The Concept of Regional Musculoskeletal Illness

The experience of musculoskeletal discomfort, even of compromise in musculoskeletal function, is one of life’s recurrent surprises (see Section I). Usually there is no precipitant. Usually we would consider ourselves entirely well were it not for this discomfort. And usually we cope effectively by taking advantage of our personal resources. Hardly a month will go by without the need to come to grips with such a predicament. Some of these events are of sufficient importance that 15% of us remember them for 1 year or more. The majority of these morbid experiences involve the axial skeleton; low back pain predominates, and neck pain is a distant second.

Occasionally, we find our personal resources inadequate and feel the need to turn to some provider of care. We are starting to understand the influences that cause people with musculoskeletal predicaments to decide that coping on their own is serving them poorly (Chapters 2, 3 and 4). The moment the person with a musculoskeletal predicament turns to a physician for assistance, that person becomes a patient and the predicament becomes an illness. If there is no overt traumatic precipitant, if there is no relevant underlying systemic disease so that the person would be well were it not for the musculoskeletal region that is involved, the illness is a regional musculoskeletal illness.¹,² Such illnesses are the chief complaint of a considerable percentage of the patients presenting in a primary care setting, ranking second or third in frequency. Regional musculoskeletal illnesses occupy a similar station in the experience of most rheumatologists. For the rheumatologist, these illnesses present a special challenge. After all, there is no systemic rheumatic disease that spares one the coincidence of a regional rheumatic illness. Lacking such a diagnosis will test the acumen of any physician; in fact, discerning the regional illness in the setting of systemic rheumatic disease is often impossible. Nonetheless, given that there are instances in which therapy is altered, it is a diagnostic exercise to be encouraged.

There is another important ramification of the concept of regional musculoskeletal illnesses; it behooves the treating physician to consider why any particular individual would choose to seek medical recourse for this particular musculoskeletal predicament. Sometimes the explanation is consonant with the tradition of scientific medicine; this person has chosen to be a patient because the predicament was too unfamiliar, too painful, too prolonged, and so forth. However, from multiple studies, some of which are discussed in Section I and many more are discussed in Section III, it is becoming clear that such constrained pathophysiologic inferences serve the chief complaint and the patient poorly. The decision to be a patient is often tempered by the psychosocial setting in which the musculoskeletal predicament
is experienced. Sometimes the musculoskeletal illness even serves as a surrogate complaint. It is a far more facile conceptualization than the realization that some other force in one’s life, such as job or marital dissatisfactions, is compromising one’s ability to cope with the musculoskeletal predicament. Regional musculoskeletal illnesses are often confounded in this fashion and are never well managed unless the confounders are recognized early on. This point will be reemphasized in Section III.

However, in this section we will focus on the clinical algorithm that has become the pride of western medicine: the establishment of a differential diagnosis for the illness that allows one to formulate a plan of intervention. Such an algorithm did not always dominate the patient-physician interaction. In fact, its promulgation can be ascribed to one man, Thomas Sydenham, at the outset of the 18th century.³ Before Sydenham, ascribing a cause for illness was an exercise with almost free intellectual range. “Fate” as an answer became far more difficult after St. Thomas Aquinas placed the burden of free will on the western psyche. Scapegoating found its way into pathogenetic inference to explain plague, venereal disease, and more; a heinous feature of medieval thought that is leaving its mark on western society even in this century.⁴ In Elizabethan England, a common inference regarding the cause of sciatica included impiety and decadence, if Shakespeare’s Measure for Measure is an accurate reflection (Act I, ii, 50-55).

THE DISEASE-ILLNESS PARADIGM

It took Thomas Sydenham to offer the insight that gave science a foothold in the diagnostic morass. Sydenham realized that most diagnostic schemes of his day were purely descriptive; they were based on symptoms experienced by a particular patient. These symptoms, which I call the illness, were carefully described so that comparisons with the experience of others were possible, leading to a nosology based on illness. So if a patient was experiencing sputum production, the diagnosis of the day was catarrh. If the illness was characterized as smoldering joint inflammation, the diagnosis was rheumatism. More cataclysmic joint complaints were ascribed to the gout, which was further divided into “podagra, cheiragra, and sciatica”⁵ to indicate severe pain of the hallux, hand, and hip (ischium, therefore ischiatic), respectively. The art of medicine was to first identify the patient’s symptoms as belonging to a particular illness category and then to prescribe nostrums and interventions designed to modify the symptoms. Sydenham said “No!” He asserted that these symptoms were the clinical representation of some underlying pathophysiologic or pathoanatomic derangement, a disease. The job of the physician was to listen to the symptoms, deduce the underlying disease, and provide specific therapy for the disease, thereby obviating the illness. Without such a conceptual leap, western medicine would still be illness-based, and we would be treating catarrh instead of treating particular pneumonias with specific antibiotics.

The disease-illness paradigm was seductive even when it was formulated, a time when the concept led to little alteration in therapeusis. It facilitates consideration of symptomatology in a framework that lends itself to scientific testing. However, it
has also facilitated speculative inferences, usually tenuous but masquerading as science, which were held up as the grounds for empiricisms that were all too often harmful. By the early 18th century, Boerhaave in Leiden took the precept to the bedside in his teaching rounds, in effect, inventing roundsmanship. Admissions of bafflement and befuddlement are rare throughout medical history; after Boerhaave, ignorance could be hidden in the complexities of the differential diagnosis. But all has not been an exercise in obfuscation and futility. To the contrary, productive conclusions from the disease-illness paradigm are the triumphs of 20th-century medicine. This century has seen dramatic inroads in the diagnosis and treatment of infectious diseases, upper gastrointestinal diseases, gout, cardiac and renal failure, and others. The disease-illness paradigm has proven so powerful that it has been elevated to axiomatic stature by physicians and layman alike. Whenever a person chooses to be a patient, the expectation is that his or her illness will be explained and that prognostic insights, palliation, and even cure will be forthcoming. For every symptom, it behooves the physician to establish some sense of the possible in regard to underlying pathoanatomy if not pathophysiology. This is the precept that underlies “differential diagnosis” and that dominates medical education, medical practice, and patient expectation.

THE HAZARD HIDDEN IN DIFFERENTIAL DIAGNOSIS

It is not my intent to cast aspersions on the precept. It triumphs daily in the clinic in those instances in which the cause of symptoms is deduced either by the demonstration of a specific pathogenesis or the banishment of symptoms with specific therapy. Because of this precept, some diseases, such as polio and smallpox, are no more. Otherwise, and more typically, our level of certainty about causation is less. When we are aware of our limitations, we tend to apply the “syndrome” label. The implication of this label is that the illness in one patient is similar to that in others, but we are sufficiently puzzled to wonder whether these associations are coincidental. Our patients may gather that we have considerable uncertainty about the meaning of the label but take solace in our willingness to prognosticate or treat despite the uncertainty. We have taught our patients to take even more solace if we label them as having a “disease.” After all, we are brandishing science to silence uncertainty. It is a labeling event with great consequences for the patient. Some consequences seem palliative, as in “Thanks, Doc. Now I know.” Others are untoward, as in “I am (will be) altered, diseased, damaged.”

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