Perspectives in Biology and Medicine

CONFUSION, FEAR, AND CHAUVINISM: PERSPECTIVES ON THE MEDICAL SOCIOLOGY OF CHRONIC PAIN WARRENJ. BILKEY* In spite of the heralded successes of modern medicine in curing specific diseases, there has been a curious failure with chronic pain. For reasons which are to be discussed below, the formidable medical technology has been inadequate to deal with chronic pain. With persisting pain and disability, and the expense to society of misdiagnosis and inappropriate treatment, the attitudes and behaviors by the health-related groups within society have actually been counterproductive. Pervading the problem is scientific and organizational confusion, the fearful emotions of pain, and chauvinism by health care providers and related third parties. Chronic pain isn't only medical. It is also sociological. Fortunately for the long run, effective technical and organizational endeavors are already making gains and do provide hope for progress. Pain problems are immensely common and expensive. With regard to demographics, lower back pain alone affects 31 million Americans; in 60 percent of these people the pain is severe enough to limit social and vocational functioning [1-4]. With pain in general, a Swedish survey noted that at any one time 15 to 20 percent of the population will have disabling pain that lasts longer than six months. Among U.S. industrial workers there is a 10 to 15 percent annual incidence of significant low back pain. Low back pain is among the five top causes for hospitalization in the United States. In approximately 85 percent of cases of lower back pain, the physician is unable to diagnose the problem. In a 1985 survey, of people with lower back pain severe enough to last longer than five days, 29 percent consulted three or more physicians for their problem. Approximately 80 percent of the population will develop a significant *Address: 3430 Newburg Road, Suite 111, Louisville, Kentucky 40218.© 1995 by The University of Chicago. All rights reserved. 0031-5982/95/3901-0930$01.00 270 Warren Bilkey ¦ Medical Sociology of Chronic Pain pain problem during their life [5]. While 80 to 95 percent will recover comfort and function within three months, if pain is severe enough to cause individuals to be off work for six months, approximately 50 percent of the victims will never return to work. And the return-to-work rate is nil ifabsence from work lasts longer than two years. Interestingly, a survey of patients who experienced chronic pain for longer than six months demonstrated that approximately halfofthe patients had spontaneous relief of pain or a reduction to a mild level of pain [6]. Confusion When an individual develops, for example, lower back pain, whether or not there was associated exertion or trauma, the primary diagnostic concern is to exclude serious disease—cancer, disc herniation with nerve injury, infection, etc. Existing diagnostic studies easily confirm these entities, and their treatment is usually straightforward. The problem is with musculoskeletal pain, or pain caused by mechanical dysfunction. This is pain resulting from irritation caused by ligament , muscle, fascia,joints, etc., being too tight, loose, weak, or inhibited to do the physical work demanded of them. For example, frequent causes of mechanical lower back pain are tight, irritated hip flexor muscles ; a tender, tight sacroiliacjoint or facetjoint of the lumbar spine; or weak trunk muscles (such that one is incapable of doing even one sit-up). A typically alleged (and as yet only partially proven) etiology is that a lumbar facet joint capsule, or overlying multifidus muscle, or a psoas muscle, etc., is strained or torn while one is performing a task or in response to an injury. Subsequent inflammation, perhaps even local bleeding, culminates in tightness from irritation, disuse contracture, or scar. To stretch out the healed but dysfunctional tissues restores normal mechanics and resolves pain. Mechanical dysfunction, as a cause of chronic pain, presents to the physician a major medical technological problem. Because structure remains normal there are no effective imaging or laboratory studies that diagnose musculoskeletal pain. Medical reasoning is based on diagnosis of structural pathology (compressed nerve, disc herniation, tumor, etc.). In practice, there is an inadequate knowledge base from which to perform a physical examination to compensate for the lack of diagnostic tests. For these examples for...