risk for long-term disability. The current system puts political, economic, institutional, disciplinary, and academic stakeholders in more powerful positions over individual outcomes. This has to change.
In the meantime, I have developed a client-centered case management approach that is qualitatively and structurally different from the currently available conventional, complementary, and alternative approaches. In addition, I have identified and formalized a clinical treatment approach to non-specific pain, which is based on decades of scientific advances in basic and experimental research into pain and its relationship with movement. Please go to the next page, "How I Can Help" for a different approach.