Insights to Help Our Patients after Acute Painful Injuries

Insights to Help Our Patients Insights to Help Our Patients after Acute Painful Injuries after Acute Painful Injuries

Fred Arthur M.D., C.C.F.P.Fred Arthur M.D., C.C.F.P.(E.M.)(E.M.)

Academic Forum, Oct 3, 2006Academic Forum, Oct 3, 2006

[email protected]@sympatico.ca

Case of I.K.Case of I.K.MVA MVA – Extricated seriously injured childExtricated seriously injured child– Released from ED with minor R arm injuryReleased from ED with minor R arm injury

Over next two days, developed significant Over next two days, developed significant R sided pain, especially lumbarR sided pain, especially lumbar9 specialists, OT, 3 PT, 2 psychologists = 9 specialists, OT, 3 PT, 2 psychologists = no clear explanation, ongoing psychiatristno clear explanation, ongoing psychiatristOngoing severe pain and disabilityOngoing severe pain and disabilityWhat happened! We have no idea!What happened! We have no idea!

Overview of ProjectOverview of Project

Realize Absence of ToolsImprove Clinical Skills

Observe, Record, Classify, AnalyzeSearch for Source

Analogues

Suffering Theory-Method

Overview of ProjectOverview of Project

Pain Authority: not research, no proof of Pain Authority: not research, no proof of concepts. ‘I can’t change the scientific concepts. ‘I can’t change the scientific method for you’.method for you’.FP Authority (IRMcW): the observation of FP Authority (IRMcW): the observation of patients during clinical encounters is the patients during clinical encounters is the basic science of medicine. The production basic science of medicine. The production of theories defines science.of theories defines science.Who is right? How can both of these views Who is right? How can both of these views exist within the same profession?exist within the same profession?

OverviewOverview

Back Pain Disability EpidemicBack Pain Disability Epidemic

Paradigm Change for Pain as a SymptomParadigm Change for Pain as a Symptom

Back Pain Guidelines: Evidence-Based?Back Pain Guidelines: Evidence-Based?

Modernizing and Expanding our Modernizing and Expanding our EpistemologyEpistemology

Summary and ConclusionsSummary and Conclusions

Back Pain Disability EpidemicBack Pain Disability Epidemic

Rising rates of disability, 14 times the Rising rates of disability, 14 times the population growthpopulation growth‘‘pain epidemic OR disability epidemic’pain epidemic OR disability epidemic’– Annals 0 / 211 relevant articlesAnnals 0 / 211 relevant articles– CFP 0 articles since 2001CFP 0 articles since 2001

Only 1 of 211 articles in Annals since Only 1 of 211 articles in Annals since inception involves theory work:inception involves theory work:– Does the disability epidemic suggest that our Does the disability epidemic suggest that our

theories/models are highly effective?theories/models are highly effective?

Paradigm Change for Pain as a Paradigm Change for Pain as a SymptomSymptom

Pain VAS to identical stimuli varies Pain VAS to identical stimuli varies from 1.05 to 8.9. The VAS from 1.05 to 8.9. The VAS accurately mirrors the degree and accurately mirrors the degree and breadth of brain activations in non-breadth of brain activations in non-sensory areas of the brain. Vas sensory areas of the brain. Vas reflects degree of brain activation reflects degree of brain activation not degree of tissue injury.not degree of tissue injury.


111 lumbar radicular injuries = degree of 111 lumbar radicular injuries = degree of disc displacement explained 12 % of disc displacement explained 12 % of variance of persistent pain at 6 months variance of persistent pain at 6 months while psychological and social factors while psychological and social factors explained 43 %explained 43 %

Prospective cohort acutely back injuries: Prospective cohort acutely back injuries: VAS not clinical factors predicted VAS not clinical factors predicted persistent pain.persistent pain.


So … the degree of patient brain response to a So … the degree of patient brain response to a given tissue injury is the strongest predictor of given tissue injury is the strongest predictor of persistent pain and disability.persistent pain and disability.

We will have to focus on managing patient brain We will have to focus on managing patient brain activations rather tissue injuries!activations rather tissue injuries!

Back Pain Guidelines: Evidence-Back Pain Guidelines: Evidence-based?based?

Detect ‘red flag’ conditions, offer tylenol when VAS is Detect ‘red flag’ conditions, offer tylenol when VAS is 10/10, don’t worry if pain remains high and patient 10/10, don’t worry if pain remains high and patient sleeps a few hours each night, don’t order tests despite sleeps a few hours each night, don’t order tests despite patient concern of a serious injury! What about the 250 patient concern of a serious injury! What about the 250 pound construction worker in severe pain?pound construction worker in severe pain?Who designed this silliness? Actually, only 1 of 39 Who designed this silliness? Actually, only 1 of 39 members of U.S. committee identifiable as primary care members of U.S. committee identifiable as primary care clinicians.clinicians.‘‘Red flag’ conditions are not the main association with Red flag’ conditions are not the main association with persistent pain/disability and high VAS predicts poor persistent pain/disability and high VAS predicts poor outcomes.outcomes.Since between 40 and 53 per cent will remain with pain, Since between 40 and 53 per cent will remain with pain, is it ethical to re-assure?is it ethical to re-assure?


Since the guidelines were constructed Since the guidelines were constructed inductively using evidence-based methods, they inductively using evidence-based methods, they should be considered reliable, perhaps like a should be considered reliable, perhaps like a scientific law?scientific law?– Philosophically illogical for at least 100 years!Philosophically illogical for at least 100 years!

Only one group has bothered to test the Only one group has bothered to test the guidelines as a whole versus regular care. guidelines as a whole versus regular care. Interestingly, they changed the guidelines to Interestingly, they changed the guidelines to focus on patient fears, a key agenda item of focus on patient fears, a key agenda item of PCM since Levenstein’s case series.PCM since Levenstein’s case series.


International Forum 1995: biomedical model of spinal disorders has International Forum 1995: biomedical model of spinal disorders has failed, without a new paradigm for clinical pain, further research likely failed, without a new paradigm for clinical pain, further research likely of limited value.of limited value.– Since 1995, pubmed = 121,404 articles with pain in abstract and still no change in Since 1995, pubmed = 121,404 articles with pain in abstract and still no change in

paradigm!paradigm!

Fourth Forum 2002: push to improve adherence to guidelines yet Fourth Forum 2002: push to improve adherence to guidelines yet admission of little effectiveness on chronicity factors.admission of little effectiveness on chronicity factors.– Is this logical?Is this logical?– More logical: scrap the guidelines and search for new paradigms for pain.More logical: scrap the guidelines and search for new paradigms for pain.


As a practicing PCM physician, I look for primary As a practicing PCM physician, I look for primary care components:care components:– Has the symptom iceberg in pain been considered?Has the symptom iceberg in pain been considered?– Has the complex agenda of the patient been Has the complex agenda of the patient been

considered, since it determines the motivation to considered, since it determines the motivation to consult.consult.

– Has the emphasis been placed on the illness Has the emphasis been placed on the illness experience?experience?

– Do we arrive at common ground with the patient’s Do we arrive at common ground with the patient’s own analysis?own analysis?

Modernizing and Expanding our Modernizing and Expanding our EpistemologyEpistemology

Medical theory of knowledge: create an Medical theory of knowledge: create an indubitable foundation of atheoretic fact, with the indubitable foundation of atheoretic fact, with the reliability determined by the quality of the reliability determined by the quality of the methods used to obtain the fact.methods used to obtain the fact.

Sounds great! … Unfortunately, this positivist Sounds great! … Unfortunately, this positivist approach was proven illogical 50 years ago, approach was proven illogical 50 years ago, never existed in the actual practiced scientific never existed in the actual practiced scientific method, and if applied to discovery claims would method, and if applied to discovery claims would eliminate their entry into our literature.eliminate their entry into our literature.

Historical-Analytical StudiesHistorical-Analytical Studies

X Y

Evolution of The Philosophy of Evolution of The Philosophy of ScienceScience

Romanticism = mental experience, fragments in PCM and qualitative work

Positivism = proven facts, atheoretic laws. Fragment remains in evidence-based medicine.

Popper = create theoretical conjectures, then try to falsify. Problem with induction prevents focus on ‘facts’.

Pragmatism = develop competing theories since facts are underdetermined. Test the practical usefulness of theories.

AI and Cognitive ScienceAI and Cognitive Science

Cognitive entity develops understanding Cognitive entity develops understanding during routine problem-solving situations during routine problem-solving situations i.e. routine clinical care.i.e. routine clinical care.Inductive behavior not inductive logic Inductive behavior not inductive logic (presently dead … but could be revived).(presently dead … but could be revived).Failures generate focus on re-Failures generate focus on re-categorizations of the environment.categorizations of the environment.A promising model for primary care A promising model for primary care research into our phenomena.research into our phenomena.

AI and Cognitive ResearchAI and Cognitive Research

ll


Disability pain epidemic suggests that our pain Disability pain epidemic suggests that our pain consultations are ineffectual. Review of our published consultations are ineffectual. Review of our published literature finds a surprising lack of crisis.literature finds a surprising lack of crisis.Our back pain guidelines have little mechanism support, Our back pain guidelines have little mechanism support, prospective outcome support, or testing against non-prospective outcome support, or testing against non-guideline care. The process is illogical. They should be guideline care. The process is illogical. They should be scraped.scraped.We need to develop new theories of clinical pain through We need to develop new theories of clinical pain through inductive behavior and searching for analogy. No EBM inductive behavior and searching for analogy. No EBM evaluation, rather evaluate coherency, check for evaluation, rather evaluate coherency, check for explanatory useful, test suggested hypotheses for explanatory useful, test suggested hypotheses for pragmatic usefulness.pragmatic usefulness.


We need to bring the clinician back into clinical We need to bring the clinician back into clinical research.research.– Clinicians produce most of the medical re-Clinicians produce most of the medical re-

categorizations.categorizations.– Disciplined clinical interactions should generate Disciplined clinical interactions should generate

Polanyi’s tacit knowledge which then generates Polanyi’s tacit knowledge which then generates creative ideas.creative ideas.

We need to discourage an emphasis on the We need to discourage an emphasis on the central tendency (from the non-clinical field of central tendency (from the non-clinical field of epidemiology) to recognize new categories. epidemiology) to recognize new categories. Physicians have traditionally focused on the Physicians have traditionally focused on the complex reality of each case individually. complex reality of each case individually.

Our Epistemologic Failures Have Our Epistemologic Failures Have Grave ResultsGrave Results

197198

199

200201

202

203

204205

206

Mortality Rate (all cancer sites)

197519902000

Pubmed = Pubmed = 1,165,012 1,165,012 articles articles 1975 - 20001975 - 2000

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Insights to Help Our Patients after Acute Painful Injuries