LOL! Well, Pain is a specialty that is available (in theory) for psych residents to apply to.
I wouldn't count on manipulative medicine to be of much use in a patient who is already on scheduled percs. I just don't believe psych and manual medicine are appropriate. Not because of the assumed reasons, but I believe that by the time a person has an interplay of the two issues manual medicine isn't going to correct the problem or break the cycle. You need a heavy hitter like injections.
Plus, now and days most MSK issues are from obese/overweight patients where their issue is not their knees hurting or their low back, but their huge belly. You can only optimize the structure of a mechanical wear and tear so much before you are trying to hold back the pannus tide.
LOL pannus tide. I love that!
But the idea that psych and manual medicine aren't appropriate for someone on scheduled percs is kinda shortsighted.
My interest in pain and disability grew because I realized how easily we write people off, even though often enough its out of compassion.
Now, with the caveat that some people are simply neurologically predisposed to feel more pain than others with the identical injury, at bottom pain is a subjective experience. And evolutionarily speaking, pain is a behavioral issue. The whole point of pain is to change your behavior.
Staying within the evolutionary realm for a minute, bodies for the most part did not evolve to cope well with chronic injury. Predators prey on the sick and the weak. Congeners outcompete the sick and the weak. An injury that significally compromises one's physical abilities is very likely to kill them before they recover.
Survivers of major traumatic injury and chronic MSK issues within the animal kingdom are thus largely restricted to certain social animals: most prominently elephants,social carnivores, and certain primate groups. Because only inthese cooperative group structures can one be supported long enough to heal, or even less likely, be tolerated and supported despite lifelong debility.
We can see that in how easily various injuries heal based on their short-term survivability in a relatively unsupported environment. Contusions are easy. Strains and sprains less so. Partial muscle tears do heal, badly. As do bones. But a spinal cord injury? perhaps they heal so badly because there's never been an evolutionary advantage to being able to heal well in that domain. You're likely to die long before a spinal cord could ever hope to heal from malnutrition or depredation.
Now with that context in mind apply it to the chronic pain patient. An antalgic limp or restricted range of motion is great for an acute and recoverable injury. It allows the affected part of the body time to heal. And two or three weeks of limping won't destroy the rest of your body.
Take a look at the hip joint of someone with a chronic limp 5 or 10 years down the road...doesn't work out so great in that chronic environment.
Not wanting to be in pain is great in an acute setting. How does it work in the long term. When you have pain. When you are going to be in pain. And it will never get better. Should your whole life revolve around the pain, or should you start to look past it?
I'm starting to get way off topic, but I think it's easy to see how antalgia...the driving force in behavior in acute injury across the animal kingdom...while it works in the short term is a bad idea in the long term.
The antalgic mind is the reason people don't fling themselves into physical therapy with gusto. Because it hurts. Oh my god it hurts. Most able bodied people coudln't keep up with my rehab regimen without trying to stab themselves in the eye with a red-hot fork. It's the reason they find their lives growing ever more restricted. Because doing things hurts. It hurts a lot.
It's the reason after their knee injury they limp. Because it hurts less. And then as the limp destroys their hip, they limp even more. And then their posture goes. And then their back starts to go. So their posture worsens. And pretty soon it's all over but the disability payment.
And can you imagine the psychological horror of living a life in which the things that give you pleasure hurt you? A jackass of a neurologist once stated at a national conference that he believed that sympathetically-mediated pain was a psych issue since so many of them have psychological comorbidities (vast majority have depression or anxiety. More than a quarter will attempt suicide. etc). I have an anecdote I like to tell about that. A 16 year old kid who'd had a sympathetically-mediated pain syndrome was on his first date. He's nervous as heck and the girl next to him is unaccountably beautiful. Something which confuses the heck out of him. For whatever reason she's actually into him. As she leans against him, he says what the hell and puts his damaged arm around her. In the seconds and minutes leading up to that agonizing decision, his arm is absolutely on fire. He's jittering like a meth addict in need of a fix but he goes for it anyway. And he's in ungodly pain the whole movie, driving back, walking her up to her door, and driving home. Instead of the cold shower you'd think he needed, he went for a hot bath instead and spent most of the night massaging...his arm. Any time he's excited, or afraid, or aroused in any sort of way, his ever constant pain is going to flare up like the fourth of july. Imagine what that'll do a person and tell me it's not a psych issue.
Earlier this year I worked with a chronic pain patient to get off his narcotics (he was on 10mg methadone QID) and he's never been happier. I myself am someone with severe chronic pain. I've rattled off a list of the physical issues on here before, and it's extensive. I get told that I shouldn't be able to do what I do. Over and over again. Like a broken record. Part of its genetics. I would bet that i'm homozygous for every freaking gene that influences resilience that we could ever find. But a part of it is psych as well. The most important part. I belong to an extremely psych-oriented faith which has helped me challenge the various stupidities that have cropped up over the years.
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Pain is a subjective experience. More importantly, it's a pervasive experience. Psych can help with the experience of pain. It can help with the cognitive-behavioral distortions of the antalgic mindset. It can help with motivation in rehab. It can help with the interpersonal and psychodynamic issues that WILL crop up. I often say that there is no such thing as a person in chronic pain without psych issues. And I mean that.
