Insights to Help Our Patients after Acute Painful Injuries

1. Insights to Help Our Patients after Acute Painful Injuries Fred Arthur M.D., C.C.F.P.(E.M.) Academic Forum, Oct 3, 2006 fred.arthur@sympatico.ca

2. Case of I.K. • MVA • Extricated seriously injured child • Released from ED with minor R arm injury • Over next two days, developed significant R sided pain, especially lumbar • 9 specialists, OT, 3 PT, 2 psychologists = no clear explanation, ongoing psychiatrist • Ongoing severe pain and disability • What happened! We have no idea!

3. Overview of Project Improve Clinical Skills Realize Absence of Tools Suffering Theory-Method Observe, Record, Classify, Analyze Search for Source Analogues

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

5. Overview • Back Pain Disability Epidemic • Paradigm Change for Pain as a Symptom • Back Pain Guidelines: Evidence-Based? • Modernizing and Expanding our Epistemology • Summary and Conclusions

6. Back Pain Disability Epidemic • Rising rates of disability, 14 times the population growth • ‘pain epidemic OR disability epidemic’ • Annals 0 / 211 relevant articles • CFP 0 articles since 2001 • Only 1 of 211 articles in Annals since inception involves theory work: • Does the disability epidemic suggest that our theories/models are highly effective?

7. Paradigm Change for Pain as a Symptom • Pain VAS to identical stimuli varies from 1.05 to 8.9. The VAS accurately mirrors the degree and breadth of brain activations in non-sensory areas of the brain. Vas reflects degree of brain activation not degree of tissue injury.

8. Paradigm Change for Pain as a Symptom • 111 lumbar radicular injuries = degree of disc displacement explained 12 % of variance of persistent pain at 6 months while psychological and social factors explained 43 % • Prospective cohort acutely back injuries: VAS not clinical factors predicted persistent pain.

9. Paradigm Change for Pain as a Symptom • So … the degree of patient brain response to a given tissue injury is the strongest predictor of persistent pain and disability. • We will have to focus on managing patient brain activations rather tissue injuries!

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

11. Back Pain Guidelines: Evidence-based? • Since the guidelines were constructed inductively using evidence-based methods, they should be considered reliable, perhaps like a scientific law? • Philosophically illogical for at least 100 years! • Only one group has bothered to test the guidelines as a whole versus regular care. Interestingly, they changed the guidelines to focus on patient fears, a key agenda item of PCM since Levenstein’s case series.

12. Back Pain Guidelines: Evidence-based? • International Forum 1995: biomedical model of spinal disorders has failed, without a new paradigm for clinical pain, further research likely of limited value. • Since 1995, pubmed = 121,404 articles with pain in abstract and still no change in paradigm! • Fourth Forum 2002: push to improve adherence to guidelines yet admission of little effectiveness on chronicity factors. • Is this logical? • More logical: scrap the guidelines and search for new paradigms for pain.

13. Back Pain Guidelines: Evidence-based? • As a practicing PCM physician, I look for primary care components: • Has the symptom iceberg in pain been considered? • Has the complex agenda of the patient been considered, since it determines the motivation to consult. • Has the emphasis been placed on the illness experience? • Do we arrive at common ground with the patient’s own analysis?

14. Modernizing and Expanding our Epistemology • Medical theory of knowledge: create an indubitable foundation of atheoretic fact, with the reliability determined by the quality of the methods used to obtain the fact. • Sounds great! … Unfortunately, this positivist approach was proven illogical 50 years ago, never existed in the actual practiced scientific method, and if applied to discovery claims would eliminate their entry into our literature.

15. Historical-Analytical Studies Y X

16. Evolution of The Philosophy of Science Pragmatism = develop competing theories since facts are underdetermined. Test the practical usefulness of theories. Popper = create theoretical conjectures, then try to falsify. Problem with induction prevents focus on ‘facts’. Positivism = proven facts, atheoretic laws. Fragment remains in evidence-based medicine. Romanticism = mental experience, fragments in PCM and qualitative work

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

18. AI and Cognitive Research ll

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

20. Summary and Conclusions • We need to bring the clinician back into clinical research. • Clinicians produce most of the medical re-categorizations. • Disciplined clinical interactions should generate Polanyi’s tacit knowledge which then generates creative ideas. • We need to discourage an emphasis on the central tendency (from the non-clinical field of epidemiology) to recognize new categories. Physicians have traditionally focused on the complex reality of each case individually.

21. Our Epistemologic Failures Have Grave Results • Pubmed = 1,165,012 articles 1975 - 2000