The trigger (but why?)

Gooooaaaaallllllllll!! I couldn’t believe it. I’d scored twice in one match. My surprise gives insight into both my footballing ability and defensive team role. After the game immediately I began my deep seated human search for meaning. What had caused this blip in my performance? What was the trigger? How can I ride this wave of form! So the search for narrative began. Could it be my fitness? Rejected, heavier and slower than ever. My preparation? Unlikely, I’d been drinking the night before + had a fry up that morning. Could it be luck? Why? Why? Why?

This search for causality is all too common in healthcare. And no less complex. Healthcare professionals + patients are keen to find the trigger. But what when there is none? Take low back pain for example. It exists but scientifically there is no cause for it on a population level (just multiple correlation). It is medically unexplained. So there is no trigger (or we haven’t found one) just a complex mix of possible ingredients. Even symptoms we can explain (e.g. rheumatological, autoimmune, respiratory disorders) to some degree succumb eventually to the why question. For instance we know Parkinson’s is caused by dopamine releasing cell death. But why that happens is not medically explained. Why? Why? Why? It’s like listening to my 4yr old son.

Early in the subjective once the length of symptoms have been detailed we often probe for a trigger. Was there trauma around onset? Change in actvity levels/environment? All too often in my clinic* the patient describes an insidious onset with no trigger or at best clutches straws at a tenuous narrative (usually prefaced with “the only thing I can think of is…..”). Which leaves big questions:

Why me? Why now? Why this knee and not the other?

What is it? What should I avoid? What is the prognosis?

How can you help? How do I live now? How will this affect me?

Often they have no narrative to express their experience. This lack of explanation leaves space for catastrophising, worry, anxiety and self-doubt. It can also devastate social interaction. With no story they can develop feelings of being misunderstood by family/loved ones, reduced social confidence and increasing physical and/or social isolation. Massively vulnerable they become open to ANY narrative that helps express themselves in their search for meaning. Often they come with a disparate tale concocted from feelings, friends, family, media and previous healthcare providers. These can range from the bizarre to the sublime. It always intrigues me patients can make sense of tissue damage in the absence of injury or a postural problem when symptoms fail to reflect this. Sometimes these stories can be a mountain at their gates. Difficult to see beyond or move. A sense of complexity is regularly experienced but often abandoned.

A case study from a typical patient in my clinic illustrates this complexity well. Mrs Multifidus (54yrs old) presents with 24yr history of low back pain with insidious worsening over last 6 months. She contributes this to a change in job 10 months ago to something heavier. She has had a MRI (prior to physio) which shows mild to moderate (i.e. normal) degenerative changes. She has been off work (healthcare assistant) for the whole 6 months has stopped thy gym, and reduced her walking and playing with grandkids. She is taking amitriptylline and cocodamol for pain control and to help sleep. She lives with her husband and looks after her grandkids a bit. Historically this is where my subjective ends. What’s missing?? Well she has gained 1 stone recently, smokes x15/day, hadn’t slept well for a longtime before pain onset, describes likely menopausal symptoms, reports prolonged significant stress, describes feeling “run down”, poor dietary intake (mainly convenience and processed foods) and family history of low back pain and fibromyalgia. A lot more going on now. Am I looking for a trigger or is it more complex than this.

When looking at biological systems complexity surrounds us: cardiovascular, metabolic, muscular, nervous, immune, skeletal, endocrine/hormonal, digestive, respiratory, reproductive, lymphatic, integumentary. Each of these systems breaks down further into sub-systems. Conservatively I tally at least 8 systems implicated from her subjective history. The person (unlike the brain) knows little of these systems (e.g. BP, platelet count, peak flow, blood sugar level). They embody the objective experience not through minute detail but collated consciousness (headache, bruising, light headed, lethargic). Maybe this is key to our efficiency. For the same processing level humans are 1/1,000,000th more efficient than supercomputers. Therefore the more objective abnormality exists (e.g. medical history) the more complicated the conscious interpretation will be. Can we help reduce objective ‘abnormality’? Can we identify and do we need a trigger? Are we better attending the individual, their story and possible ingredients? Can we help construct a narrative the patient can express easily?

So how helpful is describing injury, pain and pathology in terms of 1 or 2 systems i.e. musculoskeletal or if you’re really trendy 3 (neuro-musculoskeletal). Perhaps it makes the narrative easier for the patient to understand? Perhaps it’s easier for us to understand? But this does not sit well. If biomechanical load is the trigger for pain and injury why do we struggle for causal data. Because of the terms mechanical origin ‘load’ is often entwined with biomechanical and musculoskeletal systems, but cardiovascular, metabolic, respiratory, psychosocial systems can also be stressed. In causal terms are we mechanically loadcentric? Maybe the best interventions are those which improve multiple systems. Exercise for example is likely to have significant positive impact on at least 8 biological systems as well as psychosocial benefits. A good reason not to be loadaphobic!

Since the goal scoring feat my performances have been languishing at their usual level. My explanation is best simplified as a moment of predictable unpredictability. As healthcare professionals our role is to recognise complexity but distill this for the patient and treatment. Uncertainty is allowed. ‘I don’t know’ is not taboo. A good therapist is aware of complexity but helps the patient build a simple strategy. The purpose of the story is to give meaning. No one wants to be statistic. No one likes to be afflicted seemingly at random. This systems approach is not as concerned with answers as it is context and meaning. Not that answers are always elusive but they exist within a personal context (e.g red flags). To give someone answers a robot would do, to help someone find meaning requires a human. Even in the presence of a trigger the wider context should not be abandoned. We can be a catalyst for people to embark on smoking cessation, weight loss, returning to exericse, buying weights, weaning off long term opioids, starting appropriate medication for other disease, or timely further investigation. Indeed these are the patients who are most likely to describe significant life changes. Which I bet is a large reason most of us are in this vocation. But we need to stop reducing our thought process to a single component and instead consider wider health which extends into individual psychological, social, spiritual factors.

Be more human. Be less robot.

Thanks for getting this far.

Neil

*my clinic is a GP community clinic with a wide variation in population possibly with a tendency toward persistent pain

Further reading:
Kerry et al 2013. Medically Unexplained Symptoms. Lovely excerpt on LBP in this amongst other gems http://www.peh-med.com/content/pdf/1747-5341-8-11.pdf

I can’t talk about causality without mentioning CauseHealth who are definitely worth following on Twitter and checking out online.

Kieran O’Sullivan video. Health and pain http://bit.ly/KOShealth

NAF podcast with Mick Thacker touches nicely on immune system influence on pain http://bit.ly/thackerimmune

The Physio Matters Podcast with Ann Gates discuss metabolic factors http://bit.ly/gatesmetab and Alan Taylor haemodynamic contribution to pain http://bit.ly/1OAkkU8.

Content:

Foals (2015) Mountain at my gate. http://bit.ly/foalsMAMG

Pomerleau (2015). Where computing hits the wall: 3 things holding us back. http://bit.ly/brainefficient

Mowles (2012). The predictable unpredictability of social life. http://bit.ly/predictunpredict

5 thoughts on “The trigger (but why?)”

  1. Part of me is tempted to think that you wrote this blog just to let us all know you scored two goals in one game however it is insightful and deeply interesting which I have to admit seems to leave me feeling that your gratuitous goal boasting is almost appropriate and in context. Well done mate, nice to hear some of what is going on in that clever noggin of yours!

    Liked by 1 person

  2. Morning Neil,

    This is a thoughtful blog in several ways. By the way, I hope you gave the Leeds salute after bagging a brace.
    Anyway, some might say your goal scoring is akin to the infinite time, monkey, typewriter and Shakespeare analogy. In a way they may have a point.
    In reality, it probably is as simple as this. When you acted on the ball by kicking it, you set the ball on a path predetermined by physical laws. I think the word that can be used to describe this is teleological; things appear to happen in order to achieve a pre-specified outcome. The only thing that was going to stop this outcome was the goalkeeper.

    Compare this to a person coming to you for treatment. You are now in an environment of constant variance, even in the N=1 environment. No single issue to deal with now like kicking a ball.
    Regarding your persons issues, I sometimes wonder whether discussing the benefits of stopping smoking, drinking a bit less, cutting down on eating crap and going for a walk are more effective interventions than some in our ‘toolbox’.
    We know the above are good for us, with movement being our speciality, and isn’t the value of science for physiotherapists in its conceptual abstraction and application via a reasoned process in the N=1 environment. Along with any RCTs that happen to be half decent of course.

    Anyway, all the best with your blogs.

    Liked by 1 person

    1. I find the patients who have lost 2 stone, or stopped smoking, or have missed diagnosis found to be the most appreciative on discharge or who send cards or ring up later to give me feedback.

      We get a bit caught up with pain as a profession. In some respects rightly so. But I think we need to consider health more. Obviously the 2 can overlap to a degree. But I think we neglect health as a profession (or maybe it was just me!).

      Like

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