Am I Getting Better? Part I. Measuring Progress.

Daniel Schulman

/ 10 min read

Friday, 31 August, 2012

These are critical questions.  You should be asking them regularly with the full awareness it takes to arrive at an answer.  To be truthful, you should be asking them critically during and after ANY intervention – whether pharmaceutical, surgical, herbal, supplements, osteopathic manipulation, acupuncture treatment or anything else. Don’t just surrender all of the monitoring to the ‘health expert’ you are involved with.  It surprises me how often I question people on whether something they are doing, receiving or taking is helpful and they are unable to answer.  My position is pragmatic and simple.  Whatever you are doing, taking, or receiving – after a reasonable period of time, you should be able to tell if it is making a difference.  And if it’s not, then stop it and try something else.

Of course, it can be difficult to generalise.  There are so many different symptoms, diseases and health concerns.  Each case must certainly be considered on it’s own terms.  But having said that, there are very important general considerations I want to discuss here to help you with that most important task of determining whether an intervention is helping or not.

      A. The Nature of Episodes.

Consider a health concern for which a particular symptom flares up episodically.  In other words, there are symptomatic episodes (flareups, exacerbations) and there are periods between the episodes, during which the symptom is completely gone (asymptomatic) or very significantly diminished.  Examples would include perimenopausal hot flashes, migraine headaches, dizziness, asthma, or abdominal bloating.

While you are working with me, I like to have everyone involved (you, me and those close to you) focus on four distinct aspects of symptomatic episodes as we monitor change over time.  These are Frequency, Intensity,  Duration and Resilience.

I. Frequency.

Frequency is simple.  It refers to how often episodes occur.  For exmple, are your episodes (flareups) hourly, daily, weekly, always with the full moon, monthly, a few times a year, regular, erratic but triggered by something obvious, or erratic for no identifiable reason?

II. Intensity.

Intensity refers to how bad the episodes are.  Sometimes it helps to use a scale of 1 to 10, a 9 being very bad, a 3 being not too bad.  I am not a huge fan of this scale, but it can help.  Sometimes, it is easier to just use a descriptive scale (rather than numerical) like ‘unbearable’, ‘very bad’, ‘bad’, ‘mild’, etc.  And sometimes, it is useful to use a measure of daily-life-limitations induced by episodes.  Very intense might be reflected by the fact that none of your clothes fit (bloating) while mild might mean only certain pants don’t fit.  Or very intense might mean you are having to medicate frequently (bronchodilator use during asthma attacks) while not too bad means you aren’t having to medicate as often.

III. Duration.

Duration refers to how long each episode lasts; an hour, several hours, a day, several days?

IV. Resilience.

And finally, there is what I call Resilience.  It is actually one of my favourite measures.  It is sort of a combination of duration and intensity.  Resilience is really a measure of how quickly your body responds to and rights itself after a flareup is triggered.  This is a great measure of health, of integrity, of vitality.  If before we start acupuncture treatment, you have some symptom that once triggered, always seems to take your body days to slowly (intensity is slow to lessen) reduce (let’s say 4 days) and after several treatments, you bounce back from flareups within an afternoon – that is tremendous improvement.  Your vitality, your integrity, your resilience in the face of adversity is improving.  Living in the world is, by definition, an endless exposure to bumps and bruises.  A great measure of overall health is  how fast and effective we are at responding to them.

      B. The Observer and the Observed.

In addition to the nature of your flareups is the matter of who is observing your improvement.  It’s important to distinguish three different observers, all of whom have different contributions to make towards your assessment of progress; you, your practitioner and a third person or persons.  We all have a different role to play.  Let’s discuss each of these in turn.

I. You.

Noone knows your body better than you do.  So, you play a key role in observing and monitoring changes through a course of treatment or any intervention.  There is, of course, your main complaint (the symptom that led you to seek treatment in the first place).  Say for example, it is peri-menopausal hot flashes.   There are two things to stay keenly aware of over time, your capacity for objectivity and other signs and symptoms beyond your main complaint.

Obviously, you play a key role in monitoring the frequency, intensity and duration of your hot flashes.  But you need to adopt a sharp and somewhat distanced awareness as you do this.  You need to hone your ability to be objective about your experience.   I can’t tell you how many times someone comes to me a week after treatment and says something like “this isn’t working, my symptom is just as bad as it ever was”.  And on questioning, it turns out they had 5 excellent symptom-free days (the best they have had in many months or even years) followed by a terrible day just before their second visit to me.  We are funny creatures.  If we don’t make the willful effort to be aware, we tend to get swallowed up in subjective minutiae of what is happening in the moment (not a good way to respond to life in general – in fact a recipe for disaster!).  A huge improvement can be quickly forgotten (or diminished) in the midst of a flareup.  But, in truth, the path of healing is usually a bumpy one with improvements and flareups.  It is critical to stand back from yourself and see the bigger trends and picture.

We also tend to experience things in a very relative way, as contrasts.  If it is 10 degrees (Centigrade) outside in August, we think it’s freezing and will likely be bundled up in a thick sweater.  If it is 10 degrees outside in January (at least where I live!), it’s a balmy day and everyone is walking around in t-shirts joyfully declaring the early onset of Spring!   The same is true of your experience of many symptoms.  By the time you are reporting back to me a week after a treatment, you may be reporting something as a very different contrast to what you reported before we started treatment.

There is even a more complex aspect to this.  If you have been plagued by a particularly debilitating symptom for a very long time (years), by necessity, you have developed a life full of compensations – things you do and don’t do because of the symptom, different ways of doing things because of the symptom.  These compensations become so entrenched, they – along with the symptom itself – have become very much part of who you think you are – part of your identity.  That identity is, in fact, a choice, but it can seem choiceless unless you make the effort to distance yourself from it.  What can emerge as your symptom improves under treatment is an actual crisis of identity.  Suddenly the symptom is getting better.  It doesn’t occupy your attention as much.  The many and varied compensations you have embedded in your life are now no longer necessary.  Who you thought you were is no longer who you are.  That can be a very unsettling time, so much so, that a new set of symptoms and even a paradoxical nostalgia for the old symptoms can arise.  When your practitioner asks you how you are doing, you may well say, ‘not too good’.  It is critical to be honest and objective and investigate for yourself if you are expressing the short-term confusion of repositioning who you are, your very identity.

Finally, it is important to monitor more than just your main symptom, especially when you are being treated by a full systems approach (holistic) like acupuncture.  Be aware of everything that is going on.  Perhaps in addition to hot flashes, your sleep is improving, your anxiety is improving, your headaches have gone away and your shoulder tension has lessened.  Keep the whole picture in view as you self-monitor progress (This actually touches on a fascinating topic I will cover in another blog! – when your ‘main symptom’ doesn’t respond but a LOT of other things do).  Sometimes, signs and symptoms other than your main symptom improve long before your main symptom does – they can be important markers that your overall system is responding to treatment.

II. Your Practitioner.

I did suggest above that you not surrender all monitoring of progress to your practitioner.  And of course, that is very important.  But also don’t forget that, if they are well trained, experienced and have integrity, your practitioner has a wealth of knowledge and understanding to put towards this process.  Furthermore, there are often particular aspects of monitoring that come from the paradigm or framework within which your practitioner is practicing (Chinese Medicine, Osteopathy, Mainstream Medicine, etc) that you or even other practitioners may just not know about.

For example, I practice within the framework of Chinese Medicine.   You may be coming to me for treatment because you and your partner are having trouble conceiving.  Through the lens of Chinese Medicine, it may be very clear to me that the premenstrual bloating, breast tenderness and headaches are part of the pattern within which your conception difficulties exist.  So as we work, while you may not have conceived yet, I may be focused on those other symptoms and whether they are getting better, as indicators that your overall system is responding to treatment.

It is also important to distinguish here between ‘symptoms’ and ‘signs’.  Symptoms are things you experience with your senses – pain, heat, cold, numbness, dizziness, etc.  Signs are things that can be measured or evaluated in some way (usually by your practitioner) that are not sensed by you.  When your Doctor takes your blood pressure or measures the liver enzymes in your blood, they are monitoring a sign they are trained to make some sense of.   When I as an acupuncturist take your pulse or palpate areas of your body, I am assessing signs I am trained to make some sense of.  These are, of course, an important part of monitoring progress that typically require a trained practitioner to evaluate.  I will say that often signs can be given too much weight (this is particularly true of blood tests) and confused even by medical practitioners as actual disease when they aren’t – they are proxy signs and should be treated that way.

III. A Third Party.

Finally, in addition to you and your practitioner, a third person can make a huge contribution to the process of monitoring progress, particularly in relation to chronic (longstanding) symptoms.  This can be a husband, wife, boyfriend, girlfriend, parent, best friend or work colleague.  But someone who has known you a long time and sees you regularly can make a vital and unique contribution to the process.  They have objectivity and they know you well.  And they fall into two distinct categories; those who know you are getting treatment and those who don’t.  Both are valuable, but it is particularly telling when someone who knows you and sees you regularly and has no idea you have started treatment, comments shortly after your treatment begins on some clear observable change in your functioning, demeanor, attitude, etc.

So make full use of those around you and all of the information they provide.  Feed that information into your overall assessment of progress or lack of progress.

      C. Im Not Getting Worse.

One of my least favourite responses from patients when asked if things are improving is “well, they aren’t getting worse”.  Sure, if things truly were getting worse day by day and as soon as you started treatment, the downward descent clearly halted dead in it’s tracks, then THAT is an improvement.  But that is rarely the context in which this statement is made.  If all you can say after a series of treatments is that ‘things are not getting worse’, then it’s somewhat likely the treatments are not helping (unless there is a good reason to suggest you need more treatment – other indicator symptoms are getting better, for example).  It is certainly also always possible that things are improving but in a gradual nature that truly makes improvement difficult to discern.  You can always be a scientist about it, just stop treatment for a while and see if you notice a difference with and without treatment – this will help clarify the value of treatment for you.  Discuss this with your practitioner and develop a plan.  Again, the key ingredient here is that you are being somewhat objective and critically minded.

      D. The Bigger Picture.

Let’s not forget the big picture.  The big picture ultimately, is about your relationship to life.  Of course, some symptoms and some illnesses are just plain bad luck, or karma or inheritance or the result of environmental exposure.  But particularly in the present-day context in ‘developed’ countries, the greater proportion of illness, disease and symptoms are related to how we are choosing to live our lives.  In this context, symptoms need to be viewed as gifts – warning signs from our bodies – to wake up, pay attention, reevaluate and track a new course in life.  A good practitioner can help you to awaken to that level and facilitate clarity so you can make the best use of the opportunity that a problem with your health offers.

There is certainly nothing wrong with wanting to be more comfortable, to be pain-free, to reverse or stabilise an illness, to improve or eliminate a symptom.  But in the big picture, the wonderful capacity you are harnessing through the service of an acupuncturist or any other practitioner, needs to be viewed as an opportunity to change your relationship to life.  Don’t waste that opportunity.  Make the most of it.