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The first step in evaluating chronic pain is to obtain a comprehensive history.
One of the keys to the successful management of chronic pain is taking the time
-- the quality time -- to listen to the patient. My training as a chiropractor
has taught me to be very careful taking a history, especially when treating
functional disorders, because history may provide the most important set of
findings.
Pain Can Take on Many Faces
There's another reason why the quality of the initial history is so important
in treating the chronic pain patient: My patient, Mary, must know from the beginning
that I am going to be her partner in solving or managing her chronic pain. The
doctor-patient relationship is one of the keys to the success of chiropractic.
Chiropractors usually have a relaxed and open approach with their patients.
This makes chiropractic especially suitable in treating chronic pain, because
the stress and frustration -- and sometimes the humiliation associated with
ongoing, unresolved pain demands a partnership approach between doctor
and patient.
A good history is important for a patient, like Mary, who has already seen
a number of other doctors and practitioners. These doctors haven't been able
to solve her problem and they haven't been able to give her consistent relief
despite their best attempts to do so. The history may provide clues that have
been missed in previous approaches to treatment.
In gathering history, and throughout my work with patients, I view pain in
a holistic context. I try to gain some sense of her relationships, her work
and lifestyle, her diet and her exercise patterns, and -- most of all -- the
level of stress in her life. If stress or emotional factors appear to be strongly
associated with pain, referral to a psychologist may be indicated for evaluation.
Listening to the Body
The chiropractic examination is the foundation of care and determines the treatment
plan that follows. I look for the typical findings of the neurological and orthopedic
examination. I also draw on a number of chiropractic diagnostic findings that
can sometimes be crucial in understanding functional disorders at the root of
chronic pain.
Some of these tests and indicators are more scientifically supported than others,
but they all have strong clinical support. In chiropractic, we are in the process
of trying to understand what diagnostic tools can or cannot be supported scientifically.
The process of reading the body for functional disorders is different from diagnosing
organic disease and it means we have to be attuned to subtle signals from the
body. I always try to achieve a balance between these less scientific, more
clinical readings and traditional science-based testing. The goal is to be as
science-based as possible without ignoring valuable clinical and intuitive information.
In examining Mary, I analyze how she moves, her posture and the ranges of motion
of her joints. I examine each spinal joint with a technique called motion
palpation to see which joints might have restricted motion. I test for sacroiliac
motion and the neurological integrity of the joint. I examine the body for significantly
tender muscular trigger points. I look for what are called "positive reflex
points", tender areas, often corresponding to acupuncture points, which may
indicate functional imbalances in the body.
Low Back Pain is Common
I try to bring to the examination a cultivated intuition, based on my training
and clinical experience, which might give clues outside of typical medical findings
for the source of chronic pain. In this way, I am listening to the body
and following its lead in arriving at a diagnosis -- and I will continue this
listening process throughout treatment.
And ... The Body's Recuperative Powers
Chiropractic emphasizes the inherent recuperative powers of the body. The
role of the chiropractor is to free the body of restrictions, both structural
and neurological, so that it can heal itself. Chiropractic works through the
nervous system, the primary coordinator of all body functions to stimulate the
natural powers of the body. Listening to what the body is saying is the
first step in that process.
One important way the body talks is, of course, through pain. Listening
to the patient means finding out where and how it hurts; what makes it hurt
more and what makes it hurt less. Listening to the body through examination
means possibly eliciting pain and determining its source. I tell Mary that my
goal is to relieve her pain, but I ask her to make an acknowledgement that I
feel is crucial to my work as a chiropractor: I ask her to appreciate her pain.
If a person is in intractable constant pain, appreciating pain is, of course,
irrelevant, but for Mary and other chronic pain patients, it's the first step
in understanding my approach to treatment.
Most of us want to get rid of pain, now, so we can get back to our life and
modern medicine is geared to that patient demand. "Doc, write me up something
for this pain. I've got a lot of things to do." Busy medical offices respond
by writing a prescription and getting on to the next patient. So we come to
resent pain, to view it as something bad we need to get rid of as soon as possible.
But where would we be without pain?
If Mary fractured her leg and there was no pain, she might start running and
lose use of her leg forever. Pain tells us something is wrong, perhaps it brings
us to the doctor or the emergency room and saves our life. Our body depends
on pain for its survival.
Copyright 2005, Arn Strasser DC
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