A Stepwise Personalized Approach to Pain
In treating pain, every body has a story – what is your patient’s body telling you?
In the era of personalized lifestyle medicine, we want to discover the ideal treatment for each patient. Pain is a common symptom that lets us know something is wrong. It is probably the most common symptom for which patients seek treatment. Dr. Jeffrey Bland has always taught us that “pain is a metaphor for dysfunction.” Yet in the era of ICD diagnostic codes, how do we reach under the hood to evaluate this dysfunction? At our clinic, our practitioners routinely deal with over 20,000 visits per year, most of which address pain or discomfort.
Our approach has been to look at pain in a layered fashion. Here are the steps we suggest in addressing pain:
Step 1. A Medical Musculoskeletal Evaluation. A thorough medical understanding of the etiology of the pain is routinely the first step. We want to get to the ICD diagnosis quickly. This requires a thorough medical history and exam, and often further tests such as X-rays, MRI’s and EMGs. One caveat though – we find that practitioners sometimes treat the test and not the patient. Make sure your patient’s symptoms are mirrored by the findings on the test! Once you have this diagnosis, it is time to move on to the next step.
Step 2. Understanding Body Mechanics, Structure, and Function. As the body adapts to its locomotor activities, it tends to place strain in certain areas. Most people stoop in what we call a “head-forward” position as they drive, work on computers or even just try to stand erect. Often, their feet will tend to pronate, placing strain on our knees and back. They may clench their teeth as they deal with their stressful lives, placing strain on our richly innervated temporomandibular joints, providing further neural feedback to clench and develop myofascial head pain. Therefore, examining a patient’s gait and movements provide a necessary understanding of where they are placing stress in and on their bodies. This is an area where chiropractors and osteopaths excel. Once you have an understanding of the structural issues, you can begin to palpate the muscles a little more thoroughly. This leads us to step 3.
Step 3. Identifying Trigger Points and Myofascial Pain. A commonly missed pain generator is trigger points. In the Orient, much attention is given to blind massage therapists. Their heightened tactile senses help them to tune into this invisible scaffolding that is causing pain. At our clinic, we ask patients to draw their pain on a pain chart to assess their pain patterns. It is then possible to run your hand lightly over the skin in that area and feel for sensorimotor changes, or to palpate the underlying muscle to feel for trigger points. This is a great way to tune into where these pain generators lie. This approach, while inherent in techniques such as massage therapy, is often forgotten by medical practitioners as they stop at Step 1, the ICD diagnosis.
Step 4. An Acupuncture Evaluation. At our clinic we find that an acupuncture assessment greatly enriches our approach to pain. Enriched by five thousand years of astute observation, the compendium of clinical conditions archived by acupuncture practitioners has allowed them to see the connection between constellations of clinical symptoms. So, while a medical approach would never link lung problems, depression, De Quervain’s tenosynovitis, lateral epicondylitis, impingement syndrome and allergic rhinitis, an acupuncturist would immediately see the connection – they lie on corresponding meridian complexes. Therefore, in treating one or two of these problems, it is not unreasonable to see the rest clear up!
Similarly, a medical practitioner would not expect the treatment of knee pain to help infertility, while an acupuncturist would. There is more to acupuncture than just the therapeutic issue of inserting needles. Understanding meridian complexes is more than just an academic exercise. So that is why an acupuncture evaluation and treatment becomes the next step we use in treating pain.
Step 5. How Your Mind Affects Your Body. Our understanding of neurotransmitter function has allowed us to see where manipulating these neurochemicals can alleviate pain. Whether your choice is antidepressant drugs, seizure medications or nutritional supplements, the important thing is to assess whether your therapeutic intervention can produce maximal effects with the minimum or absence of side effects. More than that, we want to help our patients dispel the sense of hyper vigilance that so often accompanies chronic pain. As with all other suggestions, we want to give our patients options. They might need to learn a hobby, or to learn how to do belly breathing or even how to meditate. Often these simple interventions can produce profound results.
Step 6. Understanding How Your Body Affects Your Mind. As we get down further into the etiology of the pain, we need to understand why the patient is a “setup” for the pain and discomfort they are developing. What is their inflammatory and oxidative stress status? What are their vitamin, mineral, amino and fatty acid levels? How are they detoxifying? Do they display mitochondrial dysfunction? Do they have underlying genetic single nucleotide polymorphisms (SNP’s) that are predisposing them to certain problems? We need to understand the epigenetic factors that are causing their ultimate dysfunction. This is where a Functional Medicine evaluation becomes paramount.
Step 7. A Lifestyle Analysis: Finding the Causes and the Solutions. This is the big aha! As we learn how a person is living, we can start helping them make simple changes that have profound effects: what they eat; how they eat; how they exercise, and how they feel. The lifestyle analysis synthesizes all our previous steps as it allows us to know what the patient is doing and how they are behaving, giving us deeper insight into how we are going to correct their chronic pain pattern.
Step 8. An Integrative Diagnosis and a Transformational Treatment Plan. We all want our patients to change for the better, but it often seems as if they lack motivation to do so. While pain can be a huge disabling factor, it can also be one of our greatest motivators. Therefore we want to reframe pain for our patients. We want to allow them to use their pain a tool for transformation. If we allow them to see what we can do for them and what they can do for themselves, we can achieve this final crucial step.