Coal Mine Archives | Page 2 of 2

Your client is here.

You, at a normal pace, hurry to greet them but quickly slow in approach as you watch them rise from their seat with the movement quality of someone 50 years their senior.

The slow rise finishes with qualities of an old machine attempting to shift into a locked position as they intensely brace themselves through the maximal slow strenuous effort to extend their hips and spine to an upright posture.

You start your steps toward the treatment room but by your second step you realize you already passed your client 6 feet ago. You realize, it’s time to be here now.

The journey to your treatment room provides time to review testing findings and discussions both you and the client’s had coordinated with other disciplines. The patients words require significant effort for them to express.

Their words have a defeated and tired air to them but they certainly are giving all their effort.

The travels, the demands of work and the significant struggles in family life, the sheer tenacity and will to keep going in spite of a body that screams for rest. Life must go on after all does it not?

You observe the posturing that looks that of a much frailer representation of the younger client who stand before you. Your mind wants to speak of the antalgic changes in kinetic loading from foot to head and the way the sandals are worn on the feet to allow for some relief but now is not the time. The rigid shoulder and arm posturing, the clenching of the fists, and the strain of the words coming from their mouth.

You arrive at your treatment room, you lower the table. Already all plans for the session have changed four times since you first greeted your client.

Every plan shift reviewed systems, symptoms, behavior, client report, reconsideration of other discipline objectives, the social and work constraints presented by the client. Where is my entry point today, no not there, ah there, no the time is not right, could they progress on that from before, are they ready for this? No not now, let them lead.

You place the chair but the client opts for the table. They do not know their body, they do not know the struggle they themselves are adding the problem, but words do not matter now. Only the bolster and hands on guidance for ease.

The client exhales a sigh of relief for a moment, their eyes change as they seem to indicate that they just learned something in that process, and they thank you for helping them.

You notice the swelling of both ankles are improved since the last session and the client reports they are seeing improvements since the first session with the strategies you had discussed.

You know the relief is short lived and begin planning in the background the next steps and how those steps could be used to further educate and empower the patient to learn know their own needs better. You balance your words in your mind as you find ways to both the dance with the complexity of, dare I label and define it?

Moments later the next wave has arrived and stuns the client into a heightened state once again. They steel themselves and demonstrate an intensive muscular effort of the back and hips that they report provides them momentary relief of both legs but worsens their back.

The session now reveals itself dynamically.

The dance of the dialog and interactions of session now reaches a flow point. You and your client work together to engage the suffering and workability of their struggle with pain.

The dance is certainly technical, from review and progressing of meaningful understanding and application of the physiology, the cognitive, the emotion, and the social interactions.. To managing the biomechanical outputs through hands on guidance and coaching of positioning relief to allow them to appreciate value of awareness and exploration of the automatic postural and guarding response of the human body. The larger picture unfolds and the conversation naturally leads to where the client is going to engage in the process. The artistic beauty of the interaction paints the picture, rather than the technical details.

The client breaths comfortably. The pain is less, but this not important. What is important is that the meaning of the pain has changed. They feel hopeful and they know their role in the process going forward.

The time allotted is now over. Now the journey from the sterility, but subtle safety, of the room to the clients own reality begins. They arise now taller, there is a lightness present in their movement, and there is strength in their words.

I currently work with a large percentage of patients who experience “complex ” and/or “chronic pain”. Many have multiple surgical intervention histories (most repeat surgeries), every known non-invasive treatment (multiple episodes of PT/chiro/body workers), and every known pharmacological intervention known to man. All of these patients share a similar story, they were all told that “X,Y,Z” would resolve their pain or dysfunction with absolute certainty, everyone told them it was a simple fix. Yet, here they are continuing in pain, or in worse pain, in front of me.

As I sit back and review many of these cases, the most consistent theme I see of why they continue to suffer is that the traditional differential diagnosis has failed them. Many were told they had a specific diagnosis and were given a specific treatment. Differential diagnosis is based in the contemporary utilization of “Occam’s Razor”, which is the principle that “Among competing hypotheses, the one with the fewest assumptions should be selected.” (Side note: Historically it has been argued this statement is an inaccurate reference to Occam and was created by later philosophers) . Utilization of Occam’s razor is critical to many aspects of healthcare, in particular emergency medicine. However, regarding pain, it is a principle which falls far short. Pain is complex, not simple.

The absolute, “this tissue/disease is the issue”, which is both culturally and healthcare driven, is why we are in a chronic pain epidemic.When it comes to pain and movement, physical medicine and rehabilitation professionals need to come to terms with the complexity of pain. It is never a single factor, even if there is a single predominant source of nociception. This also holds true for acute injury, you must account the environmental factors and the processing, as well as the outputs:

Louis Gifford’s Mature Organism Model – 1998

This understanding makes pain and movement complicated, it makes things a bit gray, there is no absolute. You must make a clinical decision to guide the treatment, you need to be able to identify red flags quickly, you need to identify some important tissue issues, but you also must be able to confidently proceed with fair degree of uncertainty with a great deal of grace and skill. I call this skill, “Confident Ambiguity”.

Confident ambiguity allows a clinical decision to be made in the absence of an absolute diagnosis, and the absence of absolute certainty. Classically, you would look at it as a list of possible diagnosis, within your differential, but now you are asked to not just identify the possible biomedical diagnosis but also the psycho-social factors and assume for all of them to be present concurrently with a constant dynamic shift, as well as combined presence, in any given moment (Louis Gifford calls it the “Shopping basket”).

Research and clinical prediction rules help, but they need a larger framework to address all the concurrent layers of a biopsychosocial model. Personally, I, as well as many others, have been drawn to Ronald Melzack’s work on the neuromatrix at face value to help with developing a constant confident inventory of inputs/outputs in the biopsychosocial model. At all times, while interacting, assessing, and treating, in the back of my mind I play the “input/output” game, which at first appears challenging, but over time is very re-assuring both for yourself and your patient based on the dynamic nature of the interaction. This same approach has been beneficial with performance enhancement.

Melzack, Ronald and Joel Katz. “Pain in the 21st century: The neuromatrix and beyond.”Psychological knowledge in court. Springer US, 2006, 129-148

Every pain experience and every movement dysfunction cannot simply be broken down to single tissue damage, single disease, length tension relationships, muscular imbalance, tissue restriction, or any other musculoskeletal emphasized diagnosis. You must learn to accept the fact that the tests you delivered ,which you so confidently felt were reproducible to a specific tissue or movement pattern, may at least in part be a “neurotag”, a pain and/or movement memory that is driving everything you see and feel.

Microsoft Word - Figure 5

Furthermore, lumping the patient into a primary “psychosocial” driver of pain is a also problem, one cannot ignore sensory input, regardless of whether it is nociception or any other sensory input perceived as a threat.

Pain is complicated, pain is messy, if we don’t treat it as such, you will be lost and you aren’t give the patient everything they need.