Where to begin?

This opening chapter will help lay the foundation upon which the treatment strategies will be built. It makes some suggestions regarding the initial sifting and sorting required, in order to make sense of a new patient’s needs. Applying this as a routine sequence, a virtual checklist of what needs to be done, helps to turn a potentially confusing and stressful encounter into one that is reassuring for the patient and vitally helpful for the practitioner.

If the sort of information-gathering exercise outlined below is to be followed, involving a detailed interview as well as a physical examination, adequate time has to be allowed. Not less than an hour, and ideally 90 minutes, should enable this process to be accomplished without any sense of feeling rushed.

Outline

An outline of the intake procedure might include the following, or these might be used as a guideline for designing a written case history form.

Expectations

What do the two parties to a consultation encounter expect? Much depends on the nature of the consultation. If it relates to a simple musculoskeletal problem, the depth of inquiry need not be as great as in the case of someone with, for example, a rheumatic or systemic disease, such as fibromyalgia syndrome or osteoporosis. However, even in apparently simple presentations, such as ‘low back pain’, there are many pitfalls and darker possibilities (see Box 10.1 in Chapter 10, regarding ‘impostor’ symptoms or, as Grieve (1994) calls them, ‘masqueraders’; see also Box 1.1).

A lengthy, in-depth gathering of information is therefore ideal, if time allows.

The patient is (usually) hoping that his problem(s) will be heard and understood and that helpful suggestions, and possibly treatment, will result. For this to occur, the practitioner needs to be able to listen to, summarize and take notes on the information provided. Ideally, the practitioner should be satisfied that the patient is presenting an accurate history and is answering reasonably, honestly and frankly.

In the first consultation some structured direction and guidance may be called for, to prevent the symptoms, along with the history (often involving multiple life-events and influences), from being presented in a jumbled and uncoordinated manner. The more anxious the patient, the more likely this is to occur. Anxious or not, some patients seem incapable of actually giving direct answers to the questions posed and drift into delivering rambling discourses of what they think the practitioner should know. Care should always be taken when interrupting the patient’s flow; if necessary, this should be done in such a way that it does not inhibit his willingness to discuss his problems. A gentle firmness is needed to redirect the individual. ‘That’s interesting, and I am sure we will have time to discuss it, but so that I don’t lose track of the information I am looking for right now, please answer the last question I asked you.’ Such tactics frequently require repetition until a flow of appropriate responses is achieved. When information is confusing, it is best to seek clarification immediately, with a comment such as, ‘I haven’t quite understood that. Let’s try to make it clearer, so that I am not mistaken, tell me again about…’

Humor

Somewhere in the initial interview humor may be useful and appropriate. Some patients, however, may see this as making light of their undoubted anxieties, so care is needed. In most instances, a carefully moderated sense of fun may be interjected, to lighten the atmosphere and put the patient at ease, although this should never be at the expense of the patient’s dignity.

Attention should also be paid as to whether the patient is using an excessive degree of humor or is constantly joking about his/her condition. This could be a result of being shy about discussion of a physical condition (particularly in more intimate body regions) or to cover hidden emotions from having been ‘dismissed’ by other practices as being ‘psychosomatic’. Although psychological problems can certainly be the root cause or a perpetuating factor in myofascial pain, mysterious symptoms that are often associated with trigger points and other myofascial conditions often baffle practitioners who have no training or skill in treating them. It is easy to dismiss this person as having a problem that is ‘all in the head’, a diagnosis that may significantly affect the attitude and outlook of the patient.

Thick-file patients

The patient who arrives bearing a thick folder, or even a satchel or box, containing notes, records, cuttings and computer print-outs, deserves a special mention. In Europe (and possibly elsewhere) these are often labeled ‘heart-sink’ patients, since this is the effect they may have on the practitioner. Commonly these patients will have been to many other therapists and practitioners and you are probably just one more disappointment-in-waiting, since they seldom seem to find what they are seeking, which is someone whose professional opinion tallies with their perception of what is happening (which may have bizarre elements of pseudoscience embedded in it). Many such patients may be categorized as having ‘chronic everything syndrome’, ranging from fatigue to pain, insomnia, gut dysfunction and a host of other problems, including anxiety and sometimes depression. Some will have been labeled as ‘neurotic’, others may have acquired a diagnosis of chronic fatigue syndrome or fibromyalgia, sometimes appropriately and sometimes not. There are no easy solutions to handling such patients, except to dig deep into the compassion resources that hopefully have not been exhausted.

Conversely, many times this type of patient actually turns out to be a very committed person, who has been consistent in looking for help and has not lost confidence that someone, somewhere can help him. He may have tried everything except soft tissue manipulation. The thick file is a result of a multitude of tests, which have been performed without finding the source of his pain. The missing element in this file may well be a thorough trigger point examination. It is seldom performed in medical examinations and, in the experience of the authors, is very commonly a significant part of this patient’s problem. (Lymphatic drainage is often another key element missing from these files.)

It is important that the manual practitioner should not become discouraged or intimidated by the fact that the patient has already seen a host of physicians (often the ‘best in town’ or those at famous clinics). The fact that there may have been a vast array of negative tests, which have ruled out serious pathologies, should encourage a search for alternative etiological patterns, possibly associated with myofascial trigger points, lymphatic stasis, hyperventilation or any of a number of ‘low-tech’ contributory factors, which have thus far been overlooked. Once treatment of trigger points has been applied to this ‘thick-folder’ patient, who very often has been suffering for many years, pain patterns may resolve very quickly. Although there will indeed be a collection of patients who fit the first description above, the attitude of the practitioner should always be one which offers (realistic) hope and encouragement, especially in the initial and early treatment sessions.

Unspoken questions

One unspoken area of the consultation involves the concerns the patient really wants answered. Seldom said, but always present, are questions such as ‘Will I get better (and, if so, how long will it take)?’ and ‘How serious is this (and, if serious, can you help)?’ It is well established that understanding the nature of the problem, knowing something about its causes and influences is a major therapeutic step forward for the patient. The practitioner’s role should be to educate and reassure (honestly), just as much as to offer treatment. By offering explanations, a prognosis and a plan of action, the practitioner can help to lift the burden. Where there was doubt and confusion, now there is a degree of understanding and hope, but this hope must be grounded in reality and not fiction. This calls for methods of communication between the practitioner and the patient that are clear, non-evasive and not embroidered with fantasy. It also requires a comprehensive grasp of foundational anatomy, physiology, function and dysfunction on the part of the practitioner, in order to be able to confidently (and accurately) convey these details.

Starting the process

‘Where shall I begin?’ is a frequent query when the patient is sitting comfortably and has been asked something such as ‘How can I help you?’ or ‘Why have you come to see me?’ or even ‘Tell me when you were last completely well’. Another approach is to say, ‘Start at the beginning, and from your point of view, tell me what’s causing you most concern, and how you think it began’.

After such a start it is appropriate to ask for a list of current symptoms (‘What’s giving you the most trouble at present? Tell me about it and any other symptoms that are bothering you’). It is useful to ask for symptoms to be discussed in the order of their importance, as the patient perceives things. Following this, a question-and-answer filtering of information can begin, which tries to unravel the etiology of the patient’s problems. During this process it is useful to make a record of dates (of symptoms appearing, life events, other medical consultations/tests/treatments) as the story unfolds, even if not presented strictly chronologically. If the patient has already prepared this in advance, the practitioner should read through the list with the patient as other (and often significant) details may emerge during the discussion.

Whatever method starts the disclosure of the patient’s story, a time needs to come, once the essentials have been gathered, when detailed probing by the practitioner is called for, perhaps involving a ‘system review’ in which details of general well-being, cardiovascular, endocrine, alimentary, genitourinary, nervous and locomotor systems are inquired after (as appropriate to the particular presenting symptoms, for such detailed inquiry would clearly be inappropriate in the case of a strained knee joint but might be important in more widespread constitutional conditions). For the practitioner whose scope of practice and training does not include a comprehensive understanding of these systems, a more generalized inquiry in the form of a case history questionnaire might point to the need to refer the patient to confirm, or rule out, possible contributory problems.

The physical examination

Petty (2006) has provided a summary of what is needed in any physical exam, from a physical and occupational therapy perspective (Table 1.1). Lee (2004) has detailed her perspective on the ingredients for a full objective musculoskeletal examination (Table 1.2).

Table 1.1 Summary of the physical examination*

* (reproduced with permission from Petty 2006)

Table 1.2 Objective examination**

** (reproduced with permission from Lee 2004)

Information garnered through sequential assessment involving observation, joint tests, muscle tests, neurological tests, specialized tests (for trigger points, for example), functional tests, palpation and evaluation of accessory movements can be added to the information gathered from the patient’s history and presenting complaint(s). This should create the basis for formulation of a therapeutic action plan. Many of these tests, for different regions of the body, are described in the appropriate chapters in this book.

In osteopathic medicine, four basic characteristic signs are evaluated when seeking evidence of localized musculoskeletal (somatic) dysfunction. The acronym TART has been used to describe these criteria.

Where a combination of these and other characteristics is located by observation, palpation and assessment, a dysfunctional musculoskeletal area exists. This does not, however, provide evidence as to why the dysfunction has occurred, only that it is present.

The therapeutic plan

In formulating a treatment plan an objective is essential. The means by which the objective is achieved may vary but until there is a review and possible revision, the objective(s) should remain unchanged. This may sound obvious but it lies at the heart of the process of creating a plan of action. Before considering objectives a sifting process is useful, in which the patient and the condition are evaluated in relation to the following types of queries.

The treatment plan needs to take account of the patient’s ability to respond, which depends largely on the patient’s vitality levels. Kappler (1996) summarizes this need by saying:

The old adage ‘Less is more’ is an important lesson that most practitioners learn by experience, often after discovering that too much of a good thing is still ‘too much’ or because a particular approach worked well once, doing more of the same often did not. These thoughts highlight a truth that can never be emphasized too strongly – that the body alone contains the ability for recovery. Healing and recovery are achieved via the expression of self-healing potentials inherent in the mind-body complex (broken bones mend, cuts heal, etc., without external direction). Treatment is a catalyst, a trigger, which should encourage that self-healing process by removing factors that may be retarding progress or by improving functional abilities.

The summary below of possible approaches to treatment of problems such as fibromyalgia syndrome (FMS) offers insights into the need for care in making treatment choices in complex cases and conditions.

A summary of approaches to chronic pain problems (Chaitow 2007, 2010)

When people are very ill (as in FMS and chronic fatigue syndrome – CFS), where homeostatic adaptive functions have been stretched to their limits, any treatment (however gentle) represents an additional demand for adaptation (i.e. it is yet another stressor to which the person has to adapt). It is therefore essential that treatments and therapeutic interventions are carefully selected and modulated to the patient’s current ability to respond, as well as this can be judged.

When symptoms are at their worst only single changes, simple interventions may be appropriate, with time allowed for the body/mind to process and handle these.

It may also be worth considering general, whole-body, constitutional, approaches (dietary changes, hydrotherapy, non-specific ‘wellness’ massage, relaxation methods, etc.), rather than specific interventions, in the initial stages and during periods when symptoms have flared. Recovery from FMS is slow at best and it is easy to make matters worse by overenthusiastic and inappropriate interventions. Patience is required by both the health-care provider and the patient, in an effort to avoid raising false hopes, while realistic, therapeutic and educational methods that do not make matters worse are used and which offer ease and the best chance of improvement.

Choices: soft tissue or joint focus?

In this book, when you are confronted by a series of descriptions of therapeutic modalities and procedures, you will no doubt wonder which should be chosen in relation to treating a particular condition. For example, in the descriptions in Chapters 10 and 11 of low back and sacroiliac dysfunction and pain, a variety of strategies are offered for normalizing the region and/or the restricted joint. The following queries will guide decisions regarding protocols, while still maintaining diverse choices based upon what is found in examination.

Box 1.3 Hypermobility

Benign hypermobility has long been recognized as a connective tissue variant, although at times it relates to specific disease processes such as Ehlers–Danlos syndrome and Marfan’s syndrome (Jessee et al 1980). A link between hypermobility and FMS has also been suggested (Wolfe et al 1990).

It is worth considering that the tender points, used to confirm the existence of FMS are located mostly at musculotendinous sites (Wolfe et al 1990). Tendons and ligamentous structures, in their joint stabilizing roles, endure repetitive high loads and stresses during movement and activity. A possible reason for recurrent joint trauma in hypermobile people may be the proprioceptive impairment observed in hypermobile joints (Hall et al 1995, Mallik et al 1994). Recurrent microtrauma to ligamentous structures in hypermobile individuals may well lead to repeated pain experience and could possibly trigger disordered pain responses.

Prevalence rates of hypermobility

• Caucasian adults 5% (Jessee et al 1980)

• Middle Eastern (younger) women 38% (Al-Rawi et al 1985)

• Hypermobility among Caucasian rheumatology patients is reported as ranging from 3% to 15% (Bridges et al 1992, Hudson et al 1995)

Various studies of hypermobility among Finnish schoolchildren (Jessee et al 1980), rural Africans (Crofford 1998) and healthy North American blood donors (Jessee et al 1980) failed to find a link with musculoskeletal problems. However, when rheumatology clinic patients have been evaluated there is strong support for a link between loose ligaments and musculoskeletal pain (Hall et al 1995, Hudson et al 1998, Mallik et al 1994).

Hudson et al (1998) in particular noted that what they termed soft tissue rheumatism (STR), i.e. tendinitis, bursitis, fasciitis and fibromyalgia, accounts for up to 25% of referrals to rheumatologists, while they report that the estimated prevalence of generalized hypermobility in the adult population ranges from 5% to 15%. In order to evaluate suggestions that hypermobile individuals may be predisposed to soft tissue trauma and subsequent musculoskeletal pain, a study was designed to examine the mobility status and physical activity level in consecutive rheumatology clinic attendees with a primary diagnosis of STR. Of 82 patients up to age 70 years with STR, 29 (35%) met criteria for generalized hypermobility. Hypermobile compared to non-hypermobile individuals reported significantly more previous episodes of STR, as well as more recurrent episodes of STR at a single site.

It is therefore possible that lax ligaments may result in structural joint instability, leading to repeated minor, or possibly more serious, traumatic or overuse episodes. A study of military recruits supports the idea that strenuous physical activity in hypermobile subjects results in musculoligamentous dysfunction (Acasuso-Diaz et al 1993).

There is increasing evidence that at least a subgroup of patients with soft tissue musculoskeletal pain, widespread pain or FMS are hypermobile and although hypermobility is not the only, or even the major, factor in the development of widespread pain or FMS, it seems to be a contributing mechanism in some individuals. Researchers such as Hudson et al (1998) suggest that physical conditioning and regular but not excessive exercise are probably protective.

Recognizing hypermobility

Lewit (1985) notes that ‘what may be considered hypermobile in an adult male may be perfectly normal in a female or an adolescent or child.’ (Fig. 1.1).

Figure 1.1 Testing lumbar extension with patient prone, showing ranges from the starting position shown in Fig. A to varying ranges as shown in Fig. B. A: normal to hypomobile; B: slight hypermobility

(adapted from Lewit 1985).

Greenman (1996) discusses three types of hypermobility.

• Those due to conditions such as Marfan’s and Ehlers–Danlos syndromes in which there is an altered biochemistry of the connective tissue, which often reflects as extremely loose skin and a tendency for cutaneous scarring (‘stretch marks’). There may also be vascular symptoms such as mitral valve prolapse and dilation of the ascending aorta.

• Physiological hypermobility as noted in particular body types (e.g. ectomorphs) and in ballet dancers and gymnasts. Joints such as fingers, knees, elbows and the spine may demonstrate greater than normal degrees of range of motion. Greenman reports that ‘Patients with increased physiological hypermobility are at risk for increased musculoskeletal symptoms and diseases, particularly osteoarthritis’.

• Compensatory hypermobility resulting from hypomobility elsewhere in the musculoskeletal system (Fig. 1.2). Patients with compensation of this sort are very likely to present with painful joint and spinal symptoms. Greenman, discussing the spine, points out that ‘Segments of compensatory hypermobility may be either adjacent to or some distance from the area(s) of joint hypomobility. Clinically there also seems to be relative hypermobility on the opposite side of the segment that is restricted’. (See the discussion of the ‘loose/tight’ phenomenon in Volume 1, Chapter 8.)

Figure 1.2 Muscular imbalance altering joint mechanics. A: symmetrical muscle tone; B: unbalanced muscle tone, with hyper- and hypomobile elements contralaterally; C: joint surface degeneration resulting from this imbalance

(reproduced with permission from Chaitow & DeLany 2008).

• Because it is often the hypermobile segment which is most painful, Greenman points out that the practitioner can get ‘trapped into treating the hypermobile segment and not realizing that the symptom is secondary to restricted mobility elsewhere’. He confirms that ‘In most instances hypermobile segments need little or no direct treatment but respond nicely to appropriate treatment of hypomobility elsewhere’.

• Sclerosing type injections are frequently used by some practitioners to increase connective tissue proliferation and enhance stability (see notes on prolotherapy in Chapter 11, Box 11.6. p. 327).

See also Box 1.4 in this chapter.

Additionally, as mentioned above and discussed elsewhere within this text, there may be times when trigger points may be serving in a protective or stabilizing role in a complex compensatory pattern. Their treatment may then be best left until after correction of the adaptational mechanisms that have caused their formation. Indeed, with correction of the primary compensating pattern (forward head position and tongue position, for instance), the referred pain from trigger points (in this case, within masticatory muscles) may spontaneously clear up without further intervention (Simons et al 1999).