Holism as an approach to treating chronic pain
As an alternative pain rehabilitation therapist I end up seeing a wide variety of clientele who have failed to have their issues resolved utilizing traditional methods. Many times their physical therapy, chiropractic, massage, or surgical interventions fall short of providing the relief they sought, and as such, they initiate their search for any method that may be of help.
At the completion of most of my initial rehabilitation sessions I hear the phrase, “how come no one else told me this?” The client is referring to the time spent discussing their personal responsibility for initiating and maintaining the chronic pain they are in, as well as their personal responsibility for correcting it physically, mentally, and emotionally. In a medical system where efficiency, in regards to time and money, dictates health care intervention, often times the physical form is evaluated and treated with little regard to the mind or vice versa.
Chronic pain has an economic cost of hundreds of billions of dollars annually and has been on a constant rise for decades (Gaskin & Richard, 2011, 2012). This data alone is precedent enough to reevaluate our methods for treating chronic pain and injury. The current materialistic view of pain being the result of specific tissue damage or certain nerves sending signals has shown to be incomplete and as such should be amended.
In response to the poor outcomes of conventional treatment a revived approach, heavily dualistic, has emerged(Kappers, 2011; Moseley & Butler, 2015; Siddall, Lovell, & Macleod, 2015). These scholars and rehabilitation therapists view pain dominantly as subjective perception, a pathology of perception and cognitive understanding. The belief is that all signals sent from tissues in the body are up for interpretation, and that resolution from pain can only be accomplished by reframing individual perceptions of these afferent signals. Less information is currently available stating whether this approach is more successful than its materialistic counterpart. A general search utilizing the Boise State University online library using the key words pain and materialism brought up 24,931 peer-reviewed articles whereas pain and dualism brought forth only 326.
This paper argues that approaching the body from a single dimension of either body or mind is short sighted and leads to poorer patient outcomes than that of a holistic approach taking the individual, in its complete complexity, into account. In addition to markers evaluating biophysical improvement such as strength and coordination, comprehensive and repeatable procedures evaluating mental and emotional stress needs to be created and incorporated.
Renowned philosopher Thomas Kuhn introduced a framework advocating for a scientific paradigm shift back in the 60’s (Kuhn, 1996). A case will be made, using Kuhn’s model, for a paradigm shift to holism as the preferred model for pain rehabilitation. A holistic approach, treating the individual as an integrated being, will increase recovery outcomes by ensuring the human in all his/her complexity is provided with tools to treat all aspects of health.
Materialism: The common approach with a mediocre track record
Before exposing what is wrong with a materialistic approach we must first define what materialism is. Kretchmar (2005) states, “scientific materialism is grounded in the belief that everything in the world can be explained by principles of math and physics.” Within the realm of treating pain this can be seen as evaluating strength in muscles, appropriate range of motion in joints, inflammation response, or proper reflexes and nerve firing.
Although it is important to ensure that the physical form is in balance and that the different systems are operating appropriately, materialism is not taking into account the complex nature of the individual as we still see high reoccurrence and increasing financial cost of chronic pain due to failed, or perhaps, incomplete rehabilitation.
Mind-Body Dualism: The pendulum has swung
In response to these high rates of chronic pain, and based on a belief that the current materialist approach is lacking, current research has moved to a dualistic model. Kretchmar (2005) discusses dualism as taking the subjective seriously and not disregarding it due to its intangible nature. Utmost value is placed on the individual experience and as such all material objects, body included, exist only in response to individual perception. Thus, dualistic modern pain science heavily focuses on cognitive interpretation and individual subjective perception as the focal point in cases of chronic pain (R Melzack, 2001; Ronald Melzack & Katz, 2013; Moseley & Butler, 2015; Moseley, 2008). These researchers are working to prove that, even in the presence of structural dysfunction or trauma, pain can be mitigated and removed through cognitive retraining processes.
It is true that we interpret the sensation of pain in our brain, usually as a result of input from nociceptors. We also see people have varying responses to similar nociceptive signals, pain and sometimes pleasure, indicating there is a strong involvement in individual mental perceptions of what is occurring and their relationship to that understanding. These can be innate from birth or learned through activity. As a lifelong soccer player I’ve come to feel pleasure when a ball slams into my chest. I know I’m not in any physical danger and that preventing the ball from passing me means I have performed well for both myself and my team. As a child this same sensation would have hurt and terrified me. This, to some degree, demonstrates what the dualist model is attempting to accomplish in regards to cognitive reframing.
However, typically these patterns of chronic pain begin with material signals, and as such cannot be solely explained through a dualistic lens. We must admit that although important, a pure dualistic approach falls short as it does not respect the effects of a body that is either injured, not able to safely move, or suffering from neurological miscommunication(Chase, Elkins, Readinger, & Shepard, 1993; Johnson, Ekengren, & Andersen, 2005).
Holism: respecting the interrelated complexities of self
For continuity we again pull on Kretchmar for a description of holism. He states that physical existence in united with and influenced by thought, that thought is influenced through the health and capacity of the physical form, and that humans are greater than the sum of their parts. Holism emphasizes the complexity and capacity of human existence. This poses both benefits as well as confusion.
A holistic view of chronic pain requires a much broader understanding of what it is to be human. Taking into account both the physical form and subjective experience as independent, as well as understanding that no such independence can truly exist creates a dilemma for the holistic therapist in how to provide appropriate intervention and care(Papathanassoglou, 2006).
Engaging the scientific paradigm shift
Thomas Kuhn provides an appropriate framework for engaging a shift in scientific paradigm (Kuhn, 1996). His three pre-requisites include: the existing paradigm is not functioning adequately and is often narrow in discipline, accumulating evidence that no longer fits the existing paradigm, and the presence of persuasive arguments supporting new theory.
Current data in regards to the continuing rise of pain, and associated cost, clearly show the commonly utilized materialist approach to rehabilitation is lacking(Gaskin & Richard, 2011, 2012). Although posing many strengths and providing a large amount of positive outcomes, it is narrow in scope and lacking the capacity to help an expanding percentage of the population(Arvinen-Barrow, Hemmings, Weigand, Becker, & Booth, 2007; Chase et al., 1993). We can confidently state that Kuhn’s first criteria has been met in that the existing paradigm is not functioning adequately.
Exploring the second criteria, research emphasizing mind-body dualism that engages the mental and emotional aspect of the patient has shown to be effective in decreasing patient symptoms of pain regardless of physical intervention(Bandura & Locke, 2003; Moseley & Butler, 2015; Moseley, 2008; Thing, 2005). Approaches have been shown to decrease pain sensations and encourage higher levels of movement, however substantive research is currently unavailable. Given the incomplete information in support of dualism as an independent treatment and the abundance of current research supporting the materialistic approach, we can state that resolution of chronic pain from a dualistic approach too is narrow and that past and current evidence doesn’t support it as salient. However, because recent and current research does support the value of a cognitive dualist approach, we can state that Kuhn’s second criteria is met allowing us to move to the third.
Kuhn’s third criteria requires that a persuasive argument for a new theory be presented. Our current discussion of holism, pulling from emerging research and practitioner perspectives, fulfills Kuhn’s third requirement and as such has fulfilled all requirements set forth.
Holism in application
Engaging the individual holistically provides a more thorough and comprehensive approach. Although the benefits of this approach are apparent, we must also examine the negatives in an attempt to identify potential obstacle for implementation. Most of the benefits are felt by the patient as they will receive a more complex and individualized treatment plan taking into account all aspects of their personal well-being. Biophysical markers as well as psychosocial markers receive appropriate levels of attention in an attempt to create balance and stability for the person as a whole.
For the health care providers, we are now presented with a new set of obstacles. Time is money and the holistic therapist will require a great deal more time and education to do a thorough assessment and diagnosis (Papathanassoglou, 2006; Podlog & Eklund, 2006). Attempting to assess physical, emotional, cognitive, and spiritual markers would no doubt dramatically increase appointment times increasing both the cost of care as well as the number of qualified health care professionals to meet current demand. Although this creates an initial increase in cost, if outcomes are dramatically improved it will significantly lower costs in the long run.
Additionally the holistic therapist, attempting to care for all of the individual, will now require a diverse set of skill sets that many may feel either inappropriate or unobtainable. Medical providers currently dedicate themselves to specific facets of the healthcare continuum and even with this focus will never master the material. How then can we ask them to spread their studies even further? Do we want our trauma surgeons spending more time studying breathing and meditation techniques or vice versa? Obviously all practitioners need not fully commit to the full spectrum in this approach of attempting to care for all aspects of health.
A holistic approach is arguably the most comprehensive path yet recognize it is unrealistic for all practitioners to center themselves within the holistic model. Instead we can create a holistic spectrum ranging from mind-body dualism on one end and materialism on the other. This spectrum acknowledges treatment from a holistic perspective with appropriate space for practitioners of different specialties to exist. A patient’s introduction into the medical realm should begin from the center with a holistic therapist performing a comprehensive evaluation with referrals in either direction appropriately. Follow up appointments would allow for a holistic reevaluation throughout the rehabilitation process and ensure that the proper aspects of care are being received.
The status quo of materialist intervention for chronic pain has shown to be incomplete in its ability to care for a large amount of the population. Additionally, mind-body dualism doesn’t interact or build upon the abundance of research currently demonstrating the interaction between the material body and interpretations of pain. Past and current explorations of holism indicate a more complete intervention method, combining and adding to both materialism and dualism.
Fulfilling Kuhn’s framework for a paradigm shift, health care professionals should begin to transition into a holistic care spectrum model. Still allowing for essential specialty positions such as surgery or nutrition, all practitioners will be aware of the dynamic complexity of human health. Patients, through advice from their evaluative holistic practitioner, can be counseled and directed to appropriate care for all facets of health, receiving a more complete rehabilitation program.
Although increasing the cost of care initially, this method of intervention is likely to yield long term benefits, greatly decreasing the individual and societal economic burden of chronic pain both in unneeded cost of care as well as decreased or lost productivity.
Arvinen-Barrow, M., Hemmings, B., Weigand, D., Becker, C., & Booth, L. (2007). Views of chartered physiotherapists on the psychological content of their practice: a follow-up survey in the UK. Journal of Sport Rehabilitation, 16, 111–121. http://doi.org/10.1136/bjsm.36.1.61
Bandura, A., & Locke, E. a. (2003). Negative self-efficacy and goal effects revisited. The Journal of Applied Psychology, 88(1), 87–99. http://doi.org/10.1037/0021-9010.88.1.87
Chase, L., Elkins, J. a, Readinger, J., & Shepard, K. F. (1993). Perceptions of physical therapists toward patient education. Physical Therapy, 73(11), 787–95; discussion 795–6. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8234459
Gaskin, D. J., & Richard, P. (2011). The Economic Costs of Pain in the United States. National Academies Press (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK92521/
Gaskin, D. J., & Richard, P. (2012). The economic costs of pain in the United States. Journal of Pain, 13(8), 715–724. http://doi.org/10.1016/j.jpain.2012.03.009
Johnson, U., Ekengren, J., & Andersen, M. (2005). Injury Prevention in Sweden: Helping Soccer Players at Risk. Journal of Sport and Exercise Psychology, 27(1989), 32–38. http://doi.org/4643.pdf
Kappers, a. M. L. (2011). Human perception of shape from touch. Philosophical Transactions of the Royal Society B: Biological Sciences, 366(1581), 3106–3114. http://doi.org/10.1098/rstb.2011.0171
Kretchmar, R.S., (2005) Practical Philosophy of Sport and Physical Activity(2nd ed). Champaign, IL: Human Kinetics
Kuhn TS. (1996). The Structure of Scientific Revolutions (3rd ed). Chicago, IL: The University of Chicago Press
Melzack, R. (2001). Pain and the neuromatrix in the brain. J Dent Educ, 65(12), 1378–1382.
Melzack, R., & Katz, J. (2013). Pain. Wiley Interdisciplinary Reviews: Cognitive Science, 4(1), 1–15. http://doi.org/10.1002/wcs.1201
Moseley, G. L. (2008). I can’t find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain, 140(1), 239–243. http://doi.org/10.1016/j.pain.2008.08.001
Moseley, G. L., & Butler, D. S. (2015). Fifteen Years of Explaining Pain: The Past, Present, and Future. Journal of Pain, 16(9), 807–813. http://doi.org/10.1016/j.jpain.2015.05.005
Papathanassoglou, E. (2006). Scientific revolutions and the care stretcuture of critical care. Nursing in Critical Care, 11(1), 4–6.
Podlog, L., & Eklund, R. C. (2006). A Longitudinal Investigation of Competitive Athletes’ Return to Sport Following Serious Injury. Journal of Applied Sport Psychology, 18(1), 44–68. http://doi.org/10.1080/10413200500471319
Siddall, P. J., Lovell, M., & Macleod, R. (2015). Spirituality: What is its role in pain medicine? Pain Medicine (United States). http://doi.org/10.1111/pme.12511
Thing, L. F. (2005). Risk bodies: Rehabilitation of sports patients in the physiotherapy clinic. Nursing Inquiry, 12(3), 184–191. http://doi.org/10.1111/j.1440-1800.2005.00274.x