The dinosaurs commeth: 2016 round up

It’s that time of year again when we all wind down for the holidays (I’m still trying to get my head around Christmas in the summer??) and us bloggers share our musings of the year.  

2016 has been a very exciting year for me on a personal and professional level. It has delivered some amazing opportunities, some wonderful insights and I’ve met some amazing people for the first time and reunited with some familiar faces.

Before I delve into my musings of 2016 I want to thank a few people (you’ll know who you are) for sticking with me over the year and also believing in my ability. It’s just a wee list of thanks

1. To my awesome and amazing lady, she’s been wonderful, patient and supportive through all of my ups and downs.
2. To my fantastic mentor and tutor, looking forward to working with you more in the future
3. We met at San Diego Pain summit and immediately hit it off with a freakishly similar business venture! From then on I was her brotha from another motha.
4. Thanks so much for believing in me and letting me present clinicians get creative at San Diego Pain Summit 2016, I’m gutted I can’t be at 2017
5. You gave me an opportunity to bring Know Pain to the southern hemisphere and we have succeeded in getting it off the ground. More courses for 2017!

Oh if anyone is reading this from Wellington and the surrounding area click on the link for tickets:

Know Pain Wellington

Here’s to everyone else as well that I have worked with throughout the year, you are all special and important people to me. Merry Christmas and have a wonderful 2017!

My experiences with dinosaurs

Right now that is out of the way, let’s get onto the juicy part of the blog.  2016 saw me return to study, which was one of the hardest things I have had to do since graduating from physio school many moons ago. Being someone who reads research papers on a daily basis and has been on every bleeding pain course or affiliate you can think of, going back to university was… a really difficult decision.

Part of me felt that I shouldn’t have to have more letters after my name just to be accepted by the ahem “clinical elite”. As another physio highlighted in his blog, ‘having formal qualifications are not the only measure of an individuals intelligence, skill and knowledge.’ You can read more about it here.

I admit I kind of shared his views, (particularly about education not just coming from schooling) but after much deliberation, talking to clinical mentors and family I decided that I should go back to University to extend my already long surname.

My experiences of study this year have been insightful, it’s helped me to consolidate my knowledge and has refined my skills in academic writing (although there is still a long way to go!).

However, there was one experience that was nothing short of disappointing. A lecture that got my blood boiling because of the insulting, inflammatory and intimidating attitude of the tutors delivery.  I was so disgusted and outraged by this tutor I took it upon myself to duly complain about the individuals academic rigor or lack of.

Here is a small excerpt from the lecture that led to my frustration. For anonymity purposes the voices have been edited.

If you did listen to the excerpt here were my responding thoughts:

The tutor specifically highlights an editorial from a Dr De Palma with the direct proposition that ALL chronic LBP can be treated through comprehensive and competent diagnostic procedures. That “people were steered into programmes” with the insinuation that they are classed in the “Pain is in the Brain” Category. I have a number of issues to address:

1. I want to stress the notion of “Pain in the Brain” has never been promoted by pain science camps that I am familiar with due to the severe repercussions of the dichotomy that presents itself with such a notion.  The idea of dichotomy dates back to early Cartesian times and it is not something that the pain science world wants or wishes to emulate (1, 2). Pain in the brain is a misconception by medical professionals that (it would seem) is being exploited to the benefit of other pain treatment approaches.
2. The tutors mention of the De Palma editorial (3) referring to Diagnostic Nihilism appears to have been misinterpreted. The tutor states at the beginning of his lecture that 50 years ago CLBP was treated through the means of using programmes adopting a BPS approach. I would like to raise a number of queries:
   1. To my knowledge 50 years ago from 2015 was 1965 (interestingly right around the time pain gate theory was discovered). Now from my readings the BPS model was developed by Engel in 1980, a whole 15 years later. Therefore I fail to see the relevance of his point.
   2. I have examined the papers that the editorial refers too and there is no mention of the BPS model in any of the papers. It appears that the editorial makes more reference to the appropriateness of examination of spinal structures.
3. Towards the end of the lecture the tutors appear to make the point “That relying on a physical examination for chronic low back pain is insufficient and that investigations or blocks should be performed, not to hang our hat on a single physical examination” I once again assume that the tutors are referring to the content of Dr De Palma’s paper (4). This to me is a clear example of confirmation bias and also a direct infringement of appropriate critical thinking in the reasoning process, which is a fundamental part of clinical practice. Furthermore, I would like to raise that there is evidence to question the use of joint injection or nerve block (5-8) and that it is not the sole means of “resolving long standing back pain.”
4. I appreciate that we can all become disgruntled by orthopaedic surgeons using MRI scans to determine the source of symptoms and that there is very little reliability and effectiveness in the validity and prognostic values of MRI for Lumbar / cervical or other joints (9-12).  However I get a sense of dogma from the tutors when it comes to the true value of being able to identify direct causes and correlations between tissue sources and pain drivers.  It appears to me that their interpretation is that there is a clear explanation that nociceptive drivers are the direct causes of all individuals that live with persistent pain. However to my knowledge and exploration of the evidence I understand pain science has shown that this is not the case (13-14). In addition, it would also appear to be the case that any other factor associated with persistent pain is secondary to the cause and not a primary driver? It would seem that the evidence would suggest otherwise (15-18).
5. Furthermore, it would appear that the paper that the tutor refers to (DePalma) suggests that through use of diagnostic nerve blocks or discography (both highly invasive procedures) they were able to isolate the source of pain and reduce symptoms, yet (and a key point) would move through vertebral levels if they did not isolate the source of the symptoms on the first attempt (As I understand from the paper). As I am aware there are descending modulatory and facilitatory systems also at play when it comes to a pain experience. If we base our understanding of pain as a perception and based upon perceived threat a needle being placed into your back via a series of blocks would seem relatively threatening to provide modulatory effects to the area in question.  This is not to suggest that anaesthetic blocks or steroid injection won’t have an effect but there is also the additional belief and behavioural value of receiving a procedure that an individual may perceive as improving their symptoms, hence the importance of understanding the placebo effect (19).

I would like to highlight that I do value the tutors contribution, however I wish to appeal that at a PG level there would be more respect for the diverse evidence base in treating something like low back pain.

If you felt that was enough for you’re already bleeding eyes there was more to come, particularly around an assignment that I submitted. The same tutor marked my assignment and was very upfront about my use of referencing insinuating that, ‘all referencing was anecdotal, unscientific, narratives of individuals with self-serving beliefs.’

I only have one word to describe this – dogma.

The outcome

So what was the outcome? Well let’s just say that things have moved forward progressively, yet it appears there maybe more in 2017.

I want to finish up by acknowledging that the BPS model is certainly not perfect, but I know of no clinician that merely adopts the PS part of the model. To ignore the biological aspect fundamentally ignores the biology of the body tissues and more importantly the nervous system. There are some out there that appear to acknowledge the model but do not embrace the multi-dimensional nature of pain, which (to a larger extent) is what the BPS model does over the biomedical model. I’ve said it before and I’ll say it again you cannot treat a multi-dimensional problem with a uni-dimensional approach.

Thanks for having a read and have a very Merry Christmas and a Happy New Year from the Naked Physio.

TNP

References

1.        Moseley GL, Butler DS. Fifteen Years of Explaining Pain: The Past, Present, and Future. J Pain.   2015;16(9):807-813. doi:10.1016/j.jpain.2015.05.005.
2.        Thacker M. Is pain in the brain? J Physiother Pain Assoc. 2015:3. doi:10.1084/jem.20511iti3.
3.        DePalma MJ. Diagnostic Nihilism Toward Low Back Pain: What Once Was Accepted, Should No Longer Be. Pain Med. 2015:1453-1454. doi:10.1111/pme.12850.
4.        DePalma MJ, Ketchum JM, Saullo T. What Is the Source of Chronic Low Back Pain and Does Age Play a Role? Pain Med. 2011;12(2):224-233. doi:10.1111/j.1526-4637.2010.01045.x.
5.        Hansen HC, McKenzie-Brown AM, Cohen SP, Swicegood JR, Colson JD, Manchikanti L. Sacroiliac joint interventions: a systematic review. Pain Physician. 2007;10(1):165-184.
6.        Schütz U, Cakir B, Dreinhöfer K, Richter M, Koepp H. Diagnostic value of lumbar facet joint injection: A prospective triple cross-over study. PLoS One. 2011;6(11). doi:10.1371/journal.pone.0027991.
7.        van Kleef M, Vanelderen P, Cohen SP, Lataster A, Van Zundert J, Mekhail N. Pain Originating from the Lumbar Facet Joints. In: Evidence-Based Interventional Pain Medicine: According to Clinical Diagnoses. ; 2011:87-95. doi:10.1002/9781119968375.ch12.
8.        Staal JB, de Bie RA, de Vet HCW, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine (Phila Pa 1976). 2009;34(1):49-59. doi:10.1002/14651858.CD001824.pub3.
9.        Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4). doi:10.3174/ajnr.A4173.
10.      Deyo R a, Jarvik JG, Chou R. Low back pain in primary care. Bmj. 2014;349(July):1-6. doi:10.1136/bmj.g4266.
11.      Carragee E, Alamin T, Cheng I, Franklin T, van den Haak E, Hurwitz E. Are first-time episodes of serious LBP associated with new MRI findings? Spine J. 2006;6(6):624-635. doi:10.1016/j.spinee.2006.03.005.
12.      Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T, Kato F. Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. Spine (Phila Pa 1976). 2015;40(6):392-398. doi:10.1097/BRS.0000000000000775.
13.      Butler, D.S, Moseley, L. (2003). Explain Pain. Adelaide. Noigroup Publications.
14.     Louw, A, Puentedura, E. (2013). Therapeutic Neuroscience Education. Teaching patients about pain. New York. OPTP Publishing. ISBN 978-0-9857186-4-0.
15. Pinheiro MB, Ferreira ML, Refshauge K, et al. Symptoms of Depression and Risk of New Episodes of Low Back Pain: A Systematic Review and Meta-Analysis. Arthritis Care Res (Hoboken). 2015;67(11):1591-1603. doi:10.1002/acr.22619.
16.      Carleton RN, Kachur SS, Abrams MP, Asmundson GJG. Waddell’s symptoms as indicators of psychological distress, perceived disability, and treatment outcome. J Occup Rehabil. 2009;19(1):41-48. doi:10.1007/s10926-009-9165-4.
17.      Hurter S, Paloyelis Y, Amanda AC, Fotopoulou A. Partners’ empathy increases pain ratings: Effects of perceived empathy and attachment style on pain report and display. J Pain. 2014;15(9):934-944. doi:10.1016/j.jpain.2014.06.004.
18.      Linton SJ. A review of psychological risk factors in back and neck pain. Spine (Phila Pa 1976). 2000;25(9):1148-1156. doi:10.1097/00007632-200005010-00017.
19. Benedetti, F. (2014). Placebo Effects. Oxford. Oxford University Press. ISBN 978-0-19-101517-5