Critical Thinking

Cultural Interdependence

I was recently in a discussion on SomaSimple, regarding why some people hurt following a knee replacement (btw, if you aren’t a member there—join the site—it will make you “think”).   Anyways, I suspect there is no easy answer for this question.   To understand why one may hurt following a knee replacement, I believe we need to begin by understanding why people hurt before a knee replacement.   I think that we need to consider all of the variables that may be present, which may influence someone’s pain.   I wrote about some of these variables a couple of years ago, but I think we need to consider the entire picture.   I suspect the bone integrity, and surrounding musculature and nerve supply, are only a fraction of the issue.

I suspect the following cascade of variables all influence pain before and following a knee replacement:
1. A cultural expectation exists that indicates, “arthritis” = “pain”.
2. The input of  “words” by the practitioner to the “patient” (ie. your knee is the worst knee I have ever seen…)
3. An over-utilization of diagnostic imaging, giving a lay individual, who has no education in radiology, the ability to “visualize”
(another input) their “severe” arthritis. “I saw it, therefore, I  believe“.  The practitioner responds again, “This is why you hurt”.
4. The somatosensory influence of a practitioner provoking their pain either before or after 2&3 (another input). “This is where
it hurts, isn’t it” vs. using more accurate language such as “what do you feel when I touch here”.
5. A healthcare system that reimburses based upon procedural codes and a joint replacement  system that capitalizes on 1 & 2 & 3 & 4
6. A perception of healthcare that assigns “weights”  to certain practitioners and their “abilities” (ie. generally an orthopedic surgeon is weighted higher than PTs by the lay individual in treating a pathoanatomical diagnosis of “knee OA”).
7. The societal reinforcement by family members and friends (more input) that knee OA does not respond to PT and they themselves had to undergo a knee replacement to get rid of the OA.
8. An association that assigns completely unrelated variables, such as the weather, as influencing variables on their symptoms (this is a cultural belief that has not been substantiated in research).
8. More visits to a physician, often resulting in more input (chemical) via cortisone, which is a steroidal anti-inflammatory, for a non-inflammatory based condition  (does this make sense?—-for those with less medical training, osteoarthritis is not categorized as an “inflammatory” disorder)
9. I am sure 1-8 have some powerful influences over the cortical representation of that joint.

Several years ago, the buzz word in physical therapy was regional interdependence, which I am sure exists (I am sure one aspect of the body can influence another).  But when considering 1-9 (+) above, I think we need to also consider “cultural interdependence“, my term to describe the influence of society and culture on pain.   Over on body in mind, there was a discussion that involved Dr. Mick Thacker, out of Kings College, who proposed that himself and a colleague came up with the following definition of pain:  an embodied element of suffering encapsulated by an  experience of the person within the society and culture in which they live.

As Physical Therapists, we can all address the variables I described above (we aren’t limited to “bones” or “muscles”—we treat “complex human beings”).

To better educate the consumer, and tackle the issue above, we need to work together.  We need re-define and re-educate the consumer about why their knee may hurt.  We need to de-value the threat of osteoarthritis.  We need re-define cultural expectations of what we do.  We need to educate them that…we are the answer.

What do you think?

-Joe B

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2 replies »

  1. Joe, I agree completely. I recently spoke with a fellow PT about the idea of addressing psychosocial variables. We had an interesting disagreement. He felt like an MD can be a good practitioner by treating infection, for instance, without a need to address culture, psychology, etc. Furthermore, he wondered why PTs are “trying to be good psychologists instead of being good PTs.” My answer was that an MD could possibly treat candida with clotrimazole in an isolationist manner without addressing the bigger picture. Granted! He or she would be a poor clinician…but granted! However, as physical therapists, our interventions are based heavily on factors such as patient response, self-efficacy, carryover into function, etc. If we are taught to set up the physical environment for our patients to succeed (e.g. organizing one’s house to avoid a fall), why don’t we equally seek to shape their cultural environment to mitigate the pain response and optimize outcomes (e.g. de-value severity of diagnosis). Both approaches have the end goal of maximizing the patient’s function, improving quality of life and reducing the sequellae of limited mobility. Conclusion: Don’t forget the forest for the trees!! ~Chas B.

  2. Thanks for the response Chas. I whole-heartedly agree with your response to your colleague. In addition, I would add there is an overwhelming amount of evidence that we must treat the conscious human being. No way around it. We must build a therapeutic alliance. We must account for a ton of confounding variables, 9 of which I listed in this article (I would love to correspond with your colleague and understand better why they think the way they do—please share and lets create professional dialogue). While it would be much simpler to address tissue-based impairments, our patients are far more complex. As we have learned more about pain, we have learned that many things can influence its existence. Many things. And as our reimbursement system shifts from a per-unit basis, to a diagnosis/outcomes basis, I am curious if his attitude will change?

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