The Subjectivity of “Cause” (And how it can make us think we are smarter than we really are!)

A recent online discussion made me look at the concept of what we, as body workers, view as cause, in terms of pain and dysfunction in the human body. In my education, I was taught a seemingly useful adage "find the pain, look elsewhere for the cause". However, cause was always based on an antiquated model of supposed fascial dysfunction or, worse, emotional traumas stored in the fascia. Now the latter is a matter for another blog post and the former has trouble standing on its own. But identifying the so-called “cause” of pain seems to be based more on a therapist's training and beliefs than any actual factual evidence.

To demonstrate my point, any number of us would use our skills to evaluate and treat a patient in some of the following ways:- A myofascial release trained therapist might feel that the cause of back pain is a pelvic torsion. They would balance the pelvis.- A trigger point-trained therapist may feel the cause is a buildup of trigger points in the quadratus lumborum region. They would treat the trigger points.- A physical therapist may feel the cause is a weakness in the core musculature, for which they would apply strengthening techniques.- A cranio-sacral trained therapist may have found restrictions in the lumbar region dural tube that are believed to be at fault. They would release the dural tube.- A chiropractor might find a lower lumbar subluxation, for which they would provide an adjustment.- A physician may find muscle spasm and prescribe an anti-inflammatory- An orthopedically minded body worker may find sacroiliac motion problems. They might manipulate or stretch the sacroiliac joint.

You can probably insert your own method into this scenario and see other wording as to cause and treatment. The confounding aspect to all of this is that each therapist can follow their training and experience, use their modality of choice, and create positive changes in the patient's back pain. The natural assumption is for one to view their conclusions about findings and “cause” to be correct, since the patient’s pain improved. Their training taught them to think about dysfunction in a certain manner and their treatment plan created positive changes. The “cause” therefore must have been what they determined. But if all of these therapists found a different "cause", can each be correct? Can the concept of "cause" be relative/subjective and not absolute? Following the adage “find the pain, look elsewhere for the cause” may have helped the therapist reduce the patient’s pain, but did the conclusions of the therapist necessarily make any scientific/medical sense?

Without offending anyone, let’s create a hypothetical treatment scenario. A patient with lower back pain visits a therapist who specializes in a therapy that uses hand sanitizer as its primary modality of choice (I looked around my desk to find this modality...I hope I am not offending anyone!). The therapist evaluates the patient’s low back pain, finding a complete lack of hand sanitizer in the lumbar region as the “cause” as that was what the therapist was taught through a series of continuing education seminars. The patient sheepishly admitted that he never put hand sanitizer on his back before or after exercise, in fact he had never heard of the need for it. The therapist explained the theory behind Hand Sanitizer Therapy, and provided the patient with handouts written by the founder of Hand Sanitizer Therapy, who happened to own the Hand Sanitizer Treatment Center and had written countless articles which explained the body’s need for hand sanitizer and the medical community’s total lack of awareness of this important issue. The therapist then proceeds to apply an appropriate dose of hand sanitizer, rubbed into the skin with a deep, counter-clockwise rubbing action (which was the protocol that had to be followed), over a course of ten sessions (because that was what worked best), and the patient’s lower back pain improved. The therapist had validation of his or her modality, as the outcome was positive, and the patient sang the praises of Hand Sanitizer Therapy all over his Facebook page, knowing full well he was remiss throughout his life in applying hand sanitizer to his low back before and after any rigorous exercise. Dozens of new potential patients called the Hand Sanitizer Therapy Center for an appointment to help get rid of their pain, as they knew they lacked the proper amount of hand sanitizer in their life as well. Over and over, “cause” was validated.

While this example sounds ridiculous, this sequence of events happens often in our therapy world. If all of us are seeing positive results from our work, but we all approach it in totally different ways, can we all be correct about true “cause”? Probably not.

In medicine, physicians are the go-to people to get to the root of problems and few patients leave their primary physician's office or specialist's office without a diagnosis, which is usually thought of as the “cause”. But when these diagnoses are so drastically different from one physician to the next, what is one to do? A diagnosis can be simply a description of the symptoms. Take the ICD-9 code 723.1, which is for cervicalgia. Cervicalgia is defined as a pain in the neck. 723.1 is one of many possible codes used by physicians to describe a patient’s neck issues. One can many view others here. 723.1 is the most common code I see in my clinic when patients are referred for neck pain. It really does not say what is wrong (cause), it simply describes the symptoms. It is left up to me to create a treatment plan and help the patient. In a sense, it is left up to me to find the “cause” and fix it.

So if the determination of “cause” is completely subjective, based on our beliefs and training, should we even include it in our work? I do believe it has importance, but only if one truly realizes its subjectivity and limitations. In our case presented above, the true problem/cause may have had nothing to do with what any of the therapists believed. How can we, as therapists, find the true cause? Education, curiosity, reading, quality continuing education, questioning authority, and taking on an attitude of healthy skepticism will lead you to a deeper understanding of how the body works. Healthy skepticism will help you filter out those models that make little scientific sense. If your modality preaches that the rest of the medical community has not yet caught up with them, be skeptical. Above all, be humble. Take your beliefs of “cause” with some skepticism and allow yourself to be unknowing. The more I educate myself, the more frequently I tell my patients “I’m not sure, but here are a few theories that I can share”. I tell them that if they had seen me for therapy five years ago, I would have sounded a lot smarter than I do today. I now know what I don’t know, and refuse to pass on misinformation. The cause of their problem may never be known, but let’s try to help them anyway.

For now,Walt Fritz, PTwww.FoundationsinMFR.com