Barrett L. Dorko, P.T.

You may ask, "How did this tradition get started?"

"I don't know. But it's a tradition. And because of
our traditions every one of us knows who he is, and
what God expects him to do."

Tevye in "Fiddler on the Roof"

          "I really like the stuff you taught us here and it makes perfect sense to me. I have some chronic patients I think I might try it on."

          I often hear this from a smiling, enthusiastic student as they leave my workshop, and my heart sinks. Its descent is because of what I feel this statement implies about both the nature of my work and the nature of chronic pain.

          Let me explain.

          I've noticed that in our community the words "conservative" and "traditional" are used interchangeably. This is a mistake. Conservative care is that which is the least likely to lead to other unwanted effects. It is not invasive in an irreversible way, and is often characterized by a gentle thoughtfulness on the part of a therapist who constantly monitors its effect.

           Traditional care is not bound by any such constraints. It is simply endowed with repetition and the comfort of its familiar usage. Once something becomes traditional, it's very hard to get rid of it no matter how potentially harmful, irrelevant or irrational we might eventually find it. In short, traditional methods needn't be conservative in any sense, and truly conservative clinicians do not necessarily follow tradition.

           Often I hear the proponents of alternative approaches such as acupuncture and herbology shore up their weak theoretical basis with the argument; "Well, its been around for two thousand years so it must be helpful." But equating antiquity with beneficence doesn't work for ignorance and bigotry, and they are every bit as old. Traditional behavior offers us comfort and stability, but it can keep us from discovery and a new understanding of an old problem. It's simply easier to choose, and I can appreciate that in my own life.

          Now, back to why my student's comment bothers me so much.

          I think that there are two things implied here. First, that the method of management I propose that they consider using is somehow potentially harmful. Since it involves gentle touching and diaphragmatic breathing, this can't be true. In fact, it is extremely conservative, it's just not traditional.

          Secondly, there is the assignation of "chronic" patients to a group that we might as well try the odd stuff on since nothing else seems to have worked.

          Is there a predictable and consistent difference in the symptoms and dysfunction of a chronically painful problem that is not often seen in a recently painful one? Do we have reason to think that one will always respond or behave in a certain way? I don't think so.

          It seems to me that conservative management should be the first line of defense against a worsening condition, not the last. And if we try only traditional care first, we may be perpetuating the very methods that turn acute problems into chronic ones.

          What I hear that student say is this; "I'm going to stick with what I've always done unless it proves unsuccessful, and I'm going to save this strange stuff as a last resort for those patients I have the least hope for."

          I feel we can do better than this, that we should consider why we're doing something each time we begin, no matter what tradition may dictate.