5 Minute Reads: A Lesson in Pain
A lesson in pain: As a graduate student, I was early on in an internship program with a Veteran’s Affairs Hospital. This was roughly 10 months before my much anticipated graduation. As you can imagine, I knew it all. I had a backpack full of books, research articles and scholarly journals to back it all up. I was ready and geared up for anything.
About two weeks into this internship, I had back-to-back new patient consultations scheduled. At the Veteran’s Affairs hospital, all case history information was available prior to the consultation. So we were able to view health history, imaging, labs, etc. prior to the patient coming in. My first patient of the day (patient A), was an elderly individual. Prior to consultation, I accessed their chart and pulled up health history information. Along the way, I found MRI’s/Xray’s/lab’s, all the fun stuff. I found there was a history of chronic lower back pain. Within the imaging, I found some of the objectively worst findings I’d came across as an intern. Disc herniations at almost all levels, degeneration throughout the lumbar spine, fatty infiltration of muscular tissue of the region, spondylolistheses (think ‘sliding’ of vertebrae) at multiple spots. Lets just say it looked really bad. Again as a young intern, I expected to see a person debilitated in pain. I anticipated the classic signs: hunched over, holding onto their lower back, writhing in agony. I quickly tried to devise a plan of attack. Having preconceived notions of what these images told me, I was prepared for an extremely tough case. Roughly 3 minutes later, the patient arrives. Here comes this early 80’s individual, strolling into the examination room, without a care in the world. They sit down to chat, seemingly interested in everything other than their lower back pain. We talked about the weather, we talked about our families, we talked about baseball, we talked about World War II! Probably 30 minutes into the conversation, I finally snuck in “So, does your back hurt..?”
“Ah. Not really. It’s sore every now and then. Doc said I should come talk to you about it though so here I am!”
So that’s what we did. We talked about it. We talked about how it affected his life, how he felt about it, and why he wanted to feel better overall. We did a little work on movements, postures strengthening and mobility and he was gone, smiling throughout the whole encounter.
Patient B was next. A much younger individual. A seemingly quiet health history, not really much to report on. He had report of a complaint of lower back pain weeks prior, where X-rays and MRIs were ordered and were now sitting on my desktop. If you were to teach a imaging course on anatomy, you could have done it with these images. Clean bony structures, normal alignment, perfect disc spacing, exactly what you hope to see when you see on images: nothing remarkable. Again, roughly three minutes later this patient walks in. What do we see now? Classic debilitating lower back pain signs: doubled over in pain, holding onto the lower back, writhing in agony. The patient displayed inabilities to walk upright, transition, maneuver, etc. The examination itself proved difficult as the person really had difficulties doing just about anything. After 90 long minutes of evaluation, therapy and rigorous efforts, the patient left upright, but still unsteady and wary of symptoms returning. And he was definitely not wearing the same smile we saw from patient A.
What's the difference between these two individuals? There are the obvious things: age, stature, symptoms, etc. Looking at the cases before the day began, you'd imagine Patient A to be the more difficult evaluation. You'd imagine Patient B to be a relatively quick and painless (pun) appointment. That was not the case, as they presented much differently than expected.
What's the most important similarity between these two individuals? They're both right.
This was the day that I learned some very valuable lessons. I learned that sometimes, the more you know, the less you know. I learned that pain is a variable symptom that everyone experiences differently. More importantly, I learned that objectivity does not always equal subjectivity. Meaning, symptoms do not always correlate to images, labs and other findings. Looking at these two different cases from a birds-eye view, you’d imagine the complete opposite symptoms. But that was not the case. Now, this is not to discredit findings and validity of imaging, as the advances in the field have helped us progress to a time where in medicine you can now see the inner workings of the person sitting in front of you, that's amazing. But there is still an important lesson here: you are more than your images.
Pain is real, and it's a signal that something's up. It is one of the most subjective human interpretations that we experience. There is no distinguishable unit of measurement, there’s no blood test, there’s no image, there’s no one reliable finding that can describe how you feel outside of your own perception of your own symptoms. I can’t tell you when something should or should not hurt, nor can anyone else. That’s the beauty and the curse of pain. It’s one of the most intimate human experiences, that can’t be shared, let alone explained in terms which are easily comprehensible and understandable by others. Pain is your very own interpretation of a perceived “noxious stimulus”, an alert that something’s up and something’s not right. And you get to choose your response to it. My advise? Start somewhere.
Preconceptions of certain findings and conditions lead people to feel as though that they are doomed to a lifetime of pain. “I got an Xray, I have a bad back” is no longer an excuse, and age is not a diagnosis. Let's continue to work through these issues, not accepting defeat and changing the quality of our lives because we feel that our bodies dictate that we have to.