Mrs. M. came to my office complaining of pain in her knee, which had undergone replacement surgery two years prior. Most people I’ve seen with knee replacement do very well, but Mrs. M. was still having pain and she was walking with an obvious limp. Her story has three important lessons for all of us in health care.
Lesson One: Invalidation When she went to her orthopedist (who did the replacement) complaining of pain, he largely ignored her concerns. After a year and a half of pain, he was willing to refer her to physical therapy. The physical therapist agreed that her knee pain was unusual and cause for concern. Voicing that concern to her doctor, he explained that the knee pain couldn’t be coming from the replacement. Really? When the presenting symptoms do not fit neatly in the paradigm of the provider, the provider often questions the validity of the patient’s concerns. Mrs. M. felt as if the doctor did not hear her or refused to believe that the new knee could still be in pain.
I had my own experience with invalidation about 30 years ago. Saving up every penny I could muster, I drove to Chicago to get 10 sessions of structural bodywork. After 10 sessions, the asymmetry in my pelvis and shoulders was relatively unchanged. Instead of questioning the effectiveness of his treatment, the bodyworker explained that my lack of change was probably because I wasn’t emotionally ready to accept such a change. Not only had I spent $500 without seeing the changes I had hoped, but this person was telling me that I was at fault. Needless to say, this was devastating to me. About 15 years later, I discovered that I had an anatomically short leg. Short of a miraculous event, my anatomically short leg probably isn’t going to get any longer in my lifetime.
Lesson Two:
Clinical relevance
Assuming that the knee pain must be coming from another source, the doctor ordered an MRI of Mrs. M.’s back. Not surprisingly, moderate disc pathology was found. The doctor decided disc pathology was the real source of her knee pain. When Mrs. M. explained that she seldom had back pain and saw no connection in daily life that would substantiate this assertion, the doctor was unmoved. He prescribed an epidural injection in her back to address her knee pain. This was not something Mrs. M. was excited about doing; she just wanted someone to treat her knee. The doctor refused any further treatment unless she had the epidural.
It’s not surprising that her lumbar MRI showed moderate disc pathology. In a landmark study published in the New England Journal of Medicine in 1994 by Jensen et al., the majority of people who have never experienced back pain have serious disc pathologies on their MRI scans. This is not to say disc pathology is not a possible source of pain. It does, however, call into question the idea that disc pathology equates to back pain, since asymptomatic people have the same pathology. Scientifically, this is not defensible. Whether it comes in the form of a diagnostic image or a massage therapist finding sensitive soft tissue, the most challenging question for every practitioner is whether or not what is found is truly relevant to the client’s pain.
Lesson Three:
Neural patterning
After her third bodywork treatment, Mrs. M. had a substantial increase in pain-free flexion of the knee. She was thrilled with the progress we had made. After hearing my summary of what structures I treated, why, and what the game plan was for our next session, she stood up to leave my treatment room. As she walked away, I noticed her limp was still quite pronounced. I asked her if putting weight on her knee was painful. She enthusiastically replied there was no pain. I found this quite perplexing. Taking her hand, I asked her gradually to put weight on the replaced knee. Finding it comfortable, we kept increasing how much weight she put on her knee. This probably looked like a ballroom dance move we repeated over and over. We achieved complete midstance (full weight) without pain.
When she questioned why we were doing this, I remarked how her limp had not improved, yet she seemed to have no pain while bearing weight. I was having trouble reconciling those two conflicting pieces of information. A look of epiphany came over her face as she realized she was limping out of habit, not out of pain. The knee was better, but the brain hadn’t gotten the memo.
Mrs. M.’s story is a powerful mix of three very relevant lessons for all of us. It challenges us to listen carefully, and thoughtfully apply our skills for the greatest good of those we serve.
Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars and president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois. His clinic, seminars, and research endeavors explore the science behind this work. Visit www.nmtmidwest.com or email him at doug@nmtmidwest.com.