Return of the Biopsychosocialists and the “Bombproof” SI Joint
Last year, I proudly announced the death of what I call the “biopsychosocialists.” These are doctors who believe that pain is all in the patient’s head and that instead of treating pain, we should be more focused on talking our patients out of the delusion of injury. However, while the rapidly expanding hard data on why patients hurt is growing like a weed, a physical therapy phenomenon has resurrected the “it’s all in your head” theory. Let’s explore this disturbing trend.
The “Sarnoites” and Pain
Back when I was in residency training, physicians had no clue why most patients hurt and how they should be treated. Rather than admitting they didn’t have a clue, they instead created a cult where you would blame the patient if he or she didn’t get better. This evolved into a theory that it was the patient’s beliefs that caused pain or at least fueled it like gasoline on a campfire. Hence, a physician in New York (Dr. Sarno) wrote a best-selling book whose premise was that patients should ignore their pain. While I’ve had a few patients through the years read the book and report great results, for most, this approach was as effective as trying to treat an infection by reading a book.
How My Dog and Pain Killed the Biopsychosocial Theory
I used to have an Alaskan Malamute who had a noticeable limp toward the end of her life. One day I noticed that by offering her a treat, her limp would go away for a few minutes. Was she faking? Could she be helped by Sarno’s book? Could I talk her out of her delusion of injury? No. I published an article that described how she was able to activate descending pain inhibition pathways to shut off the pain signals to accomplish a biologic imperative. In this case, getting the treat was simply more important than the pain in her hip. The problem is that this didn’t change the arthritis in her hip or work for very long.
The Death of Sarno?
A while back, I published a blog post on how new imaging technologies were allowing us to image pain in the brain. In fact, that patients with chronic spinal pain experienced atrophy of certain parts of their brain. I was convinced that we had finally reached a saturation point of “pain is real” research, that the “it’s all in your head” crowd would finally have to pack their proverbial bags and go home.
The SI Joint Is Bombproof?
I’ve been following a physical therapist, Peter O’Sullivan, who seems to be quite popular on Twitter. His thesis seems an awful lot like Sarno and the “it’s all in your head” crowd. Basically, that we medical providers teach patients to be sick by giving them false narratives.Today he tweeted that the SI joint was “bombproof,” suggesting that the SI was so robust that it couldn’t be injured with normal use and abuse.
To understand this next part, it’s helpful to understand the SI joint. The joint lives between your tailbone and the back of your hip, and it’s connected by strong ligaments that help to transfer energy from your spine to your leg and vice versa. The joint doesn’t move like your knee or elbow, it “gives” as it transfers energy. Hence, studying its motion is very difficult and, frankly, a bit beyond the reach of our current technology. My guess is that as artificial intelligence, image processing, and sensors become cheaper, more widely available, and ever more sophisticated, we’ll eventually be able to “see” how the SI joint moves as patients perform daily activities.
Getting back to the claim that the SI joint was “bombproof.” Huh? We see patients all day every day with SI joint injuries and instability, whose SI joints aren’t “bombproof.” While I got into a back-and-forth with this therapist and his many minions, Twitter is not the ideal venue for discussing complex science topics. Hence, I’ll dig a bit deeper into theories of this new PT craze.
As an example, in a recent magazine article, Mr. O’Sullivan writes that since we can measure SI joint motion with little beads implanted near the joint, and since we don’t see much change in the position of the joint before and after manipulation, then by telling patients we’re “putting the joint back in,” we’re causing problems. To quote the article, “However, when patients are told that the treatment technique ‘puts the pelvis back in’, this can reinforce fear of movement, avoidance behaviours, a loss of confidence in their body and hyper vigilance. These factors can reinforce chronicity.” Hmmmm….
So what is Mr. O’Sullivan’s solution for patients with chronic SI joint or pelvic pain? From the same article, “Chronic PGP, as per best practice for pain disorders in general, should be rationalised from a multidimensional, biopsychosocial perspective.” Oh, my God! They’re baaaacccck! The biopsychosocialists, after being laughed out of serious medicine, are now invading physical therapy. Hide your children, lock the doors—this is serious.
The SI Joint Syndrome Conundrum
First, the studies that Mr. O’Sullivan quotes only tell a small part of the SI joint story. The little-metal-ball study was designed and executed in a time when orthopedic surgeons were trying hard to prove that the chiropractic and osteopathic quacks who said the SI joint moved were idiots. Did they show that the joint doesn’t move like a knee? No, it doesn’t move like a knee. However, the SI joint did move a little, in it’s role of transferring energy. (see ref 1, ref 2, ref 3, and ref 4).
A different technology has also been used to access SI joint movement. This one uses vibration and ultrasound to quantify stiffness. You see, in a joint that gives, the absolute amount of movement in the joint is pretty meaningless. However, the stiffness in that joint is key. As an example, consider a piece of hard rubber used as a shock absorber in a car. The forces come through the wheels and into the axle through the rubber. The rubber deforms and transfers energy. But if you tried to see how much movement the hard rubber piece had, it would have very little. In fact, as the rubber wore out, the only thing that would matter in accessing its viability would be its stiffness. If it had lost its stiffness and become sloppy, it would be poor at energy transfer.
The ultrasound technology conveniently ignored by Mr. O’Sullivan in his recent article accesses the stiffness of the SI Joint. This tech has been used to show that an SI belt (which is supposed to stabilize the SI joint) does actually stabilize it by adding to its stiffness. This technology has also been used to show that the muscles in the leg improve the stiffness in the joint. In addition, this measure of SI joint stiffness clearly showed that pregnant patients with chronic SI joint pain have looser joints. There has been one dissenting voice on the use of this technology, claiming it wasn’t validated. However, a validation study was published here. In addition, one of the authors of the critical paper later published a research study showing how strengthening an abdominal muscle could help SI joint stiffness, which confirmed the findings of the ultrasound technique regarding SI laxity versus stiffness.
Hence, Mr. O’Sullivan begins his SI joint argument with a logical fallacy by giving the reader only the part of the story that fits his conclusion: the SI joint doesn’t move, hence, telling patients it’s “out of place” makes them sick.” This is no more true than the observation that the hard rubber piece in our car example doesn’t move a lot, and when it’s worn out, telling the mechanic that it needs to be replaced or fixed makes our the car’s owner believe that the delusion that the car is sick.
My Experience with How the Loudest Voice Wins the Day in Medicine
Many years ago, I observed how medicine can be perverted by the loudest voice in the room. I watched two lectures about what caused chronic neck pain after car crashes. One lecturer was loud, brash, and had an alpha-wolf-type personality. The other was the exact opposite. Both theories were tenable and had nice data to back them up, but it was clear to me that the first speaker’s ideas would flourish, while the second’ speaker’s ideas would die off. In fact, looking back a decade, that’s exactly what happened.
Mr. O’Sullivan appears to be the loudest voice in the room. There’s nothing wrong with that—good presenters have always held the day, from the time of Socrates to the Internet. I’m likely just the same. However, a biopsychosocialist who can speak and present well might also set the science of why patients hurt and what to do about it back decades.
The Kernel of Truth in the Biopsychosocial Ruse and Bombproof SI Joints
The thing that’s attractive about Mr. O’Sullivan’s message is that we all have seen patients that get too fixated on their bad-looking MRIs and their diagnoses. Some of these patients can perseverate on the negative or their label, and this can cause them to act sicker than they really are, leaving life to pass them by. Having said that, taking that concept to the nth degree causes us to ignore that pain and tissue dysfunction that causes pain is real. With regard to our SI joint example, the lack of SI joint stiffness (laxity) can be measured and is abnormal in patients with SI joint problems. This can be palpated by skilled manual therapists, and manipulation can help. In addition, treatments like prolotherapy and PRP likely work by restoring that stiffness and reducing that laxity.
The upshot? The fact that the biopsychosocialists are back is scary. Enough! Pain is real, and the causes of it are being elucidated and have yet to be discovered. While imaging can mislead us and send us down rabbit holes of therapy that are invasive and ineffective, claiming that since it doesn’t always correlate, patients need to be talked out of their pain is silly. In addition, while it may be true that in the strictest sense, a patient’s SI joint doesn’t go “out” and dislocate in the same way a shoulder does, telling that patient that they have abnormal stiffness and force closure will simply cause a confused patient. Hence, the simplification that the SI joint is “out” is as good as any.