| I sat and talked with him about this loss of faith, which was a tremendous thing that had been totally buried. And he started to weep like a baby. I asked him who was the last figure in your religion (this was a Jew), who was the last rabbi your were able to talk to where you felt a personal connection? He said that there was a rabbi at the shule over in Jersey who was just a wonderful guy but that when his mother got sick, he stopped going to that synagogue. I wrote on my prescription pad, “Go and talk to Rabbi Berkowitz at least once a week for six weeks, and then come back and see me.” And he did it. It didn’t solve all of his problems, but it made a tremendous difference. So sometimes it’s something like that, something you wouldn’t necessarily think of off the top of your head. He had lost his whole sense of meaning and it was having a devastating effect on many aspects of his life.
Across all the health care disciplines that treat pain, there’s been a paradigm shift emerging over the past decade or two, that involves moving away from a primary focus on eliminating pain and toward a focus on restoring full function, even if some pain remains. This includes a shift away from passive care (doctor treatments such as medication or manipulation) once the acute phase has passed, and a move toward active care such as exercise. How deeply has this change penetrated at this point, and where do you think we’re headed?
My sense from the conventional MD community is that most people are on that page, at least the academics are. There are a lot of practitioners out there in the field who don’t necessarily attend all the meetings and who may end up just sticking needles in people over and over again, the “block shots” performed by anesthesiologists. Other than that rather large and unfortunate phenomenon in the pain field, I think most of the academic and thoughtful pain docs have a better rounded view of this. I see a general paradigm shift progressing slowly.
We are taught now at the pain meetings to document both pain and function, and it’s not adequate just to get a brief pain inventory, a McGill or whatever. You must use measures that look at the patient’s function. You can’t just do a 10-point pain scale. The other thing that’s really interesting is that it looks like the 10-point pain scale may actually measure depression and anxiety more than it measures somatic pain. This is the work of Clifford Clark at Columbia, who is a senior psychological researcher there.
Because the more depressed you are, the more likely you are to call a certain amount of pain a 9 or 10 (a more severe rating) rather than a 6 or 7?
Exactly. The 10-point VAS [Visual Analog Scale] may measure distress and anxiety particularly, and to some degree depression, or as Michael Sullivan from Dalhousie University refers to it, “catastrophization.” I think it’s important to document the somatic suffering and the symptoms but it’s really important to write down what the person is doing, what they’re able to do, how far they can walk, or whether they are able to clean up the kitchen. Are they able to go up and down stairs? How much difficulty do they have going up and down stairs?
I know that here at Cleveland Chiropractic College, there has been a major shift in that direction in recent years.
The other thing is that the focus on function allows you to some degree to get out of your head and into the physical world. I have four pillars that I talked about on my PBS special. The four pillars for any pain patient are always the same, they’re simple and they aren’t radical. Number one, a decent diet. Number two, stress management. How stressed out are you and what are you doing to deal with it? Number three is exercise. Are you in motion? What are you able to do? Number four is spiritual engagement or social engagement. Those are critical for everyone in chronic pain.
You’ve got to start a person moving and showing that they can use their body without being destroyed by their symptoms. An extension of this is the concept of work hardening programs and back to work programs, where the person is going to have a certain amount of pain but you’re going to try to get them back on track anyway. The reality is that lots of people function in pain and it’s okay with them. On some level they end up making the bargain, “Yes, I still have 3 or 4 over 10 pain, but I’m much better than I was. I’m not 6 or 7 over 10 and I promise you that I will get down to the bridge game on Thursday night because I want to see Gladys and I haven’t seen her in three weeks.” With a patient in that situation, I push them to get down to the bridge game and see Gladys, even though they may be in a 4 of 10 level of pain. |
