I’ve been puzzling for some time why it is that chronic pain seems to be so much in focus for physiotherapists at the moment. For many years, chronic pain resided along with depression, rheumatoid disease and cerebral palsy as one of the many ‘Cinderella’ disorders and syndromes that physiotherapists in the public system endured (though had little remedy for), and those in the private system indulged, whenever someone could afford to pay for the treatment which was lengthy and, at best, marginally effective. Then, a few years ago, people like David Butler, Louis Gifford and Lorimer Moseley began writing about the neuroscience of pain and it seemed practitioners began to abandon mobilisations and manipulations, and started to champion the bio-psycho-social model, Melzack and Wall, and the NOIgroup.
Perhaps it is an indication of a maturing profession finally having found a problem that expresses its more profoundly holistic, embodied tendencies? But this argument doesn’t stand up to much scrutiny, since there are plenty of other health problems familiar to physiotherapists that bear the same subjective, socially-constructed tendencies as chronic pain, but are far more prevalent and, arguably, more clinically significant, like chronic breathlessness. Chronic breathlessness is a feature of some of the largest causes of morbidity and mortality in the developed world, and because it is closely associated with death and decline, is perhaps an even greater motivator for action than unremitting pain.
So perhaps pain represents a complex problem that physiotherapists can understand and get their teeth into: a problem that we can make a real difference to? Well again, chronic breathlessness wins that race by a country mile. Pulmonary rehabilitation is one of the most effective interventions available to physiotherapists and does it without needing to argue that it is making permanent structural change to the person’s lung function. So then perhaps the thought of all that sputum puts people off? But here again, there are far more prevalent problems that bear the same hallmarks of complexity as pain, and for which physiotherapists have all the requisite skills to impress. Neurological rehabilitation from accident or degeneration has gone through a revolution in rehabilitation in recent years, but it seems it remains a specialised field for only the highly skilled and well supported.
So why has chronic pain become so popular since Butler and Moseley wrote Explain pain in 2003? I think there are three broadly overlapping reasons for this, and none of them are particularly ennobling:
- Chronic pain is dominated by private practitioners who have learnt that the management of chronic pain avoids the regulatory and funding restrictions that had increasingly accompanied treating spinal and peripheral joint problems
- Chronic pain allows us to keep our biomechanical knowledge intact, and offers a new vocabulary of neuroanatomy and psycho-neuro-immunology that can be superimposed on top of our existing knowledge without needing any radical revision to the fundamental scientific, evidence-based, knowledge-stable system that we value so highly
- Chronic pain generates a bank of stories and metaphors that the new gurus of pain science can use to explain the nature (and I used that word advisedly) or the phenomenon at hand
It would be a fine thing indeed if chronic pain provided a vehicle to move some of our most unashamedly biomechanical brothers and sisters away from their technical rationalistic backgrounds and into the world of phenomenology, social constructivism and critical theory, but this will only happen if there is a genuine attempt to break with a fixation for neuroscience and the search for the biological basis of pain, and this may be some way off into the future yet.
The upsurge of new professional interests, like our interest in trunk stabilisation, spinal mobilisation, and before that ACL injuries and fractures, amputee rehab, spinal cord injuries, and so on, and so on, happen because different ways of thinking and practicing make new affordances possible. Rarely can these ever be explained by scientific reason or political contingency alone. They are complex, but they can tell us a lot about where the profession has come from and where it might be going to. To paraphrase Foucault; ‘I’m not saying they’re bad, only that they’re dangerous.’
Butler, D.S, Moseley, L. (2003). Explain Pain. Adelaide. Noigroup Publications. ISBN 0-9750910-0-X.