Is This What's Delaying Your Patient's NMS Healing?
K. Jeffrey Miller, DC, MBA
A few years ago, one of my medical friends told me a story about attending an extracurricular event with his daughter. He described looking around during the event and realizing every other parent present was one of his patients. He said that just after that, he realized all of them were taking anti-anxiety or anti-depression medications.
The purpose of his story was to make the point, "Everyone these days seems to need these medications." To me, it just sounded like he was overprescribing.
Anxiety and Depression in Chiropractic Practice
I thought about this for quite some time and finally decided to check on the prevalence of anxiety and depression in my practice. I reviewed the case histories of 100 new patients. The percentage was not as high as my medical friend's, but it was high. Seventy-eight of the 100 patients reported anxiety and/or depression. Fifty-three had been medicated. Although this study was localized to my practice, I felt the results were profound.
Is There a Connection With Neuromusculoskeletal Issues?
Based on my experience and my limited survey, I think the following statements are accurate. Anxiety and depression are complicating factors in neuromusculoskeletal (NMS) healing. Patients whose (NMS) problems coexist with anxiety and depression heal slower than patients without anxiety and depression. In some cases, they heal incompletely.
When Did Anxiety / Depression Start? Before or After NMS Issues?
It is essential to know when anxiety and depression are present, and it is also necessary to know when they began. Were anxiety and depression already present when NMS problems began? Or did anxiety and depression start after NMS problems began?
There are two situations pertinent to anxiety and depression that exist before the onset of NMS problems. The first situation is when the origins of anxiety, depression and NMS problems are independent. History may indicate the patient has been under the care of a mental health professional and may have been medicated long before NMS problems began. History of an accident or other event that initiated NMS problems can clarify the order of occurrence.
The second situation is when established anxiety and depression generate NMS problems. Tension headaches are an example; another typical example is stress-induced grinding or clenching of the teeth resulting in TMJ dysfunction.
When anxiety and depression were not present before the NMS problems, they often develop as secondary conditions. NMS problems with substantial severity and longevity can induce anxiety and depression. NMS pain can alter the patient's emotional state, leading to pain behavior.
Pain behavior is unconscious communication of pain by the patient. Repeating questions; excessive talking; anxiety; moaning; facial expressions of pain; taking excessive use of pain medication; self-prescribing braces, supports or walking aids; limping; and constantly changing positions are common signs.
When anxiety and depression develop after NMS problems, history is essential. The order of onset of each condition is critical, as is identifying the signs of pain behavior listed above. Pain behavior that diminishes as NMS problems improve is a key sign that the behavior's origin was secondary to the NMS condition.
Is It Real ... or Malingering?
As a side note, NMS complaints generated by emotional problems evolve subconsciously. They are psychogenic and unintended. This is in contrast to NMS complaints associated with malingering. Complaints in malingering are fabricated and evolve consciously for unethical purposes.
In malingering, an unclear or vague history, a lack of objective findings, or repeatedly changing doctors may be indicating factors. An attitude of not wanting to get better or resisting getting back to everyday life are other alerts. If malingering is suspected, remember that malingering is an accusation, not a diagnosis. Tread carefully.
The Power of Pain Drawings
In addition to history, another good tool for identifying the presence of emotional issues is pain drawing. The patient is asked to use symbols to mark pain and other sensations on a body diagram. Studies show that how a patient marks the diagram helps identify emotional complications and pain behavior. This tool is easy for the patient to complete, and easy for the doctor and staff to score.1
Once the presence and order of onset of anxiety and depression are established, treatment can be more specific to the patient's situation and needs.
Treatment Considerations
Treatment for NMS conditions through chiropractic methods is assumed here. Therapy for anxiety and depression is essentially out of chiropractic's scope of practice. However, improvements in anxiety and depression can occur when NMS problems improve, as mentioned earlier.
The most challenging issue to address among the situations listed here is a mental health care provider referral for anxiety and depression when they complicate or generate NMS problems. Doctors must find polite and non-threatening ways to discuss these situations with patients. If not, the patient will lose confidence in the doctor. Nothing is worse for these patients than feeling as though their doctor is saying, "It's all in your head."
Reference
Ransford AO, Cairns D, Mooney V. The pain drawing as an aid to the psychological evaluation of patients with low back pain. Spine, 1976;1:127-134.
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