Does musculoskeletal care thrive because there are so many groups of healthcare professionals working in it? Does the care benefit or suffer from some competition and rivalry between different professional groups? Or is communication so variable that cooperation is difficult to achieve?
These are just a few of the questions which may come to mind, when you read the book review in our previous issue (2013 No. 2) of Pain Comorbidities, edited by Maria Giamberardino.Citation1,Citation2 If you did not read it, you missed an interesting three pages. The book explores research and ideas relating to the fact that typical chronic pain patients almost always have more than one physical condition, and almost always have one or more psychological problems continuing, and are likely to have social problems also. These will need different professional skills; and I would say that the stress that this puts not only on the patient, but also onto the healthcare system is there for all of us to see.
In his review, FoellCitation2 is very fair to all the players, but he is portraying the strange disarray that greets the chronic pain patient. In so many of these patients, musculoskeletal symptoms are an important part. More and more is now known about the causation of chronic pain, its course, and methods of alleviating it, or of alleviating its effects. But in practice, how well is this knowledge applied for the benefit of the patient? Are not Foell and Giamberardino showing that the patient's ‘journey’ in this area of healthcare may look a bit like Gulliver's Travels? If the inhabitants of Brobdingnag, Lilliput, and Laputa are shown by Jonathan Swift to be working away earnestly in their various strange ways – rather as he saw European government in the eighteenth century – should we not take care that our difficulty of bringing physical assistance, psychological assistance, and social assistance to our patients might not be caricatured also?
As FoellCitation2 says, it isn't the modalities of multidimensional treatment that are the problem, it's the people who deliver these modalities; or rather, certainly in the British National Health Service, the administration which seems to separate, rather than bring these people together.
It brings to mind a case observed over 20 or more years: a woman who has led the life of an invalid, with musculoskeletal pain. Early on, the simple diagnosis of fibromyalgia was questioned – could the inability to walk more than a few metres be her only problem? Referral to tertiary care specialists was arranged, but nothing else was ever found. Gradually, she became bedridden for most of the day. The general practitioner did well to rationalize and minimize the medications, such as diazepam and non-opioid analgesics; but from time to time requests for more help had to be responded to. In recent years an inpatient stay in a tertiary care hospital brought no real physical or psychological change, and that hospital's request was for 6 months of physiotherapy and for occupational therapy help. The physiotherapist was not able to get the patient standing again, or walking; the occupational therapist arranged for various physical aids to be delivered – but they were discarded as being of no use. It seems typical that each of these new attempts at help was a professional ‘new’ to the patient; the only constant in her life was the primary care doctor.
The primary care doctor is so often in the strongest position to judge the individual's needs, but whether he/she can influence the often independent regime of the other healthcare workers, is another question! At least there is the possibility: and therefore it would be a pity if expertise in musculoskeletal care at the primary care level were to be diluted or transferred. But because there will seldom be more than one or two severe cases of this type in a single doctor's practice, there must be help from those with more concentrated experience and expertise. The patient's first port of call needs easy and helpful assistance both vertically up the specialist tree, and horizontally across the spectrum of different advice for those comorbidities.
IMM is happy to report, in this issue, the recent meeting of the International Academy of Manual/Musculoskeletal Medicine, where all the disciplines involved in musculoskeletal care were welcome, to unite in discussing the latest research in the science and the art of musculoskeletal care.
References
- Giamberardino MA, Jensen TS. Pain comorbidities – understanding and treating the complex patient. Seattle: IASP Press; 2012.
- Foell J. Book review: Pain comorbidities. Int Musculoskel Med 2013;35:88–90.