Pain MEDICINE/Politics: Are You Left, Right or Centre?

28 July

On the weekend, my wife sent me another Anti-spinal cord stimulation article published in the paper by Australia’s Anti-Interventional Academic Cartel (AAAC). The “AAAC” have repeatedly published articles that have been refuted, again and again, but as they have a journalist on their team, it hits the media, achieving the goal for whoever funds them.

This article was a little different to their others, starting with some fantasy horror sci-fi and ending with an advert for “Cognitive Functional Therapy”, for which I could find the grand total of zero scientific papers.

Maybe it was my crappy lit search, but this article was starting to feel a little like “lying”.

Here’s the thing: because of current politics, no one seems to care about lying anymore. It made me think that the “Medicine of Pain” is more like “Politics” than “Medicine”, with the same deep divide between the Left and the Right, and patients stuck between.

So I decided to split the approaches to pain into Left-Wing, Right-Wing and Centrist, and this is what I got.

Left-Wing Pain

The Left-wing explains pain as:

Pain is a false alarm
(Chronic) Pain is useless
It’s a misinterpretation of a signal
There is no cause for the pain
You can't diagnose the cause.
The pain is centralised - “It’s in your head”
The pain is driven by the patient’s psych status, social stressors, and perpetuated by pain behaviours

Left-Wing Pain Management

Treatment is about gradual load and thinking differently about your pain
Focus is on coping strategies, meditation, Cognitive behavioural therapy, pain neuroscience education, and exercise
Imaging is of no use and makes the patient worse
Medications are avoided
Interventions don't work
Spinal Cord stimulation doesn’t work

Right-Wing Pain

The right-wing explains pain as:

Pain means something is damaged
If you can't find a cause, the patient is crazy, and it is all in their head

Right-Wing Pain Management:

Diagnostic blocks
Interventions
Imaging: If you can’t see it on a scan, I can’t treat it
Surgery
Spinal cord stimulation is for when surgery doesn’t work
Psych, meditation, exercise and rehab are a waste of time
Medications are dominantly opioids

Centrist Pain

The centrist explains pain as:

Pain is a warning system
There is likely an underlying cause that may or may not be diagnosable or treatable
Sensitisation of the peripheral and central nervous system amplifies pain
Sensitisers include psychosocial stressors, metabolic abnormalities, and untreated or incompletely treated injury or disease

Centrist Pain Management:

Treatment aims to identify a cause and address it with indicated interventions or surgery
Amplifiers/Sensitisers are addressed with CBT, rehab, exercise, education and diet as appropriate
Imaging is of use and may or may not direct us to the cause
Medications are used to target the underlying mechanisms of pain
Spinal Cord stimulation is used as indicated

So, what kind of clinician does the patient need?

It occurred to me that this was not a bad way to think about “what”, or more to the point, “who” patients needed.

Patient Pain Patterns:

Left wing

Widespread or disproportionate pain
High level of central sensitisation
Significant psychosocial stressors

Right wing

Focal, proportionate nociceptive pain
Low to no central sensitisation
Little to no background psych, social issues or metabolic abnormalities

Centrist

Focal or widespread pain
Proportionate or disproportionate
Moderate to extreme sensitisation with psychosocial stressors, metabolic abnormalities and undiagnosed/untreated injury or disease acting as sensitisers

Where do I sit?

I sit Centre-Right. I am an interventionalist with a background in Sport and Exercise Medicine. I think pain is a warning system asking us to look for something that is wrong. This may be physical, emotional, social or metabolic. It is a signal meant to protect us, and whatever the source, it is not meaningless.

Politics Vs Medicine:

ALL approaches, left, right and centrist are valid and successful at treating patients.

Everyone has good intentions when treating patients. There is nothing wrong with sitting in any of these camps. They arise from our interests, skill base, patient successes and failures and how we make a living to feed our families.

Unfortunately, the patient gets caught in our politics.

The approaches aren’t wrong, but applying a “Left-Wing” approach to a patient with a “Right-Wing pain pattern”, and vice versa, doesn’t work.

The patient who fails to get better inevitably gets labelled as “It’s in your head”, and we all attack each other as incompetent.

I know the “Left, Right, Centrist” analogy is an over-simplification, but maybe thinking differently could move our language from “It’s in your head” and “Those guys are incompetent” to “I am not the person you need. You’ll benefit from seeing this “type” of clinician.”

What are you, left, right or centre? Drop it in the comments. Some of my friends I tested this on have been hilarious.

Andrew Ford

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