How Stuff Works — Does It?

I came across this post, How Does Chronic Pain Management Work, at Healthskills Blog by Bronwyn Thompson. If you have pain or help people with pain do yourself a favor and follow her excellent blog. The post asks us to consider what parts of a pain management program may be working to help people with pain get better and whether the research done to date answers that question very well. I'd like to expand that beyond CBT and self management skills to include all treatments for chronic pain including biomedical ones like medications and injections. As Bronwyn Thompson points out, the trouble is that we study treatments in isolation to determine if there is a real effect, and on groups of dissimilar conditions where the only common factor is the presence of pain. The research result is often that the effect of anything is pretty small or nil.  Yet we all know people can and do get better. So why? Is it something in the treatment? Is it attention itself? If we do nothing do some people get better anyway? If it has anything to do with treatment we gave, which part of which treatment, or group of treatments was responsible? 

My view is there are no magic ingredients. You need a matrix of options to deal with the matrix of your pain. Every ingredient is a tool. Just like carpentry, a single tool doesn't work for all jobs, and all jobs require different sets of tools.  The process of using those tools needs to lead to a better outcome. Better is in the eye of the beholder — the person living with pain. Does it matter what tools you are using in the process as long as you are improving (and there is no, or minimal, harm)? If having a needle based therapy floats your boat and gets you movin' and groovin' — keep doing it.  If talking through issues you are having, whether pain related or not, is working, then keep talking. But before you think I'm an anti-evidence based quack, progress needs to be measured to determine the value of the therapy, and the chosen measurement is based upon the desired goal. Then we need to distinguish between short term benefit and long term benefit, as the former is common and can be due to nonspecific treatment effects, commonly known as placebo, and the latter we think of as "real" treatment effect. Real versus placebo is another issue entirely and worthy of another post.

The only thing real to me is whether the person is moving forward or not. Are they reaching their self-determined goal? Maybe that's less pain, but maybe it's to be able to walk their kid to school each day. In this respect, pain management combines medical knowledge with coaching approaches. There is a context that includes specific knowledge of broken body bits, neurophysiology, and biomedical disease in addition to knowledge of coaching theory, psychology, and social processes.  


But I realized I'm conflicted here: on the one hand, as long as someone is improving, I don't care how it happened or what we believe was responsible for it. On the other hand, I want to understand why things work, and the scientific method of discovery is still the best way to do that. This is why this blog is so important to me. We are taking the hard scientific method and applying it to something entirely, and utterly human, subjective and purely conscious. It is not easy. (It also leads to another question to explore another time: what should we pay for? Do we pay only for the thing we can explain and show works, or for anything that seems to work even if we have no idea why or makes no sense? How do we define "works", when it comes to deciding if we pay for it or not? How much does it have to work and for how long?)

Back to Bronwyn's post, it is reasonable to assume that we will have similarities in our physiology, psychology, and social processes despite the huge individual differences that exist. That means as we unpack what "works" through better experimental design, it is also reasonable to assume we will find certain things that work better than others, and groups of things that work better together than other groups of things. We should be able to predict with greater accuracy what will work for someone long before a trial and error process risks deterioration in physical and mental function. It's a tall order and a long way from Star Trek's Tricorder diagnostic thingy. But if we don't proceed we will continue to fumble around in the dark, vulnerable to snake oil and those wishing to profit from our pain, fiddling while Rome burns.

As for my conflict, I try to satisfy it by advocating for the research answers and keeping up to date, but if someone is getting better with non-evidenced treatments or stuff I can't explain, I just celebrate their success, tell them to keep going, and see if I can learn something from them.