Tell me if this sounds familiar: A young orthopaedist who has been practicing for about five years walks up to his secretary and says, "If you let one more backache in here, you're fired".
I begin this story to my classes by saying that when the doctor started out he was glad to see anything remotely related to his training. He said, "Knees, ankles, necks, backs, shoulders, I don't care, just get them in here, I've got bills to pay". As the years passed he found that the rhythm of his practice was disrupted by the management of problems that simply would not progress steadily through protocols of care in the same way as so many others. After awhile he saw that he was expending effort that yielded a very small or uncertain return, and that this happened when the patient's complaint of pain was behind them.
A local clinic advertising for a therapist recently described their case load: "Fifty percent sports and orthopaedic and fifty percent spinal". I don't think that this is an especially unusual categorization, and it reveals the sense we have that spinal pain is essentially different from orthopaedics as we normally approach it.
Since my own caseload is almost entirely "spinal", I've developed some ideas of my own about the health profession's attitude toward these patients. I've so often seen them treated as undesirable relatives that I was easily led to the title of this column.
Let me shift gears here for a moment. When a system is not responsive to provocation in a consistent manner it is likely to contain behavior that is chaotic i.e. periodic and unpredictable, highly sensitive and, at times, astoundingly stable.
Behavior of this sort creates a shape known as a fractal. This special geometry can be seen in clouds, trees, coastlines, oceans, lakes, rivers and mountains. When random patterns replicate themselves at different scales (a common characteristic of fractals), human beings are drawn to gaze at them. Think about how much more you pay for a hotel room with an ocean view.
The computer engineer and fractal expert Homer Smith says "If you like fractals, it is because you are made of them. If you can't stand fractals, it's because you can't stand yourself. It happens." Smith is referring to the fact that several very important organs clearly reveal a fractal dimension, chiefly our blood vessels and nervous system.
The significance of this and the connection to the young orthopaedist at the beginning of this column is clear when you understand that fractal shapes do not respond predictably to provocation. The nervous system is like a river in that placing your foot in it will undoubtedly change it's course, but we cannot say how much or in what way. Beyond that, its current state is altered from moment to moment, or, as Heraclitus said in the fifth century B.C., "You can't put your foot in the same river twice".
Clinicians learn soon enough that some diagnoses carry with them a protocol for care that produces reliable change in a fixed time period. Others defy our efforts, or simply get better in their own time regardless of what we do. Linear tissues (connective, muscular and most viscera) form the first group and nervous tissue is definitely in the second. Even so-called back specialists in the surgical community are often disdainful of those patients without frank bony or disc pathology, and they funnel them toward therapy as a last resort. They do this with a shrug of their shoulders since they don't understand how therapy might help.
Maybe one day an orthopaedist will say "This patient has a fractal problem. Please send them to someone with the time and expertise they require. Send them to a therapist who can welcome them, and make them feel at home."
A reference list; "Fractal Geometry and Manual Care" is available from the author.