“It’s all in your head”, noted rogue London neurosurgeon, Henry Marsh, on a recent visit to Australia.
As someone whose tamperings have altered more people’s memories and capabilities than nearly any other, he speaks with some authority. Marsh asserts that the brain is the ultimate integrator of the psyche and the soma, and that its role in formulating our perceptions is paramount.
Nevertheless, convincing patients that the brain is where they feel their calf pain is a common and often difficult task for GPs.
“The problem’s in your back where your sciatic nerve is getting squished. However, you feel the pain is coming from where the nerve goes, and that’s down your leg. You're actually aware of the pain because of the nerves going the other way, up to your brain.”
“That’s not much comfort, doc. How about some pills to get rid of the pain?”
This seems like progress. At least we both agree that the final common pathway for pain perception is the brain. However, our therapeutic armamentarium has been sorely depleted in recent years. Paracetamol, non-steroidals and pregabalin have all had their day in the sun, only to be deemed ineffective by night fall.
Narcotics are not much better (and may be worse) and Australia is on the same path to a prescription opioid epidemic as is currently being experienced in the USA. On recent figures three million Australians, received 15 million prescriptions in 2014 and 600 people died.
“You’re not much of a quack are you, doc? The chiro reckons he’ll get me sorted if I sign up for his two year maintenance plan.”
“What about one of them MRIs? My neighbour’s got some bulging discs and he’s a lot better after some spinal injections.”
Unfortunately the correlation between symptoms and MRI changes is poor. Degenerative or narrowed discs occur in more than 60% of cervical spine MRIs in asymptomatic subjects aged more than forty.
Even if something shows up, in the absence of focal neurological symptoms, it is unlikely that injections will provide more than mild short term relief. The results for spinal fusion are not much better.
In recent years it has been appreciated that patients’ resilience plays a major role in chronic pain. Anxiety, depression, stress and a tendency to catastrophise issues contributes greatly to a patient’s perception of pain. Similarly, as has been previously discussed in GPSpeak, low job satisfaction and adverse early childhood experiences are also associated with a more severe experience of pain.
As a result, a more comprehensive approach to pain management using a biopsychosocial approach has been the focus in recent times.
The Local Health District's Pain Management Services have been a great resource for North Coast GPs and their patients, but demand far outstrips their capacity. Thankfully, chronic disease management plans allow patients to link up with exercise physiologists and other health professionals to manage their pain.
“So what are we going to do now, doc?”.
“Well you’ve had the pain for more than three months so this is not going to go away in a hurry and there’s no magic bullet. We don’t want to waste your money and we don’t want to make you worse. Some people see physios or chiropractors or masseurs. Some people like acupuncture but the things that work best are the ones where you move.
“Losing weight helps and eating sensibly is the best way to achieve it, but we probably should have started with that 10 ten years ago. Nevertheless if we can get your weight down 5 kg, we should see a 30% improvement in your knee pain and function.
“You need an exercise program. People often do yoga, tai chi or pilates. The cartilage in your knees and back has some restorative capacity and the best way to stimulate that is with light impact exercise.
“How about buying a dog, and walking it at 6 am every morning?.”
To know more about the science behind this approach, Dr David Hunter, Professor of Medicine at Sydney University, has summarised our current understanding of the optimal management of musculoskeletal pain and also explained it in conversation with Dr Norman Swan.