This Blog is a Discussion of The Amazing Clinical Acumen and Clinical Skills of The Past Masters of The Human Arts
Beyond Mundane Modern Medical Science and Technology.
Their Feats of Diagnosis and Inspiration Needed to be Seen to be Believed. The Human Possibilities and Great Potential of The Clinician Are Being Forgotten. Let Us Remember Them Before They Are Forever Lost in The Mists of Time.
Chronic pain clinic is incredibly challenging, stimulating and rewarding. It is perhaps the most complex of specialties, covering the cutting edge of all medical specialties because this is where patients come to when standard medicine has failed. Most are the exceptional cases. It also requires a crossdisciplinary approach, including as a minimum, medicine, physical therapy and clinical psychology. All this is compounded by its newness as a medical specialty.
It is no empirical science. The all-important evidence is subjective. The theories as to what pain really is in scientific terms, are more hypothetical. Theoretically based medicine is somewhere between limiting and already failed. Everything that science knows how to do has already been tried in most patients before they get to pain clinic.
Psychology is of prime importance. It is the final path between hard trauma, pathology and physiology of the nervous sysstem and what the patient actually experiences. 'Pain is only in the mind' but only on a technicality. It is an incomplete statement that devalues the human experience and the need to take it seriously. It would be better to say that 'The word pain is defined as being the mind's perception and response to injury'.
Psychologically, patients appear to fall into two functional groups: pain fearers and pain haters. Fear always makes pain worse, whether it is fear of the pain itself or the implications of the presence of pain, fear of the diagnosis behind that pain. Pain fearers burn out and get depressed which always exacerbates the pain itself. Where pain and depression go hand in hand, both must be treated aggressively.
The pain hater has a fight or flight, adrenaline reaction to the pain. Adrenaline is rarely considered as an analgesic but it is innately so. The fight or flight response is an evolved system to maximize survival in violent situations, including ignoring injuries and pain to keep fighting or running for your life.
These two groups are of particular importance in musculo-skeletal pain. The pain fearer avoids pain if at all possible, resting the affected part. The muscles grow weaker and the joints grow stiffer. Pain and disability increase in the long term. This also relates to a cluster of other psychomedical problems, including dependency and the sick role.
The pain hater uses their hate to break through the pain barrier. They exercise and stretch the muscles and joints without fear, innately knowing that this will maintain their mobility and ease the pain in the long run. They are basically doing their own physiotherapy.
Here, in pain clinical, every patient is a complex individual who has defied the odds in most unfortunate way. Few categorizations exist except neuropathic, musculo-skeletal and a few named conditions. Patient numbers are often small for quite unique problems. Positively proven Evidence Based Medicine is rare. The lack of evidence is only a lack of evidence.
These are the patients who have fallen through the net of EBM. What usually works did not work. EBM has failed them. TBM can't help them. All that is left is experience based and anecdotal medicine. All that is left is the clinician's inspiration and art. The only rule is 'Firstly, do not harm' or take minimal risks considering that the quality of the patient's life is being devastated and terrorized by pain.
And this is where the 'Positive EBM' of Europe, deaasigned by doctors for doctors and patient health, versus the 'Negative EBM' that has been inflicted on US style medicine can help. My experience of European Pain Clinics and rehabilitation is a very open minded approach to complementary medicine, especially acupuncture and anything that relaxes the body and mind. Anything is now worth a try especially when little or no harm will be done and in EBM, it does not matter if science does not currently understand how a therapy works. It does not matter even if these therapies are just regarded as placebos. They could be super-placebos enhanced by caring human contact and ritual.
The only objective in pain clinic is the reduction of the subjective experience of pain. It often becomes a matter of repeated trial and failure; failure not error because therapy is based on outsider chances rather than hot favourites.
Neither doctors nor patients should give up just because the first therapy does not work. Just keep trying new things, so long as they are relatively safe. Only once one pain clinic expert has run out of options should another be seen. They might have another trick up their sleeve and find that magical ease for that individual patient.
This is about the art of the individual clinician as much as it is about the individuality of every case. This is a world of trying everything and open minded inspiration for therapies that may not work on average for 'average patients' (if there such a thing) and innovation for what has not been tried before.
I do hope that in the US, EBM is not being blindly imposed on pain clinic in ignorance of this context for the sake of cost cutting. In fact, pain clinic is relatively cheap. If the physician is denied the possibility of open minded inspiration and trying the unusual and novel, the patient will just keep presenting for the standard treatments that have not worked in the past. They will have more and more very expensive investigations and surgery instead of the relatively low tech approach of pain clinic.