UPFRONT | Columnist BUSINESS TALK The future patient history I Why practitioners are missing the mark BY DR. ANTHONY LOMBARDI penned this piece while on an over-night flight from Hawaii to Vancou-ver in early January 2022. Once I reached Vancouver we caught our connecting flight to Toronto five hours later. In total my family and I flew 10 hours across five times zones. Jet lag was something that we would experience over the following days after two weeks in Honolulu. Why was this appropriate to this topic? Because after two weeks in Hawaii, our autonomic nervous system was about to make the adjustments it needed to reset necessary function – and in at least 60% of our patients, the autonomic nervous system is dysfunctional to begin with. In school, if we are fortunate, we learn a multitude of orthopedic, neurological, and kinesthetic testing. Moreover, we learn an alphabet of history taking ques-tions. However, as manual practitioners, the history and testing are geared to treating mechanical dysfunction. This means that if we are not aware of the effects of co-morbidities, then we will be treating our musculoskeletal patient in-correctly. In fact, this is what is happen-ing among chiropractors, medical prac-titioners, acupuncture practitioners, and massage therapists across the majority of our planet. I have been teaching the above practi-tioners in an academic setting for the last 18 years, and each time I cover the role of the autonomic nervous system on musculoskeletal pain they are astonished to realize the clinical consequences of misreading mechanical dysfunction in co-morbid patients. What is the autonomic nervous system? In brief, the autonomic nervous system (ANS) is in charge of involuntary bodily functions. Breathing, heartbeat, circulation, digestion, and especially our had at least one of seventeen co-morbid-response to constant or repeated stress ities. This is likely to increase with age in -are all products of the ANS. There are western cultures due to poor diets, poor two distinct and opposite parts to the sleep habits, mental health conditions, ANS: the fight or flight (sympathetic) lack of exercise and overall higher levels and the rest and digest (parasympathetic) of family and work stresses. In a landmark study in the European nervous systems. In short, pain activates Journal of Pain by the journal of the sympathetic nervous, but so does co-morbidities. If we are not (name the journal), two groups Therefore, musculoskeletal aware of the of patients with neck pain asso-effects of ciated with fibromyalgia diag-pain plus co-morbidities equals what is called: high co-morbidi-nosis were randomly selected to sympathetic tone. ties, then we three groups. One group re-What are examples of will be treating ceived intramuscular acupunc-ture in the motor point of the co-morbidities? Any physi-our [MSK] cal or psychogenic systemic upper trapezius muscle (GB patient illness, condition, or disease is incorrectly 21), the second group received considered a co-morbidity. I acupuncture at cutaneous depth refer to these as chronic systemic char-only at the same site, and the last group acteristics. This means any autoimmune, received sham acupuncture at the same systemic inflammatory, metabolic, or location. The results? The sham group ongoing psychological disorder. Com-reported no change in pain/function, mon examples we see everyday in prac-the cutaneous group reported a signifi-tice are: diabetes, diabetic neuropathy, cant improvement in pain and function, fibromyalgia, chronic fatigue, rheuma-and the intramuscular group reported a toid/psoriatic arthritis, ankylosing spon-significant amplification of their muscu-dylitis, lupus, metabolic disorders, skel-loskeletal pain. The reason for this? etal deformities like scoliosis, spinal Muscle spindles are richly innervated stenosis and severe degenerative arthritis by sympathetic nerves and an irritation – to name a few. Also, anxiety, depres-of this in a patient with chronic system sion, and alcohol or drug dependency characteristics will increase sympathetic can also qualify as a chronic systemic tone leading to more pain. (source?) characteristic. The consequences If we perform a misdirected patient history, we could potentially apply ma-nipulative, soft-tissue, or acupuncture interventions that will slow clinical progress or more likely amplify the pa-tients’ pain symptoms. In 2018, the journal BMC Musculoskeletal Disor-ders reported that of their sample size pf back pain sufferers -over 60% of them Time to re-write (patient) history The rubric I teach is simple and effective for revealing chronic systemic character-istics in musculoskeletal patient pain presentation. It focuses on branches of three questions: When, What, Where. WHEN When did it start? Establishing a time-line is a simple start. Chronic systemic conditions most often have been around for a very long time -even if the muscu-loskeletal pain has only been present for a few months. The initial patient history www.Cndoctor.ca ANTHONY LOMBARDI, DC, is a private consultant to athletes in the NFL, CFL and NHL, and founder of the Hamilton Back Clinic, a multidisciplinary clinic. He teaches his fundamental EXSTORE Assessment System and practice building workshops to various health professionals. For more information, visit www.exstore.ca. 6 Chiropractic and Naturopathic Doctor March/April 2022
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