Everything in moderation, even the best things

This is a really well-written post on an important subject from The Sports Physio.

It is by a physiotherapist, intended for other physiotherapists, but it was also really meaningful to me as a patient. (For my readers in the US, physiotherapist means the same thing as physical therapist).

The author, Adam Meakins, talks about how many physiotherapists are now jumping on the “bandwagon” of viewing chronic pain as a function of a sensitized nervous system.

This is obviously a really important concept to be aware of.

My entire life changed for the better when I finally met a physical therapist who could explain to me that the pain I’d been feeling for so long, which all the other medical professionals were telling me was psychological, was actually due to changes in nervous system function.

But it is possible to take this idea too far—to be so excited about the fact that now you have a straightforward explanation for some patients’ complicated, ongoing pain that is also new and exciting—perhaps, in some cases, even “trendy”—that you overlook other things that could be going on.

Basically, before physical therapists knew anything about the phenomenon of central sensitization, they figured that all pain must be caused by a biomechanical or structural problem in the body. For example: the patient has flat feet and needs orthotics. The patient has a slight difference in leg length. The patient sprained his or her ankle and has scar tissue left over that must be massaged away.

However, as anyone who is educated on the complexities of chronic pain can tell you, there hasn’t always been sufficient evidence to back up these ideas. As Meakins explains,

“… thousands of therapists (are) realising that the traditional postural, structural biomechanical model just doesn’t seem hold up to scrutiny or to the evidence base anymore, and that pain isn’t just due to these factors.”

In the case of chronic pain patients, pain is often being perpetuated by a process within the nervous system, rather than a physical, structural problem. And you, as the treating professional, can achieve miraculous results by educating this person on how their nervous system is playing a role in maintaining their level of pain.

This is why many PT’s now speak somewhat disparagingly about the older, traditional “structural, biomechanical” model.

But when you are too quick to write off the idea that a patient might also have structural issues contributing to their level of pain, you might miss other factors that could be contributing to their pain.

This also happened to me. The PT that first taught me about pain and the nervous system—who, again, changed my entire life for the better—did take these ideas a little too far.

As much as he helped me figure out the mysterious pain that had been plaguing me, in one part of my body or another, for years, he also second-guessed my orthopedist and told me I didn’t have chondromalacia patella in my right knee. And this had overarching, years-long consequences for me, as I ended up injuring that knee to the point where the chondromalacia patella was excruciating and I could barely walk.

Along similar lines, Meakins tells the story of a patient who was diagnosed with Complex Regional Pain Syndrome, after breaking a leg. Her pain stretched on for months and months, and she was told “she would need extensive cognitive rehabilitation and medication for her pain.”

She later sought a second opinion, and it turned out she had physical damage (an osteochondral defect, specifically) that hadn’t healed.

I’ve also noticed a tendency for non-medical professionals to also jump on this bandwagon, without appreciating the other factors that can cause pain.

For example, I have certain members of my family who tend to assume whatever happens with my physical issues is somehow my fault. If I can’t do something, I haven’t tried hard enough. If I do something that makes the pain worse, I’m trying too hard.

Once these family members learned a little bit about how pain can be caused by changes in the nervous system, they started getting angry at me for “giving in.” For not “fighting” the pain hard enough (even though that is exactly what you’re NOT supposed to do when dealing with a problem of this sort. You’re actually supposed to be gentle with your nervous system to allow it to calm down).

And the articles they’ve read by medical professionals dismissing the biomechanical model have only given them ammunition to tell me I don’t have a real problem.

I think this is why I’ve been so reluctant to really talk about the specifics of my sacroiliac joint issue on this blog. I know that some of the pain, of course, is likely being magnified by my nervous system. And I’ve done so much reading on the workings of chronic pain, and the failures of the traditional structural mechanical model, that it’s made me a little bit hesitant to say hey, I think I really have a structural problem here.

But the truth is: I really do think it’s a structural problem. The irony is that it doesn’t actually hurt that much, not in the joint itself. What hurts is all the other areas that have to compensate when I’m limping. When I really stop and think about it, my problem doesn’t even feel like pain, in the truest sense of the word. It actually does feel like a structural problem.

So I’m going to stop apologizing for this problem, and stop doubting its veracity. None of the medical professionals I’ve seen at this point (which includes three physiatrists, seven physical therapists, and four chiropractors) have actually told me I don’t have a problem.

I think we all need to take a step back and realize that while the recent advances in pain science truly have the potential to change patients’ lives for the better, everything– and I do mean everything– is best in moderation.