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Regional Arm Pain

Should technology be kicked into touch?

Michael Hutson

The chronicity of much arm pain & associated symptoms is attributable to neural dysfunction - a consequence of adverse upper body posture at work and psychosocial factors - for which there is no diagnostic advantage from contemporary technology

Thankfully, a skilled manual diagnostic approach is rewarding, the common  clinical features including:

  • Secondary hyperalgesia
  • AND (adverse neural dynamics)
  • Cervico-dorsal spinal dysfunction

 …. and appropriate management by:

  • An explanation
  • Ergonomic evaluation
  • Treatment of spinal dysfunction
  • Improvement in environment stresses
  • Reduction of neural dysfunction

A SHORT JOURNEY
Exploration of philosophy and conceptual basis of MSMed practice, with reference to regional pain. Avoidance of hazards
…… the hazards of:

  • Structuralism and reductionalism
  • Nihilism (“slings & arrows”)

Asclepius (“God of medicine”) associated health with the absence of disease
  ….. whereas
Hygeia (“Goddess of health”) considered that health was natural, equivalent to the modern view of “well-being” or the absence of dis-ease
These contrasting views resonate with the current concepts of modernism and postmodernism that permeate the changing face of medicine in the 21st century

HISTORICAL PERSPECTIVE

  • Plato (428-348 BC) – associated the healthy mind, body, and society with the rule of reason
  • Hippocrates (460-377 BC) freed science from the influence of the supernatural ….. his legacy is the empirical approach to detailed observation
  • Galen (130-201 AD) undertook a multitude of experiments, setting the work of Hippocrates within a wider anatomical and physiological framework

From Plato to the present day, scientific philosophy has been based on the existence of discoverable truths, which are universally valid. Despite some scientific progress, the art of medicine was dominant until the Age of the Enlightenment when science, reason and logic became established. The scientific method in the Age of the Enlightenment was based on:

  •  Positivism – a linear approach to explain cause and effect, using facts derived from the senses and reducing them to component parts
  •  Value-free knowledge
  • Rationalism
  • Reductionism

Galileo (1564-1642) laid down the principles of the scientific method of investigation, comparing theories (or models) with the outcome of experiment and observation
Andreas Vesalius (1514-1564) and William Harvey (1578-1657) were in the forefront of modern scientific medicine: 

  •  “Fabric of the human body”
  • “Circulation of the blood”

Gradually, attention switched from the patient to the disease, stimulated by the work of:

  • Robert Koch (1843-1910) – a disease conforms to his (Koch’s) postulates
  • Louis Pasteur (1822-1895) – helped to develop the sciences of bacteriology and microbiology
  • Rudolf Virchow (1821-1902) – stimulated the development of histology    … “Die cellularpathologie”, 1858

THE MODERN ERA
The biomedical model became established towards the end of the 19th century
 … and has persisted as the dominant model in medicine today
The disease-illness construct of contemporary medical practice is predicated on the biomedical model, embracing positivism and rationalism
The Medical Act of 1858 gave rights to practice medicine to doctors, relegating other practitioners to “alternative” health care practice
The hegemony of medical practice, supported by an emerging welfare state, developed in the second half of the 19th century
The hegemony of medical practice has only become undermined within the last one or two decades in which CAM, mind-body medicine, and new-age philosophies have established a much greater resonance with sections of the population
The emergence of EBM supported the biomedical model – a natural consequence of the increasing demands of (and “for”) a reductionist approach, combined with increasing awareness of the need to improve cost-effectiveness
Despite recent trends, in which over-reliance on EBM is criticised (and EIP – evidence informed practice - is advocated by some) ….
Traditional science continues to dominate …. driven by the advance of technology

THE ADVANCE OF TECHNOLOGY
  …… strengthened by the perception that “objective technology” diminishes the much-maligned contribution to patient assessment (and management) of subjectivity …..
  …… a concept that is roundly condemned by postmodernists

  • Laennac developed the stethoscope in 1816
  • Roentgen …. X-rays in 1895
  • Mansfield et al MR imaging 30 years ago

… providing precision, certainty, and evidence that medicine is “scientific”

HOWEVER …. IN PRACTICE, TECHNOLOGY TENDS TO PERFORM LESS WELL

  • Disagreements in interpretation of results
  • Difficulties in correlation of “abnormalities” with symptoms
  • Confusion regarding management of “non-organic” conditions

According to Dixon and Sweeney (2000) …….“Certainty” was being manufactured (by science and technology), where doubt continued to confound”
(Dixon & Sweeney (2000) The human effect in Medicine)

CURRENT TRENDS
Medical practice is changing – a consequence of diverse factors …

  • An increased interest in humanism
  • An awareness of the flaws in EBM
  • An acceptance of value judgements
  • (for some) belief in heuristics

CURRENT TRENDS AND PERCEPTIONS
An emphasis on health and “dis-ease” rather than disease
Recognition of limits to traditional science, which is perceived as …..
… dealing with generalities than individuals, not the whole picture
Health workers are gaining equivalence to doctors …

  • MCPs (medical care practitioners)
  • Nurses that prescribe
  • Physiotherapists that inject
  • Musculoskeletal medicine BEWARE!

For MSK disorders, community based patient management is gaining equivalence with secondary care …..
 … thereby distorting (& undermining) traditional power bases and interdisciplinary relationships
There is greater recognition of the unpredictability of human responses, for instance behaviour and suffering
Disease is increasingly understood within the context of the sick person and his suffering

Uncertainty and indeterminacy are always present in medicine

Grieves (1996) stated that traditional science promotes “medical technology in a way that is objective and morally neutral, and by contrast any activity which does not conform to its tenets becomes viewed as retrogressive …”
Grieves (1996) The expansion of technology “hinders medical practice” (Greaves, D “Mystery in Western Medicine”)
Robert Kidd (2005) “… a corrupting effect on the practice of medicine …. a veneer of scientific legitimacy” (Kidd, R “Neural Therapy”)

DISEASE AND DIS-EASE
Cassell (1991) has focused on suffering and health
 “a technological positivist approach to medical practice …. endangers our fundamental responsibility – relief of suffering”
(Cassell, E (1991) “The nature of suffering and the goals of medicine”)
Ivan Illich (1973) identifies health as the process of adaptation to life’s stresses, ageing, disease and death, by the use of coping mechanisms associated with prevailing culture(Illich, I (1973) “Medical nemesis: the expropriation of health”)
 There is more than a suspicion that conventional medicine, society and culture have created a nanny state with respect to health issues – to the disadvantage of individuals’ capacity for self-management
As a consequence of over-reliance on EBM, and the dominance of technology, there is a tendency to label somatic complaints that are diffuse, widespread or unusual as MUS (medically unexplained symptoms) ……often inappropriately

PATIENTS WITH DIFFUSE REGIONAL PAIN
….. benefit from careful neuromusculoskeletal evaluation, using core manual diagnostic procedures that are at the heart of Manual or Musculoskeletal Medicine – to identify somatic dysfunction

COMPLEXITY THEORY
Per Bak (1947-2002) became interested in the complex behaviour of systems “on the edge of chaos”
According to complexity theory, many biological systems are characterised by uncertainty, unpredictability and non-linearity
In complex adaptive systems, agents have freedom to act in ways that are not always totally predictable, but whose actions are interconnected ……… so that one agent’s actions change the context for other agents
This construct is essentially holistic, offering an explanation for unpredictability that is an essential feature of many biological and ecological systems
…WHICH IS CONSISTENT WITH MY PREMISE

Uncertainty and indeterminacy are always present in medicine

REGIONAL ARM PAIN
The chronicity of much arm pain & associated symptoms is attributable to neural dysfunction - a consequence of adverse upper body posture at work and psychosocial factors - for which there is no diagnostic advantage from contemporary technology

In the absence of identifiable relevant pathology, regional arm pain (type 2 WRULD or NAP) may be viewed using the complexity model
Characteristic “diffuse” symptoms are associated with the interaction of diverse factors - psychosocial and ergonomic
PSYCHOSOCIAL AND ERGONOMIC FACTORS

  1. Repetitive stereotyped work
  2. Adverse ergonomics
  3. Psychological (e.g. work) stresses
  4. Frank psychiatric illness
  5. Misattributions and beliefs
  6. Iatrogenesis
  7. Litigation

Science and technology are not rejected, but their relevance to dysfunction and dis-ease has to be questioned and the socio-political-cultural implications of the use of technology recognised  …. so that quality is accepted as important as (or should replace) “truth”

APPLICATION OF M/MM TO REGIONAL ARM PAIN

  • Holism
  • Humanism
  • Wisdom

HOLISM: beautiful, eclectic & satisfying, in which decision making accepts unpredictability; demanded of complexity
HUMANISM: value judgements & patient participation in decision making
WISDOM: the ability to apply compassion well, allied to a sound evidence base, and an ability to see ……
…..  “the content of the container”
“Science cannot solve the ultimate mystery of nature.  And that is because, in the last analysis, we ourselves are part of nature and therefore part of the mystery that we are trying to solve” (Max Planck (1858 – 1947))


EVEN SO, LET’S HOPE WE REACH THE PROMISED LAND OF MUSCULOSKELETAL MEDICINE



Mike Hutson is the author of Musculoskeletal Medicine

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