Tuesday, September 10, 2013

Persistent Pain, Part 2 (Everything Else)

For Acute Trauma, Severe Injury, and Disease... Always see your M.D.

For everything else, what can you do?  In part 1, we covered how the persistent pain starts, and how most of us trouble shoot it until we have exhausted our basic knowledge.  Which can often end with an unsatisfying experience with your typical M.D.

If you've read my previous posts, you'll know I'm not the "Appeal to Nature" type.  Modern Medicine has done many amazing things, but right now it is rubbish for the most typical pains that we all live with: low back pain, neck stiffness, headaches, shoulder pain, and of course foot and ankle pain. These conditions send millions of people to their family doctors, cost billions in healthcare annually and countless people just have to live with it.  So what can be done for them?

What's My Alternative: Things that may be worth trying

You don't want to be defined by a cranky ankle.  You've tried everything you knew to do, and your General Practitioner didn't help much.  Now what? For most people: Internet Search. (I'm assuming you don't look for answers at Pubmed)

With a basic search, you've gone from no clue to being confronted with too many possibilities.  Assuming you don't limit yourself to solutions with documented evidence, the sky is the limit.  From the statistics, it looks like most people still want an "expert"  and some kind of "medicine" to treat them, and they don't much care if those treatments are evidence-based.

So, what about Acupuncture?   Here, you may get perfectly practical treatment.  Dry-needling for example, can be useful in changing pain states, and has some evidence to back it up.  Most of the time, however, what is being treated is based on what amounts to a mistake due to poorly-translated Chinese.  Energy and Meridians didn't exist in the original ancient texts and are a construct of early 20th century translational misunderstandings. Which hasn't seemed to stop anyone from claiming it as effective, despite regularly getting "no better than a placebo" reviews by the major medical journals or at best: About 10% better than sham treatments.  You will likely be asked to come in for multiple treatments, and you will not be likely to receive a clear and reasonable explanation for why you hurt.  If you are living with pain and nothing else works, it is worth giving a try, but make sure you go to a well trained professional.  The consequences of a small miscalculation can be life destroying.

How about Herbal Medicine? (supplements, herbs, and nutrition)  Here we have a different kind of pill to take, often expensive and rarely tested properly.  Sometimes Poisonous. It is tempting to imagine that pain could be a symptom of some nutritional problem, or that supplements like Glucosamine could help.  Evidence is mixed here, and far too complicated to address in one blanket statement.  My advise?  If you want nutritional information, go to a dietician; someone with medical training at the college level.  If you want to try herbal stuff, make sure your supplements have some evidence behind them, as most don't and can quickly cost you hundreds of dollars.

Chiropractic?  You want to see different kind of doctor, usually get an xray, but there is no medication to take.  Not all chiropractors are the same.  The treatment you receive here can be practical  such as manual therapy and rehabilitation exercises. But much more often, the treatments are baseless or scientifically disproved; such as applied kinesiology, detoxification, or spinal subluxations. Most chiropractic treatments are focused on the spinal joints supposedly impinging nerves and affecting surrounding tissue.  You may get a back adjustment to fix your ankle (or even your allergies.)  The subluxation of the spine model has been written off by many chiropractic authorities:Here is one.    And another.  The experience, most of the time, is to be asked to come in 3 times a week at first, and keep coming (slowly tapering down to monthly) in some capacity forever.  If you choose to go to the chiropractor, go to several and really listen to what they have to say.  Find one that gives you a clear understanding of what is being treated and how the applied treatments will help. 

Exercise and Yoga?   Generally, these can be both pain creators and pain reducers.  Ignoring the spiritual and energy faith practices of Yoga, I'm an advocate of most movement and exercise regiments to reduce pain.  The evidence, however, is still quite mixed.  As an example of how mixed: exercise (unsupervised) has been shown to decrease future ankle problems, while exercise (supervised) has been shown not to help much. And of course, you'll also get a fair amount of nonsense included with your practical exercise advice.  Back pain, for example, probably has nothing to do with a "Weak Core."  You will likely hear a lot of "no pain, no gain" with some trainers going so far as to claim that the pain holding you back can be cured by toughing through it.  Pain is a warning message, and it is best not ignored completely.  Be sure to find someone you trust not to push you into injury.

I'm excluding Physical Therapy, Occupational Therapy, and other rehabilitation medical professionals here. Seeing one of them requires a referral from your M.D., which would makes this whole section not really apply to you.  I have a lot of respect for PT and OT treatments, although they too can fall short of following the best available evidence and science.  Many of my patients come to me because their insurance didn't cover the amount of PT/OT sessions they needed, or because they didn't know where else to turn after conventional and/or alternative treatment didn't work, but I'd always rather they come to me AND get conventional treatment.

In part 3, I will discuss massage and my own approach. What should you expect if you see me for your persistent ankle (or any other) pain?

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