Treating chronic musculoskeletal pain and lifestyle disease- A cynical view

I get to see a lot of people who have long term complaints of pain, tingling and weakness of their limbs.
Most of them have been through several rounds of scans, and nerve conduction testing with hardly any definitive diagnosis.
With the upper limb symptoms, they get told that they’re suffering from a “pinched nerve” or cervical spondylosis.
With leg pain, they’re told that they’ve got abnormal wear and tear of their joints. If the pain starts from the back and radiates down the leg, they’re told that it is due to a “disc problem”
These are all problems that need to be excluded. I agree.
What next?
Medications? Local injections? Surgery?
Has already been tried and not worked at this stage. More of the same is not something that I’d like done to me, if I was a patient.

Local injections
Can be very effective if done right, for the right reasons.

If there is proven nerve compression that’s causing definite, detectable weakness (not just a feeling), or if there’s proven sensory loss, surgery *may* be indicated, if the imaging studies correlate perfectly with the physical examination findings.

However, wouldn’t it be better to give a proper try  of conservative methods first?

See if their posture is reasonable. Assess their soft tissue quality. Correct strength imbalances. Give correcting these issues a sincere effort, and if still not successful, move on to more aggressive treatment strategies? It should take around 2 months of half an hour physical practice daily to show improvement. If there is improvement, the patient and the doctor can now have more confidence in their plan. I consider a wait of two months reasonable, as most of these patients have been in pain for much much longer anyway. Provided, there are no danger signs in physical examination or on imaging. This process is prone to failure, because the most important factor in this, is the patient himself. Without consistency, there will be no effect. The myofascial chains, the neurologic patterns of muscle activation/ relaxation have all taken years to develop, settle down and become deep rooted.

Too aggressive a practice will cause severe increase in symptoms. Too mild a practice will result in too slow a change(or no change at all). Deciding on how aggressive or mild the practice should be, will depend on the patient’s current physical condition, and the patient’s temperament. My job would be to make an assessment of those and decide who is suitable for exercise and who isn’t. Most patients tend to severely overestimate their capacity for pain tolerance along with the severity of their discomfort. Without considerable self awareness and body awareness, treating with exercise is difficult. Especially without daily interaction. In case of hospital visits, the most frequent visits that can be offered are twice monthly. And if the patient isn’t intelligent, brave or motivated enough, that frequency is not enough.

Getting patients into a facility daily for supervised exercise will work like magic, provided the supervisor has the patience to guide them gently and without time pressure. There patience of a saint. Not my cup of tea. I’m more drill sergeant from marine boot camp, than motherly yoga instructor.

Modern medicine doesn’t seem to take this path because
1. There isn’t enough emphasis on these facets of treating chronic musculoskeletal pain, in formal medical education. That part is outsourced to the physical medicine department, or the physiotherapists.
2. It takes a lot of work. For both the doctor and the patient. More for the patient actually. Because he or she has to go home after the doctor has showed them what to do, and then do it for weeks together, to get only slow progress.
It’s difficult to find patients with that kind of commitment to their own health.
3. There’s not enough profit. People aren’t willing to pay for the time spent by physiotherapists who teach people to move. People would gladly pay huge money for a treatment being*done to them*. But they will not pay event a fraction of that money for a method that teaches them to treat themselves and become independent
4. Ayurvedic centers have also shifted to this model of offering treatment, instead of educating the patients to stand on their own two feet. Same reason. Not enough profit in educating the patient to be independent. Patients don’t want it either

The blame lies on both sides, but I’m apportioning most of it to the patients, because they’ve expected coddling from day one. Most of the chronic musculoskeletal pain that populations world wide suffer is of their own making. Without accepting that reality, progress cannot be made. People want to continue their dysfunctional, mindless lifestyle without having to suffer the consequences. And giving any sort of push back is met with hostility, and allegations of high handedness and being inconsiderate on the part of the medical practitioner and the therapists.

Perpetuating and encouraging the same dysfunctional lifestyle that got them their pain, by helping them mask the symptoms seems insane. But that is what the customers demand, and the customer is king. The customer and the service provider are now locked in a destructive vicious cycle. The service providers have no incentive to break out, because they’re making money out of the process. The initiative has to come from the patients. I don’t see that happening.

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