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.


7 thoughts on “Everything in moderation, even the best things

  1. Thanks for sharing this post. I have a lot of painful diseases and illnesses. You are the first one I’ve come across that even knows what chondromalacia patella is. I have it in both knees and when it flares up, often for no reason at all, is very painful and I have to walk without bending my legs at the knee when I’m off my feet, it throbs, which is also so very painful.
    I must admit, I do have a problem with moderation. I’m an all or nothing kind of person. I am working on it, though.
    Have a great day.
    Peace out,
    Tammy :)

    1. Hi Tammy, thanks for your comment! I just wanted to ask if you had ever tried using Kinesiotape on your knees. It was really a miracle cure for me. I basically got worse and worse over the course of weeks until my PT at the time introduced me to it. I now look back on that appointment as my turning point.

      There are lots of instructions on how to tape your knees on the Internet, but I definitely recommend having a PT tape you the first few times to make sure you get it right. You want to find someone who has been trained in Kinesiotape (it’s a continuing ed thing– not something they learn in school).

      I looked and looked for a picture of the way I tape my knees. This link was the only one I could find that shows the way I do it. It’s the method they show on Page 16. It was so effective for me, I never needed to try another way. http://www.mccc.edu/~behrensb/documents/KinesiotapingforChondromalaciaNHepburn.pdf

      Good luck!

      1. No, I’ve never even heard of that, but tomorrow I will click on that link and most definitely check it out. Can I just buy this tape at any pharmacy? Can’t wait to try it. Thanks so much for sharing this info. with me. I think me and you are the only one’s in the whole wide world with this very painful affliction. I had fallen asleep listening to some music on my itunes and someone came along and just shut my laptop and got me all in an uproar because we all know that’s not how you shut down your computer. I had to turn it back on to log out of everything I was logged into and saw your notification. Good night for now and I’ll let you know how it works for me, of course I’ll have to wait til it flares up again, but it always does. :)

        1. You can buy similar tape at pharmacies, but I don’t think it’s as effective. I just buy my Kinesiotape on Amazon. It’s not cheap, but in my honest opinion, it’s totally worth it! (If they tape you during a PT visit, you don’t have to pay for it. You’d only have to buy it if you started taping on your own. So definitely go to PT first and try it out!).

          Sorry, no matter how I copy and paste it, the link keeps showing up as an ad…?

          http://www.amazon.com/Kinesio-Tex-Tape–Color-Economical/dp/B000FP04CO/ref=sr_1_2?s=hpc&ie=UTF8&qid=1414171538&sr=1-2

          1. Thank you so much for sharing this information with me. That’s okay, all I need is the picture. Now, I sit back and wait for my knees to flare up, again, and then I’ll call my doctor and request that I go back to PT. I’m so glad that you’ve found something that works for you and prevents you from having to have surgery, which has been my fear for a long, long time. I’ve had chondromalacia patella since I was 11 years old. Have a great day, my friend. :)

  2. Well written! it’s so easy to jump from one bandwagon to the other, and to ignore the physical for the physiological. One would expect that smart people would remember that pain is complex, but we so want the simple solution.
    An inherent difficulty in educating people about pain (health professionals and people in pain) is that the educators seek to simplify it. it is imperative that your message is heard – don’t jump from one mechanism-based perspective on pain to another.
    In addition to moderation, we need to be circumspect.

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