On the (f)utility of pain measures

Karl C. Kranz, DC, Esq., is the Executive Director/Staff Counsel for the New York State Chiropractic Association. In this post Dr. Kranz offers an “interesting twist on the concept of pain…” and a few thoughts. These call into question the “utility” of pain measures and, in some ways, the “futility” of justifying reimbursement based on a demonstration of “functional improvement” if that “improvement” is based, in part, on a subjective pain measurements. In our quest to help patients with their pain, it is necessary and helpful to remember that a patient’s goal of “0” pain on a pain scale may not always be the best target for our interventions.

As brief as the article link below is, it speaks again to the subjective nature of pain. As you may recall from a previous email (Mar 2), a journalist questioned recently what it mean to be a “2” out of “5” (or 10) on pain particularly since there is no standard for a “2” or “5” (“10”). In a Cartesian mind-body dualistic and theoretical point of view, this article calls into question again the “utility” of pain measures and, in some ways, the “futility” of justifying reimbursement (including Workers’ Compensation) based on a demonstration of “functional improvement” if that “improvement” is based, in part, on a subjective pain measurements.  While the “numbers” supplied by patients and scored from different tests and measures might assuage us into believing that there is some sort of quantifiable, deterministic objectivity in patient supplied numbers, the specificity of the exercise seems deceptive.  The whole pain measurement system seems messy and slipshod but what is the alternative?

The article also underscores, albeit in an indirect and subtle way, the two-decade long debate about whether evidence-based medicine is applicable to CAM; the insistence of medical critics of CAM that nothing from CAM should be accepted by medicine without evidence from systematic reviews of randomized controlled trials of CAM, as if all of medicine were supported by such evidence. [See: Bloom BS. Commentary. What is this nonsense that complementary and alternative medicine is not amendable to controlled investigation of population effects? Acad. Med. 2001; 76(12): 1221-1223.; Gorski DH, Novella SP. Clinical trials of integrative medicine: testing whether magic works?  Trends in Molecular Medicine, 2014; DOI: 10.1016/j.molmed.2014.06.007; Byerstein BL. Alternative Medicine and Common Errors of Reasoning. Acad. Med. 2001; 76: 230-237.; Sierpina VS, Philips B. Need for scholarly, objective inquiry into alternative therapies. Acad. Med. 2001; 76: 863-864.]

Loretta Kopelman, PhD argues that “CAM should not be exempt from rigorous testing and should be examined using either the best available methods or the same methods used to test conventional therapies. This is because, first, CAM cannot be differentiated well enough from conventional interventions to justify different testing standards.  I will argue . . .  that important and well-known proposals about how to separate conventional medicine and CAM fail to distinguish them for the purpose of excusing CAM from rigorous testing standards. If they cannot be clearly distinguished, it is questionable why one set of interventions should be exempt from rigorous testing and another should not.” [Kopelman LM. The Role of Science in Assessing Conventional, Complementary, and Alternative Medicines. In Callahan D. (Ed). The Role of Complementary and Alternative Medicine. Accommodating Pluralism. Washington, DC: Georgetown University Press, 2002, pp: 36-53.]

And at the opposite pole . . . several critics to the Academic Medicine articles above, point out that the authors of those articles “went beyond healthy skepticism and showed a strong bias toward how to reveal the ‘quacks,’ and that looking for the evidence supporting complementary and alternative medicine (CAM) is a failure or misconception,” since “it is diametrically opposed to the development of evidence-based medical practice.” [Frenkel M, Ben-Arye E. Letters to the Editor. Acad. Med. 2002 Sep; 77(9):869-875.  Those who intimate that the biomedical research hierarchy may not be applicable to CAM are convinced but less strident than CAM opponents.  See: Astin JA. Complementary and alternative medicine and the need for evidence-based criticism. Acad. Med. 2002; 77(9): 864-868.; Tonelli MR, Callahan TC. Why alternative medicine cannot be evidence-based. Acad. Med. 2001 Dec; 76(12) 1213-1220.; Tonelli MR. The philosophical limits of evidence-based medicine. Acad. Med. 1998 Dec; 73(12): 1234-1240.; Taylor DK, Buterakos J. Commentary. Evidence-based medicine: not as simple as it seems. Acad. Med. 1998 Dec; 73(12): 1221-1222.; Keshet Y. The untenable boundaries of biomedical knowledge: epistemologies and rhetoric strategies in the debate over evaluating complementary and alternative medicine. Health 2009; 13(2); 131-155.]

Clearly, as Julia Segar pointed out the obvious, “[d]ebates over the efficacy of complementary and alternative medicine (CAM) are highly polarized . . . .” [Segar J. Complementary and alternative medicine: Exploring the gap between evidence and usage. Health 2011; 16(4): 366-381.]

It seems that ideological dogmatism springs forth from all sides, which raises an interesting epistemological question of why people believe the things that they do and why do they often appear so certain in their personal beliefs.

One problem seems to be that those in control of health care reimbursement are populated by the former rather than the latter and that, justified or not, reimbursement revolves around the biomedical, evidence-based research hierarchy and tyranny of the evidence (a Triano-ism) [See: Cohen MH. Chapter 8: Third-Party Reimbursement.  In: Cohen MH. Complementary and Alternative Medicine. Legal Boundaries and Regulatory Perspectives. Baltimore, MD: John Hopkins University Press, 1998, pp. 96-108.]

In any case, after that long aside, this article points to a piece of an alternative research hierarchy based, in part, on ethnography and ethnographic fieldwork, similar perhaps, to the sort of fieldwork promoted by Ian Coulter, PhD at RAND, and a part of Health Services Research. [See: Coulter ID, Khorsan R. Chapter 7. Health Services Research as a Form of Evidence and CAM.  In: Lewith GT, Jonas WB, Walach H. (Eds). Clinical Research in Complementary Therapies. Principles, Problems and Solutions. (Second Ed) New York: Churchill, Livingstone, Elsevier, 2011, pp.: 135-147.]

Here, the author highlights his “longitudinal ethnographic fieldwork” which adds fodder to the debate about whether the RCT is or should be the center of the universe around which evidence-based medicine turns, or is it an ideological black hole sucking air out of scientific epistemology, after all, how can you measure a patient’s pain and suffering with an RCT objectively except by subjective proxy measures. And are these proxy measures really objective quantifiers of science, or quantifiers of subjective science? It is interesting on how the author, or rather his patients and acquaintances distinguish between “pain” and “suffering” . . .  And his interpretation of their spoken language, not only focuses attention on the problem of communicating what is in the patient’s mind, and communicating meaning in terms of the subjective philosophy of language and linguistics, but it illustrates the ongoing dilemma of the mind-body dualism and its post-modernistic interpretation.

Open access at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60708-5/fulltext