Culture - The Greatest Impairment
Culture was defined by anthropologist E.B. Tylor as “that complex whole which includes knowledge, belief, art, morals, law, custom and any other capabilities and habits acquired by man as a member of society.” (1) We are all born into a culture where our parents, friends, family members, other fellow humans, and environment we interact with from a local to global perspective form our beliefs and behaviors. It is developed by social learning in societies where we learn how to perceive and react to the experiences we have as a human moving through life.
Our cultural definition of pain that dominates culture today was first formally discussed in the literature in the 17th century. Rene Descartes defined pain as a relatively linear experience where the body picked up noxious stimuli and transmitted them to the brain where it arose in our consciousness as pain. The mind played a minimal role in this as the brain was mainly a passive receiver and expresser of this noxious information from the periphery. It is here where Cartesian dualism was born in the 17th century and it is here where biomedicine continues to attempt to define and treat the pain of those who seek medical help for their painful problems.
Western medicine’s approach to pain is to apply a biomedical approach which is defined by mind-body dualism. The problem that this approach faces is that science is showing that we absolutely cannot disregard the mind when it comes to pain especially when pain moves past the time where we can use tissue healing as a possible mechanism for pain. To be fair, biomedicine can do a fine job identifying and treating pain. A fracture shows up beautifully on imaging and gives a patient a clear label as to why they hurt. The problem arises when we attempt to identify injured tissue with low back pain where science tells us we are unable to identify such a tissue. With the demands primary care physicians face on the front line of clinical practice I rarely hear stories of thorough physical examinations being performed prior to a label being given. Instead imaging and subjective report is used to define musculoskeletal pain even though research has clearly pointed out that pain and the state of the tissues on imaging have a tenuous relationship especially after tissue healing time frames have passed(2,3).
A study that illustrates the effect of culture on pain and disability was done where Aboriginal Australians who were dealing with chronic low back pain were interviewed (4). They were divided into highly, moderately, or mildly disabled groups. The results of the qualitative study were as follows:
Most participants held biomedical beliefs about the cause of CLBP, attributing pain to structural/anatomical vulnerability of their spine. This belief was attributed to the advice from healthcare practitioners and the results of spinal radiological imaging. Negative causal beliefs and a pessimistic future outlook were more common among those who were more disabled. Conversely, those who were less disabled held more positive beliefs that did not originate from interactions with healthcare practitioners.
Those in the aboriginal culture who did not contact biomedicine were better off in this study. Well-meaning health care professionals looking at pain through a narrow scope provided the patient with a negative outlook based likely on discussions of fear-inducing (yet likely age appropriate) radiologic findings and instructions to protect the back and avoid activity that engendered fear and disability.
When we understand the complexity of pain and all that factors into the experience we can see why the problem of chronic pain continues to get worse instead of better even with the progression of modern medicine. I see examples of this daily in the clinic. Two recent cases come to mind that to me are a great example of how this dualistic view can fail patients. One patient arrived with a history of some on and off back pain that had been blamed on various degenerative discs in her back over the years. The other patient had widespread pain that was also blamed on the degenerative findings that were identified on imaging. Both of them previously had coped and were able to manage their conditions successfully. The problem with this diagnostic practice is that these findings are not a unique thing. One could say they are a consequence of aging and moving in life. Kieran O’Sullivan had a great take on this issue when he said that we do not tell balding men (like myself) that they have degenerative scalp disease yet we do this to the very normal age-related findings in the spine. We will all age and we will all have some “degeneration” and there is no need to fear this.
An argument could be made that the best thing to do in regards to “degenerative findings” is to not know about them and live. This may sound a bit harsh, but the labels of “degenerative disc disease” and “degenerative joint disease” often harm patients. The common thread the above patients had in their presentation was that their pain started after their husbands passed away from a terminal diagnosis. They both had acted as caregivers for their husbands and gone through a massively traumatic experience. I cannot imagine how hard this must have been for them. To see a loved one slowly slip away in front of your eyes has to be one of the more painful experiences a human can endure. I purposefully described this experience as painful due to the fact that EMOTIONS CAN HURT!!!(5)
A study by Meier et al(6) stated the following in regards to this, ” in the transition from (sub-) acute to chronic LBP (Baliki et al., 2012) (7). Hashmi et al. (2013)(8) have convincingly shown that during the transition from acute to chronic back pain, brain activity related to the perception of back pain shifted from regions linked to nociception to brain networks associated with emotion.”
Our culture has defined pain as a physical experience for patients. If we hurt we must have a corresponding physical issue that will explain it. The biomedical culture will gladly oblige this belief and take normal age-related findings and demonize them with the fear-inducing and disability-inducing labels that I discussed above. The patient now not only is dealing with a horrible emotionally challenging and painful experience, but now they are “falling apart” and they have the images to prove it. They now also can jump on an expensive pathway of further imaging, prescription medications, specialist visits, procedures, and surgeries.
As physical therapists I see our profession not doing much better. Some of us will continue the narrative of degeneration with our patients while others will create a new narrative for the patient that in my opinion is equally harmful. Now patients can fear joints being out of alignment, leg length issues, crooked pelvises, stuck joints, fascial restrictions, trigger points, craniosacral rhythms, gravity, faulty posture, a weak core, or other physical issues to label the patient. Our labels come from whatever system of bias we were trained in. They make us feel better as it is our way to feel like we are providing an answer and giving the patient a label.
Some patients will take the label of whatever physical fault the therapist is biased towards finding and their confidently delivered narrative will result in a therapeutic encounter that is sufficient to produce belief and trust. The neuro-immune-endocrine system then will produce a cascade of events that, from a top-down mode of effect, will down-modulate pain and the patient will feel a positive response. This may even be a response that will help them better cope with the biopsychosocial challenges they face outside the clinic and long-term improvement will occur. For the therapist this will strengthen their belief that it was the peripheral mechanics of their treatment and not the top-down modulatory effects that the narrative produced from the patient (ie contextual effects). Before we get too excited about interventions let’s search for proof that their effects are unique to the intervention and not just a way of generating belief and expectation and capitalizing on contextual effects. Without considering this the therapist will continue with their narrative and the patient can continue to not address the biopsychosocial or lifestyle drivers of their condition. Our lack of understanding as a profession of natural history, regression to the mean, and contextual effects of treatments will continue to have us stuck in dated theory the prevents us from being the sleeping giant that Patrick Wall felt we were.
For other patients the result may be different. Once they leave the refuge and safety of the clinic with the therapist they continue to struggle to face and cope with the biopsychosocial stressors that drives their system in to a pro-facilatory, pro-inflammatory, pro-arousal state and the pain returns. For the patient the pain may worsen as your narrative failed, the doctor’s narrative failed, the specialist’s narrative failed, and the medicines are failing. It is easy to see how this could raise stress levels and negatively effect pain. As clinicians this is when we blame the patient. They are non-compliant, lazy, don’t want to get better, have secondary gain issues, or it’s all in their head.
When I hear heart-wrenching stories like those above come from patients my immediate instinct is to recognize my scope of practice and understand that I am not qualified to perform grief counseling or to help someone navigate such a challenging situation from a psychological perspective. The problem I face in clinic each day is the biomedical culture that prevents a patient from considering that their pain is much more than their imaging or the physical narratives that well-meaning clinicians give to them. What may have started as a physical tissue issue now is much more complex. Pain neuroscience education has given us a great tool to explain this complexity, but it is not a home run intervention. Some people are in the non-contemplative stage of change where they are so entrenched in their beliefs that it is extremely difficult for them to consider that their pain may be more than what their imaging looks like. I also sometimes wonder if it may not be easier for a patient to focus on a degenerative disc as a diversion from facing a situation of grief that I can only imagine.
I see this story play out daily with deaths of loved ones, financial troubles, relationship troubles, workplace issues, and other psychosocial factors. You couple that with a culture that struggles to engender a healthy lifestyle and you have a lot of people that are unhealthy and on constantly living on the verge of a painful problem. Louis Gifford discussed this as the vulnerable organism model. He nicely frames this within Hans Selye’s general adaption syndrome in the graph from his Aches and Pains series(9) below.
We need a cultural shift in pain and it has to start in medicine. Speaking for myself, I see patients who have already failed physical therapy before we even start treatment. I hear their stories and beliefs and can usually recognize very early on that this patient is stuck in a narrow reductionist biomedical viewpoint of a much more complex issue. The imaging findings and labels that accompany them, along with the opinion of the physician who they hold in higher regard, are simply too great to overcome. Of course this may be my lack of ability to find an inroad to change with them, but often they are convinced an expensive pain procedure or surgery is their only hope as they see their body as a car that simply needs a squirt of oil or a part replaced/fixed/removed to fix their pain. It is scary how many health care professionals will oblige them in this pursuit. Until we have a health care system that does not financially reward this expensive pursuit that goes against most clinical guidelines we probably should not hold our breath for any significant change.
Often the patient does not even know why they are attending therapy and basically are checking off a box before they get the expensive procedure or surgery that is what they really need. As physical therapists we need to do a better job educating and working with our physician colleagues. If we can only get them to start leading a cultural change and start de-threatening their labels and imaging practices. I would love to see a study done where after red-flags and serious pathologies were ruled out a physician was required to state the following six words to a patient, “You are going to be okay”.
Thankfully I do regularly come across patients who I firmly believe got better from hearing three things – your imaging findings are normal for your age, it is safe and important to move with them, and you are going to be okay. After years of traveling in a biomedical paradigm some patients are ready for a different narrative. Pain neuroscience education gives us a narrative that science supports and also one that gives a patient hope. Sometimes it takes some showing the patient they are safe to move and, as I have heard Greg Lehman say, confront them with their strength or abilities. The question we must ask ourselves is whether we will be a clinician who will saddle a patient with more labels or one who will empower them to believe in their body’s innate healing and movement abilities and work with them to maximize their potential.
As clinicians is it about us or the patient?
DISCLAIMER – The opinions expressed in this blog are strictly those of the author and do not reflect the opinions of the author’s employer
- Culture. “Wikipedia”. Retrieved 12/19/2016
Brinjikji W, Diehn FE, Jarvik JG, et al. MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol. 2015;36(12):2394-2399.
Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T, Kato F. Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015;40(6):392-398.
Meier ML, Stampfli P, Vrana A, Humphreys BK, Seifritz E, Hotz-Boendermaker S. Fear avoidance beliefs in back pain-free subjects are reflected by amygdala-cingulate responses. Front Hum Neurosci. 2015;9:424.
Baliki, M. N., Petre, B., Torbey, S., Herrmann, K. M., Huang, L., Schnitzer, T. J., et al. Corticostriatal functional connectivity predicts transition to chronic back pain. Nat. Neurosci. 2015:15:1117–1119
- Hashmi, J. A., Baliki, M. N., Huang, L., Baria, A. T., Torbey, S., Hermann, K. M., et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain 2013:136:2751–2768
Gifford LS. Aches and Pains. Falmouth: CNS Press; 2014.