Recently Steve Kamper at the George Institute in Sydney published a blog entry outlining some thoughts about the idea of recovery from musculoskeletal pain. And by the way, thanks for the citation Steve :)
I'd like to follow his lead and take the opportunity to expand on the challenges of defining recovery from musculoskeletal pain and injury, which is something I've given considerable thought to as have Steve, Julia Hush, Kathryn Refshauge, James McCauley, Chris Maher and others in that group.
To undersand my take on this, I think I need to position myself from an epistemic standpoint (epistemology: the way you view truth and reality), in comparison to other common philosophical approaches to understanding truth and reality.
Positivism, in a huge nutshell, is the position that the real world can be accurately measured objectively, and that cause and effect can ultimately be determined with little variation. Positivism works best in disciplines like physics and chemistry, where laws can be developed that are pretty invariant over time. It doesn't really work for studies involving living things, because there are few (if any) laws of human nature.
Post-positivism, growing out of positivism, is a position that a single 'true' reality exists, but that it can't be directly and objectively measured. In other words, postpositivism suggests that a hypothesis can't ever be proven 100% correct, but that alternative hypotheses can be proven incorrect such that, with the rejection of more and more alternative hypotheses, we get closer to the truth. In practice, this is why we have things like p values and confidence intervals in statistics - we're never 100% that a null hypothesis can be rejected and that a relationship exists, but we can be 95% sure (ie. a p value less than 0.05 tells us we can be 95% certain that a difference or association has not occured by chance, and we can therefore justify rejecting the null hypothesis which states that no difference or association exists. You follow?).
Constructivism can be largely considered the polar opposite of positivism. This position suggests that there is no singular reality, that we all create our own reality through our experiences and the way we interact with the world. Traditional statistical tests of association hold really no meaning from a purely constructivist standpoint because, for example, it's impossible to detach the tester from the object being tested, and hence the results will always be coloured by the lens of the researcher for example. Constructivism also states that our understanding of reality changes from moment to moment. In other words, my understanding of reality is different now...................than it is now. You dig?
Critical Realism, from an epistemic standpoint, can be thought of as falling somewhere between postpositivism and constructivism. Very basically, critical realism allows us to accept that some qualities of reality can be accurately appreciated through our senses or through measurement tools, while other qualities cannot be accurately sensed or measured. Statistical tests of association still hold meaning, but we accept that the results obtained are necessarily coloured by our own interpretations and that we can't separate ourselves from our understanding of reality.
OK, there's philosophy 101 for today. So why the lesson, and how does this relate to understanding recovery? It goes back to the statement that my understanding of reality changes moment to moment. Both constructivism and critical realism assert that the very experience of having an injury or pain will change our understanding of what is 'normal'. To bring it down a notch, you know how you can't unhear something, even though sometimes you wish you could? As a child, learning about things like fire or burglary changed my view of the world as a secure place. I can't un-learn that. I know it's true so my understanding of reality was permanently changed.
The same goes for an injury - having experienced the injury will change your understanding of things like your body's frailty or mortality, or that the world is an unpredictable place through which your body usually carries you but can, at any time, break down. From a constructivist or critical realist standpoint, the 'pre-injury normal' no longer exists. Thefore, it's impossible to reclaim.
So does that mean that recovery is impossible? Not at all. The question again comes back to what myself and others have been working towards - what is recovery and how do we define it? Both us here at c-WhIP and the folks at the George have been trying to understand this through interviews with patients and providers. We're actually sitting on a paper right now that reveals a number of domains of recovery that are important to people with pain. We're just working on running another focus group or two to improve our confidence in the results. I can share a bit with you now, without giving too much away.
Want to know what our focus groups have told us so far is the most important indicator of recovery? It will be when they can enjoy intimate relationships again. This doesn't necessarily mean sex, although it might, but intimacy as a deep connection with important others can occur in different ways. How often do we measure that? Here's another one, and I think this is really important - it's less about how the person they are right now, and more about the person they have the potential to become. I sort of touched on this in my Dis & Rehab paper linked to above, but it requires an acceptance of the idea that we're all traveling through life on some trajectory towards an ideal (in self-discrepancy theory parlance) or fully actualized (in Maslow speak) version of ourselves. Assuming we thought we were at least on the right path prior to an injury, our focus groups have said that getting back onto some satisfying life trajectory once again would suggest they are recovered. Again though, realize that what I'm extracting from the dialogues in the focus sessions are necessarily coloured through my personal lens and that if you were to read the transcripts you may get something different, but I think this makes sense.
So can we define and measure recovery? I believe we can, and it has something to do with happiness, satisfaction with current self, and satisfaction with one's perception of their ability to achieve greater things in the future. Happiness, as defined by Ryan and Deci, is composed of competence (ability to perform), autonomy (ability to direct one's own life), and relatedness (connection with others or with the community at large), which seems to be a construct that kind of jives with what we're hearing from patients.
So, take home message time - we can't go back in time. The past is the past, and we must deal with what we've got. A return to pre-injury normal, if you can accept a critical realist point of view, is not possible. A better target for identifying recovery would be happiness or satisfaction. Well-being or quality of life would also probably fall in there. While it's not possible to be the person you were prior to an injury or pain experience, it is more possible to be as happy with yourself as you were prior, and until we have reliable time machines, happiness seems like a more achievable target.