While there are many reasons people come to see a chiropractor, among the most common is chronic pain that has not responded to orthodox medical care. These folks have often been dealing with their pain for a considerable amount of time, and have exhausted their usual options. Diagnosing these problems begins with three questions: first, are there any reasons that this patient should not be in my office? Second, what hurts? Third, why does it hurt?
Rarely, pain is caused by ominous disorders which necessitate a referral to the appropriate provider. Occasionally, the symptoms have a cause which is not amenable to chiropractic care, and again, this necessitates a referral to the appropriate provide. But, both of these are infrequent, at best.
The second question (“What hurts?”) is about what we call the “pain generator.” Careful examination can often pinpoint the pain generator. This guides what kind of treatment will relieve the symptoms, and what kind of treatment will be ineffective.
In acute cases, the third question (“Why?”) can be generally straightforward. For example, an accident has injured the pain generator, and we need to help it heal. In chronic cases, it may not be that simple. Subtle loss of motion in distant body regions (sometimes known as “regional interdependence”) can force something else to move more than it is supposed to. The pain generator might have become unable to protect itself (known as “instability”). The nervous system may have become hypersensitive, perceiving normal motion as causing injury. Finally, beliefs about the problem, or other psychological factors can contribute to prolonging the problem. All these categories, and others, need to be assessed.
Listening to the patient, and performing the exam, there are cues suggesting each of the above. Each can then be addressed specifically, but there is what you might call an “order of operations” of which must be addressed first. Sometimes relieving one of these factors (regional interdependence, instability, sensitization, and psychology) will relieve others. While it is rare that I assess someone has having pain that is only psychological in origin, beliefs we have about pain frequently increase our suffering. For example, I speak with most low back patients about the fact that back pain is frequently short-term disabling, but very rarely long-term disabling. Not being able to straighten up can be a scary experience, and it can do a lot to set the mind at ease that it is very likely temporary.
Insurance companies generally believe that treatment for all these factors can and should be completed in 8-12 visits. In acute cases, that may be enough, but in chronic cases it may not. For example, an ankle sprain that never healed can continually distort how one walks, in order to protect the injury. However, this may cause a number of other subtle injuries throughout the body, changing how the knees and hips rotated, altering movement of the spine, possibly even subtly tilting the head in a direction that could cause a headache. Nerve entrapments are classic for this. The body will protect nerves above almost everything else (obviously excluding acute breathing and circulatory problems), even to the point of severely damaging joints in the process. This will also install dysfunctional movement patterns in the body, which cause their own difficulties.
With chronic cases, order of operations is very important. This leads to what I call a “victims and culprits” approach. First, concentrating only on the pain generator can lead to simply torturing the victim. I would rather attend to the underlying factor first (within a given treatment visit) and finish by caring for the pain generator.
While no provider can ever claim success with every patient they have seen, the above approach has been extremely successful in my office for many years. Ultimately it has led me (through many of my own injuries) to coin the phrase titling this blog post: healing happens. Unrelenting chronic pain can lead us to despair. Keeping the faith is about the idea that there are solutions out there. Even if I can’t provide one, I’ll do my best to point you in the right direction. Likewise, if we reach a point where improvement remains incomplete, I very careful to tell my patients that “I cannot improve things further,” which is a far cry from “things cannot improve.” There is always hope. Another psychological factor is that pain is a liar. Pain tells us things will be like this forever. In time, this too shall pass. Our job is simply to try and make that time as short as possible.
Even with chronic joint pain, the body is trying to heal. Even if a joint is “bone on bone”, as people like to say, the body is trying to fix it. While it may be that the loss of cartilage has gone so far the body can’t repair it, it might also be there is something else going on that keeps re-injuring it. As discussed previously, there may be a joint elsewhere in the body that has lost range of motion, isn’t complaining, but is what the injured joint is making up for. Searching carefully for and fixing that problem can give the body what it needs to heal the chronic problem. Hence, “healing happens.”