Positive Health Online

22 years ago I was at medical school and doing a GP attachment. This was in Bath and I watched the young GP I was shadowing manipulate the acute back of a 25 year old labourer. Walking up the stairs to the surgery was almost impossible for this man but after treatment of only a few minutes he went down the stairs as if on air, pain free.

A very moving experience for a young and impressionable student, my first real introduction to hands on medicine. Since then I have learned and practised many techniques related to manipulation of the spine and peripheral joints from Osteopaths, Chiropractors, Massage and Aromatherapists and together with acupuncture, vega testing, allopathic medicine and injections have offered patients a broad based approach. With my pre-specialisation training in general practice I am a great proponent of the role of the Generalist, to take an overview of patients problems and recommend the best therapy, either conventional (surgical or medical) or counselling, psychotherapy or complementary (acupuncture, homeopathy, reflexology) referral as indicated.

Within Medicine there is a reluctance to accept manipulation treatments as valid, so provision of services and training in this area is very sparse. Patient groups caught in this void in HealthCare provision, include the physical dysfunctional problems like whiplash injury and low back pain for which National Health Service provision is absent or poor. This is where musculoskeletal medicine fits in. Doctors working together with physical therapists of all persuasions, with a functional examination approach.

Musculoskeletal Medicine is a relatively new terminology, partly synonymous with orthopaedic medicine. However, a change in nomenclature was necessary, as musculoskeletal medicine encompasses the more gentle arts of osteopathy and manipulative medicine, a variety of injection techniques, ‘blind’ needling or trigger point acupuncture, and the treatment of sports injuries.

These talents have always been frowned upon by academic doctors as unscientific, because clinical trial work is often anecdotal and uncontrolled. However, manipulation in some form, like hypnosis, predates the current practice of medicine as we know it.[1]

The practice of hypnosis has attracted followers since Franz Anton Mesmer (1734–1815), although mostly outside the recognised medical establishment. However, it has suffered from research work that is difficult to control to the satisfaction of the medical establishment. Its use for the treatment of smoking and obesity has also alienated it from the establishment.

A Broad Application

Hypnosis is ‘an altered state of consciousness’, more related to being awake than asleep. It is used for a wide variety of different conditions, including migraine, asthma, IBS, insomnia and pain, as well as in a variety of practices other than psychiatric and psychological, including dentistry, surgery, anaesthesia, dermatology and obstetrics. There are also many lay practitioners.

In a recent paper,[2] the use of hypnotic techniques suggesting ‘relaxation’ and ‘analgesia’ have demonstrated a difference in the appreciation of pain for the parameters of ‘unpleasantness’ and ‘intensity’, respectively, in hypnotically susceptible volunteers. The majority of papers on hypnosis in the management of pain are experimental and volunteer based, rather than clinical. There is little doubt, however, in the minds of those who use hypnosis that major benefits can be gained by some patients suffering from a wide variety of chronic and recurrent acute painful conditions.

Hypnosis has a specific relevance to musculoskeletal medicine: papers using rheumatic[3] and low back pain[4] have been used as pain models for work with hypnosis. The choice of patients is very important as only 80–90% of patients will respond.[5] Everyone is probably susceptible to light trance states, but 50–60% will achieve medium to deep states with little difficulty, while 20–25% will be able to achieve deep states. For chronic conditions, speed is not essential and two or three half-hourly sessions will allow a sufficiently deep state (and even self hypnosis) to develop. Subsequently, as little as ten minutes may be needed for reinforcement to take place.

Certain conditions are essential to success:

•    Motivation.
•    Removal of doubts and fears.
•    Fixation of attention.
•    Relaxation/limitation of voluntary movements.
•    Concentration.

Preparation of the patient begins with the identification of adequate motivation to develop the necessary skills. The fears that society may have placed in the mind about hypnosis, especially the ‘lack of control’ demonstrated in stage shows, must be discussed prior to induction.

Other common misunderstandings include expectations of amnesia, the part played by ‘will power’ in trance induction, and a fear of being dominated by the hypnotist. Most of these apprehensions may be overcome by empowering the patient prior to induction and advising them that ‘at any time, if you do not like what is happening, you will be able to open your eyes and say so.’

General Principles of Induction

The hypnotic state is induced by mutual consent. The practitioner guides the patient using repetitive sensory stimuli – from the normal waking state to a state of altered awareness, where suggestibility is heightened. It is this state of increased suggestibility that is used for the patients best interests.

Starting with relaxation and heaviness in the arms and legs (periphery), the development of suggestion is modified by the progressive response of the patient.

As feelings are modified by suggestion, so these may become more relevant to the presenting problem. Mental relaxation is then offered as a development of the physical relaxation, and the state may be deepened by a variety of techniques, including counting and breathing.

Hypnotic Techniques

Mild states are certainly satisfactory for use with spinal manipulation techniques in the surgery. Patients who have back and neck pain in the primary care setting may be surprised to be offered manipulation, rather than pills, for their symptoms.

After informed consent to the examination and manipulation process has been gained, a form of hypnosis may be used to encourage more rapid relaxation of tense muscles. A rapid eye-closure technique takes only moments and leads to a more efficient examination with accurate ‘end point feel’ and less voluntary muscle tension.

An accurate examination of gross mobility and segmental mobility is essential for specific manipulation treatments to be effective. The examination is a time for the patient to become relaxed in the ‘manipulator’s hands’ and the repetitive movements and calming voice will deepen the state of hypnosis. With constant verbal contact, explanation and suggestion for relaxation, the examination may progress rapidly to therapeutic manipulation.

As the patient is in an altered state, but awake rather than asleep, communication is always possible, both ways in the therapeutic relationship. The practitioner may be sure that the patient will be able to indicate uncomfortable movements without being distressed or ‘jumping’ in response to any pain during positioning.

Moderate to deep levels are required for the treatment of chronic pain states or the preparation for surgery, dental treatment and childbirth. Over several sessions, the state of hypnosis is encouraged and deepened without reference to pain, but concentrating on relaxation, feelings of lightness or heaviness, hot or cold. When it is possible to induce changes in feelings of weight and temperature, these can be modified to affect pain sensations.

Some conditions benefit from a feeling of heat, so a ‘heated’ hand is moved to the area of pain and the ‘heat’ is transferred to the site. Similarly with cold, an area may be ‘frozen’ by suggestion, allowing a change in pain perception. Having established a regimen in the surgery, the patient can be taught self-hypnosis and use the techniques at home. The benefits increase rapidly with practice. A patient with two or three rheumatic joints could enjoy major relief within a few minutes each day.

From this brief outline, it should be possible to identify many of your patients who might benefit from this treatment. There are few, if any, documented side effects. The cost is time, initially, and the result is an empowered patient, in charge of – and not a victim of – their pain.

Case History

M.J. aged 34 presents with an 8 week history of headache across the frontal area of varying intensity. The pain is worse in the evening and on Friday better in the morning and over the weekend. Pain killers produce little change in the pain but heat and massage both help. (Typical symptoms of tension headache.) Migraine headaches have been more frequent during this period up to two per week at worst.

Earlier history is of increased work pressure for 1–2 weeks before the episode started, with deadlines and a change in position at work with a new PC. The relevance of the new PC had been recognised at work and a more ergonomic station provided by her employer, but the headaches continued.

Worry about work had crept in as there had been significant time off. Sleeping was upset with both pain and anxiety at night.

History points

•    Change of position at work
•    Increased pressure at work
•    Frontal headache
•    Variation of pain with time and day
•    Variation of pain with heat and massage
•    Increased frequency of migraine attacks

Putting the work situation right had not corrected the problem which had already become established.

Examination

Pain and tenderness with all neck movements and in all neck muscles was found down to the level of the shoulder blades. So much so that satisfactory examination was not possible.

The first therapeutic option was satisfactory pain relief and sedation to allow sleep, followed by manipulation at another appointment. The patient was not keen on medication of any kind so hypnosis was discussed and offered. As a medical practitioner patients are always offered a medical opinion first, unless they are referred for, or request a broader opinion

Progress

Opportunity for treatment in this first consultation was marginal for full hypnotic induction so a rapid eye closure technique was used followed by Vogt’s Fractionation procedure for rapid deepening. Examination continued with suggestions for muscle relaxation accompanied by massage applied whilst examining the soft tissues. Range of movement testing followed, with end points identified as tender or not by the patient, ending with local mobility testing not previously possible due to muscle spasm and tenderness.

The problem area was revealed as occipito-atlantal dysfunction with upper thoracic stiffness which was amenable to manipulation at that time. On ‘waking’ there was little change in the patients symptoms although she did feel positive that something had been achieved. The next day after a good nights sleep, the first for some weeks, most of the symptoms were gone. Further manipulations to the cervical and thoracic areas were required three days later allowing complete return to work.

Conclusion

I would compare hypnosis and manipulation with aspirin and propranolol – they have been around for a long time and, as time has gone by, the range of conditions for which they are relevant has grown. Aspirin has matured from being an analgesic-antipyretic to an acute treatment and prophylaxis for MI and stroke, the prevention of bowel cancer and the diagnosis and treatment of pain of osteoid osteoma. Propranolol now has relevance for migraine prophylaxis, the treatment of anxiety, and thyrotoxicosis, as well as angina, hyper-tension and tachyarrhythmias.

The conditions treatable by musculo-skeletal medicine overlap cardiology, general medicine, gynaecology and obstetrics, neurology, pain management, psychiatry and surgery. Hypnosis could be useful to all specialists and GPs.

Further information for doctors

British Institute of Musculoskeletal Medicine, 27 Green Lane, Northwood, Middx, HA6 2PX. Tel/Fax: 01923 820110 BIMM@compuserve.com
British Society of Medical and Dental Hypnosis, 17 Keppel View Road, Kimberworth, South Yorks. S61 2AR. Tel/Fax: 01709 554558

References

1.    Friar Moulton. The Complete Bone Setter 1656
2.    Dahlgren LA, Kurtz RM, Strube MJ, Malone MD. Differential effects of hypnotic suggestion on multiple dimensions of pain. J Pain Symptom Manage 1995; 10 (6): 464–460.
3.    Donaghue BB, Margolis CG, Leiberman D, Kaji H. Biochemical correlates of hypnoanalgesia in arthritic patients. J Clin Psychiat 1985; 46: 235–238.
4.    Twomey TC, Saunders S. Head, facial and low back pain. Am J Clin Hypnosis 1983.
5.    Hartland J. Medical and Dental Hypnosis and it Clinical Applications. Balliere Tindall, 1982.