There is nothing new under the sun


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A new journal of pain has been published: The Scandinavian Journal of Pain, published by Elsevier, and contents lists available at ScienceDirect. One of the papers I flicked through today caught my eye – and it reminds me that although there is a huge amount of new information about chronic pain available now, many of the concepts are not really all that new.

Stephen Butler, a well-respected researcher and clinician in the chronic pain world, writes about his experiences learning from two of the great ‘pain pioneers’, JJ Bonica and W Fordyce. Dr John Bonica was the editor and author of the monumental ‘The Management of Pain’, which has evolved into ‘The Textbook of Pain’, he was also the founder of the International Association for the Study of Pain (IASP) in 1973 – along with around 100 researchers and clinicians, including Christchurch’s own Dr Barrie Tait. John Bonica also established one of the first authors to ‘insist’ on multidisciplinary pain evaluation and management, setting the scene for this approach to be the standard around the world.

Bill Fordyce is another pioneer in pain management – he was one of the first ‘champions’ of the application of behavioural principles to the treatment of chronic pain, and indeed incorporated these principles within the multidisciplinary pain management programmes and like John Bonica, his approaches have been and still are being used around the world. His major mark was in applying the biopsychosocial model as an explanation for disability and suffering in chronic pain.

Both of these men worked in the mid- to late- 1970’s and beyond – and what they had to offer people with chronic pain was revolutionary. At that time the prevailing models for managing pain could be separated into ‘mind’ (ie psychiatric) and ‘body’ (ie medical) – and never the twain should meet. A question to ponder today is whether this revolution has accomplished all it needs to yet.

Stephen Butler was introduced to John Bonica in 1973, on the end of a phone call at 0300, according to this article. From all account, John Bonica was a larger than life driving force who lived, ate and breathed work, particularly pain management. Bonica’s dictum was to evaluate patients with ‘at least three blocks for diagnosis’. I can hear some medics of my acquaintance rubbing their hands with glee at this! Yes, one block was placebo, one short-acting, and one long-acting. Then to move to ‘consider a series of blocks that were diagnostic, prognostic or therapeutic’. At the same time, Bonica emphasised the need for pain physicians to be physicians – to consider the whole person, to read all their medical history, but not to ‘take for granted that it is factual or complete’.

Bonica was aware that the results from diagnostic blocks were ‘confusing’ (have things changed any?). So he ‘assembled a group of experts from several fields to work with him’, meeting once a week after they had all seen the person, and discussing as a team, diagnosis and management. This team included people from several medical specialties, as well as psychology, nursing, social work and others. Part of the philosophy was for junior members of staff to learn from these discussions: an amazing experience! I can recall a similar situation happening for me at Burwood in the mid-1990’s, when the whole team was brought together to discuss (on a level playing field, no hierarchies!) the management of individual patients.

Butler goes on to describe his time with Bill Fordyce, who was a very different character from Bonica, but no less significant in impact. Fordyce worked with Butler who found the psychological insights from Fordyce enhanced his practice and especially the ‘common sense’ approach to managing pain behaviours. Butler went on to work on the pain management programme (a three week in-patient one) for the next 15 years!

Butler then lists what he learned from both of these pioneers. I won’t list them all, but a couple from each:

  • John Bonica taught that you need to take time and listen to pain patients; you need to do a very careful examination…as part of a more comprehensive general examination;  you need to have as much information from past evaluations as possible, especially testing; you need to discuss with the patients all the findings, discussing what is not present as well as what is present is important.
  • Bill Fordyce taught – if you have something better to do, you do not hurt; hurt does not equal harm; use it or lose it; no pain, no gain; information is to behaviour change as spaghetti is to bricks  (talk therapy may not help, you need to watch them exercise, monitor daily activities – they may just ‘tell the nice doctor/therapist that he/she is working’)

And the final learning that Butler says he got from both John Bonica and Bill Fordyce is ‘treat the patient, not the diagnosis’.

Butler completes his paper with a reminder of Santayana’s curse: Those who forget the past are condemned to repeat it.  What he means is this: the reductionist view continues and affects both the bio (medical inputs) and the psychosocial.  Under the ‘bio’ aspect, loads of new research is happening – but no magic bullets.  Under the ‘psychosocial’ aspect – new therapies, but one size does not fit all, and some of the new approaches represent the older ones (fear-avoidance being one!) in new guises.  Flexible, individualised care is emphasised, but Butler warns that there is a problem with the rush to implement ‘new’ and ‘improved’ – as he puts it, ‘any ideas that are a few years old are considered passe’.  He warns that these new therapies ‘are accepted rapidly and assume importance far greater than they deserve because we do not analyse them carefully and do not look at them in light of past experience and past knowledge in the pain field.’

I don’t think I can add to that – except to quote one last sentence from this paper: ‘The modern assembly line medical clinic does little for pain patients.  We owe our patients more and they come to us as failures of modern medicine.  We should not be another failure of the system due to Santayana’s curse.’

Butler, S. (2010). A personal experience learning from two pain pioneers, J.J. Bonica and W. Fordyce: Lessons surviving four decades of pain practice Scandinavian Journal of Pain, 1 (1), 34-37 DOI: 10.1016/j.sjpain.2009.09.009

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