The Problem with Pain

What is your pain from zero to ten, ten being the worst pain you have ever felt? Does that look like anything you have come across before at a doctor’s office? If you have a child you may have come across the faces pain scale. A common variation found in many pediatric clinics. There is a long list of pain scale variations, each with their own set of advantages and disadvantages. The major problem across the board is that you can not collect true objective data in a subjective manner.

“Pain is an unpleasant feeling that is conveyed to the brain by sensory neurons. The discomfort signals actual or potential injury to the body. However, pain is more than a sensation, or the physical awareness of pain; it also includes perception, the subjective interpretation of the discomfort. Perception gives information on the pain's location, intensity, and something about its nature. The various conscious and unconscious responses to both sensation and perception, including the emotional response, add further definition to the overall concept of pain.”(Online Medical Dictionary)

Philosophy has dealt with the problem with pain as far back as Plato’s The Republic, written in 380 BC. Plato speaks of reality through his theory of forms. In his famous allegory of the cave, Plato speaks of reality being like shadows on a wall. We do not ever see the truth, just the shadows that we use to make inferences of reality. Rene Descartes (1596-1650) proclaimed “Cognito ergo sum” or “I think therefore I am.” He explains how perception must be part sensory and part cognitive. This is, for example, how one can observe a candle melt into liquid wax yet still know that the solid candle and the melted wax are one in the same. In fact, the oldest quantitative law in psychology is the Weber-Fechner law, a law concerned with the relationship between the intensity of physical stimuli and their perceptual effects. Ernst Weber found a logarithmic relationship between stimulus and perception.

What all of this means is that on a pain scale, my severed arm might feel like your stubbed toe. But with a stubbed toe and a pain rating of ten, I have learned something valuable about you and your road to recovery: you have a very low pain threshold and it’s going to be a long road. And that is in fact the value of the pain scale. Its benefit and its downfall walk hand in hand. You can not accurately describe pain with severity alone but you can use the data for other purposes. Maybe you will be less aggressive; maybe you will start with a more passive approach, either way you can avoid scaring off a patient and formulate the best way to approach his or her treatment.

And what if I walk into your office years after my severed arm and I circle a ten again for my pain? You better give me some immediate medical attention because something is seriously wrong. Unlike the other guy, when I cry wolf granny has been eaten and I am about to be dessert. However, if I walk in with a stubbed toe and a pain level of two you can more than likely be as aggressive as you would like for a quick recovery.

Pain scale ratings are important and very necessary. Use them as a basis for treatment approach and use them as a way to monitor progress. If you would like something more reliable, use more complex pain scales such as the McGill Pain Questionnaire which uses twenty subclasses of words that break down into four major groups to describe the sensory qualities of pain, the affects of pain, the overall experience of pain and some miscellaneous characteristics of pain. No matter which pain scale you use and how you use it just remember this: perception is reality and perceiving is believing.

Confidence

At the Movement Center we preach the importance of confidence. No matter what industry you exist in confidence confidence precedes success. Namely: confidence in the providers, confidence in the provider's education and confidence in their services and products. As a chiropractor too must be confident, confident that you can deliver what you promise.

There are few educated and objective people out there that will still argue the total ineffectiveness of chiropractic. In a previous post I spoke of my gripe with the fact that the word chiropractic is often used erroneously as a service when it is in fact a profession. When you realize that the services we employ are often the same as medical doctors, osteopaths and physical therapists, you come to the inevitable acceptance that the profession of chiropractic is obviously not ineffective. Even the chiropractic manipulation has been shown to be effective in treatment of low back and neck pain.

So how confident should you be in our education? Here is my current curriculum at the University of Bridgeport Chiropractic College: (Click here for full details on curriculum)

Year One
Semester One						Sem.
	Number	Course	Lecture	Lab	Hours	Hours
	AN 511	Cell and Tissue Microscopic Anatomy and Physiology	3	0	54	3
	AN 512	Functional Anatomy I: Spine	3	3	108	4.5
	PP 511	Principles and Practice I: Chiropractic History and Philosophy	2	0	36	2
	BC 511	Biochemistry, Metabolism, and Nutrition	4	0	72	4
	PP 512	Principles and Practice II: The Doctor Patient Relationship: Communication Skills, Ethics, and Case History	2	0	36	2
	AN 513	General Anatomy I: Viscera	3	3	108	4.5
	TE 511	Chiropractic Examination Skills I: Palpation and Biomechanics of the Spine and Pelvis	2	0	36	2
	TE 511L	Chiropractic Examination Skills I: Palpation and Biomechanis of the Spine and Pelvis	0	3	54	1.5
	AN 514	Clinical Embryology I	1	0	18	1
TOTAL HOURS			20	9	522	24.5
Semester Two						Sem.
	Number	Course	Lecture	Lab	Hours	Hours
	DI 521	Diagnostic Imaging I: Normal Anatomy of the Spine and Pelvis, Introduction to X-Ray Imaging and Physics	2	2	72	3
	PH 521	Organ System Microscopic Anatomy and Physiology I	2	0	36	2
	NS 521	Neuroscience I	3	0	54	3
	PP 523	Principles and Practice III: Contemporary Chiropractic Studies	2	0	36	2
	AN 525	General Anatomy II: Head and Neck	3	3	108	4.5
	AN 526	Functional Anatomy II: Extremities	3	3	108	4.5
	MB 521	Clinical Microbiology Introduction to Infectious Diseases I	2	0	36	2
	TE 522	Chiropractic Examination Skills II: Palpation and Biomechanics of the Extremities	1	0	18	1
	TE 522L	Chiropractic Examination Skills II: Palpation and Biomechanics of the Extremities	0	3	54	1.5
TOTAL HOURS			18	11	522	23	.5

Year Two
Semester Three						Sem.
	Number	Course	Lecture	Lab	Hours	Hours
	NS 612	Neurosciences II	3	0	54	3
	PA 611	Fundamentals of Pathology	2	1	54	2.5
	PH 612	Organ System Microscopic Anatomy and Physiology II	4	2	108	5
	MB 612	Infectious Diseases II	2	0	36	2
	TE 613	Technique Procedures I: Introductio to Full Spine Technique	1	0	0	1
	TE 613L	Technique Procedures I: Introduction to Full Spine Technique	0	3	54	1.5
	DX 611	Diagnostic Skills I: Orthopedic Examination of the Spine, Pelvis, and Extremities	2	0	36	2
	DX 611L	Diagnostic Skills I: Orthopedic Examination of the Spine, Pelvis, and Extremities	0	4	72	4
	DX 612	Diagnostic Skills II: Physical Examination	2	0	36	2
	DX 612L	Diagnostic Skills II: Physical Examination	0	3	54	1.5
	DI 612	Diagnostic Imaging II: Normal Anatomy	1	2	54	2
TOTAL HOURS			11	15	576	24.5
Semester Four						Sem.
	Number	Course	Lecture	Lab	Hours	Hours
	PA 622	Systems Pathology II	4	2	108	5
	TE 624	Technique Procedures II: Intermediate Full Spine and Upper Extremity Technique	2	0	36	2
	TE 624L	Technique Procedures II: Intermediate Full Spine and Upper Extremity Technique	0	4	72	2
	DI 623	Diagnostic Imaging III: Bone Pathology	2	2	72	3
	DX 624	Laboratory Diagnosis	3	0	54	3
	MB 623	Public Health I	2	0	36	2
	DX 623	Diagnostic Skills III: Clinical Neurology and clinical Examination of the Nervous System	2	0	36	2
	DX 623L	Diagnostic Skills III: Clinical Neurology and Clinical Examination of the Nervous System	0	4	72	2
	TE 625	Technique Procedures III: Soft Tissue	2	0	36	2
	TE 625L	Technique Procedures III: Soft Tissue	0	2	36	1
	CN 621	Nutritional Pathology	2	0	36	2
	PP 624	Principles and Practice III: Research Methods	2	0	36	2
			16	12	504	22

Year Three
Semester Five						Sem.
	Number	Course	Lecture	Lab	Hours	Hours
	TE 716	Technique Procedures IV: Intermediate Full Spine and Lower Extremity Technique	2	0	36	2
	TE 716L	Technique Procedures IV: Intermediate Full Spine and Lower Extremity Technique	0	4	72	2
	DI 714	Diagnostic Imaging IV: Arthritis and Trauma	2	2	72	3
	PT 711	Physiological Therapeutics I	1	0	18	1
	PT 711L	Physiological Therapeutics I	0	2	36	1
	DD 711	Differential Diagnosis I: Internal Disorders	5	0	90	5
	DD711L	Differential Diagnosis I: Internal Disorders	0	1	18	0.5
	CN 712	Clinical Nutrition: Treatment and Management	2	0	36	2
	PH 713	Toxicology/Pharmacology	2	0	36	2
	TE 717L	Technique Procedures V: Soft Tissue II	0	2	36	1
	ER 711	Emergency Procedures	1	0	18	1
	ER 711L	Emergency Procedures	0	2	36	1
	RS 711	Thesis I	0	0	0	1
TOTAL HOURS			15	13	504	22.5
Semester Six						Sem.
	Number	Course	Lecture	Lab	Hours	Hours
	DI 725	Diagnostic Imaging V: Chest and Abdomen	1	2	54	2
	TE 728	Technique Procedures VI: Advanced Chiropractic Technique I	2	0	36	2
	TE 728L	Technique Procedures VI: Advanced Chiropractic Technique I	0	3	54	1.5
	DI 726	X-Ray Positioning and Physics	3	2	90	4
	DD 722	Differential Diagnosis II: Neuromusculosketal	4	0	72	4
	PT 722	Physiological Therapeutics II: Rehabilitation	2	0	36	2
	PT 722L	Physiological Therapeutics II: Rehabilitation	0	2	36	1
	DX 725	Special Populations	3	0	54	3
	CS 721	Clinic Services I: Student Clinic	2	4	108	4
	MB 724	Public Health II: Community Health and Wellness	2	0	36	2
	RS 722	Thesis II	0	0	0	1
TOTAL HOURS			17	13	540	24.5

Year Four
Semester Seven						Sem.
	Number	Course	Lecture	Lab	Hours	Hours
	CS 812	Clinical Services II	0	25	450	12.5
	DI 827	X-Ray Review	2	0	36	2
	PP 815	Small Business Management, Insurance, Office Procedures, Jurisprudence and Ethics	4	0	72	4
	TE 819	Technique Procedures VII: Advanced Chiropractic Technique II	0	6	108	3
	PS 811	Clinical Psychology	2	0	36	2
	RS 813	Thesis III	0	0	0	1
TOTAL HOURS			8	31	702	24.5
Semester Eight						Sem.
	Number	Course	Lecture	Lab	Hours	Hours
	CS 823	Clinical Services III	0	25	450	12.5
	RS 824	Thesis IV: Completion and Submission	0	0	0	1.5
	TOTAL HOURS
	CS 824	Clinical Services (Six weeks) Summer Session	0	25	150	4
TOTAL HOURS			0	5	600	18

The Center for Studies in Health Sciences based out of Washington, DC put together this comparison of a chiropractic physician's versus a medical physician's education:

	Chiropractic Schools		Medical Schools
	Mean	Percentage	Mean	Percentage
Total Contact Hours	4822	100%	4667	100%
Basic science hours	1416	29%	1200	26%
Clinical science hours	3406	71%	3467	74%
Chiropractic science hours	1975	41%	0	0%
Clerkship hours	1405%	29%	3467	74%
Comparisons of the Overall Curriculum Structure for Chiropractic and Medical Schools Source: Center for Studies in Health Policy, Inc., Washington, DC. Personal communication of 1995 unpublished data from Meredith Gonyea, PhD.

The largest difference is that a medical doctor will go on to do a residency after medical school to specialize in their interest, while the chiropractor will go into either private practice or work as an associate to continue to fine tune his or her skills. But lets face it, chiropractors aren't performing major surgeries and they are not directly treating life and death pathologies. Embrace this fact! Chiropractors treat dysfunctions not pathologies. The beautiful difference being that dysfunctions are often reversible, while pathologies are often a life long condition and typically much more serious. And we treat these dysfunctions with great efficiency. This is why Consumer Reports lists chiropractors at the top of the patient satisfaction list for low back pain and why the scientific community supports chiropractic for soft tissue dysfunctions like low back pain (British Medical Journal, Western Journal of Medicine and Ontario Ministry of Health).

No matter what industry you apply the necessity of confidence to, there is one universal denominator that must exist. What do all the aspects of chiropractic that I have listed have in common to allow for confidence? They are all empirically supported and tested. Scientific literature is the chiropractor's product testing and research and development. Thus, it is extremely important that chiropractors employ methods that are tried and true. This why I have no problem looking a prospective patient in the eyes and telling him or her that I can help them. Everything I use is supported and tested and I have the most current research to back the statements that I make.

So chiropractors, have confidence in yourselves, your education, and your services so that your patients can have confidence in you and your profession.

Share Openly and Freely,

John Giacalone Jr

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