Stepping Back Part II
In Part I of this series, I discussed the limitations that exist with our current beliefs and theories we hold when it comes to dealing with pain. For most of us, this involves having theories rooted in a mechanistic worldview believing that our bodies are like a machine and can be fixed with certain interventions. To understand some of the content in this next part, it’s important you read the first part to process through some of the complex nuances discussed.
Throughout this post, my intent isn’t to give you a new philosophy you need to learn, and it isn’t to suggest which interventions are the best; it’s simply to challenge some of your root beliefs and provide a new worldview that is able to adequately explain with enough scope, depth, and precision why certain interventions work for some people in the right context. By doing so, my hope is that we can move our profession forward through a new worldview that isn’t often discussed or taught in the medical field.
When investigating research surrounding pain, many of the interventions we use have demonstrated some effectiveness, but not necessarily for the same reasons we are led to believe. It wasn’t until the early to mid-2000s when researchers began to challenge some interventions that we idolized with sham-placebo controls. This began to unravel questions as participants seemed to improve equally as well with the intervention compared to the control. Why did people do so well with an intervention that was fake? Surely, if our theory was encapsulated in a mechanistic worldview, it would make no sense; the participant didn’t get the thing that changed the mechanics of the issue, yet they still got better?! This must mean there has to be more to the story. Besides the several thousand differing physiological interactions and processes occurring, there has to be some CONTEXT involved that interacted with the human receiving the intervention.
To work with pain more efficiently, we don’t necessarily need to add any more tools to our toolbox, we just need a better framework that is rooted in a philosophical worldview that can adequately explain with enough scope and precision all the complexity that is involved. Having a mechanistic worldview to explain pain might have been what was needed when Descartes first discussed his theory of mind-body dualism, but now that we are in the 21st century, it’s time to move on to a better worldview that accepts and helps us understand the importance of context involved with every unique situation. This worldview is known as Contextualism, and by embracing the scientific philosophy of pragmatism, the framework we want to implement is called a process-based framework.
Shifting from a mechanistic worldview to contextualism acknowledges the importance of context in every situation. For people with pain, this includes all the unique individual biologic, psychologic, and sociological factors influencing one’s experience. Even though the Biopsychosocial Model (BPS) was proposed in the late 1960s, we still have not had a chance to fully understand its scope because we have forced it into a mechanistic box. However, when you start to view the BPS Model within the worldview of contextualism then the idea of application becomes a little clearer. We can’t just use the model to help explain all the mechanisms involved within each realm. Instead, we must show enough flexibility and willingness to shift our philosophical perspective based on the context that is involved with each realm. This entails having the ability to quickly and efficiently shift between different perspectives based on the CONTEXT involved in one’s unique case.
To help explain this practically, let us think about someone with low back pain. When you take on a contextualistic worldview, your thinking becomes more dispersive allowing you the opportunity think about the back pain mechanistically to rule out any serious red flags, and then can easily transition into a different perspective recognizing all the different dynamic and interacting processes that are involved. Without that ability to zoom in and out in an efficient manner, you either miss the boat completely on red flag issues and risk the ability to help someone receive a necessary life-saving intervention, or you become stuck trying to find a single cause for something that has many different synthetic processes constantly interacting and interconnecting to formulate one’s pain experience.
Failure to become aware of all the differing, complex networks involved often results in a loss of coherence for both the clinician and the patient. This happens often as their beliefs suggest one thing, your words say another, and the intervention you describe doesn’t align with either of them. They may be hearing that their pain is multifactorial, yet you both are in search of the one single cause. (To learn more about coherence within a clinical setting, be sure to read our prior blogs here, here, here, and here.)
So how does viewing pain from a contextualistic worldview change what we are doing in the clinic? Many people have the belief that with a new framework comes a ton of new interventions. That isn’t necessarily the case for this. As mentioned in the very beginning of the first blog of this series, when we think about interventions for pain, it’s better we challenge the thought process behind them rather than the intervention itself.
Let’s take core stabilization for example. Many people have their patients with low back pain perform core stabilization interventions. This idea is often formed from the mechanistic belief and theory that the back is unstable and needs to be fixed or stabilized. The belief becomes stronger when patients who perform these interventions report improvements in their pain experience, which we know happens quite often. Since patients are improving, it must mean that their backs were unstable, right? This all sounds appropriate, however, when you investigate the research and find that people with low back pain are often more tense and guarded around their low back, why would stabilizing an already tense muscle make much of a difference? If people with low back pain show less mobility and coordination then other healthy controls, that doesn’t sound like the back is unstable to me. But why then do some people get better with core stabilization interventions? There has to be context associated with their unique history, beliefs, expectations, etc, and by performing low graded movements mixed in with increased awareness into the low back is just what someone may need to gain the confidence that they were indeed going to improve over time. It’s hard to truly explain the exact reasons which is why it’s much easier to say it depends on the context and several other thousand interacting, dynamic processes concomitantly occurring for that individual!
Okay, so now that we may have a better rationale for explaining why someone with low back pain benefits with core stabilization, with thousands of interventions already existing, how do we know which one will be the best? This is the path we will take in Part III of this series where we dive deeper into the concepts related to process-based thinking and clinical-decision making.
Some great thoughts here