PRINCIPLES OF TREATMENT

I suspect in lay circles, most people would understand the term treatment to reflect a disease modification. That is clearly the case if a malignant or inflammatory process is identified. In simple terms, treatments would be either surgical, that is invasive, or medical. Treatment may be palliative in order to facilitate living without modifying the disease course, or it may be curative as for instance removing an appendix in an individual with appendicitis or the treatment may be symptomatic, that is designed to make an individual feel better. Taking two paracetamol tablets for a headache would fit into that category.

 

 

SYMPTOMS

Symptoms arise when our body malfunctions. Symptoms intriguingly may come about as a consequence of a physiological process such as hyperventilation or be due to a pathological process. All symptoms are as a consequence of brain processing.

If there is a disease process then the symptoms that arise will depend on the site of the disease. What happens if the symptoms, when investigated do not seem to have a cause. The brain must still be responsible for the symptom and hence it is the brain that is generating whatever is the negative experience. Under these circumstances, there is no surgical treatment available and the management must be medical.

Sometimes a condition can generate symptoms when there is a cause and there may be no surgical or specific treatment option and once again symptom control is paramount.

 

At all times, doctors and examining specialists are dependent on what they are told by the suffering individual. Only rarely in clinical practice would there be any doubt about the veracity of the symptom and there is no need for validation. Within the medico-legal process however that is a different matter and the validation of symptoms will be the subject of a further paper.

 

 

MEDICAL TREATMENTS OF SYMPTOMS

Most symptoms requiring treatment involve an unpleasant sensation of different types. This is often pain or a nociceptive symptom as it is known. Neurological symptoms may include numbness, tingling or pins and needles and there may be a range of musculo-skeletal aches and pains as ll as non-specific bowel and bladder symptoms.

 

Overall, whatever the symptom, if it is unpleasant, then the treatment modalities available are similar. In simple terms, there are four generic styles of treatment which are listed below.

 

 

PHYSICAL TREATMENTS

The first and most obvious group of treatments are the physical therapies. These include physiotherapy, occupational therapy when indicated, chiropractic, osteopathy and other manipulation therapies such as reflexology or yoga. The use of ice-packs, local heat, vibration and massage would also be regarded as physical treatments.

 

These treatments are not curative. They may or may not have a significant effect on the pain or other symptoms. They should not however be ignored and they can be particularly effective when dealing with headache, balance disorders or any difficulties involving the axial skeleton or the limbs.

Physical treatments usually demonstrate benefit within the first six to twelve sessions. There is certainly no need for anyone to continue having unlimited osteopathic or chiropractic treatment without an exercise programme being given particularly if the symptoms do not resolve.

 

 

INJECTION TREATMENTS

Injection treatments include acupuncture, acupressure and the use of a transcutaneous electrical nerve stimulator (TENS). More sophisticated and invasive injection treatments can be given by a pain specialist and these could include literally injecting into tender spots with local anaesthetic and hydrocortisone or more target led injections into the epidural space, facet joints or nerve roots. Injections can in fact be given to almost any superficial area of skin or subcutaneous tissue, underlying muscle or any joint and its surrounding structures. Sometimes they give benefit, rarely "cure" and often need repeating.

 

 

TALKING THERAPIES

Talking therapies should never be under-estimated. The clinical consultation in itself should be talking therapy in reassuring that no pathology has been found and that the scans and other tests are normal. It is essential to explain that the clinician does not perceive that the suffering individual is making up the symptoms. The symptoms would be regarded as being real. It is explained that the symptoms arise from the brain and do not mean any harm is happening. Activity will not damage the individual.

 

The legal process is very much the opposite. Specialists have to spell out to lawyers the worst possible scenario and this acts as a so-called nocebo effect to the suffering individual. The more times an individual is given a negative outlook, then the more they are likely to believe and perceive not quite their own propaganda but how the matter is being advanced. An old adage "more symptoms equates to more cash" should not be forgotten.

Any individuals seeing a clinician with symptoms that are not caused by a sinister underlying disease should always feel much improved on leaving the consulting room than when they came in.

 

 

PHARMACOTHERAPY

Pharmacotherapy effectively means using drug therapy in order to block the symptoms.

With pain, there would be a pyramid of treatment options with simple analgesia being at the bottom but often contra-indicated in chronic pain. There is a gradation of analgesic usage starting with paracetamol, aspirin and ibuprofen at the bottom and moving up to opiate derivatives at the top.

There are also a range of prophylactic therapies. These medications block the symptoms. The thinking behind this strategy is to block the symptom for a number of months. At that stage if all is going well with the individual, then an attempt is made to slowly withdraw the analgesic medication. There is some evidence to suggest that the brain is then capable of re-learning normality and switching off giving the suffering individual a period of remission.

The symptoms may then still re-emerge and the medication will need to be given again.

 

There are a whole range of treatments that fit into symptomatic therapies. These can be acute treatments or prophylactic, that is designed to prevent symptoms. There are a range of conditions that are known to respond to prophylactic pharmacotherapy.

 

Although science tells us which medications to use, it is an art to titrate each medication to the right level for the individual.

 

It is essential that the patient and the doctor are on the same team as far as treatment is concerned. A symptom or pain diary is also a fundamental part of the management of chronic symptoms. I also advise all my clinical patients to keep a diary, not just of their pain but also their personal needs. I suggest that individuals monitor their day by day living experience and see how much time they have for themselves on a day by day basis.

 

 

MULTI-MODALITY TREATMENT

Most people with complex symptoms and especially individuals within the medico-legal invariably need multi-focal or multi-disciplinary treatment. This will involve physiotherapists, speech therapists, personal trainers, acupuncturists, clinical psychologists and neurologists. Each individual will attempt to help the patient distract the pain or other symptom using the lowest amount of drugs possible but medication frequently in my experience becomes inevitable and essential. Without such serotonin enhancement the rest of the treatment programme may fail. It is in a way a pharmacological crutch and should be regarded as such and not a failure of personality to need!