Pain management

Last night I spoke with a woman diving for the first time into the world of intractable pain.  She had not come to consult with me, so I needed to be careful how I spoke to her.  She had come to talk to me about Taiwan, a place she loved that I will visit for the first time soon.  I noticed nothing until she got up from our couch nad hobbled around, trying to dispel the awful drawing pain of sciatica.

I have been on this journey with so many people in my practice, though I have only plunged myself for short times and not to too great a depth.  My partner’s journey through her brain injury was perhaps my closest hand-in-hand encounter with the unendurable that must nevertheless be endured.

In this case, a very active hiker and outgoing woman was struck suddenly by sciatica with no particular precipitating event, which usually means that something was slowly strained and strained some more until finally it broke through – a wearing out, in other words, rather than a direct injury.  She was in the early stages of going to doctors with the ‘Fix me!’ attitude, and finding the usual panoply of orthopods who have no hope except through surgery, inconclusive MRI’s (a herniated disc at L4-5, but who knows how long that’s been there or if it is symptomatic), and over-rough PT that, sincere though it was, only exacerbated the problem.

‘What should I do?’ – the mantra of these folks.  She was considering acupuncture, change of diet, surgery, more PT – make the list as long as you want – in this information age, another alternative insisiting they can help is a mouse click away.

The only answer is: “Explore!’  Each pain is unique, each individual, each situation.  The modern scientific world still bases itself on the Cartesian idea that the body is a ‘soft machine’, and like a machine it has parts that wear out, and the parts need replacing – like an auto, like a computer.  The body is a fractal event, more like an atmosphere or a culture – it is a pattern of swirls.

So each pain like this – whatever the mechanics, which must of course be examined – has its own flavor, its own tendrils reaching into the fabric of meaning of the person’s life.  It’s not her disc (or osteophytes or piriformis or stenosis) that is ‘causing’ the pain, but a whole pattern that has tried to distribute this strain for some time, and has finally come to the end of its tether.

After the sojourn at the door of the doctors (which is the end of the journey if it works, the beginning of it doesn’t) comes healing by the shotgun method: fire everything at it, and see what works.  But of course it is impossible to tell what is working if you are doing 12 programs simultaneously.  Again, the end of the journey if one or some combo happens to work, but the results are more often some diminution, some relief, but the problem continues or returns.

Then the exploration begins, and this is so often when people show up at my practice door.  Each journey is unique, but there are a couple of things to say in general:

1) If you have surgery, to paraphrase Bonnie Bainbridge, you move out of the evolutionary cycle of healing.  There are no genes for surgery.  There are genes for broken bones, for soft-tissue repair, for nerve healing, for organ restoration – however imperfect, the body has dealt with these interruptions from time immemorial.  Surgery, only around for 150 years, invades the body in a way that few wounds would mimic.  Every surgery, no matter how benign or how successful, leaves a scar, which is a restriction of movement, which creates new strains to be distributed through a system already strained by the injury.  When it works, yay!  When it doesn’t work, the doctor is not always faced with the sequelae that show up somewhere else two years later.

2) While surgery has 150 years on-the-job training, walking has 4 million years – since the australopithecines stood up.  Especially for conditions of the lower back and lower body, including knees, hips, and feet, walking is the great restorer.  Not running, with its pressure, but simple walking from place to place.  Time the walk, if possible, to create feeling in the injured area, but not deep pain.

And pay attention.  How is your foot traveling over the ground, how does the weight come?  How is it different on your left and your right?  Where does the movement go ‘though’ and where does it get stuck?

And not only during the walk – all the time.  Is not pain a call for attention?  So many want pain fixed: Get it out of the way so I can put my attention on the things I want.  But pain is the body’s way of getting our mental attention and focus, as our television culture has little time for the real needs of the body, or considerations for its feelings.  ‘Come back!, Come back!’ says pain, ‘You’ve been away too long.’ We didn’t heed the earlier whispered warnings, so the body begins yelling.

Like a kid having a Force 5 fit on the floor of a supermarket, in intractable pain the body has gone beyond the ‘talking reasonably’ stage. Usually the pain is out of all proportion ot the damage – lots of pain with little actual tissue damage, the pain amped up by positive feedback loops within the nervous system.  The walks are the equivalent of taking the kid out of the store and walking him around the parking lot until the screaming and sobbing is done, and you have some chance of finding out what lies beneath the over-reaction.

With neck or shoulder pain, we take another route.  Organic pain is something else again.  But for pain of the lower body, take a lesson from Lucy: walk, walk walk – and be patient and attentive.

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2 Responses to “Pain management”

  1. Greg Says:

    Tom
    I appreciate your thoughts – as I am familiar with this person.
    As a practicing PT for 15 years, this “fix it now feeling” is seen often.
    With this person it has been a trial of treatment modalities and education to decrease the symptoms-(MFR, MET, gentle manual traction, postural positioning, trans. ab training, etc).
    I am familiar with your book(we have it in one of my clinics) and have personally been thru a course of Rolfing a few years back, which worked tremendously for me.
    Again, thanks for the input.
    Professionally
    Greg

  2. Donal Says:

    The ‘fix me’ attitude is a symptom of the society within which we live, the so called Western World. We expect to be able to purchase instant gratification. THe most unfortunate thing is that it is probably our most pervasive export.

    Pain is indeed a call for attention. Actually, the body offers many more subtle messages to inform us that all is not well. By the time we have pain, the message is more akin to a desperate scream.

    Symptom based treatment is at best short sighted. At it’s worst it is unnecessary invasive surgery with little or no relief.

    Fortunately the body has many forms of communicating and posture is available for all of us to see. As posture is a snapshot of function (the ability of the muscles to perform a given task without pain, limitation or compensation) deviations from design posture tell us of imparment.

    By addressing the posture and treating the body as the highly integrated unit it is we begin the process of REPAIRMENT –

    “the dynamic process of regaining health and vitality, far beyond the absense of symptoms and limitations.”

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