Patient A/Patient B: Thought Experiment on Pain

____Start of thought experiment:

Imagine, for the sake of a thought experiment, that you could instantly clone your body as an exact replica, where you would then have version A and version B of yourself. In this world you can also rewind time, and create a version B of a person, at the moment before something bad happens to them (although the rules are A has to continue and meet their fate).

You have a patient with right knee pain. It is severe, and started 7 months ago. The patient subjective notes they had started increasing their daily walking a little in preparation for some travel about 7 months ago, and this is around the time the knee started to bother them. They endured their travel, but the pain only worsened after 2-3 months. The deep medial knee pain started to be felt with almost all activities, and the tissue was even tender to touch all around the area.

The patient received imaging noting radiographic knee OA, limited medial space and osteophyte formation. The patient is now seeking help as the pain is not getting better, and the prognosis does not sound great. But they would like to avoid surgery. They also saw a prior therapist, and they brought in a few evaluation papers. The previous therapist jotted a long list of things, but the sum of it revealed that their gait catered to the stresses of the medial knee, that they had a weaker glut medius, and that the right L1/2/3 facets were “stiff”.

Because this story takes place in the aforementioned world, we decide to create a version patient B at 9 months ago, a few months prior to pain onset. At the time of replication, we instruct them that their other self (patient A) was about to acquire severe knee pain over the next 9 months. We talk to patient B about a strategy to avoid this. This includes a more careful increase in walking as to help the knee adapt to changes in load and frequency, additional strength exercises to toughen the tissues, and some unloaded light aerobic exercise (cycling) for joint health and circulation.

Return to the present and patient A and patient B are now sitting together in the same room, for a consult.

The pathway that patient B took was successful. Patient B’s knee was doing just fine. Patient A is on the brink of surgery. At this moment it seems especially relevant, in light of patient B’s condition, to ponder of patient A, what is the cause of their pain?

Is it the tissue morphological change at the medial condyles? Was it the travelling, and the walking? Is it “bad knees” or genetics? Was it that gait and those shoes? Or possibly the health of the L2/3 nerve root under it’s “stiff” environment? Is it a structural problem? Is it a tissue problem?

The only true answer must accommodate the existence of patient B, sitting there in the same room in no visible discomfort, who hadn’t given a thought to their right knee in the last 9 months. In fact, patient B reported that his left knee was aching a little bit! It could have been the cycling last week, they mused.

_________ End of thought experiment.

It is recommended that patients receive a diagnosis. The suffering is in the not knowing why the pain is there. We need to be able to answer the question why is my (enter body part here) hurting like this. And, it has also been recommended that the patient can describe this explanation to their family as well.

Can we give an answer that accommodates for a previous version of that patient, in a different iteration, having the same body part without a complaint of pain? Lots of findings can be, and are relevant to pain. But it is difficult to say that they’re causative. And which findings are still present for patient B, at that awkward cloned patient consult? Picture anything you say to patient A, patient B chiming in “hey I have that too, why doesn’t my knee hurt???” That may leave you fumbling for explanations.

Even if the findings of Patient A that do differ from Patient B, (likely non structural) for all we know all the “findings” that are revealed after examination of patient A may just be how they are presenting because of the pain, and because of the last 7 months of pain. Not causative, but simply related to a limb functioning under the influence of pain.

If we can tie the onset of pain to a series of events that have to do with all sorts of tissue response (how tissue responds to load, strain, stress, sleep deprivation, overtraining, undertraining etc.)… we can view the pain as a phenomenon that happens when X amount of variables are met. We don’t have a patient B to act as an example, as a “see, its possible to exist in a better state, under the majority of your individual circumstances”. How the tissue is acting, isn’t necessarily reflective of how the tissue is, how it can be, or how it could have been otherwise.

Regarding causes, patients will get loads of answers from loads of professionals. Many of these professionals might get the same person better with their best approach to “their answers”, while many may fail to get the same person better.

The example above used knee pain, but I think this type of experiment and thought processes are even more relevant toward something like back pain. Something I’ve thought of recently is, how can I best frame an explanation and plan for said pain problem, that doesn’t take a strictly deterministic approach and that leaves the door open to returning to their “patient B” state while having the patient take an active approach in rehab to return to their pain-free version of themselves. Part of this is viewing pain as a reaction to a specific set of variables in the environment, and not necessary a product of its environment. In this sense, pain is a more fluid phenomenon, and is malleable for better or for worse under any set of conditions (this applies to tissue of great integrity and tissue of poor integrity). Through the course of rehab, laying out the variables and influences on pain, as well as options to address these variables and revert them to their best condition (patient B), might be a good way to frame it.

-Tal Blair, DPT