Neil Maltby’s excellent blogpost yesterday (Algorithm is going to get you) was a refreshing reminder of some of the odd things we do in the name of science-based physiotherapy.
Neil’s post was about how we look for pseudo-scientific measurement of things that otherwise can’t (and shouldn’t) be measured. I’ve blogged about this before (see here, for example), and complained bitterly about our lack of sophistication when it comes to subjective phenomena like breathlessness, pain, loss (of functional ability), etc., that are the bread-and-butter of everyday life for working physiotherapists.
No-one ever wakes up in the morning with a bad headache and says “Wow, I’ve got a really bad number four today!” and yet we insist that this is the most useful way to interpret other people’s pain.
It is an evolutionary miracle that we cannot remember pain – only the remembrance of being in pain persists. And it is the embodiment of a subjective phenomenon. Given this, the last thing a real scientist would seek to do is try to measure it objectively. And yet, in the absence of anything better, and a belief that we must measure things to be credible, we persist in asking ridiculous questions like “On a scale of zero to 10…”
Coincidentally, at the same time Neil posted about the dangers of visual analogue scales, the very eminent Lorimer Moseley was explaining pain to the readers of theconversation.com. Starting the piece with a lovely quote from Ludwig Wittgenstein – himself no stranger to the existential struggles offered by pain – Moseley proceeded to explain pain as an entirely biological phenomenon. Pain is not ‘in’ the body; ‘The brain produces pain’ (note the Cartesian mind/body separation here).
“we aren’t going to uncover the genius of physiotherapy at the end of an axon”
Moseley’s acknowledgement of lived experiences, cultural and social norms, beliefs, etc., was a welcome change from the kind of purely neurophysiological explanations that would have made Melzack and Wall happy, but everything still returns to the brain. It is the brain that must make sense of these things and moderate the neural signals that tell you whether something hurts or doesn’t.
Notwithstanding the almost constant rhetoric that pain is always bad and must be managed or removed – something we really do need to have a professional conversation about at some point – I’m not really sure where a biologistic understanding of pain really takes us professionally. Its not as if physiotherapists are adept at changing the biological structures that we concentrate so much on in our explanations of pain. Where we do come into our own, however, is in helping people to adapt to their lives in pain, in breathlessness, in recovery, and in rehabilitation.
Problems like breathlessness and pain are complex, inter-personal, culturally-nuanced, socially-mediated, existential experiences that form the bedrock of skilled, experienced everyday physiotherapy. Although we think we have to measure pain, perhaps we are inadvertently doing ourselves a disservice by focusing on this and ignoring the ‘other’ ways that physiotherapy matters? Truth be told, we aren’t going to uncover the genius of physiotherapy at the end of an axon, and the sooner we stop telling ourselves that pain is all in the brain, the better.