Developing the Chronic Pain Picture and Chiropractic Care
Developing the Chronic Pain Picture and Chiropractic Care
Arn Strasser, D.C.
hen I present my findings to Mary, I am presenting a picture of what I feel the body is telling us regarding her pain. This picture for the chronic pain patient is often complex. Mary, for instance, has chronic leg and back pain that has persisted despite numerous treatment approaches. I find mechanical problems in her spine, causing muscular tension and inflammation.
Imaging studies and examination indicate compressed discs in her spine and spinal stenosis, but no frank herniation of the disc. She has what appears to be a sensitive, or sensitized, nervous system. She has indications of an inflammatory condition in her muscles called fibromyalgia that appears to be associated with this sensitive nervous system. She has considerable stress in her life, which may trigger her nervous system to react and contribute to inflammation and pain. Her dietary habits are not always the best for someone with inflammation and she almost never exercises.
What is important are not the specific findings, but the idea that the diagnosis is a complex picture involving a number of interrelated factors. If there were a single cause, it probably would have been identified and treated. (However, chronic pain can be caused by a single identifiable cause that has been misdiagnosed or poorly treated and allowed to become chronic).
A Chiropractor's Care of Chronic Pain
Mary is anxious to begin treatment. My first task is to give her a realistic idea of what she should expect from my treatment plan. I need to help her understand that my treatment program for her chronic pain is going to take time. My treatments are not a quick fix, but a process.
In our society, we're geared to expect quick results. Television drug ads promise instant relief from pain. A woman is in pain, her face grimaced as she clutches her neck. Magically a picture of the drug flouts onto the screen. The woman reaches for the package, takes the drug and Wow! in an instant, she's running around the backyard playing with her grandkids.
It's easy to understand why chronic pain patients want quick results. Mary's back and leg pain impacts every activity she attempts from the minute she wakes up from fitful sleep to the time she goes to bed, exhausted. And she doesn't actually sleep in a bed but in a lounge chair because sleeping in a bed on her side begins to bring on her pain and she wakes up. All her activities in between have to be modified because of her chronic pain.
Yet helping Mary to have realistic expectations is important. Conservative care takes time and effort for both the doctor and the patient. Results are not linear with slow improvements and, at times, a temporary return of symptoms. What is important is to help Mary appreciate from the beginning is that she is engaging in a process of care.
This process takes concrete form in a treatment plan. I give all patients a plan of care with an evaluation at the end. In Mary's case, a chronic pain syndrome with a long history, I tell her that I expect at the end of her 10 visit treatment plan some appreciable improvement both in how she feels and on her re-examination.
With Mary's help, I establish clinical markers that will determine progress. These clinical markers include Mary's primary symptoms as well as my objective findings. For example, one clinical marker is that Mary has a +7 (on a 1-10 scale) pain in her left leg when she walks for more than one block. When I evaluate Mary after 10 sessions, I will ask her about this pain and to what degree she has or has not improved. Similarly, objective findings, such as a particular test that is positive, will be rechecked in the evaluation to measure progress.
Having an organized, logical approach to care based on an evaluation that makes sense to the patient that has an end point with clear clinical markers, is vital to success in treating chronic pain patients.
The chiropractic management of chronic pain depends, of course, on each individual's needs. For many chronic pain patients, I have found gentle techniques to be the most effective. I use flexion-distraction technique (disc decompression), non-force and low force chiropractic manipulation, cranial work, osteopathic muscle techniques and other manual techniques. The findings of the initial examination and frequent brief re-examinations allow feedback between the body and the therapy.
The chronic pain patient is an active participant in the treatment plan. Mary is given exercises to do at home and is asked to keep a progress diary, a checklist of symptoms, stress level and her home instructions. As in almost every condition I see in my office, especially chronic problems, stress is the most important factor impacting on the patient. As I treat, I inevitably touch on goals Mary and I have set regarding working on stress.
Outcome: Evaluating a Chiropractor's Care of Chronic Pain
Mary had a successful outcome to her program. She showed persistence and determination and she was able to return to normal activities. She was seen 10 times in the first month of care and periodically over the next two months, and then released from active care. Not every outcome is this positive. Some patients give up because they aren't getting results quickly enough.
Some patients are found to have a psychological component to their pain that blocks success with physical treatments. A number of these patients, are unable or unwilling to face the possibility that stress or emotional factors are significant causes for their chronic pain, turn to the next drug treatment or physical practitioner hoping for relief. (And, such are the vagaries of treating pain, sometimes they will find that relief). Some patients need medical care and the services of interdisciplinary pain management specialists.
What I have found important as a chiropractor treating chronic pain are often intangibles that are not always taught in chiropractic college or medical school:
(1) listening to the patient and establishing communication based on good boundaries and genuine care;
(2) listening to the body, trusting the intelligence of the body and sometimes trying new ways to access that intelligence;
(3) treating the patient with chiropractic therapies that seem appropriate, but always evaluating and listening to the body to know when to change course in a treatment protocol; and
(4) always looking for signals that a patient needs a medical referral or a specialist opinion.
Chronic pain is a challenge for the patient and doctor alike. Chiropractors who take time with their patients, and who treat chronic pain as a complex disorder that demands a multifaceted approach, offer a reasonable option for those patients who are appropriate candidates for conservative care.