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Achieving an Integrated Approach for Treating Musculoskeletal Conditions

by Wendy Emberson(more info)

listed in bodywork, originally published in issue 54 - July 2000

The Problem

Summer was well underway way and on Saturday you went out to the Garden Centre. The temptation was too great and you bought a range of pots, all the plants to go in them and a huge bag of potting compost. The kind man at the Centre lifted them all into the car for you, but there was no one at home to help you lift all the goodies into the greenhouse. So feeling strong and independent you managed, with the help of the wheelbarrow, to get everything put away.

That night you woke up at about 3am with a niggly pain in your shoulder muscles between your neck and left shoulder. By 7 o'clock, the pain was now really quite sharp up into your neck and beginning to push down into your upper arm. You had to get up and try and move around to reduce the pain. That helped, but you had to resort to some pain killers to even think about going to work.

You made it to work and sat down in front of your computer. The pain by now had become more severe and had even reached your left hand where it seemed to be concentrated in your thumb, index and middle fingers. To make matters worse, your boss had given you a deadline that had to be met with the understanding that unless you did the work today, then you may not have a job tomorrow.

So what now? Any number of colleagues at work offer any number of possible causes, and even worse – any number of possible cures!

The problem now is – who can you believe and where do you turn for help and advice?

Treatment Options

  • Your family doctor
  • A chartered physiotherapist
  • The pharmacist
  • A chiropractor
  • An osteopath
  • A physiotherapist
  • A reflexologist
  • An aromatherapist
  • A sports masseur
  • A sports therapist
  • An acupuncturist
  • And many others!

Now let's look at the decision making process that may hopefully lead to you making the right choice and getting better quickly.

You don't know what is wrong with you and you need someone who can tell you

This needs someone who has the knowledge, training, experience, skills and time to examine you, understand your problem and suggest a possible course of action. You need the answers now because you cannot afford the time off work. You can't carry on with this pain getting worse. You need to know whether it is a serious problem that might need hospitalization. If it is not a life threatening problem you want to know what treatment is right for you and how to stop it happening again.

You also need someone who can treat the condition

This needs someone who can not only get rid of the problem, but also someone who is not going to make the problem worse.

You need someone who can treat the wholeproblem from diagnosis to treatment to education and prevention

Painkillers, anti-inflammatories, massage, acupuncture, aromatherapy, and reflexology may all help to ease the pain, but are they all treating symptoms and not the cause? The answer is "Yes" – but they may all have a part to play in helping you to resolve the condition.

From a practitioner's viewpoint, we may all have seen patients with symptoms like yours. We may all think that we can cure the condition for you. We all have training, skills and experience that we can bring to the party. But which one of us should it be? Who can look out for you and recommend the right course of action?

Your family doctor is considered to be the 'gatekeeper' of all your medical care. He/she needs to be aware of any medical treatment that you undergo, and quite rightly. But, how much does the average GP know or understand about musculo-skeletal conditions and the range of treatment systems available? In general, GPs have very little training in this area unless they have undertaken post-graduate specialist courses – that is why there are so many different people offering the service. [It is also why 80% of my patients, for example, come to me first.]

Your Needs as a Patient

So, let's look at your whole problem. You are unique! You may have signs and symptoms of a condition that fits a particular medical condition, but what of all the other contributing factors that may affect the actual presentation of your pain and therefore the right treatment programme. I have purposely said 'programme' because there are many facets to a successful outcome, the most important of which, is to prevent the onset of chronic pain.

However fine, laudable and provable this all is, where can you go now to find an answer to the problem in your neck and arm? I would suggest you search out practitioners and/or therapists who can provide all the necessary skills between them.

It is always advisable to only consider seeing people who have recognized qualifications and training – for your safety, but also consider them as people in their own right. Their personality, and attitude to you as a person is as important as their clinical knowledge and expertise.

So remember, you may need a mix of skills from a number of practitioners or you may find one that can provide them all. But what must not be missed is your input. If you can take the responsibility of identifying any factors that may influence your condition such as your working conditions or family pressures, and try and resolve any problems in these areas, then you may well see a marked improvement before having to ask for help from any of us.

In this way, the truly integrated approach will come from many areas of skill and expertise, and not just from people who historically offer treatment for your condition and not you!

Benefits of an Integrated System

You may find this whole idea to be blindingly obvious! After all, everyone I have mentioned so far belong to a group called 'the caring professions'! The problem, as I see it, is that we have lost sight of the 'care' in the profession. With the enormous pressure on all medical staff to reduce waiting lists, to only work to evidence based practice, to provide strict standards and codes, to work within very tight budgets and with increasing demands for service in both the NHS and Private sector, is it any wonder that few have the time to care for the patient?

The irony is that by making the time to provide the complete service for the patient, the final outcomes would be so much more cost effective, and would ultimately lead to a reduction in the numbers of patients with chronic pain and disability.

Steven Linton's work (1998, 1999) has shown that identifying and addressing the known risk factors in early management of back pain can reduce chronic disability by 8 fold over 'treatment as usual'.2

BOX 1: The Bio-Psycho-Social Model (Not Shown)

Gordon Waddell, a Consultant Orthopaedic Surgeon, made the following comments in the epilogue of his book The Back Pain Revolution

Human beings have had back pain throughout recorded history;

  • Back pain has not changed: it is no different, no more severe and no more common than it has always been;
  • What has changed is how we think about back pain and what we do about it;
  • We have turned a benign bodily symptom into one of the most common causes of chronic disability in Western society today;
  • But if we can create that epidemic, we can also reverse it.

There is a growing body of research evidence that is beginning to change our attitudes to treatment away from being a pure medical condition model – "this is the structure that is causing your pain, and this is what I must do to you to relieve it." There are now proven physiological links between your psychological make up, your social situation, your anatomical make up and even your genetic make up tha t all influence each other to determine how you and your body react to an injury or condition.

Unless all these factors are taken into consideration, then there is a real chance of ultimate chronic pain and disability.

This may be a function of modern medicine that has conditioned us into believing all we have to do is to present our problem to a doctor or therapist of any sort, and they will do something or give us a pill that will solve everything. We are expected to leave our brain, personality, social situation, fears and worries outside the door while these people attempt to change the mechanics of our bodies to put it right.

Chronic pain and disability may be linked to your distress at work, to the way your family reacts to you, or perhaps to some loss in your social life. Change these and you may get better. Overwhelming fear that moving your neck will make it worse can also impact on the progress of your condition – take away the fear, start simple, specific exercises to gradually loosen the induced physical hold of your muscles on the joints and the condition gets better.

The fear may be work related. If you cannot work because of the pain, you may lose your job, then your house and even your family. The family influence may come from most musculo-skeletal conditions being 'invisible'. Someone with a broken leg gets far more sympathy, help and understanding than someone with a bad back or RSI.

This bio-psycho-social treatment model can be simply explained as a genuine, caring approach. If we care for our patients as individuals, then we care about their work and family situation, we care about their fears and worries, and we care enough to bring to bear all our diagnostic, treatment, interpersonal skills etc to help you to help yourself.

What is fascinating is that the research is demonstrating how this truly holistic approach actually affects the mind and body at all levels, even down to cell and gene level.

References

1. Butler SD. Mobilisation of the Nervous System. Churchill Livingstone. 1991.
2. Topical Issues in Pain 2. Biopsychosocial Assessment and Management. Relationships and Pain. Editor Louis Gifford. Physiotherapy Pain Association CNS Press. 2000.
3. Waddell G. The Back Pain Revolution. 1998.


The Need for an Integrated Bodywork Gatekeeper System


by Sandra Goodman, Ph.D.

The Problem Now

Anyone who has experienced an injury or chronic problem – back, shoulder, neck, legs – will know how difficult it is for a patient to find the most appropriate treatment. Over the years, I and those in my family and workplace have suffered a variety of injuries, including back pain, hamstring tears, Achilles tendonitis, rotator cuff inflammation, knee problems. The GP or osteopath may be the usual first port of call, for a diagnosis. Sometimes the GP may provide a referral for physiotherapy; however, the waiting list is often 6-8 weeks. My personal preference has usually been to see my cranial osteopath, who can provide a diagnosis, gentle treatment and self-help advice – i.e. use ice, certain exercises, and a prognosis.

While osteopaths and physiotherapists are highly knowledgeable about many bodywork problems, they are not often able to, or in a position to offer other required allied treatment. For example, it may be appropriate to have acupuncture, remedial massage, Feldenkrais or Alexander lessons at various phases of the acute injury stage through to rehabilitation and recovery. At present, most doctors and practitioners know merely their own speciality and perhaps one or two additional therapeutic modalities. Most physiotherapists may know about acupuncture and massage, but very rarely do they know the entire spectrum of bodywork techniques available. It is therefore, at present, up to the patient to decide which kind of treatment they think is appropriate, and then to seek out a skilled practitioner in their area. From personal experience, even having contact with practitioners across the UK and internationally, this has been a nightmare. In my rehabilitation from a serious hamstring injury, brought about by shortened muscles, I have had osteopathy, physiotherapy, sports massage, which is still ongoing. However I had to decide that the treatment I was having wasn't working, decide which other therapy would be most appropriate, and then seek out a local practitioner. Very hard work! This situation is not acceptable!

The Solution

A bodywork gatekeeper system needs to be set up, in order that patients can benefit from cross-fertilization between bodywork modalities. The bodywork gatekeepers ideally should be highly trained to a medical standard, but be knowledgeable about and have access to a database register of all bodywork practitioners, from Alexander teachers to Zero Balancing.

Who should be in control of the bodywork gatekeeper system is the key question. It would seem not sensible to tack it onto the GP's already overburdened responsibilities. Having a database register of practitioners from even one profession, i.e. Osteopathy, has been a mammoth task, achieved over a 2-3 year period. Developing a register of all bodywork disciplines and making it work for the likes of you and I, the patients, does appear a daunting task! We look forward to receiving suggestions from Positive Health readers.


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About Wendy Emberson

Wendy Emberson is a chartered physiotherapist who has been working in her private practice for 20 years specialising in orthopaedic medical and musculo-skeletal conditions. She can be reached at her clinic on Tel: 01279 654020.

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