Where Do Our Beliefs About Pain Come From?
Warning: LONG READ
A History Lesson… Sigh…
I don’t think for a minute you really came here for a medical history lesson. Neither did I to be honest. I just want you to understand your pain in a way that empowers you to move past it.
The simple fact is that regardless of whether you have back pain, hip pain, sciatic pain or headaches – you have an infinitely better chance of getting pain free if you understand not only your pain – but where your current understanding of pain comes from. Cliché phrase or not – knowledge truly is power when it comes to navigating your way free from complaints like back pain, headaches and sciatic pain.
Understanding where your existing knowledge of pain comes from is a deeply practical foundation. It is the start point of a software update that will empower you to navigate your pain more skillfully.
We have no real consensus about what we should do about most of our pains, or what really causes them. But there are definitely some common assumptions many of us share. S0, how is it that we reach adulthood with a certain number of core assumptions around issues like sciatic pain? Well, there are various channels but the vast majority of the breadcrumbs on the ‘pain beliefs trail’ lead straight to the front door of modern orthopaedics.
There is no question that the orthopaedic profession is the pre-eminent force that has shaped our mainstream understanding of pain; and it almost certainly will have shaped many of your own basic assumptions about your pain. It’s likely that you are currently fairly unmoved by this fact – I would argue that you should be somewhat concerned by it however. To understand why, you may benefit from bearing with me while I whisk you through the orthopaedic back story.
The evolution of healthcare professions is complex, contextual and cultural. There are many worldly forces that shape their development. Just as individual lifeforms are shaped over time by their interaction with the physical environment – healthcare professions are shaped over time by their interaction with the cultural ecosystem that incubates them.
In many ways the evolution of healing professions is often not dissimilar to the evolution of political parties; culture and context are what mould the clay. Healthcare professions claim to be forged out of science, and of course it plays a huge role – but historically they are shaped more so by the full and rich tapestry of happenings that is human history.
In the healthcare trenches themselves, where the skills and understandings are formed, there are two types of evolution that drive improvements – the evolution of science (sound theories and hard data) – but also healing professions evolve as skills/art forms (the actual tools and tricks developed in the front line. Orthopedics is no exception to this rule, and in its case the expansion is to this day driven far more by the art than it is science.
Picture 300 years of personal transport evolution – from horse to Tesla. You basically see a steady and linear improvement in performance over 300 years. With a few secondary subjective sub plots like styling. That’s what the evolution of a science looks like.
Now picture 300 years of painting and sculpture – it’s way more complex and subjective. There is undeniable evolution, but there’s also personal expression / experimentation / technical skill / religious influences / cultural influences / philosophies and theories on life being expressed. That’s what the evolution of an art form looks like.
So as you are going to find out – modern orthopaedic surgery has mostly shaped by culture, history and the evolving ‘art’ of surgery – as opposed to it having being shaped by hard scientific principles like quality research data.
If we were able to go back to the surgical story, as a time traveling fly on the wall. Orthopaedic surgery would appear to us very clearly as a brutally painful yet well-intentioned art form. An art form, where most of what was painted on the canvas is blood and bone splinters – for better or worse. But interestingly if we went back to the very early beginnings of the orthopaedist there was no blood whatsoever – but plenty more about that later.
Professions Are People
Melted down to their purest and realest form, heath care professions are something highly organic – groups of people! When the abstractions that are theories, wards, boards, committees, universities, and associations are said and done: professions are made up of human beings.
Healthcare’s shop window is calm, clean, caring, scientific and collaborative. A focused light – guiding us towards better health. But in the back office of the shop there are always groups of human beings, human beings just like you and me. Struggling to figure out very complex problems, and often struggling even more to agree with each other about the answers to important questions. And that’s exactly what you find behind the professional veil when you look back at the evolution of modern pain management.
The story of a healthcare profession is a story about humans, more specifically it’s a heroes story. A story about humans trying to rescue other humans from their physical suffering. And you know how it is with hero stories, never straightforward.
Like most heroes, healthcare professions must often fight for their own salvation as well as for their patients- they are driven in large part by their own egos and their own survival instinct. And then of course there is the inevitable Dark Side factor that comes with power, the power to heal or harm others.
People are full to the brim with complexities and imperfections, and healthcare professions are made up of people!
The easiest way to understand orthopaedics is to look at its autobiography as you would the career of an individual person who had pioneered a novel healthcare profession. This is because an uninterrupted and undeniable human element has been the primary force behind the way the profession navigated the last 300 years.
So, for the purpose of deeper insight into where our own understanding of our pain came from, we’re going to rip through the orthopaedic origins movie script: as if it was the story of a single man who has lived 300 years. And we’ll call him Robert – to honour an amazing man named Robert Jones, who was one of a now extinct breed – true orthopaedists. A man who once changed the world, and saved more young men’s lives than can be counted.
The Early Days
Believe it or not, the way we approach our pain in the 2020’s is still firmly tethered to the management of childhood diseases in 1741. It is also tied to an dynastic history of disease, war, ambition, inter-professional healthcare piracy.
In 2021, there is a class of life events that virtually all of us have experienced by the time we’re 30. The standard graduations, relationship break ups and seasonal flu’s. In 1741 having your baby die was on that list. Two thirds of all babies born in London in 1741 were stone dead before their 5th birthday candle.
There are some specific reasons why the (now so cushy) North European childhood was so dangerous less than 300 years ago. I hope you’re ready for this, take a deep breath…
Ricketts – small pox – polio – scarlet fever – yellow fever – diphtheria – influenza – cholera – measles – flux – worms – Saint Anthonie’s fire – ulcerative pharyngitis – pertussis – whooping cough – dysentery – summer diarrhea – purulent lung disease – varicella – tuberculous meningitis – tuberculosis of the lung – tuberculosis of the spine – coryza maligna – ‘nine-day fits’ – neonatal tetanus – post streptococcal nephritis – bacillary dysentery -typhoid fever – lobar pneumonia – hip joint abscesses – abdominal purpura – infectious hepatitis – scarlatina rubella – congenital syphilis – rheumatic fever & malaria.
1741 is so recent, it is only about 4 people ago, if you go by today’s average lifespan. Yet, living through the violent and diabolically slow strangulation of your child by a bacterial predator like diphtheria was a common occurrence. No prevention, no antibiotics, no hospital, no pain relief, no respirator. Hard for us to imagine, thankfully. It may be worth flagging these historical tid bits to the next person who complains to you about how bad the healthcare system is today.
As you might imagine, the survivors of all that childhood disease were often in pretty appalling condition too. Large numbers of children had deformities and disabilities caused by diseases like polio, metabolic disorders like rickets, and congenital issues like club foot.
A crippled orphan on a London street in 1741 was about as shocking and noteworthy as a pigeon with a deformed wing is in 2021.
Europe 1741 was not a great time in human history to be a crippled child either. While many ancient cultures had viewed issues like club foot as a reason for compassion and care: it was within cultural norms for Europe in the 1700’s to see a club foot as a sign that a child was inherently evil. Not only was there a lack of interest in the care of the bedraggled malnourished and crippled children – open contempt for them was quite normal.
This is the world that gave birth to our hero Robert.
Roberts dad was a surgeon, and Robert himself was an unusually sparkly diamond in the rough. Robert had developed an unusual and compassionate interest in the charitable care of crippled children. He had been inspired by his extensive reading on how the Greeks and Romans managed childhood deformities… a lost art.
In 1741 Robert wrote a book – Orthopedia ‘The Art Of Correcting And Preventing Deformities In Children’.
The book was designed to help parents, teachers and caregivers work on preventing deformities in children. In his book, Robert defined exercise therapy as the most important treatment for childhood deformities and disease. He also placed great emphasis on proper design of shoes and chairs.
This is the beginning of the modern worlds acceptance of exercise therapy as a legitimate part of mainstream healthcare. A fantastic contribution to our collective wellbeing.
In the writing of his book Robert had minted the word Orthopaedics, derived from Greek words. Orthos = straighten & paedia = children. Orthopaedics – the art of straightening deformed and disabled children.
Robert knew a lot, enough to be able to help children in ways that very few others could. He was a pioneer. But in the healthcare world good ideas are not a guarantee of success. To further his cause Robert would need to gain some credibility. Credibility and reputation are the pick the shovel that dig up the necessary raw material for building any healthcare profession – lots and lots of patients!
In 1741 general surgeons were considered the pre-eminent experts in the world of serious healthcare – so becoming a surgeon was a straight forward path to some level of professional credibility. So Robert made the easy decision to tread the same bloody path his father had cut. He applied for a surgical internship, and was promptly rejected. This rejection was a seminal moment in Roberts career, and proved to be one that would shape him for many years to come.
Credibility – access to patients – and rejection by the surgical fraternity would all prove to be major themes that shaped the orthopaedic profession. Themes that would eventually come to define many of its greatest successes, and failures.
At that time though, Robert just dusted himself off and redirected his efforts. He settled for a doctors certificate instead. Many doctors treated children with clubfoot. As a doctor he would be able to pursue his interests in that at least.
‘This is the genesis of the orthopaedic specialty’s integration with the medical fraternity. Individuals with an interest in (the then obscure) topic of childhood deformities taking on doctors qualifications – thus gaining professional credibility and access to patients’.
Once he was established as a doctor, Robert had greater access to patients. His practice and general standing at that time was not dissimilar to a modern physiotherapist, with 2 major differences. He used far more ‘devices’ like braces and splints than a modern physio – and all his patients were crippled children, who couldn’t pay. Orthopaedists were a bit like Plunkett nurses in the sense that orthopaedics was more or less a charitable endeavour.
All of which was fine by Robert, he just wanted to make the world a better place by easing the suffering he saw in so many impoverished children .
Some productive time passed. Robert the doctor/ orthopaedist was able to do some valuable and truly pioneering work. But like so many ambitious young men, in addition to his altruisms Robert had an innate thirst for knowledge and greater recognition. Also, no matter how much clinical success he attained, deep down he still felt a bit like a failed surgeon. Somewhat like modern day chiropractors and osteopaths Robert was as qualified as any of his more mainstream peers – but was perceived in his day to be less credible than a surgeon. The awareness of this served to fuel his growing professional ambition.
By chance, in 1826 Robert stumbled across a German doctor, who was having some success treating children with club foot by cutting the Achilles tendon. It was a procedure that Robert immediately and wholeheartedly integrated with his practice. And it turned out that this ‘Achilles tenotomy’ procedure was to be a revolution in the treatment of clubfoot.
Harnessing the power of ‘tenotomy’ (which dramatically improved the mobility of a child with clubfoot) opened Roberts mind to a world of new orthopaedic possibilities, beyond straps and braces. Were there other tendons that could be cut to reduce pain and shame inducing deformities?
Much of Roberts work relied on braces for terrible deformities of the spine caused by diseases like polio and tuberculosis. The notion of assisting these conditions by cutting tendons around the spine logically presented itself. The possible dawn of a new era in correcting childhood deformities.
Tenotomy added a glimpse of the potential application of surgery to his his chosen field. Robert had already secretly craved the recognition that came with being a surgeon – and seeing its potential clinical uses inevitably stoked this fire.
Either way, from circa 1826 onward Robert claimed tenotomy as an orthopaedic principle. And to us it might seem strange that a healthcare provider who wasn’t a surgeon could spontaneously start snipping the achilles tendons of their child patients.
Surgeons are a fiercely territorial species, so there was a professional risk in performing tenotomy’s when you were a low ranking Orthopaedist . But at the time, embracing tenotomy was a pretty safe professional step for Bob. The simple fact was that surgeons at that time couldn’t have cared less about children with clubfoot.
There were no real surgical specialities in the 17-1800’s, all surgeons were essentially generalists. Tenotomy was such a minor procedure compared to the surgeries of the day, that it was deemed inconsequential. Most of the glory was in the fast and dirty removal of major body parts. Robert could start performing tenotomy’s without being professionally harassed by surgeons in the same way that your doctor can burn off warts and remove splinters without impinging on a surgeons professional boundaries.
**Imagine a time when peoples general level of health was so poor, and the healthcare they received was so harsh; that cutting through a childs achilles tendon with no anaesthetic was categorised in the same we categorise the minor procedures performed at a GP’s office.
A self styled doctor who’d been rejected as a surgical intern had quietly established a small surgical procedure as his own. Without drawing any unwanted attention from fiercely territorial surgeons. This was a pivotal moment in Roberts professional evolution**
**Despite being overlooked by surgeons, the orthopedists decision to add the cutting of tendons to their use of exercises, buckles, braces and exercises was anything but inconsequential. You could make a case for it being a pivotal moment in the genesis of modern healthcare. A moment that would impact millions of lives in generations to come. If you’ve had surgery that wasn’t for a major bone or joint trauma – you are part of a history that began with the simple snip of childs achilles tendon.
Up to this point in human history, surgery was used almost exclusively for major trauma and life threatening illness, and for good reason. Prior to anaesthetic and sanitization, surgery was an horrifically painful and dangerous tool, literally the stuff of horror movies.
In healthcare, the more quality tools you have access to, greater your ability to heal. Combining tenotomy and the traditional orthopaedic braces, exercises etc. was hugely successful. There were many more children that Robert could help. And on top of that, it was time for some good fortune.
During the early 1800’s there was at last the beginnings of an interest in children’s health, and in the concept of charitable work. The first charities in human history were childrens charities geared towards easing the suffering associated with poverty.
Philanthropic interest in the care of crippled children suddenly meant Robert was ideally placed to gain funding for the first of many Orthopaedic Children’s Hospitals. The trappings of this newfound financial backing from wealthy patrons, allowed Robert to consolidate orthopaedics as a recognisable medical specialty. As opposed to the healthcare niche it had been up to that point.**
**Despite its growing professional profile, orthopaedics was still entirely focused on disabled children. At no point had the question of treatment for biomechanical pain or injury pain arisen. Nor were adults included in Roberts scope of care. Adults with injuries, diseases and biomechanical pain were treated by bonesetters, barbers, regular physicians and surgeons. Roberts was about as interested in adult back pain, hip pain, shoulder pain, headaches, foot pain and knee pain as dentists are in ingrowing toenails and bunions.
During the late 1800’s urbanisation meant greatly increased population density and this had a profound effect on healthcare. People were becoming less geographically spread out. This meant sick people became far more accessible to healthcare providers. Urbanisation and jobs also meant people were increasingly able to pay for healthcare.
For the first time Robert started to make some money, through providing care to those who were able to pay for it. Inevitably he felt the universal (and in his case well deserved) warm fuzzy feelings that come with profit – after a long period of hard charitable work and personal sacrifice. The shift away from orthopaedics as a charitable endeavour had begun.**
** At its inception orthopaedics was a humanitarian cause. It occupied the same type of niche as animal charities do in modern society. Modern orthopaedics in contrast is part of a multi-billion dollar industry, backed by colossal biomedical corporations; who profit immensely from the design and manufacture of surgical technologies.
Urbanization also led to the establishment of the first general hospitals. Dangerous places, with higher mortality rates than many of history’s worst war zones. Places where the average surgeon did not hand wash at any point in a shift – not even between disease autopsies and delivering babies. **
**A curious historical fact, given that Hippocrates himself was a staunch advocate of medical hygiene practices – nearly 2000 years earlier). Healthcare can be forgetful process – and as you will soon see there is none more forgetful than modern orthopaedics.
The 1800’s were a time when the words ‘Mary has been taken to hospital’ would have struck the same chord that ‘mary has stage 4 breast cancer’ does today. Hospital was more or less a death sentence. When the worst happened to those with money, they would pay to have their sick and broken body parts hacked off at home in their own kitchen, as it was far safer.
Many died in the hospital settings. But they proved to be a place where Robert and his orthopaedic tools could thrive; and continue the process of merging into the fully mainstream.
Resources in the hospital setting allowed Robert to develop more specialised equipment. His presence in mainstream hospitals also led to a further expansion of Roberts job description. He began treating adults for the first time, and as part of that he began managing hip dislocations with traction. Another seemingly insignificant shift of Roberts professional boundaries that would ‘echo in eternity’.
** Roberts (once again seemingly minor) addition of traction for dislocated hips to his repertoire was in reality the start of something big. It was the beginning of modern orthopaedics taking control of trauma management. In the 1800’s treatment of injuries was a fiercely guarded part of the surgeons territory. But like tenotomy for clubfoot, surgeons were not overly interested in relocating hips. Without realising it the surgeons were giving up ground to a then minor profession, one that would soon grow immensely in power and prestige.
Robert was making quiet incursions into surgical territory, and blurring professional boundaries that would later be completely overrun. All thus far unnoticed by the brooding alpha specialty of surgery. Robert was already a part of the mainstream, but he was still as low down in the hospital food chain as a modern physiotherapist is. So for the time being keeping his head down was important.
The deeper truth about Roberts knowledge sat in contrast to his relatively low rank. When he moved into the hospital setting in the late 1800’s, he did so with a formidable toolkit and a great deal of knowledge. He was different to a surgeon, but not of lesser value. It was even possible that Robert was able to do more good than a surgeon, and he knew it. He had built a legitimate, effective and hugely important healthcare speciality from nothing. Either way, there was no science or research to say a surgeon was more valuable than an orthopaedist, it was hospital politics that dictated that perception.
** Humans are complex, and as a result much of what we create is complex too. On the one hand, healthcare systems are high functioning and sophisticated constructs. One of the creations that truly set us apart as a species. On the other hand, healthcare is every bit as primitive and hierarchical as any chimpanzee troop. Even in today’s hospitals there is a strict dominance hierarchy. Behind the undeniably sophisticated veneer of hyper- modernism, if you peel back the layers, an ancient structure is easily revealed.
Dominant chimps flex muscle and strong alliances. Surgeons flex certificates, titles and professional influence. A Dominant chimp is concerned with control of access to resources and territory. The surgical species is concerned with access to certain groups of patients and control of everything that is associated with their management. In the late 1800’s that lion’s share was largely bone fractures – bone trauma was the surgeons guarded territory.
In modern hospitals, surgeons (specialists) and anaesthetists are at the top of the food chain. Surgical interns and high grade nurses sit somewhere in the middle. Lower grade nurses and healthcare assistants at the bottom. The hierarchy is reflected across the board, from who gets paid the most to who makes all the decisions (and of course who swings on the nicest tyres in the nicest office).
The dominance hierarchy in hosptals is built on the concept that those at the top always hold the most knowledge, which is not always the case (just ask any senior nurse). The big holes in the 18th Century’s incarnation of this dogmatic framework would form the hand grips that orthopaedists would use to climb to the top of the medical food chain. The simple fact is that while a surgeon or specialist may know a lot about certain things, there is always much that they don’t know.
Despite all the frustrations of being a low ranking primate, hospital was still a chance for Robert and his bag of tricks to truly shine. He was successfully filling the space created by a knowledge vacuum. But unbeknown to him, the medical mainstream that was about to swallow Roberts’ fledgling speciality whole – with what easily still stands as healthcare’s greatest success to this day. Robert the orthopaedist had created and occupied a niche that was essentially about to vanish in the biological blink of an eye.
A momentous event in human history was about to unfold. An event that looking back now, arguably makes the invention of the microchip appear as trivial as the invention of a new pizza topping.
In the 50,000 years prior to orthopaedics inception we had done a pretty one sided job of wiping out nearly all our natural predators; possibly with a small bit of help from climatic events and the like. In any case, we came out of the dark ages seemingly having removed ourselves from the food chain. In reality however, nothing could have been further from the truth, and we didn’t even know it..
During the latter part of the 1800’s, after an eternity spent being unwittingly preyed upon in vast numbers by bacteria, viruses and parasites – ‘we’ finally cottoned on to the fact. It turned out that in a very real sense we were still very much on a low rung of an invisible food chain.
We found out ‘overnight’ that we were being preyed upon by an utterly invisible yet enormously powerful world of microscopic monsters; so many in number that they outnumber the stars in the night sky. And each potentially every bit as terrifying as any large predator. There has surely never been a more shocking and bizarre scientific discovery before or since.
Millions of us (the majority of whom were frail children) were still being savagely and constantly predated upon – by a microscopic world that no one even knew existed.
Like everyone else, Robert had been utterly oblivious to the fact that conditions like polio and tuberculosis were caused by a microscopic lifeforms attacking a child’s body. And that tuberculosis smuggles into children through contaminated milk. (Or even that the rickets epidemic was caused by a lack of vitamin D for that matter.) Naturally, Robert and the entire medical world had simply assumed that poverty was just so hard that it caused children to deform.
In the period between 1881 to 1914, the previously unseen and unidentified causative agents of more than 30 infectious childhood diseases were identified. And a cascade of solutions that transformed humanities existence followed. Penicillin, immunisation, pasteurisation, sanitation, improved sewage systems, supplements, antimicrobial agents. And the rest is healthier history.
In a very short space of time, the core of Robert the old school orthopaedist’s work was all but wiped out. He thought that he had been treating the effects of poverty had been treating diseases all along. And now those diseases were gone, Robert found himself in a very scary new normal.
Robert was of course pleased and amazed that the scourge of horrifying children’s disease had finally been broken. But being pleased about that didn’t help his own innate human needs for recognition survival. It was a deeply traumatic and helpless moment in Robert’s professional life, and it left its mark. No one enjoys having their entire life’s work obliterated in an instant by someone else’s life’s work, that’s just human nature. And Robert was after all only human.
In any case, there was no longer enough work to support Robert’s area of specialty or his standard of living. Success for the humanity at large represented professional extinction to Robert.
**The professional, scientific and philosophical shock of discovering that 95% of bone and joint deformities were caused by diseases left a permanent mark on orthopaedics. A mark that remains to this very day.
As a result of the impression left by germ theory, modern orthopaedic surgeons still essentially divide the world of musculoskeletal pain into 3 classifications – congenital deformities – injuries – diseases.
Their knowledge of congenital deformities (that happen before birth) and injuries prescription-dated germ theory and remained intact. After the advent of germ theory they created a 3rd explanation for everything else that would go wrong with the musculoskeletal system – ‘diseases.’
Paraphrasing their approach to pain management in the latter part of the 20th and early 21st centuries reads like this…
‘Everything that isn’t an injury or a congenital disorder is some form disease process’.
When in fact the vast majority are caused by long standing biomechanical issues.
At the time it was an understandable conclusion for a profession that nearly became extinct – due to a whole world of diseases it didn’t even know existed
Pains that are caused by persistent issues with movement (like poor posture/weakness/faulty gait patterns) are classified like diseases by modern orthopaedics. Because of the old impressions that scientific progress in the field of microbiology left on a previous generation of orthopaedists.
In turn, germ theory thinking would subsequently impact the entire modern worlds (that means yours) understanding of pain: through the influence of orthopaedics.
Symptoms of biomechanical strain in the body have been henceforth given confusing names like diseases prevalent in the 1800’s. Severs disease, osgood schlatters disease, scheuermann’s disease, carpal tunnel, osteoarthritis, chondromalacia patella, tenosynovitis, tendonitis,, sciatica, degenerative disc disease, sub-acromial bursitis, migraine, lumbago, sciatica.
Names that obscure their true biomechanical nature from generations of sufferers. Even on its 21st century websites run by the orthopaedic profession would still refer to their collective job description as ‘the treatment of trauma and musculoskeletal disease’.
The orthopaedic profession still to this day holds firmly to a disease-like concept of pain – because of the seemingly indelible impression left by it’s near death experience experienced at the hands of germ theory.
No meaningful attempt whatsoever has been made by orthopaedics to explain or acknowledge musculoskeletal pains underlying biomechanical nature – a job which has ultimately been left to other professions.
Other professions who have gradually moved into the knowledge vacuum, much like orthopaedics once did when it moved into the hospital setting alongside surgeons.
In terms of the public consciousness we have been forced to our own distinctions in order to navigate pain management. We subtly assume that pain is made up of a milder set of disorders (weak core and a bit of back pain for eg.) that we should see an osteopath etc. for – and a more serious set of disease states that we should see an orthopaedic surgeon with an MRI scanner for (osteoarthritis – calcified tendons – carpal tunnel).***
***The truth is that of course there are a few instances where this is more or less the case.
In the 99.9% type percentile of stubborn pain cases the disc disease / the bursitis / the weak core / the poor posture – are all part of a spectrum where the breadcrumbs lead back to biomechanics – its faulty movement that causes your hip to wear out – not a disease called arthritis.
Some forms of arthritis are auto-immune states and genetics admittedly play a role in the manifestation of all painful conditions to some extent. The point here is that ‘osteoarthritis’ for example is a disease style diagnosis that offers no description of the actual cartilage degeneration or its primary cause.
The primary causative agent behind childhood sickness and deformity in the 1800’s was not poverty – it was microbial disease.
The primary causative agent behind adult pain and tissue degeneration in the 21st century is not disease – its biomechanical weaknesses and imbalances.
If this biomechanical truth received the same amount of attention now as microbial truth did in the 1800’s –orthopaedics would experience another near-death experience!!
But back to the story…
Germ theory could so easily have been a professional mass extinction event. But true to form, Robert adapted.
Fortunately, by the time germ theory reared its head Robert was an established part of the medical hierarchy; and he had already dipped his toe in milder forms of trauma and congenital deformity This meant that he had some small amount of scope to explore other areas. And by 1907 he was treating more adults than children. There wasn’t much interest at first, and it wasn’t easy. But there were enough in the way of milder injuries and club feet around to bring in some work. Robert could basically continue to function like a hospital physiotherapist; but times were lean and his dreams of ascending the medical food chain had never looked more improbable: germ theory having placed his profession into a form of hibernation.
There was however a bit of good fortune headed Bob’s way. Just as the microscope took from Bob with one hand, it gave him a gift with the other.
Progress in our understanding of hygiene meant that surgery could be performed without the same astronomically high risk of infection. And on top of that, anaesthetic showed up for the first time. These changes that made surgery a far more accessible art form. The surgical door that was never far from Bob’s mind cracked open a jar. Adaptation and prestige were beckoning once again. The opportunity for survival that presented itself was in occupying the management of musculoskeletal injuries. Robert was at this stage the true expert on the musculoskeletal system and he knew a bit about surgery – surgeons were generalists – he knew that specialisation their inevitable superior. He was however headed for dangerous territory as the management of physical trauma was a fiercely guarded surgical privilege.
Robert’s position in the hospital food chain had improved with time. This meant he could eventually ride the wave of progress in surgical hygiene and tentatively branch out from cutting tendons. He could perform a few small surgical procedures, as long as they were only on chronic complaints; and not on surgical territory. But of course, it would not go completely unnoticed by the keen eyed brooding alpha profession.
As news of Roberts surgical insurgency circled; the inevitable happened. Surgeons registered a challenge to the pecking order. Naturally they began thumping on tree roots and pissing everywhere, but the times where Robert was willing to tiptoe around surgeons were coming to an end.
The beginnings of a long and bitter turf war over professional boundaries and the management of injuries to the musculoskeletal system took root. A battle that was about to be accelerated massively by a conflict of a different kind.
Word War 1
WW1 gave rise to a style of conflict and types of suffering the world had never seen before. Howitzer cannons and machine guns inflicted high velocity trauma. But those weapons also meant fighting in the open was simply no longer an option. This meant troops living in filthy trenches for months and years at a time. The increase in fire power may have killed more through the filthy conditions it created than it did blasting holes in people. **
**The Howitzer cannon created the trenches – and the trenches almost certainly incubated spanish flu – it follows that Mr Howitzer deserves much of the credit for the spanish flu. Spanish flu accounted for more human deaths than two world wars and the holocaust combined. Quite an invention.
WW1 was a time of great opportunity and prosperity for influenza. But it was not the only species that saw an opportunity to strengthen its position in the ecosystem. The new rules and technology of war meant unprecedented numbers of high impact skeletal injuries – and shocking rates of infection. Never missing a chance to flex its muscle, general surgery had soon taken the reins.
Bullish about its experience with trauma and its shiny new understanding of hygiene; WW1 was a challenge that general surgery felt certain that it was more than equal to. Unfortunately for the young men of Europe, surgery was catastrophically wrong in that confident self-assessment.
It is one thing to work on an open fracture in a relatively clean hospital ward. It’s another thing to work on an open fracture that’s been contaminated with mud and fecal matter -then dropped several times by stretcher bearers on its sludgy 2-mile journey to the operating table.
It is one thing to surgically repair a fracture – and another thing to get that same soldier to a point where he can return to a job without severe lifelong disability.
Rehabilitation and surgery are skill sets that bear absolutely no resemblance to one another. Despite bearing the divine professional authority to monopolise trauma care, from very early in the war it became apparent that surgeons were not up to the task.
Soldiers with open fractures were removed from the field with a grave lack of care; operated on and dispatched with no meaningful after care or rehabilitation processes in place. Fractures were not properly splinted before or after surgery. There was no consistency of care. And after the fact – occupational therapy was not even a passing thought.**
**Surgeons are concerned with the mechanics of surgical procedures – not the context of the surgery. Civilian life is relatively forgiving of this kind of narrow view. WW1 could not have been any more unforgiving of it. At the beginning of the war 90% of open femur fractures were fatal, due to poor care ‘off the table. And of the survivors, almost all were left with very severe long-term disability to due to appallingly sloppy fracture care and a lack of rehabilitation.
With hindsight, it’s almost hilarious that there were questions over whether Robert would be of use in the war effort. Knowing more about the care and rehabilitation of the musculoskeletal system than a 100 surgeons as he did. Robert was ultra-qualified for the healthcare challenges presented by this new form or warfare. But the reality is that there was a great deal of resistance to the presence of orthopaedists in the theatre of war.**
**The basic surgical assertion at the time was that taking orthopaedists to war was like taking a massage therapist to a 10 car pile- up on a motorway. At best a pointless exercise – but at worst a dangerous one – on account of them getting in the way of the real work that needed to be done.
But the reality was that high velocity rounds and shrapnel made for exactly the type of musculoskeletal injuries that Robert could design management processes for. It was time for his knowledge, understanding and integrity to shine, in history’s muddiest bloodiest mess.
Tendon and nerve injuries could be braced in much the same way as polio patients.
Soft tissue injuries could be carefully immobilised. Robert knew how to save lives and prevent bone deformities by splinting fractures before they were moved. He created systematic pre and post-surgical fracture care. He gave injury prevention advice to soldiers. He developed systematic splinting procedures; and developed structured rehabilitation for wounded soldiers. The tools of the biomechanical specialist, the same ones he had used to help countless crippled and deformed children – were effortlessly adapted to help freshly crippled and deformed soldiers.**
**While surgeons were in sole charge of fracture care the mortality rate for an open thigh bone fracture in WW1 was 90%. Once Bob was involved in the war effort that mortality went down to 20% – due to careful splinting of fractures before they were stretchered. This one statistic above all others gives an indication of the value orthopaedics bought to the world during WW1.
WW1 revealed the truth about Robert. He was at least as useful as a surgeon in many instances, and far more use than a surgeon in many others. Naturally there was ferocious resistance from surgeons from start to finish. But once the military machine itself had glimpsed the bloody truth about general surgery’s sloppy and ignorant approach to fracture care there was no going back. In war the truth about Robert became undeniable. When it came to muscles joints and bones Robert was the expert.
Robert had entered the war as an officer but by the end was conferred the rank of major general and knighted. Queen and country knew of his true value to the collective. But more significantly to Robert, by the end of the war he was given equal and shared responsibility for bone and joint trauma. Equal with the surgeons at last!
On a human level, it was a huge relief to finally be acknowledged appropriately. Robert was finally receiving the type of credit he was severely overdue for; and understandably he liked it. He had finally laid the first major building block of becoming not just a healthcare speciality, but a full blown surgical speciality.
Thanks to the war, Robert had successfully adapted to a post-germ theory world, and not only survived, but thrived. The rehabilitation of soldiers after the war merged seamlessly with the care of industrial civilian trauma. Orthopaedics had moved on from dwindling childhood diseases, to the treatment of disabled adults and even the management of injuries.
But Robert still faced challenges, and demons! His ultimate goal was to assume complete control of musculoskeletal injury care – and he would not rest until he could take his rightful place.
The surgeons had conceded much ground to Robert during their time behind the trenches, he was now essentially their professional equal in the eyes of the crown. But despite this shift in the hierarchy, surgeons still held significant authority in peacetime. Healthcare’s political root system doesn’t budge easily. General surgery campaigned hard to discredit Robert on the grounds that he wasn’t a ‘real surgeon’ for decades. But Robert had seen the bloody proof that he should be fully in control of all musculoskeletal disorders. His surgical skill had slowly expanded over the many years of tackling ‘smaller’ procedures – and his superior knowledge of the musculoskeletal system made him the natural choice to take charge of all musculoskeletal care.
Success has a track record for intoxicating and corrupting human beings, and partial success can be even worse. Like so many high-achievers Robert also had his own very human ego to deal with. A century or more of never-ending comparison with surgeons had begun to consume his character. He was certain that the only way to be truly fulfilled was to become a fully-fledged surgical specialty – and not have to share the territory. He had become fixated with becoming the alpha. Roberts character had changed (into the nearly universal, unappealing and egoic profressional character that would be passed on to countless future orthopaedic surgeons).
A Tough Decision
Ultimately and unsurprisingly it was the pressure applied by surgeons, that forced Roberts final metamorphosis into a fully-fledged surgical specialist.
The last stand that general surgery chose in defending its territory was the argument that Roberts toolkit was holistic in nature; therefore he couldn’t be ‘a real surgeon’ – and shouldn’t be allowed to treat trauma. His practice was split evenly between surgeries and the more traditional rehab exercises, braces, splints and frames etc. This enabled the surgeons to argue that ‘surgery is a speciality… so it cannot be effectively pursued by a generalist’. After all Robert had been through to prove himself this argument actually proved to be persuasive; it gained some traction and threatened to derail Roberts plans to monopolise musculoskeletal care.
You could argue that given it’s perspective the orthopaedic profession didn’t have much choice in what came next. Tuberculosis was all but gone, rickets was gone, polio was all but gone, and WW1 was over. What remained in terms of a prospects for a strong healthy profession was the rising tide of factory and railroad injuries covered by workers compensation. This was no work that they wanted to share with general surgeons. On top of that they had spent 200 years providing irrefutable proof of their expertise, and yet were still vulnerable to attack; and unable to establish their rightful place in the healthcare system.
At this stage in the story Roberts driving force was no longer ‘the best treatment’ , it was success and survival – through the achievement of a lifelong goal. Without realising it he had allowed the healthcare politics to corrupt his decision making. Robert was not entirely conscious of this – and he justified what followed on the basis that he was better at treating musculoskeletal trauma than surgeons, which of course he was.
A very difficult choice needed to be made – for the survival of the profession.
Robert had realised that if he didn’t give away the braces, splints and straps of his professionally low-ranking past; he would never fulfil his dream of becoming a fully-fledged surgical silver back. The tools that had established the profession and changed untold millions of lives were now holding back the profession from a triumphant ending to its 100 year turf war with general surgery. And just like that.. it was done.
All the exercises, braces, splints, frames and casts went. Orthopaedists became orthopaedic surgeons and the ‘generalists can’t be surgeons’ argument was put to bed. It was check-mate. General surgeons were forced to let go of injuries to joints, bones, muscles and connective tissue. Bob gave away 200 years of orthopaedic heritage and superb clinical outcomes for his own survival and the prestige of a shiny blade.
The underlying post-war irony of all this was that Robert success had been predicated on his holistic mind-set. His ability was in clearly seeing the whole picture of an injury, and providing comprehensive rehab solutions (on and off the table). Yet, he had chosen the prestige, power and ultimately profit of vanquishing his old foe, and becoming a surgeon.
By 1948 the art of bracing and rehabilitation had completely yielded itself to the art of surgery. From then on, orthopaedic students learned about how to perform surgery – no more rehabilitation. Ironically similar to those narrowly focused surgeons who made such a terrible mess of treating fractures in WW1.
The orthopaedic decision to specialise in surgery pre-determined the lack of appropriate rehabilitative care we receive for our diabolical levels of biomechanical pain in society to this day. The speciality in complete charge of our musculoskeletal care had given away all of the tools of its rehabilitative past in. The gatekeeper to our societies healthcare for the musculoskeletal system had decided that there was only one type of intervention it was interested in. Digest this while understanding that surgical procedures are relevant in the care of less than 1% of the pain and disability that 21st century humans experience. But at least back in the mid-20th this paradigm tended well to the huge number of injuries that people suffered in an age of poor occupational health & safety – orthopaedic surgeons always were and still are excellent at treating bad injuries.
The Modern Era
For better or worse Robert had received his medical knighthood as a full surgical speciality, and shaken off the stigma of his low ranking medical origins. Going into WW2 – Robert was the surgical specialist in the driving seat. And he once again did an impressive job. His ability to manage trauma in the field was reaching new heights. WW2 further cemented orthopaedics as the pre-eminent speciality in all things musculoskeletal – somewhat ironically – given that all of its powerful rehabilitative tools and insights had been consciously and deliberately deleted from its CV in order to pursue surgical glory.
During WW2 the emerging field of physiotherapy filled the vacuum left by the orthopaedic re-invention and tended to rehabilitation, but with a fraction of Roberts experience and training.
In spite of his successes in WW2, like an elite soldier on a post-conflict come down Robert found himself in yet another existential slump. Childhood disease was gone. The physical trauma of two world wars was over. And now on top of that health and safety standards meant that industrial accidents were dwindling fast. This only left sports injuries and car accidents in the waiting room – but that’s not enough to live on. After the dust had settled on the WW2 mess was finally a fully grown bristling male surgeon but in the post-war era he had no one to fix. But of course you know by now – the orthopaedic profession has more lives than a cruise ship full of cats.
Robert was once again was required to adapt. And there were three remaining opportunities for professional survival. Biomechanical pain – the wear and tear that comes about when biomechanical pain isn’t managed properly (osteoarthritis – bursitis – calcified tendons) and as always major injuries.
So on top of the car crash level injuries – all the neck pain, shoulder pain, back pain, hip pain, knee pain, ankle pain, osteoarthritis, disc protrusions, rotator cuff tears, bursitis, cruciate ligament tears etc. etc. would all be claimed as Roberts new territory. Despite mostly having been of zero interest to him over the preceding 3 centuries.
After WW1 orthopaedic surgeons poured societies biomechanical pains through the filters they developed during the chapters of war and disease that forged their profession. If by now you understand how influential they are – and the ‘life lessons’ of their past – you will understand why we manage and understand pain so poorly today.
Their early conditioning led them to the belief that surgery represents ultimate credibility – the ‘highest expression’ of meaningful healthcare. And that physical deformity is a major cause of suffering that can be corrected.
Their near-death experience with germ theory had left them with a strong intuitive sense that stubborn pains were ‘types of disease to be diagnosed and treated’ – even when they weren’t.
Their experience in a centuries long turf war with general surgeons left them a strong sense of entrepreneurialism, competition and somewhat ill tempered.. or at least lacking in bedside or inter-professional manners. It also left them with a reinforcement of the (subconscious?) belief that surgery is ‘they key to success’.
Their experiences with war left them with a rightful sense of confidence in the expertise in treating major injuries.
The subtleties and complexities of what causes modern biomechanical pain (postural issues – weak core – flat feet etc.) amd the types of problems it leads to (osteoarthritis – bursitis – Osgood schlatters) didn’t get a look In during all this. And yet orthopaedic surgeons had the professional clout to monopolise biomechanical pain from the very moment became of interest.
In the modern world our basline approach to pain has been pre-determined by the survival story of orthopaedics.
Biomechanical issues like back pain are often believed to be caused by injury – as opposed to persistent muscle imbalance.
Complex biomechanical issues like osteoarthritis are often thought of as incurable diseases to be ‘cut out’ or ‘fused’ – as opposed to signs of chronic biomechanical strain and inefficient movement.
Complex injuries like the majority of cruciate ligament tears are thought of as simple injuries – as opposed to signs that the ligament had weakened over time.
Biomechanical pain became something that you diagnosed like a disease or something you explained as an injury. But even more disturbing is the fact that without a shred of scientific rigour biomechanical pain suddenly became something that you might performing surgery on.
A Less Than Glorious Ending
During the latter part of the 20th C Robert faced his proferssional extinction for what would have seemed like the 100thtime. His original role in treating crippled street urchins was a distant memory. There were no more opportunities to shine in the theatre of global war. Progressive industrial health and safety shrank the number of serious injuries in the population down to a tiny fraction of what there had been in the preceding century. All of his major incarnations had become irrelevant – each only leaving a residue of the former workload associated with each. So to survive, he pulled himself up by his boot straps and set about tackling the only musculoskeletal problem that were left in any real numbers, the back pain, the osteoarthritis and the sports injuries etc.
Robert took what he had learned over 200 years of shrapnel wounds, industrial accidents and childhood disease and applied it to the challenge of modern pain, modern biomechanical dysfunction, and the creeping incremental tissue damage it causes.
He re-interpreted what he had learned from disease, poverty, and war – and applied these lessons to the remaining (and far less serious) challenges that the industrial and microchip revolutions created presented to the human body. But he did this after setting aside the exercise prescription, braces and straps and occupational rehab that he cut his teeth on. He did have the option of breathing life back into these tools (as they are surely more relevant to modern biomechanical pain than surgical tools) – but the simple fact is that they lacked the prestige of surgery – and from the standpoint of a ‘career move’ for Robert they would have constituted a huge step backwards.
Instead a new set of tools and devices would be designed to serve the new market he was targeting. Tools that would retain the prestigious rank of surgeon while targeting his new ‘target market’. Franken-tools that would ironcially be inspired by his distant therapeutic past – spuriously validated by his excellent track record with trauma – but that would fit into the story of his ambition. Surgical devices.
Robert had forged (during war time) close alliances within the political and industrial machine; this meant that he was able to easily partner with large biomedical corporations and develop new surgical devices to suit his needs. To treat biomechanical pain he would pioneer ways of fusing painful joints with plates, pins, rods and metal bars. He cut away torn cartilage, and he would invent the prosthetic joint replacements.
**As he did all this Robert was referencing his earlier experience with ‘devices’ and ‘supports’. But he was also merging with a vast commercial enterprise, and birthing a new multi-billion dollar industry. He was creating a market and ensuring the long term survival of the profession – partly to the benefit of society – and partly at the expense of untold millions of dangerous, needless, unscientific and highly invasive surgical procedures.
There is a shocking fact about orthopaedic surgery that is revealed at this point in the story. Unlike many other specialties, the evolution of the orthopaedics specialty was not based on hard science.
There was virtually no rigorously designed clinical data guiding any part of the story we have just walked through. Despite what we are led to believe – story of orthopaedics is almost exclusively a history lesson not a science lesson. It is the evolution of an art form not the evolution of science. This evolution of orthopaedic surgery has been based on theories, expert opinion, trial, error, adaptation, medical politics, and war.**
Current high-level reviews (amalgamations of many studies) of the scientific literature conducted by orthopaedic scholars have already discussed the serious problems with a widespread lack of quality research supporting the use of orthopaedic interventions for chronic pain. This is essentially common knowledge among those who are familiar with the state of the orthopaedic evidence base.
Orthopaedics’ failure to rise to the challenges presented by an epidemic of modern back pain perfectly illustrates its failures to translate its skills into safe and effectively treatment for modern pain syndromes. The circumstantial evidence alone is concerning – given that the increase in disability caused by back pain sharply increased to epidemic levels in developed countries following WW2 . During the price era that orthopaedists took over its care. But more incisively the specific data regarding the efficacy of the modern orthopaedic approach to back pain is damning. In academic circles this essentially common knowledge, preeminent orthopaedic scholars like Gordon Waddell having made it their life’s work to assimilate this data
After decades of rolling out unsafe and unproven spinal surgeries as a primary therapy for back pain we now know from reputable sources and long painful experience that surgery is rarely the correct way to treat back pain – as highlighted by this Harvard article.
Repeat spinal surgery for example is an extremely risky treatment option with diminishing returns. Around 50% of primary spinal surgeries are considered successful, and some studies estimate up to 74% of back surgeries ultimately fail – these are poor clinical outcomes yielded from risky procedures. But no more than 30%, 15%, and 5% of the patients experience a successful outcome after the second, third, and fourth surgeries, respectively – there are expensive and highly risky procedures that present extremely poor outcomes for patients.
There have never been any studies comparing spinal fusion to a placebo procedure, astonishing but true. Perhaps part of the reason for this is the concerning lack or orthopaedic surgeons who engage in research. Or maybe it is because they are more interested in designing studies to prove that they have a stronger grip strength than other doctors, like this one.
When he took his scalpel into the biomechanical realm in the latter part of the 20th century; Robert did so as a further expression of his human ambition. As humans often are, he was entirely consumed by whether he could, rather than when he should. And the scariest thing of all is that he was so influential that he wasn’t required to support his decisions with high quality scientific proof. His expert opinion which carried the weight of his successes in 2 world wars, and a few scraps of poor quality experimental data were sufficient.
Even in the 21st century only 3% of what is published in orthopaedic journals meets the necessary criteria to be called ‘high quality evidence’. The topic of evidence based care in orthopaedics and pain management at large is awkward to say the least, there really isn’t much of it to this very day. The Illustrious British Medical Journal itself has weighed in on the scandalously poor evidence levels to support orthopaedic surgical procedures for pain.
On top of all this, modern orthopaedic research that does exist has utterly unavoidable and convoluted financial connections; to a mulit- billion dollar industry that puts food on the table in the home of every orthopaedic surgeon on the planet; by manufacturing surgical devices. Which without utterly mindless faith makes near impossible for the rest of us to really know what’s what in the professions research methdologies.
This mess brings us up to the present day. And you now know the back story behind most of what we have been led to believe about pain in our society. We absorbed it from the powerful and ambitious gatekeepers of modern musculoskeletal healthcare. Gatekeepers who’s medical philosphy was forged in past glory treating Victorian childhood diseases open bone fractures in the trenches of WW1.
But how is it that the beliefs and attitudes orthopaedists collected during their epic story of professional survival became our attitudes and beliefs about pain in 2021?
Our media, government, health system and education system are where the vast majority of our understandings about health are incubated. And all of these resources have used orthopaedic surgery as ‘pains expert witness’ for the past 70 or more years. Because of the professional pre-eminence in musculoskeletal care that orthopaedics emerged with after its successes in WW1. That is how orthopaedic beliefs became public beliefs.
When society wants to build a bridge – it calls civil engineers. When ‘society’ has a question about heart disease – it calls cardiologists. And when’ society’ wants to know about pain – it calls orthopaedic surgeons. But cardiologists have always been into heart diseases and civil engineers have always been bridge buffs. But as you know now – orthopaedists have not always been in the pain, far from it. Orthopaedic’s legitimate areas of speciality are skeletal deformities and high impact trauma, not the rehabilitation of biomechanical pain. Their modern dominion over biomechanical pain has been little more than an over-confident bluff.
There’s no question that an orthopaedic surgeon’s ability to heal broken bones and repair ligaments is still of great value, it always was. There are also occasions when only a joint replacement will do. But in terms of serving the bulk of societies pain, following WW2, after 200 years of successful adaptation: Orthopaedics reached the zenith of its efficacy and hit a therapeutic brick wall. Because as far as biomechanical pain is concerned – Robert’s story is one of a butterfly that turned into a caterpillar.
At the beginning of this story I stated that way we approach our pain in the 2020’s is still firmly tethered to the management of childhood diseases in 1741. This is because the orthopaedic profession imprinted on a ‘disease model’ of modern pain in it’s interpretation of the challenges it presented. This above all others is the primary corruption of understanding and science that has left us so profoundly and systematically confused about the topic of pain to this day. Secondary is the misinterpretation and inflation of injury as a factor in modern pain. The truth is that genuine injuries to healthy tissue play a far larger role than disease processes in generation the pain so many of us now suffer – but only a very small part in our pain as a whole.
Modern pain is caused by a trifecta of lifestyle – biomechanics – environment. Not a pairing of diseases & injuries: these concepts are orthopaedic baggage shipped in from much harder times. This is the corrupted legacy of orthopaedics that holds us back from a healing for the millions of chronic pain sufferers in our society – through a mainstream embrace of rehabilitation principles and high quality biomechanical care.
Pain is not a disease – it’s a symptom.
Weakness is not a disease – it’s a lifestyle/movement issue.
Normal back pain is almost never an injury, nor it is an indication for x-rays and surgery – it’s a stubborn muscle imbalance informed by complex lifestyle factors.
Osgood Schlatters disease is not a disease – it’s caused when biomechanical imbalances effect immature bone and soft tissue in the human knee.
Bursitis is not a disease calling for a steroid injection – it’s irritation of soft tissue that is in need improved posture biomechanical efficiency.
Osteoarthritis is not a disease – it’s a failure in the joint cartilage – caused by repetitive strain in the joint – that like any form of some of us are more genetically susceptible to than others.
In cases where surgery is warranted for chronic pain – years of diligent rehabilitation should precede and and follow the procedure; in order to restore the soft tissues and stabilising muscles to full health and strength.
Neck pain is not an indication that you need an x-ray or a conversation with a surgeon – except in extremely traumatic and exceptional circumstances. Neck pain is a sign that your biomechanics, lifestyle and wellbeing need to be closely scrutinized.
Spinal discs don’t degenerate because of ‘disc disease’ – they degenerate when they are injured or persistently overloaded.
X-rays and scans do not assess biomechanical issues – therefore they cannot explain the overwhelming majority of pains we suffer with.
Surgery is to pain management what civil war is to politics – it is supposed to be a desperate last resort – not a default solution !!
The current scientific evidence indicates that many modern orthopaedic surgeries are no better than a placebo.
These and many besides are the re-learnings you may need to undergo as a modern pain sufferer. As you free yourself from the legacy of orthopaedics and the hold it has had over our understanding of pain.
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