Giving back whatever's missing

I respect the peer-review process immensely.  It's the glue that holds the academic world together.  But one is rarely given the chance to just 'riff' about things in peer-reviewed publications - although sometimes you can.  I think that's what I'm going to enjoy about blogging, assuming I can find the time and motivation to do so consistently.  It's a chance to share your thoughts, and to get feedback on them from others.

I enjoy looking at common problems from different angles.  I think this is what I enjoy so much about teaching, research and clinical practice - they all require flexible thought and comfort with uncertainty.  So here's one of those 'from a different angle' things - what if we were to change our paradigm for managing chronic pain from the 'find what's wrong and fix it' to 'find what's missing for the patient, and help them reclaim it'.  It's a subtle shift, but a profound one in my experience.

The structural-pathological model from within which many health professionals practice is centred around the search for the 'culprit' as it were - x-rays, MRI's, EMGs, special physical tests, stressing, twisting, poking and prodding, all in an attempt to identify something that's there that shouldn't be.  A problem that, once removed, should lead to resolution of the patient's pain experience.  In practice this might be something that's strained, pulled, torn, deteriorating, not transmitting enough, transmitting too much, stiff, loose, or out of place.  Unfortunately, and this is especially true in the case of chronic pain conditions, there are two problems we frequently run into: 1. if we search hard enough, we'll find something.  I've never met the 'perfect' body, I don't even know what that would be, and 2. Often times, once the culprit is reformed, the patient's problems don't necessarily go away.  There are of course some obvious exeptions here, things like fractured bones, infections, tumours and the like, that do need to be identified and remediated.  But even then, the 'what's missing' rather than 'what's there that shouldn't be' approach can still hold.

In this new approach, the goal is to find out what's missing in the patient's life.  In other words, what is preventing the patient from feeling like the person they think they ought to be?  This may in fact be something that's present that shouldn't be, but in many cases it's probably something more.  If you were to pose the question 'what would have to change in order for you to feel satisfied with your health?', in many people who experience chronic pain, the answer would be something like 'My pain would be gone'.  If we were to stop there, we would then begin our search for the pain generator, a search that is often frought with frustrations and dead ends, for both the patient and the clinician.  But if we were to take the line of questioning a few steps further, the path towards the best intervention would probably become more clear.  Questions like 'And what would having no pain allow to do / be / become?',  or 'Of the things you've had to give up, what do you need to reclaim in order to feel satisfied with who you are?'  On the surface this feels like an attempt to evaluate the patient's losses from the participation-level of the ICF, but it may not be that.  Participation-level losses may not necessarily be the most important thing to that person.  We need to be cautious about jumpting to conclusions.

Here's an illustrative tale: one of the things I do for research purposes is interview people with chronic pain, mostly chronic whiplash-related pain.  During one of these sessions, I was working through the Brief Illness Perceptions Quesionnaire, a tool designed to capture perspectives from the illness representation model.  One of the questions asks peope to rate the degree to which their injury/illness has affected their lives, on a scale from 0 (no affect) to 10 (completely changed).  The person I was interviewing thought for a moment and answered an 8.  Fair enough, I jotted down an 8.  But then she said 'But I don't want you to think that's a bad thing'.  I was dumbfounded a moment.  Clearly this question was supposed to be oriented such that a higher number was negative.  But she continued 'My life is completely different from what it was prior to my injury.  Now I've been forced to slow down.  Now I no longer take for granted the small things in life.  Now I am much more aware of my health and my body.  While I'm completely different than the person I was prior to the injury, I'm now at a point where I wouldn't say I'm worse.'  

WOW, that was unexpected.

My point about this whole 'what's missing' thing, is that if I had seen that patient in clinic back when I was a fresh-faced newly graduated PT, I would have immediately begun my search to identify what in this person's body had changed, so that I could resolve the problem and revert her back to her former self.  But now, I'm recognizing that if someone comes into the clinic to see me, they've been motivated by some desire to regain something they've lost.  I don't presume to know what that something is, but I feel I had bloody well find out.  And once I do, the correct intervention is often presented for me, plain to see if I'm ready to look for it.

Would welcome your comments.