For a lot of its advocates, and there are many, pain has become a touchstone for new kind of physiotherapy practice: a more holistic, complex and person-centred practice that is more in tune with the modern face of healthcare; a healthcare where people want more from their health professional than 15 minutes of interferential and a quick manipulation.
Some of the pain specialists in our profession are treated like rock stars and their presentations are guaranteed to fill out venues whenever they speak. People like Lorimer Moseley and David Butler have built their careers on bridging the divide between science and practice, the profession and public, and finding ways to make pain understandable. They are wonderful teachers and brilliant thinkers.
But for all of their work connecting people with a better understanding of pain, however, their message is still underpinned by a scientific, biomedical view of the body in health and illness. Granted, there is much more talk about pathways, systems and structures than we used to entertain, but pain is still understood as a biological process, coordinated by the brain, organised by psychology, and objectively mapped by science.
In many ways this is serving the profession well, because it is making us think about how complex health is; how our approach might intersect with other professional discourses; and how much more might be known about multifaceted health problems like pain. But I would make two more critical observations about our present interest in chronic, persistent pain.
Firstly, why are we focusing so much on pain and not on other long term, complex, subjective phenomena like chronic breathlessness, long term mental health problems, disability, or frailty in the elderly? Why are there no rock stars of COPD or addiction, diabetes or TBI? Are these not equally as challenging as pain (for clients/patients, therapists, and the healthcare system)? Are they less of a government priority? Are they, in some way, less worthy?
Secondly, despite the rhetoric, our recent interest in pain remains firmly embedded in the biological sciences. Lorimer Moseley’s book Painful Yarns for example, uses metaphors as a powerful linguistic device used to make complex things understandable. But these metaphors are not used to explain the true nature of suffering that accompanies pain, but rather to understand modern pain biology.
Equally, in the abstract to Butler and Moseley’s Explain pain book, the authors use the metaphor of the orchestra to explain why the book is necessary:
Imagine an orchestra in your brain. It plays all kinds of harmonious melodies, then pain comes along and the different sections of the orchestra are reduced to a few pain tunes. All pain is real. And for many people it is a debilitating part of everyday life. It is now known that understanding more about why things hurt can actually help people to overcome their pain.
The orchestra metaphor works well to explain certain things about pain, but the metaphor is interesting because it still resonates with the kind of reductive thinking that has been characteristic of medicine since the late 19th century. Some of the proponents of the ‘new pain’ have trumpeted the value of the biopsychosocial model as evidence of a more holistic view, but this model itself has been criticised for being an attempt by the medical profession to appear more holistic whilst retaining its monopoly on bio-centric thinking (see, for example, Malmgren, 2005; Nassir Ghaemi, 2010; Quinter et al, 2008; Weiner, 2007). This abstract from the paper Pain medicine and its models by Quinter and colleagues provides a flavour of this criticism:
Objective. To identify whether the biopsychosocial framework of illness has overcome the limitations of the biomedical model of disease when applied in the practice of pain medicine.
Design. Critical review of the literature concerning the application of biopsychosocial models to the praxis of pain medicine and the concepts of living systems.
Results. The biopsychosocial model of illness, formulated by Engel in 1977, has generated the International Association for the Study of Pain (IASP) definition of pain, two major conceptual frameworks in pain medicine, and three putative explanatory models for pain. However, in the absence of a theory that seeks to understand the lived experience of pain as an emergent and unpredictable phenomenon, these progeny of the biopsychosocial model have been caught in circular argument and have been unable to overcome biomedical reductionism or the perpetuation of body–mind dualism. In particular, the implication that pain can be a “thing” separate and distinct from the body bears little relationship to the lived experience of pain. Such marginalizing results when an observer attempts to reduce the experience of the pain of another person.
Conclusions. The self-referentiality of living systems (through their qualities of autopoiesis, noncentrality and negentropy) sees pain “emerge” in unpredictable ways that defy any lineal reduction of the lived experience to any particular “thing.” Pain therefore constitutes an aporia, a space and presence that defies us access to its secrets. We suggest a project in which pain may be apprehended in the clinical encounter, through the engagement of two autonomous self-referential beings in the intersubjective or so-called third space, from which new therapeutic possibilities can arise.
The problem physiotherapists face with coming to understand the real complexity of chronic pain is emblematic of the larger struggle the profession faces as we move into a post-biomedical, post-welfare, post-acute illness world, where people live with multiple, complex problems that, like pain and breathlessness, can only be understood by the person experiencing them.
Fortunately, there are other rock stars in the profession, whose work points to some entirely new ways to think about phenomena like pain, and many of these have been immersed for years in a deep appreciation for the lived experience of health and illness (see for example, the work of people like Jennifer Bullington, Tove Dragesund and Malfrid Råheim – references below).
What these authors address is not so much pain as suffering: the human, lived, embodied experience of spending day after day unable to sleep, worrying about your future; anxious to try to be brave, but always trying to prove to health professionals that what you feel is real; struggling even to get dressed in the morning; battling with self-doubt and feelings of worthlessness: exactly the kinds of things our clients/patients bring with them when they come to see us for care, cure, support, advocacy, reassurance, validation and the hope of a better tomorrow.
There are perfectly valid reasons why physiotherapists should continue to draw on biologically-centred models to help us to understand pain better, but pain itself remains a metaphor for a scientific approach to the body that constrains as much as it enables, and perhaps a shift in focus to the more human phenomenon of suffering might allow our practice to become more person-centred in the future?
References
Bullington, J. (2009). Embodiment and chronic pain: Implications for rehabilitation practice. Health Care Analysis, 17(2), 100-109. doi:10.1007/s10728-008-0109-5.
Bullington, J., Nordemar, R., Nordemar, K., & Sjöström-Flanagan, C. (2003). Meaning out of chaos: A way to understand chronic pain. Scandinavian Journal of Caring Sciences, 17(4), 325-331. doi:10.1046/j.0283-9318.2003.00244.x.
Bullington, J., Sjöström-Flanagan, C., Nordemar, K., & Nordemar, R. (2005). From pain through chaos towards new meaning: Two case studies. The Arts in Psychotherapy, 32(4), 261-274. doi:10.1016/j.aip.2005.04.007
Ghaemi, S. N. (2010). The rise and fall of the biopsychosocial model : Reconciling art and science in psychiatry. Baltimore: Johns Hopkins University Press.
Dragesund, T., & Råheim, M. (2007). Norwegian psychomotor physiotherapy and patients with chronic pain: Patients’ perspective on body awareness. Physiotherapy Theory and Practice, 24(4), 243-254.10.1080/09593980701738400.
Dragesund, T., & Råheim, M. (2008). Norwegian psychomotor physiotherapy and patients with chronic pain: Patients’ perspective on body awareness. Physiotherapy Theory and Practice, 24(4), 243-54. doi:10.1080/09593980701738400.
Lundberg, M., Styf, J., & Bullington, J. (2007). Experiences of moving with persistent pain: A qualitative study from a patient perspective. Physiotherapy Theory and Practice, 23(4), 199-209. doi:10.1080/09593980701209311.
Malmgren, H. (2005). The theoretical basis of the biopsychosocial model. In P. White (Ed.), Biopsychosocial medicine (pp. 21-35). Oxford: Oxford University Press.
Øien, A. M., Råheim, M., Iversen, S., & Steihaug, S. (2009). Self-perception as embodied knowledge-changing processes for patients with chronic pain. Advances in Physiotherapy, 11(3), 121-129. doi:10.1080/14038190802315073.
Quintner, J. L., Cohen, M. L., Buchanan, D., Katz, J. D., & Williamson, O. D. (2008). Pain medicine and its models: Helping or hindering? Pain Medicine, 9(7), 824-834. doi:10.1111/j.1526-4637.2007.00391.x.
Råheim, M., & Håland, W. (2006). Lived experience of chronic pain and fibromyalgia: Women’s stories from daily life. Qualitative Health Research, 16(6), 741-761. doi:10.1177/1049732306288521.
Weiner, B. K. (2007). Difficult medical problems: On explanatory models and a pragmatic alternative. Medical Hypotheses, 68(3), 474-479. doi:10.1016/j.mehy.2006.09.01.
Great summary of where there are needs for ongoing exploration and understanding. I believe Moseley has made attempts at this – see http://www.bodyinmind.org/wp-content/uploads/tha10468_fm.pdf – but the work by Bullington is the standout. I need more time to digest the attack on the biopsychosocial model but my main criticism would be how people interpret such frameworks rather than the intent of creating an understanding that directs us to acknowledging pain as an emergent and personal phenomenon. Thanks.
Thanks, yes-we should all be careful not to be 1D about pain.
Thank you-great blog. And a reminder not to be 1D about pain.
Wondered if you had heard of Assoc Prof Kevin Vowles and his work in Acceptance and Commitment Therapy in Chronic Pain- drawing on a persons own values and utilising MI approach ,working with people in their terms and pace on what their lives might be like if their pain persists. Real people , reframing pain for themselves with good ,caring ,safe guidance.
I find the use of the word “suffering” an emotive stirring choice. Interesting. If pain – short or long term – is present , is someone obliged to suffer? And are the list of issues that people with pain bring to us any different from those that people with stress , Panic Disorder ,Depression, Breathing Pattern disorders , Chronic fatigue or Alcohol and other drug dependencies have? Not really. From my work , I know people are multi faceted, there is very rarely one issue in solitude. So yes , if we hear someones pain story we should acknowledge it , we should also look beyond that . Just as if someone comes with breathing issues, we need to look beyond just the pattern of breathing and anatomy.
I would disagree that there are not rock stars in Breathing- Tania Clifton -Smith and Dianah Morrison at Breathing Works spring to mind.They are well know , published and do amazing courses. In Mental Health and Addictions we had Barbara Guthrie for 26 years, who taught me what i take forward in my work in Addictions now.
My feeling is people don’t celebrate these amazing Physios, not because what they do is not “pain ” or “rock star” stuff … but because Physio schools appear to focus on Musculo skeletal practice , and media, ACC and Physiotherapy in general has musculo/ sports as its focus. There does not appear to be a breadth of teaching or passion from AUT in teaching students a broader perspective about people in general. In four years of supervising students all but 2 ,(of 12), have wanted to work in private practice in musculo- to be famous for that!
So if we want the profession to be whole person focused, to look beyond the immediate presenting problem , to see people before us as not just a hurt knee , a LBP , a limp, a panic attack… but as people with both goals and limitations to those goals, it seems we need to be starting at the beginning of a Physios journey- at our Physio schools.
I think that the move Butler , Moseley et al are taking is towards this ‘holistic’, person centered approach .
As with all Physio- the basics of research , anatomy, physiology , pathophysiology will underpin what we do. It has been what Physio in NZ has been pursuing for 20 years.