Many people, many organizations

R. Ellis
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These will need different professional skills; and I would say that the stress that this puts not only on the patient, but also onto the healthcare system is there for all of us to see. In his review, Foell is very fair to all the players, but he is portraying the strange disarray that greets the chronic pain patient. In so many of these patients, musculoskeletal symptoms are an important part. More and more is now known about the causation of chronic pain, its course, and methods of alleviating it, or of alleviating its effects. But in practice, how well is this knowledge applied for the benefit of the patient? Are not Foell and Giamberardino showing that the patient’s ‘journey’ in this area of healthcare may look a bit like Gulliver’s Travels? If the inhabitants of Brobdingnag, Lilliput, and Laputa are shown by Jonathan Swift to be working away earnestly in their various strange ways – rather as he saw European government in the eighteenth century – should we not take care that our difficulty of bringing physical assistance, psychological assistance, and social assistance to our patients might not be caricatured also? As Foell says, it isn’t the modalities of multidimensional treatment that are the problem, it’s the people who deliver these modalities; or rather, certainly in the British National Health Service, the administration which seems to separate, rather than bring these people together. It brings to mind a case observed over 20 or more years: a woman who has led the life of an invalid, with musculoskeletal pain. Early on, the simple diagnosis of fibromyalgia was questioned – could the inability to walk more than a few metres be her only problem? Referral to tertiary care specialists was arranged, but nothing else was ever found. Gradually, she became bedridden for most of the day. The general practitioner did well to rationalize and minimize the medications, such as diazepam and non-opioid analgesics; but from time to time requests for more help had to be responded to. In recent years an inpatient stay in a tertiary care hospital brought no real physical or psychological change, and that hospital’s request was for 6 months of physiotherapy and for occupational therapy help. The physiotherapist was not able to get the patient standing again, or walking; the occupational therapist arranged for various physical aids to be delivered – but they were discarded as being of no use. It seems typical that each of these new attempts at help was a professional ‘new’ to the patient; the only constant in her life was the primary care doctor. The primary care doctor is so often in the strongest position to judge the individual’s needs, but whether he/she can influence the often independent regime of the other healthcare workers, is another question! At least there is the possibility: and therefore it would be a pity if expertise in musculoskeletal care at the primary care level were to be diluted or transferred. But because there will seldom be more than one or two severe cases of this type in a single doctor’s practice, there must be help from those with more concentrated experience and expertise. The patient’s first port of call needs easy and helpful assistance both vertically up the specialist tree, and horizontally across the spectrum of different advice for those comorbidities. 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Abstract

Does musculoskeletal care thrive because there are so many groups of healthcare professionals working in it? Does the care benefit or suffer from some competition and rivalry between different professional groups? Or is communication so variable that cooperation is difficult to achieve? These are just a few of the questions which may come to mind, when you read the book review in our previous issue (2013 No. 2) of Pain Comorbidities, edited by Maria Giamberardino. If you did not read it, you missed an interesting three pages. The book explores research and ideas relating to the fact that typical chronic pain patients almost always have more than one physical condition, and almost always have one or more psychological problems continuing, and are likely to have social problems also. These will need different professional skills; and I would say that the stress that this puts not only on the patient, but also onto the healthcare system is there for all of us to see. In his review, Foell is very fair to all the players, but he is portraying the strange disarray that greets the chronic pain patient. In so many of these patients, musculoskeletal symptoms are an important part. More and more is now known about the causation of chronic pain, its course, and methods of alleviating it, or of alleviating its effects. But in practice, how well is this knowledge applied for the benefit of the patient? Are not Foell and Giamberardino showing that the patient’s ‘journey’ in this area of healthcare may look a bit like Gulliver’s Travels? If the inhabitants of Brobdingnag, Lilliput, and Laputa are shown by Jonathan Swift to be working away earnestly in their various strange ways – rather as he saw European government in the eighteenth century – should we not take care that our difficulty of bringing physical assistance, psychological assistance, and social assistance to our patients might not be caricatured also? As Foell says, it isn’t the modalities of multidimensional treatment that are the problem, it’s the people who deliver these modalities; or rather, certainly in the British National Health Service, the administration which seems to separate, rather than bring these people together. It brings to mind a case observed over 20 or more years: a woman who has led the life of an invalid, with musculoskeletal pain. Early on, the simple diagnosis of fibromyalgia was questioned – could the inability to walk more than a few metres be her only problem? Referral to tertiary care specialists was arranged, but nothing else was ever found. Gradually, she became bedridden for most of the day. The general practitioner did well to rationalize and minimize the medications, such as diazepam and non-opioid analgesics; but from time to time requests for more help had to be responded to. In recent years an inpatient stay in a tertiary care hospital brought no real physical or psychological change, and that hospital’s request was for 6 months of physiotherapy and for occupational therapy help. The physiotherapist was not able to get the patient standing again, or walking; the occupational therapist arranged for various physical aids to be delivered – but they were discarded as being of no use. It seems typical that each of these new attempts at help was a professional ‘new’ to the patient; the only constant in her life was the primary care doctor. The primary care doctor is so often in the strongest position to judge the individual’s needs, but whether he/she can influence the often independent regime of the other healthcare workers, is another question! At least there is the possibility: and therefore it would be a pity if expertise in musculoskeletal care at the primary care level were to be diluted or transferred. But because there will seldom be more than one or two severe cases of this type in a single doctor’s practice, there must be help from those with more concentrated experience and expertise. The patient’s first port of call needs easy and helpful assistance both vertically up the specialist tree, and horizontally across the spectrum of different advice for those comorbidities. IMM is happy to report, in this issue, the recent meeting of the International Academy of Manual/
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很多人,很多组织
肌肉骨骼护理蓬勃发展是因为有这么多的医疗保健专业人员在这方面工作吗?不同专业团体之间的竞争和对抗对护理有益还是有害?或者是沟通如此多变,以至于很难实现合作?这些只是你在阅读我们上一期(2013年第2期)由Maria Giamberardino编辑的《疼痛共病》(Pain comorbidties)书评时可能会想到的几个问题。如果你不读,你就错过了有趣的三页。这本书探讨了与典型的慢性疼痛患者几乎总是有不止一种身体状况,并且几乎总是有一种或多种持续的心理问题,并且可能也有社会问题有关的事实的研究和想法。这些都需要不同的专业技能;我想说,这不仅给病人带来了压力,也给医疗保健系统带来了压力,这是我们大家都能看到的。在他的评论中,Foell对所有参与者都很公平,但他描绘的是慢性疼痛患者所遇到的奇怪的混乱。在许多这样的病人中,肌肉骨骼症状是一个重要的部分。现在人们对慢性疼痛的起因、病程以及减轻疼痛或减轻疼痛影响的方法了解得越来越多。但在实践中,这些知识如何应用于患者的利益呢?Foell和Giamberardino不是在表明,患者在这一医疗领域的“旅程”可能有点像格列佛的旅行吗?如果乔纳森·斯威夫特描绘的布罗卜丁奈格、利力浦特和勒皮他的居民正以各种奇怪的方式认真地工作着——就像他所看到的十八世纪的欧洲政府一样——我们在给病人提供物质援助、心理援助和社会援助方面的困难,难道我们不应该注意,以免也被讽刺吗?正如福尔所说,问题不在于多维治疗的方式,而在于提供这些方式的人;或者更确切地说,在英国国家医疗服务体系中,政府似乎将这些人分开,而不是团结在一起。这让我想起了一个20多年前观察到的案例:一位患有肌肉骨骼疼痛的女性,她的生活像一个病人。一开始,纤维肌痛这个简单的诊断就受到了质疑——不能走超过几米的路是她唯一的问题吗?转介到三级保健专家,但没有发现其他任何东西。渐渐地,她一天大部分时间都卧床不起。全科医生在合理和减少药物使用方面做得很好,如安定和非阿片类镇痛药;但时不时地,需要更多帮助的请求必须得到回应。近年来,在三级医院住院的病人没有真正的身体或心理变化,医院的要求是6个月的物理治疗和职业治疗帮助。物理治疗师无法让病人再次站立或行走;职业治疗师安排了各种物理辅助工具,但他们被丢弃了,因为没有用处。似乎很典型的是,这些新的帮助尝试对病人来说都是专业的“新”;她生活中唯一不变的是初级保健医生。初级保健医生往往在判断个人需求方面处于最有利的地位,但他/她是否能影响其他卫生保健工作者的独立制度,这是另一个问题!至少存在这种可能性:因此,如果初级保健水平的肌肉骨骼护理专业知识被稀释或转移,那将是一种遗憾。但是,由于在一个医生的实践中,这种类型的严重病例很少会超过一两个,因此必须有那些经验和专业知识更集中的医生的帮助。病人的第一个电话需要简单和有益的帮助,无论是垂直的专家树,水平跨越不同的建议,这些合并症的频谱。IMM很高兴在本期报道国际科学院最近召开的会议
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