Business Talk: The future patient history – why practitioners are missing the mark
Anthony LombardiFeatures Business Management
I penned this piece while on an overnight flight from Hawaii to Vancouver in early January 2022. Once I reached Vancouver we caught our connecting flight to Toronto five hours later. In total my family and I flew 10 hours across five times zones. Jet lag was something that we would experience over the following days after two weeks in Honolulu.
Why was this appropriate to this topic? Because after two weeks in Hawaii, our autonomic nervous system was about to make the adjustments it needed to reset necessary function – and in at least 60% of our patients, the autonomic nervous system is dysfunctional to begin with.
In school, if we are fortunate, we learn a multitude of orthopedic, neurological, and kinesthetic testing. Moreover, we learn an alphabet of history taking questions. However, as manual practitioners, the history and testing are geared to treating mechanical dysfunction. This means that if we are not aware of the effects of co-morbidities, then we will be treating our musculoskeletal patient incorrectly. In fact, this is what is happening among chiropractors, medical practitioners, acupuncture practitioners, and massage therapists across the majority of our planet.
I have been teaching the above practitioners in an academic setting for the last 18 years, and each time I cover the role of the autonomic nervous system on musculoskeletal pain they are astonished to realize the clinical consequences of misreading mechanical dysfunction in co-morbid patients.
What is the autonomic nervous system? In brief, the autonomic nervous system (ANS) is in charge of involuntary bodily functions. Breathing, heartbeat, circulation, digestion, and especially our response to constant or repeated stress – are all products of the ANS. There are two distinct and opposite parts to the ANS: the fight or flight (sympathetic) and the rest and digest (parasympathetic) nervous systems. In short, pain activates the sympathetic nervous, but so does co-morbidities. Therefore, musculoskeletal pain plus co-morbidities equals what is called: high sympathetic tone.
What are examples of co-morbidities? Any physical or psychogenic systemic illness, condition, or disease is considered a co-morbidity. I refer to these as chronic systemic characteristics. This means any autoimmune, systemic inflammatory, metabolic, or ongoing psychological disorder. Common examples we see everyday in practice are: diabetes, diabetic neuropathy, fibromyalgia, chronic fatigue, rheumatoid/psoriatic arthritis, ankylosing spondylitis, lupus, metabolic disorders, skeletal deformities like scoliosis, spinal stenosis and severe degenerative arthritis – to name a few. Also, anxiety, depression, and alcohol or drug dependency can also qualify as a chronic systemic characteristic.
If we perform a misdirected patient history, we could potentially apply manipulative, soft-tissue, or acupuncture interventions that will slow clinical progress or more likely amplify the patients’ pain symptoms. In 2018, the journal BMC Musculoskeletal Disorders reported that of their sample size pf back pain sufferers – over 60% of them had at least one of seventeen co-morbidities. This is likely to increase with age in western cultures due to poor diets, poor sleep habits, mental health conditions, lack of exercise and overall higher levels of family and work stresses.
In a landmark study in the European Journal of Pain by the journal of (name the journal), two groups of patients with neck pain associated with fibromyalgia diagnosis were randomly selected to three groups. One group received intramuscular acupuncture in the motor point of the upper trapezius muscle (GB 21), the second group received acupuncture at cutaneous depth only at the same site, and the last group received sham acupuncture at the same location. The results? The sham group reported no change in pain/function, the cutaneous group reported a significant improvement in pain and function, and the intramuscular group reported a significant amplification of their musculoskeletal pain. The reason for this? Muscle spindles are richly innervated by sympathetic nerves and an irritation of this in a patient with chronic system characteristics will increase sympathetic tone leading to more pain. (source?)
Time to re-write (patient) history
The rubric I teach is simple and effective for revealing chronic systemic characteristics in musculoskeletal patient pain presentation. It focuses on branches of three questions: When, What, Where.
When did it start? Establishing a timeline is a simple start. Chronic systemic conditions most often have been around for a very long time – even if the musculoskeletal pain has only been present for a few months. The initial patient history is usually a reliable indicator especially if they check off most every box.
When does it hurt? Chronic systemic patient presentation will usually say the pain is always present nearly all the time. Mechanical pain is more likely to be episodic based more on certain positions, time of day, and specific activities
Does it keep you from sleeping? Chronic systemic presentations always affect restful sleep because when the sympathetic nervous system is always engaged the parasympathetic nervous system is compromised.
What happened? Asking for a specific onset and nature of initial injury is important because they can sometimes suggest a psychogenic component such as PTSD. In which case co-treatment with a mental health professional may be warranted. Other times chronic systemic patients are unable to pinpoint one event because the pain has been “going on forever”.
What makes it better or worse? Again, typically nothing makes chronic systemic associated musculoskeletal pain better except maybe certain medications when continually or daily consumed- sometimes “take off the edge.” Usually any type of activity will worsen the pain after a limited amount of it.
What treatments have you tried? It is not uncommon that chronic systemic presentations such as fibromyalgia will have tried “everything” or many treatment options. The biggest reason for their lack of success is that there pain is being treated like a purely mechanical problem.
Where is the pain? Even though pain is usually the consequence and not the cause – it’s helpful to know where they are feeling the discomfort. Also, a chronic systemic presentation especially in a long-standing problem will often render the response: “The pain is everywhere”
Describe the pain. Lastly, I have the patient describe the pain. Mechanical presentations provide a more distinct description. For example, a sharp back spasm in a distinct quadrant versus a more diffuse presentation in an ongoing chronic problem.
Practitioners will find that even if they do not know how to proceed to treat musculoskeletal pain associated with co-morbidities – their clinical results will increase simply because they are not aggravating the patient’s symptoms by applying treatments that amplify the sympathetic nervous system.
Anthony LOMBARDI, DC, is a private consultant to athletes in the NFL, CFL and NHL, and founder of the Hamilton Back Clinic, a multidisciplinary clinic. He teaches his fundamental EXSTORE Assessment System and practice building workshops to various health professionals. For more information, visit www.exstore.ca.
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