Why Conventional Medicine will always fall short in the treatment of chronic pain

Firstly, its important to note that most chronic pain (long term, dull, achy) is soft-tissue (muscle, tendon, ligament & fascia pathology) in origin. It is estimated 75-95% of regional (chronic) pain is myofascial (muscle and/or fascia pathology). Furthermore, most soft-tissue pathology does not show up on medical scanning techniques (x-ray, MRI, ultrasound etc) or blood tests, meaning medical investigation may not reveal the ’cause’ of your pain.

Chronic Pain is a health problem, so your doctor or the NHS is the place to go to get your pain (musculoskeletal issue) treated, right? If your really lucky you will be referred to a pain consultant, neurologist, or rheumatologist who can diagnose and fix your problem, sorted! After all, no one could be better qualified to treat chronic pain than a highly intelligent, top medic who has spent 10 years studying evidence based medicine (and 5 further years specializing), can they? Besides, even if you don’t get a consultant referral, an NHS physio should be able to sort you out with some decent treatment, no?

If you have ever suffered with chronic pain and gone the conventional medicine/NHS route you are likely to have found yourself somewhat frustrated and disappointed with your treatment options. What use is a diagnosis if your still stuck with the pain, or just ‘dosed up’ on painkillers? But why is this? With all the science, money, specialist consultants, physios and specialist equipment, why does conventional medicine still struggle so much in the effective treatment of chronic pain? In this blog I aim to discuss some of the main reasons I feel conventional medicine falls short, and will continue to do so, unless it integrates specialist ‘hands on’ practitioners into the NHS.

Perhaps the most important point is that most chronic pain is ‘soft tissue pain’. Interestingly, no medical specialty covers ‘soft-tissues/muscles’. We have neurologists, rheumatologists, orthopaedic surgeons etc, but no ‘musclologists’! Soft tissue pain, of course, requires soft-tissue treatment… MASSAGE! Massage (& Bodywork) Therapy are not part of conventional medicines remit. Therefore, if you are going to a ‘Pain Consultant’ with chronic, soft tissue pain, they are unlikely to be highly trained in the specialist massage and myofascial treatment required to effectively address your pain! Even, by some miracle, if the consultant is a highly skilled soft-tissue therapist (ie. Level 5+ qualified, including extensive trigger point therapy & myofascial release training) they would not be able to book you in for a 1 hour treatment on the 4-8 consecutive weeks required to address soft-tissue pain (neither can your GP, in a 10-12 minute appointment slot). You get your half hour, a prescription, possibly booked in for a ‘pain treatment procedure’, or referral to a physio. So, why can’t the physio just do the required specialist hands-on treatment to address your pain?

Contrary to popular belief, most physios are not experts on ‘hands on’ treatment (esp NHS/junior physios) . Generally physios are experts on rehabilitation (teaching you exercises/stretches to help your body heal & repair). Their degrees are packed full of information on anatomy, pathology, theory, electrotherapy, exercise, diagnostics, and neurological/respiratory/injury/surgery rehab; there is very little time left for ‘hands on’ interventions (I have been told many modern physio degrees don’t even include massage training). More and more, physiotherapy is moving away from ‘hands on’ treatment, and focusing on motivating the patient to help themselves with rehab. This is a noble aim, and important, but most soft tissue pain also requires decent soft tissue (massage/myofascial) treatment, at least until the stage your pain is reduced enough to effectively do your rehab. Few physios have high level massage & bodywork skills, most of their massage training is also taught by physios who may also lack massage/bodywork expertise. To give physios a sound knowledge of massage/bodywork treatment university’s would have to add (at least) a year to their degree courses, or cut a massive amount of their current syllabus to make way for this training; neither is going to happen! To get specialist soft-tissue treatment you need to go elsewhere, or find a physio who has extensively trained in specialist massage & bodywork before, or after, their physio degree.

So what about the specialist procedures, injections and operations the doctors employ, to treat chronic pain conditions? Unfortunately, most of these options do not actually treat the soft-tissues of the body. The aim is usually to reduce the symptom (pain sensation, or inflammation), as with painkillers, not actually address the cause of the pain (eg. soft-tissue pathology, musculoskeletal problems). They can help relieve the pain (often they don’t) but they may not treat the causative problem; often the relief is also short-lived or not acceptably substantial. Another point to consider is that chronic pain conditions are complex and multi-faceted. Medical pain treatment procedures usually target 1 part of the chronic pain picture, looking for the single ‘silver bullet’ to fix the issue. Unfortunately, a course of treatment is usually what the body really needs; holistic (complementary medicine) treatment does this while attempting to address all aspects of the chronic pain picture. I will give an example to highlight my point:

Facet joint injections for lower back pain

A common, conventional treatment for lower back pain is facet joint injections. These aim to reduce pain and inflammation in the compressed/irritated lumbar facet joints to reduce back pain. But what aspects does the conventional medicine treatment fail to address:

  • Muscle imbalances which have caused the facets to become compressed by hyperlordosis. A massage therapist would lengthen hypertonic muscles/fascia to reduce facet compression.
  • Painful trigger points causing dull-achy pain. Trigger point therapy (massage) would address these to reduce chronic myofacial pain.
  • Restricted fascia around the back/pelvis. Myofascial treatment could release this easing pain/stiffness, and correcting aggravating structural misalignment.
  • Fixated (stuck) facet joints. Mobilization and/or manipulation could free up painful stuck facets, restoring lumbar biomechanics.
  • Muscle spasm and fascial tension. Massage and myofascial treatment can be used to address spasm and tension which may be contributing to chronic pain.
  • Visceral restrictions around the abdominal organs which refer to the lower back, or cause related muscular spasm.

As you can see from my example, chronic pain is not simply the ‘one thing’ which medical procedures often aim to address. Many of the aspects which need treating, also need ‘hands-on’ interventions outside of the remit of doctors (and many physios). If you need/want medication, injections, rehabilitation or surgical intervention conventional medicine can cater for you well, however for specialist hands-on intervention for pain/injury it falls well short.

So the solution is simple then, conventional medicine/NHS just needs to employ Massage/Bodyworkers to address chronic soft-tissue pain, and Osteopaths/Chiropractors to address neurological & joint pain. If only, but where is all the extra money going to come from to pay for 1000’s of extra NHS staff, when the NHS is already understaffed, underfunded and overstretched; higher taxes? Surely all the hospitals, community hospitals and larger GP surgeries could employ Massage Therapists & Osteopaths instead of Physiotherapists, to get better results in treating chronic pain? Not really, they (rightly) cannot ‘fire’ current physios to make way for complementary therapists, without good cause. Also, if NHS institutions started to hire non-medically trained (ie. unqualified) Massage Therapists & Osteopaths, instead of physios, the physios (& CSP) would be up in arms… “their taking our jobs, and there aren’t enough jobs to go around as it is!” Therefore, even if NHS institutions had the foresight to employ a percentage of complementary ‘hands-on’ therapists, instead of physios (for chronic pain treatment), it would not be easy to implement (and NHS budgets may not allow non-physio employment).

In 2009 NICE decided the evidence for massage, osteopathy, chiropractic and acupuncture was good enough with back and neck pain, to allow NHS funding for these treatments through the Any Qualified Provider (AQP) route. Many complementary therapists (and patients) were excited, hoping that ‘at last’ patients could easily get decent hands-on treatment for chronic pain, on the NHS (as an alternative to Physiotherapy). Unfortunately bureaucracy & regulation put many obstacles in the way of this happening. NHS Clinical commissioning groups (CCG’s) were only looking for large-scale musculoskeletal practices in their area, which tended to be the bigger private physio clinics (all but 3 AQP contracts in Hampshire were physio clinics). Most of the Massage & Bodywork Therapists (soft-tissue specialists) best qualified to address chronic (soft-tissue) pain were one man bands, who had no chance of securing a contract. Further to this, clinics who tendered for the AQP contracts had to to undertake unnecessary, costly and time consuming training, deal with endles ‘red-tape’ and prove their treatment effectiveness through statistical data (which most therapists don’t have). This took months of work and many great therapists were either too small to apply for AQP, could not meet the required criteria, or decided it wasn’t worth the hassle! It’s turns out the ‘Any’ in Any Qualified Provider was far from literal, and most complementary therapy providers could not get NHS funding! NHS funding of soft-tissue specialists therefore remain a rarity.

This last point I wish to address in this blog, which deserves a blog all of its own, is if Massage & Bodywork is so ‘amazing’ at treating chronic soft-tissue pain, surely the scientific evidence would reflect this? Well no, sadly not! Why is this? Its quite simple really; there is no money to be made in proving massage is highly effective in treating chronic pain. This is because there is no ‘product’ to sell at the end of the study (eg. drug, biomedical technology, retail product). If your going to invest £10million in a good quality, large scale randomized controlled trial (RCT) you have to be pretty sure your going to make at least £20million back! Most massage schools, therapy teachers and (massage/bodywork) professional bodies are not valued at the cost of one, good quality study. Good quality scientific evidence remains the privilege of pharmaceutical giants, biomedical companies, multinationals and governments, ‘you get what you pay for’. Conventional medicine is ‘evidence based’ so makes it treatment decisions based on the best evidence, pay-rolled by big business. Doctors are not about to prioritise hands on treatment (with sketchy evidence) they cannot do, over proven drugs, biomedical procedures and operations within their remit!

In summary, the majority of chronic pain is soft-tissue in origin. The best people to treat chronic soft-tissue pain are not, in fact, the doctors and physios who treat it in a conventional medicine/NHS setting. Soft tissue pain requires specialist ‘hands-on’ soft tissue treatment by Massage & Bodywork Therapists, this is rarely available with NHS funding, and most NHS physios have little quality training in this area. Drugs, injections & biomedical procedures tend to focus on treating the symptoms, not cause of chronic pain; they also only tend to deal with ‘one part’ of a multi-faceted problem. It is unlikely the NHS will ever be able to employ/fund the required numbers of Massage Therapists (or Osteopaths/Chiropractors for neurological pain) to effectively treat a large proportion of the UK population in pain. Radical improvement in chronic pain results are possible in the NHS, but only if it employs large numbers of (non-medically trained) ‘hands-on’ specialists who do what the drugs, medical devices, doctors and physios cannot, and this, for now, seems an unlikely scenario.

Should I get an MRI scan for my back or neck pain?

This is a question I get asked quite often in my clinic and not one with a simple, quick answer, so I used it as inspiration to get my blog started. The answer depends on a number of factors, of course, and while there is no doubt that there is much you can see with an MRI scan that you cannot with the naked eye (or x-ray), there is also much you can ‘feel’ (through palpation), which you cannot see with an MRI! It’s important to note here that your GP or consultant is unlikely to have the refined soft-tissue palpation skills required to feel smaller myofascial/scar tissue adhesion’s, trigger points and subtle soft tissue pathology. To be an expert at assessing these you need to be a soft-tissue (massage/bodywork) specialist, with advanced training in trigger point therapy and myofascial release.

Other, common, ‘pain-causing’ musculoskeletal issues, which don’t generally show up on an MRI scan, are better assessed by case history, orthopedic testing and movement observation (eg. fixated joints, muscle imbalances, facet joint irritation); an Osteopath, chiropractor or Physiotherapist can better assess these than an MRI. So, MRI’s are great for identifying disc & vertebral pathology, bone spurs, narrow spinal foramen etc, but what CAN’T they see?

Pain causing musculoskeletal issues, which are unlikely to show up on an MRI scan:

  • Myofascial trigger points
  • Myofascial tension or adhesions
  • Smaller scar tissue adhesions
  • Muscle imbalences
  • Muscular hypertonicity or acute spasm
  • Fixated facets, costovertebral and sacroileac joints.
  • Facet joint irritation

…the majority of chronic (long-standing) back pain, would in fact be due to a combination of the above musculoskeletal issues, all of which would probably not show up on an MRI! So if they don’t show up the majority of pain causing back/neck issues, why have one?

Factors to consider:

Type, severity and length of pain

Dull-achey pain tends to be muscular or myofascial (soft-tissue) in origin. Not only will the likely causes of this not show up on an MRI scan, but also conventional medicine has little to offer in regards of effective treatment of soft-tissue pain (painkilling drugs to mask symptoms, ineffective injections, poor NHS access to specialist massage/bodywork treatment, & surgery not indicated). If the pain is mild to moderate, and dull-achey, I would therefore advise that there is little point in having an MRI scan. If the dull-achey pain is severe, especially if long lasting (over 1 year) it may then be worth having an MRI to see if it can shed any light on your pain, which assessment and palpation cannot. Extreme lower back stiffness and difficulty bending forwards or standing up can also indicate disc issues, so this further indicates an MRI, even with dull-achey pain.

The type of pain MRI scans are far more useful (indicated) for is neuralogical, ‘nerve root’ (or severe pain). This type of pain tends to be more acute, sharper and ‘stabbing’. Numbness, burning, electric/pins and needles indicate nerve pain and an MRI can identify causes such as disk pathology, bone or cartilage impinging nerves, larger scar tissue issues and spinal pathologies. If you have moderate to severe nerve-type neck/back pain then I would say an MRI scan would be wise. If the pain is very severe and disabling you then it might be prudent to get an MRI regardless of ‘pain type’. However, if your back/neck pain is due to an injury, an MRI is not indicated unless the severe pain persists past 2-3 months as the severe pain is likely to be due to the tissue not yet having healed fully (& resultant inflammation/muscle spasm pain).

Cost of an MRI scan

MRI scans are expensive (£200 > £700, average £350), so ‘is it worth it?’ is an important consideration, less so if the NHS or your health insurance is footing the bill. Can you afford this expense? Even if you can, you could get 7-10 treatments for this price, which might do your back/neck allot of good, perhaps fix it! If you are hoping to get an NHS referral for an MRI scan, you should also be aware your GP can no longer refer you directly for this (to save the expense of unnecessary MRI’s). GP’s have to first refer you to a consultant, it it their decision whether an MRI is an appropriate scanning technique for your back/neck. You may also be required to try a course (possibly 6 appointments?) with an NHS Physio, to try and ease/resolve your back/neck pain before they refer you to a consultant. Most of my patients report this does not help their symptoms much, but either way you will have a delay while you wait for a consultant appointment and/or have your course of physio (perhaps 2-4 months?). Going private skips much of the delay, but it will cost you! Other points to consider regarding funding a private MRI:

  • Will you be gutted if they find nothing? If the MRI scan does not find the ’cause’ of your pain, will you be upset, feel like a fraud? Maybe not, now you know many issues which cause back pain wont show up on MRI.
  • Will you be in the same situation as before? So finally you have your coveted diagnosis, so the doctor can fix it, right? It may well be your treatment options are similar to before, are undesirable to you, or non-NHS ‘hands on’ treatment is more effective at bringing relief.

Is the MRI discovered pathology ‘really’ the cause of my pain?

Is what they find the ‘real’ cause of your pain? MRI scans will probably find something, and one of the problems with medical scans is it can be assumed the ‘found’ issue is the cause of your back pain! But what about all the other causes of back pain the MRI cant see which we discussed earlier?

Studies on asymptomatic individuals (people without back pain) have shown high levels of disc bulges and spinal degeneration, as discussed in the following studies:

Magnetic resonance imaging of the lumbar spine in people without back pain

Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations

This means the pathology/s the MRI finds may not be the cause of your pain, but will likely be assumed as the cause, and pursued medically. An important point to note here, however, is that if your pain is obviously neorological (eg. true sciatica), and the MRI finds something pushing on the nerve corresponding with your pain pattern, it is pretty damn likely to be the main cause of your pain! Dull-achey pain is more likely to be due to musculoskeletal issues which wont show up on an MRI scan. Also, the vast majority of back pain (even neurological/disc) is due to a combination of musculoskeletal issues (9/10 times), not just the ‘1 pathology’ (eg. disc bulge, bone spur, facet joint) conventional medicine aims to identify & treat.

Likely outcome regarding treatment

Before you see your GP about back/neck pain, see a pain/orthopedic consultant or have an MRI scan, consider what treatment conventional medicine has to ‘fix’ your pain. Conventional medicine for musculoskeletal issues/pain is generally based on medication, operations, therapeutic injections and rehabilitation exercise (Physio). If these treatment options don’t seem appealing, or have proven ineffective in the past, then you really should go elsewhere for treatment as this is whats on offer! Just because the MRI has shown up something, and/or you have a diagnosis, does not mean they can fix you in other, non-medical ways…

You could be offered painkillers, anti-inflammatorys or other pain relieving medication (you don’t want long term pain medication). You might be offered a course of Physio (you tried this and it didn’t help much). You might be offered an operation (you don’t want risky, invasive, spinal surgery). You might be offered spinal injections (these didn’t work, or wore off after 3 months). You might be offered a sensory nerve block (you want they cause treated, not the nerve fried).

However, although you might not be exited with the medical treatments on offer, after your MRI results/diagnosis, this information can still be very useful for a non-medical ‘hands on’ therapists (few NHS Physios are proficient at ‘hands on’ treatment, in my opinion), to inform their treatment! I have found MRI results very useful for my treatment plans when they have identified disc issues, spondylolisthesis and severe spondylosis, for instance. I have been able to tailor more effective treatment protocols and avoid possibly aggravating techniques in my clinic.

I hope you find this blog informative and helpful in your decision as to whether have/fund an MRI, and you have a better understanding of the possible outcomes and treatment options.

Kipp Clark JACSMT

Alton Advanced Bodywork web-page