The June 25 issue of the British Medical Journal of Sports Medicine carried a short paper that asked an important question via it’s title; Is it Time to Reframe How We Care for People with Non-Traumatic Musculoskeletal Pain? While the simple answer is ‘yes,’ allow me to show you why I’ve been beating this functional drum for the better part of three decades. Against a backdrop where MUPS is arguably the most common health ailment facing Americans today, allow me to dissect this paper just a little bit.
Functional
The authors started by stating the obvious; “The current approach to musculoskeletal pain is failing, a new approach is needed.” How did they describe the “old approach” —- the approach largely used today? Mostly, they described it as a myriad of tests for making diagnosis that are typically unhelpful in solving people’s problems; particularly their chronic problems. They mentioned the phenomenon of ASYMPTOMATIC DISC HERNIATIONS as well as the fact that most of what is seen on x-rays or musculoskeletal MRI’s is not useful as far as determining where a person’s pain is coming from (see the following link). “The majority of persistent non-traumatic musculoskeletal pain disorders do not have a pathoanatomical diagnosis that adequately explains the individual’s pain experience and disability.” In other words, most of these problems are functional as opposed to being based on visible pathology. What does this mean?
“First, structural changes observed on imaging that are highly prevalent in pain free populations, such as rotator cuff tears, intervertebral disc degeneration, labral tears and cartilage changes, are ascribed to individuals as a diagnosis for their condition. Second, it is arguable that musculoskeletal clinicians have invented treatments for conditions that may not exist or be readily detected.”
While the first statement is AS TRUE AS TRUE CAN BE, the second sentence is much more open to debate; especially in light of the first. The first sentence (as explained by the provided link) shows what we have known for decades; that just because ‘something’ shows up on an MRI does not mean it needs to be surgically dealt with. The famous sports surgeon, James Andrews, showed us this with shoulders (HERE), but it’s true with any number of other issues as well, including ever-common KNEE PROBLEMS and subsequent surgeries done for them. There are many others (HERE). The second sentence above, however, is even more problematic because it insinuates that because something is not “readily detected” it doesn’t exist.
The examples these authors used were MYOFASCIAL TRIGGER POINTS, postural distortions / muscle imbalances (UPPER CROSSED & LOWER CROSSED syndromes as well as FORWARD HEAD POSTURE always come to mind first) and sacral torsions (chiros call these “SUBLUXATION” and they can be associated with everything from SI ISSUES, SCIATICA, CUTANEOUS NERVE ENTRAPMENTS as well as PIRIFORMIS ISSUES). And that’s just for starters. If you have ever dealt with these or similar issues you quickly realize that such problems are not merely ‘JUST IN YOUR HEAD‘ (thanks to an anatomical short leg and numerous roached ankles — grade III sprains and several avulsions from my basketball days, on varrying levels I have at times dealt with of all of these, including occasionally fighting the dreaded LEVATOR / PEC MINOR SUPER-TRIGGER).
The unifying factor that I believe helps explain the majority of these and other problems (we could easily throw WHIPLASH into this category as well because there are no good tests that detect it or truly describe what’s going on) is the FASCIA SYSTEM. When people end up with injuries or systemic issues related to INFLAMMATION, they have to realize that the consequence is always some sort of fibrotic change (HERE). And while practitioners may refer to said changes by numerous names (DENSIFICATION, SCAR TISSUE, FASCIAL ADHESIONS, etc, etc, etc), the bottom line is that just because FASCIA DOES NOT IMAGE WELL with traditional, insurance-covered technologies doesn’t mean these problems don’t exist.
And while I completely agree with the author’s assessment that most non-traumatic musculoskeletal problems revolve around “lifestyle,” they discussed numerous management ideas (better sleep, quitting smoking, etc) without as much as mentioning diet and its relationship to systemic inflammation. Honestly, how can struggling patients successfully address the problems they are having (“the individual’s self-efficacy to take control and ultimately be responsible for their health“) without a strong emphasis on the quality of food they are consuming on a daily basis (HERE, HERE, HERE, HERE, or HERE)? But then again, it’s not news that most doctors fail to discuss diet with their patients in any meaningful way (HERE) —- an issue that strikes at the very heart of the moot debate over who should be paying for American healthcare; individuals, employers, or the government (HERE).
“We need to reframe what is currently doable and achievable in the management of many non-traumatic musculoskeletal presentations, and honest and open conversations regarding the outcome evidence for these disorders needs to be sensitively communicated. Interventions such as manual therapy, pharmacology and injections, when provided, should be seen as an adjunct, and their risks and benefits must be considered and honestly communicated. To achieve this, the efforts of many institutions, including educational, healthcare, political and professional organizations, health funding bodies and the media, need to be involved.”
Ahhhh; utopia. It’s lovely isn’t it? To bad IT’S NOT REAL. There are some hard facts underlying all of this; namely that “management” of your problems and pain may require some real effort on your part. If, as the authors of this paper argue (I totally agree with them on this point), your doctor / clinician can’t make someone healthy via the things they do for you such as drugs or surgery, what would make one think that government or media (or for that matter, education) can play a significant role? That’s just it folks, they can’t. While this paper seems inclined to agree that Westernized populations are receiving far too much of at least certain types of health care (HERE), it’s unfortunate that it didn’t acknowledge the deeper truth — that both EDUCATIONAL EFFORTS and PREVENTATIVE HEALTHCARE do not work as touted. What does work if a person is willing to actually get off the couch and make some lifestyle changes?
Firstly, if you have chronic musculoskeletal pain (HOPEFULLY IT’S NOT CENTRALIZED), it might be beneficial to see if I can help you. What’s cool is that like the people HERE and HERE, you will know if my approach is helpful in a single visit (just click the links to see what I mean). Secondly, while I may be able to help get you out of pain, if you are looking to stay that way and get healthier in the process, you might find a few good ideas for reducing your inflammatory load in THIS POST. And since the holiday season is upon us, why not commit to giving yourself the best Christmas present ever this year (HERE)?
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