Today’s post is about a truly perfect example of my favourite theme lately: surprising causes of pain, chronic pain mysteries that finally get solved. This one’s a doozy.
That paper is all about a patient who had “sciatica” for thirty-five years and was misdiagnosed many times until finally getting not only a definitive diagnosis but a cure. He had a narrowed artery (arterial stenosis causing “claudication,” the pain of impaired circulation). That’s it! Not even a difficult diagnosis in the end, really. There were some pretty glaring clues there that got ignored by a lot of people who should have known better.
“When Chronic Pain Is Not "Chronic Pain": Lessons From 3 Decades of Pain”
But not only was he misdiagnosed many times over more than three decades, he was misdiagnosed fashionably: that is, each misdiagnosis neatly fit a paradigm in physical therapy, better than it fit his symptoms. This carried on right up to and including the present day fascination with psychosocial factors and sensitization (which served him no better than any of the other paradigms had).
Interestingly, the patient’s belief that something ‘was actually wrong’ had remained with him throughout the journey. This, of course, had been explained away to him (more recently) by current research and evidence-based thinking on central sensitization and pain.
Just fascinating. The authors thoughtfully explore the implications of this rather shameful episode (definitely aimed at pros, some jargon, but readable enough for anyone — and behind a paywall, unfortunately). The bottom line? Good diagnostic skills are never out of fashion. Or shouldn’t be, anyway!
Update: There are criticisms of this paper from a couple of my favourite experts and writers, pointing out in a letter to the journal that one of the “fashionable” paradigms impugned here, the biopsyschosocial model, “includes the considerations [the “bio” part] that eventually cured the patient’s pain.” I like the criticism and I like the authors’ response — I see only healthy debate here.