Pain Management – Making The Case For Colouring Outside The Lines 

Introduction

In our society we are often encouraged by the medical fraternity to only pursue treatments for our pain that are ‘scientifically proven’. There is a core of wisdom in this advice but unfortunately it does not always lead to the best outcomes for patient, many of whom are suffering terribly with chronic pain. I am going to use a martial arts metaphor to introduce you to the idea that there is such a thing as ‘valid but unproven science‘. In fact, many of life competencies happen to fall into this basket and are no less effective as a result.

Brazilian Jiu Jitsu 

Over the past 20 years Brazilian Jiu Jitsu (BJJ) has moved from complete obscurity to becoming one of the worlds most popular martial arts. BJJ is a reiteration of Japanese Jiu jitsu, modified into a shockingly effective system of grappling, chokes and submissions. The primary feather in the cap of BJJ is that it was at one time tested in open competition against many other martial art forms and came out on top of the heap. Thus taking a major step towards ending countless testosterone fueled debates about which is the most effective martial art. BJJ also developed a track record for enabling smaller men to beat much larger men in martial arts contests, this is a major feat, and one that has been performed repeatedly with the BJJ system.

For those of us who have no experience with the grappling arts, rolling around on a mat with even a relatively amateur BJJ practitioner has the potential to be a life alteringly unpleasant experience. On being asked to do our best not to get choked, pinned or submitted we would make a few instinctive attempts at self preservation. Depending marginally on our level of physical strength, within a handful of moments (or possibly just one) we would find ourselves in very serious trouble. An instinctive movement of our neck, arm or a leg that seemed like the right thing to do could at any moment lead us to an instant realisation that our elbow was about to snap out of its socket… for example. Other exciting possibilites include blacking out due to a lack of blood in our brain faster than we had ever dreamed was a physical possibility or having our ankle joint snapped. Luckily for us though,  BJJ practitioners are usually pretty wholesome types who wouldn’t dream of actually hurting us, and the whole thing could be put down to a near death experience.

BJJ is a powerful example of how many of life’s valid disciplines are as yet scientifically unproven, but nonetheless completely valid.

Now. if we take that same novice BJJ practitioner and put him or her against a fully fledged black belt their experience could easily be over quicker than ours was. They would almost certainly lose 100/100 matches against their teacher in other words. Then having conducted that experiment, if we take that black belt and put them against a BJJ world champion once again we would see a human being submitted very fast. 

You could go to any number of countries and conduct the above experiment with different clubs and practitioners, you would find a gravely consistent disparity in ability on the mat between yourself and the novice practitioners, and between the novices and the pros. In other words BJJ is a real thing, it is a real art and it is a real science. If you think it isn’t all you need to do is go to your local club and tell them, they will help you understand better I am sure. 

Now that I have hopefully helped you to understand BJJ a bit I want you to take a deep breath because I have shocking news. ‘There is no ‘scientific evidence’ to support the assertion that BJJ is effective. It is ‘scientifically’ completely unproven. 

There are no research articles published on BJJ’s effectiveness at breaking elbows, there are no literature reviews on how consistently easy it is for a black belt to choke out a blue belt. There are no in depth peer reviewed and published technical papers on the best way to secure an arm bar. And there are no randomised blind controlled studies on the reliability of getting choked unconscious by the club black belt when you show up to your first class and tell them it is an unscientific system. BJJ’s effectiveness is ‘purely anecdotal’.

The closest you could come to ‘scientific proof’ of BJJ being a valid system are some scraps of research into the breaking strain of certain joints in dead bodies carried out by orthopedic researchers. And yet, this crushing lack of data has no bearing whatsoever on the stark and visceral reality of what it would feel like to get your arm broken 100 out of 100 times trying to wrestle a seasoned practitioner with ill intent.

If BJJ practitioners limited themselves to the parts of their artform that were scientifically proven all they would be able to do is a couple of warm up exercises that have been proven to prevent injuries. After that they would all just have to sit on the mat for an hour looking at each other. But they don’t worry about that, they just get on with it… and they get on with it extremely well at that. 

The reason they get on so well despite being an ‘unproven system’ is because there is absolutely  ‘a legitimate science’  to what they do, it’s just not a science that is practically or morally easy to study and measure in the Western ‘scientific’ terms. Or one that anyone cares to study for that matter. There is also ‘an art’ to what BJJ practitioners do, and legitimate arts are extremely effective systems. Both arts and forms of unmeasured science can be legitimate areas of human endeavour.

Pain Management 

Believe it or not effective pain treatment has a great deal in common with BJJ…

– Both BJJ and effective treatment for issues like back pain etc. involve manipulation of the bodies tissues. 

-Both BJJ and effective treatment for shoulder pain etc. must involve a wide variety of techniques to be effective.

-Neither BJJ nor effective treatment of neck pain etc. will be comprehensively measured by science in our lifetimes.

-Both BJJ and effective treatment for hip pain etc. have been witnessed and experienced as being effective first hand by millions of individuals.

-Both BJJ and treatment for headaches and neck pain are effective via a combination of mind and body. 

-Both BJJ and effective management of back pain etc have their benefits and risks.

-Both BJJ and effective shoulder pain management etc. play by the rules. 

-Both BJJ and effective foot pain management have a foundation of ‘scientifically valid’ knowledge as their basis, in the form of basic anatomical and physiological principles. 

-Both BJJ and effective pain neck pain treatment are a mixture of art and science. 

-Neither BJJ nor effective hip pain treatment offer any major financial incentive to those with the most to spend on scientific research. Thus both are woefully under-tested in scientific terms.

-Both are BJJ and effective plantar fasciitis treatment are highly complex and broad in scope which makes them extremely awkward candidates for study the way western science.

Treatment for shoulder pain has more in common with martial arts than you might think!

The key difference between BJJ and the best pain treatment for conditions like shoulder pain is that the effectiveness of BJJ is far more immeditely verifiable with the 5 senses of an onlooker. Theoretically a person’s chronic shoulder pain may go away just as reliably as the consciousness of a white belt getting choked, but the only person who can truly verify that change is the sufferer themselves.

The other issue is that the sequence of moves it takes to get rid of the shoulder pain often take months not minutes. This time dependent factor is not related to efficacy, it’s just the nature of rebuilding vs destroying. The forest burns down quicker than it grows. 

The tricky thing to understand for many, is that physical effects and changes that are slower and happen out of your line of sight are still absolutely real. It is this ‘unseen’ nature of pain relief that appears to set it apart from more immediately and broadly verifiable actions like those of martial artists. But all is not always what it seems. 

Playing Devils Advocate 

Many of those who identify themselves as sceptics (really they are usually cynics) would weigh in on this topic (perhaps understandably) and point out that you can’t have your arm broken via placebo; whereas back pain can be resolved though the effects of placebo. The reality is though, that the fear psychology of facing a martial artist way better than oneself is a major part of what inhibits all the necessary physical requirements for BJJ skill, like breathing and relaxation. I am also sure that all of sports psychology would broadly agree that the power of suggested dominance held within a blackbelt is something that no doubt influences what happens on the mat. If this is true then the psychology of the situation has a huge impact on its probable physical  outcomes. That’s the same thing as placebo. Does this psychological aspect somehow diminish the realness, effectiveness and authenticity of jiu jitsu? If you think the answer is yes I would love for you to try it out against some experienced practitioners and reassess its validity.

The constituent parts of healthcares effect on a patient are not considered as being equal in value in the eyes of medical science. The placebo portion of all interventions is basically deemed non-efficacious. ‘This treatment doesn’t work any better than a placebo so we can’t recommend it’, being the battle cry. This portion also has a great deal of sense to it from one perspective, we want to maximise the value of everything we do, so if something works even better than a placebo let’s use it. From a ‘’medical’ perspective placebo is a non-valid mechanism of action. From a truly scientific perspective placebo is just another effective mechanism. From a human perspective placebo is something that has eased the suffering of millions of people who were experiencing significant pain and suffering, for them is was most certainly valid.  

Another understandable but poorly conceived observation we may hear from the peanut gallery is one around ‘quackery’. No matter how much truth there is to my assertion that effective hands on pain treatment is a legitimate discipline, the fact remains that we can be certain there are both quacks and douchebags out there for sure. ‘Practitioners’ who would clear out our bank accounts and render ineffectual or worse still harmful treatments for back pain, shoulder pain, neck pain, knee pain, foot pain… you name it.

The martial arts metaphor beautifully illustrates as follows the absurdity of citing the inevitable presence of quacks in the marketplace as a reason to avoid pain relief methods that may be as yet ‘unproven’. 

A quick visit to YouTube is all you need today to see a veritable feast of complete charlatans practicing martial arts. Countless chubby men with dad bods performing unintentionally hilarious martial arts moves on subordinate students who throw themselves on the floor in relation to a flick of the wrist, or a ball of energy emanating from a podgy palm of death. There are also enough videos of these types of characters getting completely smashed by kickboxers and the like to verify 100% their area of expertise is fakery. It is a fairly universal fact that wherever there is money to be made or an opportunity for enhancing ones sense of  self,those who are given to taking shortcuts will show up and usually in numbers.

Now let us be really clear headed for a moment. Does the presence of these charlatans in the ‘martial arts market place’ in any way diminish the validity of true martial artists? Do they diminish the authenticity of those who possess absolutely verifiable skill and integrity like BJJ black belts? Of course it doesn’t, if anything it reinforces the validity of true martial art and science. Seeing the Youtube video of the thai kickboxer chopping the legs off a morbidly obese self styled kung fu death touch master validates the authenticity of kickboxing.

And so it is with pain management, the eternal presence of quacks in the marketplace does absolutely nothing to diminish the skill, integrity and valid art/science of truly effective pain management. There is absolutely a risk when you head into the pain marketplace that you might come up against the odd quack if you don’t know all the signs and signals are that you are dealing with one. ALL of healthcare carries risk unfortunately, medical negligence and malpractice are statistically significant risks too but we still go to the hospital when we are very sick. 

Reductionism & Statistics

I hope that this BJJ/pain management metaphor enables you to see the wisdom in being willing to colour outside the potentially crippling lines that ‘science’ and ‘data’ would impose upon you; in your search for pain relief and more lasting freedom from pain.

If you are not willing to go beyond the useful but relatively tiny threads of quality data that exist on the topic of back pain and explore what is actually possible you risk being like one of those BJJ practitioners sat on a mat staring at each other for 90 mins because their system is ‘unproven’. 

In the realm of healthcare Western science operates on the isolation and testing of individual moving parts with a context, and slowly building a picture. ‘Reductionism’ is a core principle, defined as ‘the practice of analysing and describing complex phenomena in terms of their simple or fundamental constituents or elements’. This is a wise and valuable endeavour often and in many instances. Peeling back the veil of realities complex nature, in order to improve both our comprehension and  potency of our interventions is great stuff. 

Western medical science takes this a step further than pure reductionism and states that to be valid each part must be coherently measured, recorded and statistically analysed. This is reductionism being subjected to statistical analysis. So now we are wisely isolating all the moving parts, measuring their effect and recording them with a view to building a broader picture of how our findings relate to a population. This is a lot of work, and in many cases important work at that. 

Like all wisdom, western science must be applied judiciously. To maintain their high value reductionism and data must not be wielded like big sticks that can answer every important question with a hard whack. We already know this. This is why we don’t attempt to apply them rigorously when we are learning to cook, learn jiu jitsu, surf, play bagpipes and play music. There are many areas in life which are safe and cost effective enough to participate in based on little more than common sense, and so mulit-faceted that they cannot and will not be ‘measured up’ by science in our short lifetimes. ‘Hands on’ pain management and Brazilian jiu jitsu are both such areas. This means that we can and we must procede without the blessing of data or those who worship it to the exclusion of all else. We must forge ahead with a critical and cautious eye but on our own terms and in relation to what works for us as individuals. 

An Important And Practical Closing Thought

A  final  reservation that must be addressed. The question of how we avoid the quacks. This is thankfully actually easy at this stage. Osteopathy, chiropractic, acupuncture and physiotherapy are all fully emancipated and fully regulated healthcare professions with high level, modern university degrees and government legislation relating to their application in society. If you don’t want to go to a quack go to a registered healthcare provider, and maybe see which of the above train for the longest period in your country.

We also now live in a world with Google reviews in it, if a given practitioner is a charlatan it’s not likely that they are going to have a mass of quality reviews. These are practical ways to get yourself in front of someone who may be able to help you. 

Waiting for the purist medical paradigm to give us permission in the form research it is not realistically even engaged in is not practical. And by ‘not engaged’ I mean that we have not to  even moved forward from referring to back pain as ‘non-specific lower back pain’. This means ‘they’ haven’t even figured out what it is they are actually studying yet, beyond knowing there is a common symptom. I don’t mean to be disparaging, there are actually a tiny handful excellent researchers out there working hard on this stuff, the point is though we are lifetimes away from the data to support what can already be achieved. Time is short, we must push on.