by David Wadsworth
Why Persistent Pain is Hard to Treat – Missing Puzzle Piece One:
What Causes Persistent Musculoskeletal Pain?
Many patients are desperate to get a scan to see what is causing their often severe back or neck pain. But in 90% of cases the scan doesn’t show the cause but a skilled clinician can. Why is our best technology not better than our best clinicians? Read on to find out.
Musculoskeletal pain is the most common cause of persistent pain in our community. If it’s so common why then do most practitioners struggle to treat persistent or chronic pain effectively? What’s the “missing pieces to the puzzle” that get overlooked? In this post, we’ll look at why the medical model of pathology based assessment and treatment doesn’t work for most types of persistent musculoskeletal pain. The majority of people with persistent pain need a different approach and this is well supported by scientific literature.
Missing Puzzle Piece One: Most Persistent Musculoskeletal Pain Involves Dysfunction Not Pathology
You may be wondering what does this mean so let’s start by explaining the two terms.
Dysfunction (meaning something is tight, loose, weak, inhibited or overactive) is a reversible problem. Dysfunction is not visible on Xray or scans. It requires a highly-skilled physical examination to identify dysfunction, not lab tests. Dysfunction reflects something that simply isn’t working quite right – it isn’t broken but it isn’t performing properly either. An analogy would be trying to run a 10km race whilst jet lagged – you don’t perform at your best but you aren’t permanently damaged either. Some good sleep and time to adjust to your new time zone will rectify the dysfunction in your body clock. But it’s hard to create a blood test or Xray that can “see” or “prove” jet lag. Dysfunction accounts for around 90 percent of all cases of spinal pain (termed “non-specific back or neck pain”) (Kent & Keating 2008; Hall 2014). For anyone concerned about whether a scan should be ordered for their back pain see the official guidelines at http://www.choosingwisely.org.au/recommendations/ranzcr#1184 (recommendation #4).
Pathology indicates structural damage that usually is visible on a scan (like a fracture, degenerative joint or disc, torn tendon). In many cases pathology is a result of years of untreated or inadequately treated dysfunction. The additional load caused by dysfunction results in things wearing out prematurely resulting in a more significant level of damage. In this case treatment is about helping the patient to live with and manage their problem with as little pain or disruption to their life as is possible. Pathology accounts for only 10 percent of chronic musculoskeletal pain.
Understanding this has huge implications for managing persistent pain:
If you don’t make the effort to properly and adequately treat your problem when it is in the early dysfunction stage then it may progress to more significant pathology (ie the structure (joint, disc, tendon) may wear out, resulting in a more difficult and potentially more permanent problem).
When is a pathology approach useful?
Pathology is a model of assessment and treatment well suited to acute pain arising from trauma, such as a torn hamstring muscle. Whilst pathology is what doctors and physiotherapists are trained to look for, it’s physiotherapists (not doctors) who also receive training in the assessment and treatment of dysfunction, which causes more than 90 per cent of persistent (chronic) pain, or pain of insidious onset (pain that begins without any trauma or clear trigger).
Treating chronic pain caused by dysfunction using a pathology based model simply does not work
In my next two posts I’ll explain other reasons why practitioners may struggle to manage persistent pain, including the many different types of dysfunction that they need to be able to identify and treat.