Cause & Effect In The Physical Realm - How Do
You Know What Is Causing What
The Hammer and the Nail
one of my earlier books, A Question of Balance, I shared a story
that aptly illustrates cause and effect in the physical realm. It
is also a suitable example of the "hammer and nail" caveat.
For this purpose, I would like to share it again here. Some time
ago, I had the opportunity to evaluate the concerns of a young man
who came to me with symptoms of pain in the left shoulder.
Despite numerous attempts by a wide variety of healthcare professionals
to eliminate his discomfort, it persisted and seemed unaffected
by these efforts. Prior to his reluctant appearance in my office,
he had subjected himself to many of the usual, and some quite unusual,
assessments and treatments for the symptom of shoulder pain. His
pain was unyielding in its response to treatment. He continued to
be passed along with the diagnosis of chronic shoulder pain. All
of the treatments to date had been directed toward the site on his
shoulder where the symptom of pain expressed itself.
Physically, he seemed to be a healthy and robust young man with
an interest in weightlifting. The symptoms had progressively worsened
over a period of months. X-rays, MRI, orthopedic evaluations and
diagnostic ultrasounds yielded no clue as to the source of the pain.
Cortisone injections, massages, and a wide variety of home therapies
provided no relief. Despite the best-intentioned efforts of all
the individuals he consulted for the problem, his shoulder pain
He remained a victim of the hammer and nail syndrome. As you recall,
this caveat dictates
that when all you have is a hammer, everything looks like a nail.
As I suggested earlier, one of the dilemmas of our specialized healthcare
environment is that we all tend to evaluate and treat from the perspective
of our specialized training.
a broad-based foundation in differential diagnosis, an orthopedic
surgeon might perceive the shoulder pain as a joint dysfunction.
A chiropractor may view it as a spinal instability. A massage therapist
might construe it as a muscle imbalance. An acupuncturist may see
it as a meridian problem, while a psychotherapist may diagnose unexpressed
In reality, they may all be right to some extent. Unfortunately,
none of them accurately reflects the causal mechanism that resulted
in the expression of the specific symptoms. The actual source of
the imbalance was direct trauma to the subscapularis muscle. This
is a small, frequently overlooked muscle that lies beneath the shoulder
blade, i.e. scapulae. It was originally injured due to a combination
of using too much weight in conjunction with poor technique, overstretching,
Repetitive micro-trauma accumulated into small trigger points as
he continued to try and use the injured shoulder. This simply means
that, at some point, he actually injured one of the muscles attached
to the shoulder joint. The initial injury itself was so subtle that
it went unnoticed until it escalated to the point that it affected
his performance. To that point, he simply assumed it to be post-workout
As he continued to use it, scar tissue began to form. The circulation
to the tissue was compromised. Nutrients could not be delivered
and waste product could not be removed. So the metabolic waste became
trapped in the tissue and caused inflammation. This reactive inflammation,
once identified and neutralized, eliminated the shoulder pain during
the course of his initial treatment utilizing a combination of moist
heat, manipulation, and neuromuscular therapy.
Superficially, this appears to be a tribute to astute diagnostic
skills. However, it is illustrative of the potential inherent in
the application of the caveats. If you look closely at this case
history, you'll see all of the caveats present. Of course, there
is the hammer and nail caveat. Not far behind is the hoof beats
and horses caveat. This is followed closely by everything works,
no panaceas, and the action/reaction caveat.
Everything Is What It Isn't
As observed in the previous example, the apparent shoulder pain
was, in fact, pain in the shoulder. However, it was not shoulder
pain per se. It was pain expressed as a result of an imbalance in
the underlying musculature that presented itself as pain in the
shoulder. A similar dilemma exists in a broader deliberation of
cause and effect. In the case of expansive symptom complexes, the
diagnosis are frequently a moot point.
Too often, the temptation is to see the presenting symptom as the
focus of well-intended efforts, rather than acknowledging the person
who is exhibiting the symptoms of imbalance A whole person point
of view presents the simple complexity of determining cause to determine
effective treatment. This model can be simplified to represent the
entire domain of human experience, as it obviously includes the
physical, the biochemical and the psycho-emotional-spiritual (or
virtual) realms of possibilities.
The Chicken and the Egg
from this whole person model, the age-old "chicken and egg"
metaphor can be aptly referenced. For centuries, a debate ensued
among the great minds of the healing arts. The essence of this controversy
revolved around the proposition that disease entities actually caused
For instance, a germ or virus would invade the body and advance
an assault resulting in an ailment. Disease was thought to be organism-specific.
Opponents of this view held that disease agents were everywhere
all the time, and merely took advantage of an opportunity to invade
and subdue susceptible or diseased tissue.
This would suggest that the various agents of doom were not the
actual cause of the affliction. Rather, the nature of the diseased
tissue was the determining factor that dictated the extent to which
symptoms might express themselves. On his deathbed, Louis Pasteur
is reported to have yielded to this theory, suggesting that the
terrain is everything.
Despite this quiet acknowledgment, the "doctrine of specific
cause" was adopted as a basis for the modern medical model.
This theory asserts that a single microorganism is the sole causal
factor in producing specific symptoms of disease in an otherwise
healthy organism. The overall condition of the whole person was
discarded in exchange for the single cause theory.
Despite overwhelming evidence to the contrary, the millennium of
the microscope unveiled detailed descriptive data for examining
the effects of disease. It also abolished any consideration of the
susceptible environment in which disease might propagate.
H.R. Holman, M.D., from Stanford University, aptly summarized this
dilemma in his presentation on "the crisis in healthcare."
He stated, "Some medical outcomes are inadequate not because
appropriate technical interventions are lacking, but because our
conceptual thinking is inadequate."
Based upon this premise, we might assume that healthy tissue could
be the ultimate defense against the ravages of foreign intruders.
What causes or allows normal, healthy tissue to become compromised
to the extent that it yields to these disease-generating trespassers?
What can we do to prevent the ravages of age from becoming the source
of an endless series of painful physical experiences resulting in
disease and death?
A consideration of the intrinsic nature of balance within each
of the three realms is essential to fully grasp the latent potential
in these questions. Since the realms embody the entirety of one's
life experience, a closer look is central to an appreciation of
is a subcategory of patients who function well in mild degrees of
imbalance. In these cases, it is difficult to identify a cause simply,
since it exists in the mind of the patient experiencing the symptoms.
These symptoms are typically chronic and low-grade. These symptoms
also tend to involve all three realms, since an undisclosed need
is being fulfilled by the functional imbalance.
In other words, the patient is deriving some satisfaction from
his or her apparent dysfunctional behavior. There is some pay off
for perpetuating the imbalance that produces the symptoms. Usually
the symptoms are more pronounced than any objective findings.
Any attempt to address cause is quickly thwarted by distractions.
These typically arise in a realm other than the one being focused
on for treatment. This is, by and large, a sure sign that one is
on the right tract. However, efforts to shape a remedy are discouraged
and resisted by the patient. If one persists in their efforts to
encourage resolution, more times than not, the patient will discontinue
Meanwhile, these patients tend to be devoted to the point that
a pseudo-dependency develops, along with enough cooperation to maintain
the relationship. Generally, these individuals are harmless and
simply experience some deep lack. This allows them to present themselves
with just enough low-grade symptoms to feed their need through a
relationship with a caring provider. Once identified, it becomes
the choice of the caregiver as to whether or not to continue with
the relationship. Nurtured over an extended period of time, these
individuals tend to respond productively, albeit slowly.
Richard A. DiCenso