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is my pain real or all in my head?


“There are some clinicians who feel that the only approach to identify the true nature of pain is to demonstrate physical or chemical pathology.  The reasoning behind this approach is based on the faulty assumption that physical findings are directly related to the pain experience.

Unfortunately, biomedical research has not been able to confirm that the existence of physical pathology and pain are directly related. In fact, a number of studies have found that significant pathology can exist in individuals who report little or no pain, and conversely, studies have found significant levels of pain with little or no physical pathology. Turk and Melzack have written that “the association between physical abnormalities and patient’s reports of pain is often ambiguous or weak.”

Despite these findings, there are still many clinicians who feel that if pain is not associated with physical pathology, then by simple deduction, pain must be psychogenic in origin. Again, as I have pointed out previously, there is no creditable empirical research to support this position.” 

The quote above comes from Dr. Kern Olson from a recent article in Practical Pain Management (History of Pain: The Psychosocial Assessment of Pain / Physical Pathology May Not Equate to Pain).  I’ve written extensively about the difference between Functional Problems and Pathology.  Do you know the difference?  Fail to grasp the importance of what Dr. Olson was saying in his quote above, and you’ll undoubtedly end up riding the MEDICAL MERRY-GO-ROUND.

FUNCTIONAL PROBLEMS:  Functional problems are problems that do not show up on PHYSICAL EXAMINATIONS or with STANDARD MEDICAL TESTING (or HERE).  According to YourMedicalDetective’s website, Functional Medicine is, “patient-centered medical healing at its best. Instead of looking at and treating health problems as isolated diseases, it treats individuals who may have bodily symptoms, imbalances and dysfunctions. As the following graphic of an iceberg shows, a named disease such as diabetes, cancer, or fibromyalgia might be visible above the surface, but according to Functional Medicine, the cause lies in the altered physiology below the surface. Almost always, the cause of the disease and its symptoms is an underlying dysfunction and/or an imbalance of bodily systems.”  In other words, instead of simply covering symptoms, the goal is to deal with the underlying cause(s) of those symptoms.  That’s why dealing with Functional Problems is invariably going to require some effort on your part.

PATHOLOGY:  According to Webster’s Dictionary, pathology is, “the study of diseases and of the changes that they cause: changes in a person, an animal, or a plant that are caused by disease“.   Because of our increasing reliance on 3rd party payers who want hard evidence in the form of objective findings of a person’s illness before they pay the doctor for treatment, they do not like “Functional Diagnoses”.  A great example of a Functional Diagnosis would be FIBROMYALGIA.  Despite the myriad of symptoms, there are no definitive standardized medical tests that reveal a diagnosis.  And here’s the rub; Functional Problems are more common than Pathology — far more common.  This is partially why such a huge percentage of chronically ill people are being misdiagnosed (HERE). Which of these two problems would the average doctor rather see, diagnose, and treat?  That one is easy to answer —- patients with outright Pathology. 

Doctors typically have little idea what to do for Functional Problems.  A person I know who works in an Emergency Room told me that (I am quoting loosely here), “In the ER, we want to deal with things we can see or touch.  The people we most hate dealing with are those who come in complaining of headaches, neck pain, or back pain.”  When asked why this is, the individual replied, “there are no good or valid tests for these types of problems.  Everyone in the industry knows how difficult it is to try and correlate test findings to symptoms.”  [HERE and HERE are great examples of this phenomenon]  When quizzed about the sorts of problems that ER doctors typically enjoy dealing with, the answer was equally intriguing (and somewhat disturbing).  “We would rather see someone come in with a compound fracture — the bone sticking out of the skin — and actively bleeding.”  Why, I asked?  “It’s easy to fix.   Set the bone, sew them up, give them a few weeks to heal, and most of the time they’re as good as newEverything is cut and dried, and you end up the hero“.

What are some of today’s common health problems that used to be Functional, but because of advances in technology and testing procedures, are starting to be seen for what they are?  Here are four that go hand in hand with each other and are often times seen in unison. 


But the differences between Functional Problems -vs- Pathology do not stop there.   What about some of the musculoskeletal problems that I see each and every day in my clinic that are caused by ADHESIONS OF THE FASCIA?  I’ve said for a very long time that the microscopic scar tissue that makes up Fascial Adhesions sets the stage for a “PERFECT STORM” of Chronic Pain.  Think about it like this for a moment.  Do you think it’s potentially problematic that Fascia; which is not only the single most pain-sensitive Connective Tissue in the body, but also the most abundant connective tissue as well, cannot be imaged with MRI?  This scenario sets the stage for a wide range of musculoskeletal problems that can be painful to the point of debilitating, yet do not present with a definite set of objective findings and frequently don’t show up with even the most advanced imaging techniques.

How about PIRIFORMIS SYNDROME?  What about CHRONIC NECK PAIN or HEADACHES as mentioned above (especially in people with NORMAL RANGES OF MOTION)?  What about kids who have OSGOOD SCHLATTERS but have not yet developed the classic “Tibial Tubercle” even though there is pain blow their knee?  How about SKULL PAIN?  The truth is, almost anything on THIS LIST could be considered worthy of being included in this paragraph.  For those looking for some resolution, HERE is a good place to start.


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