The View from Sports Center

The Painster

Juli, my father-in-law's girlfriend, painted this for me after reading my description of pain in Chapter 7. It's brilliant.

Win-Lose

Chapter 12: The Deck of Cards

Where would you start your journey back to health, if you have a disc herniation, cannot sleep more than a few hours or sit on the commode without your leg filling up with a numbing pain and are certain that there's an alligator clamped onto your right hip? Would you grasp for just about anything to get rid of the pain? I think most people would and I'm not any different - well mostly, I'm not.

In my teaching, we used to say,"Stop the bleeding" to help us stay focused on the first things to do with clients, like me, in acute pain. Pain management is really important. That probably seems obvious but clinicians often either overlook it or over treat it because they're so freaked out by how miserable someone is and they react to their own level of fear. I was probably in the "overlook it" category for a good portion of my career. It's just how I dealt with stuff that bothered me - remember? I stuffed it down deep to ferment. I once ruptured a client's surgical repair that he had had for a fractured patella. He had been placed in a cast for months so when he came out, his knee was nearly rigid; couldn't bend his knee more than a few degrees. The only option we had was to stretch and in my eagerness to help, I tore the tissue completely and nearly ruined the surgery. I can still remember the feeling and the sound of his knee tissues ripping. He screamed. I said nothing. I was petrified. Quite literally. I just stood there like a block of 6'3" 215 lb of granite watching and listening to him sob into the pillow. I felt awful, scared, awkward. I finally said, "Are you ok?" Great. That's a keeper. And, about two days later, we were back at it. So much for pain relief (and now you know why physical therapists have such lovely monikers as "physical terrorists" or "physical torturers"). Fortunately, I didn't start teaching others until I had figured out how to better manage pain (and don't worry, I'm really a lot better at a lot of things now).

I don't want to hurt anymore than the next guy but I also want to know what's going on and not be stumbling around in a medicated stupor. So, I want to feel better but not at the expense of not feeling at all. I decided that I would only take pain medication during the day if I felt like I had become Mr. Hyde or if my wife politely asked me, "Have you had a pain pill lately?". I felt like I could probably manage my activities and environment enough to keep the alligator at bay for most of the day light hours.

For rehab, the first thing you have to decide is what you really want which, trust me, if you had asked me at the right time I might have screamed, "Just give me something, anything! Now!" like a pregnant woman about to deliver her first baby. Deciding what you want seems simple enough: feel better. Or, is it to do more? Or is it both? Or do both happen at the same time? Or is it to just not hurt at all as fast as possible? I remember asking a client that once, a man in his late 40's with a disc herniation similar to mine, what he wanted. He looked at me like I was a complete idiot and yelled, "I want you to fix my f@%*ing back!" Hmmm...clear enough I guess.

A friend gave me a great analogy to use when talking about this topic of what you really want: a deck of cards. Imagine that the cards represent all of the things you could focus your energy on; things that could be really important to you. What's the top card? What's the most important thing? Pain is "A" problem; not "THE" problem - at least for me. It's the fifth vital sign as far as I'm concerned until it reaches a level of chronicity where pain becomes THE problem. For me, although at times it's really bad, it still is A problem. The pain is a reflection of what is happening in and to my body and mind and how I am reacting to it. So, while reducing and eliminating my pain is very important, it's not the top card. Getting my life back is the top card. Being able to jog, cycle, workout several days a week, lift weights, and yes snow ski again - that's the top card. Now, it seems like being able to jog would naturally be the result of no longer hurting - right? Some people fall for that trap -  that if you just could get rid of the pain you could do all of those things. Nope. It just doesn't work that way. Here's why. Within just a few days of inactivity, and by the time I got to see Christine it had been a month, you lose substantial amounts of muscular strength and endurance that take weeks to get back and that's assuming you're able to and know how to train to get it back. Within about three days, the muscles that control the fine motions of my spine have atrophied and function at a fraction of their original capability and do not recover on their own even if you eliminate the symptoms. So, in other words, pain relief is important but being able to regain my muscular strength, endurance, coordination, balance and functional abilities is more important. What I'm looking for is something that does three things - controls symptoms, facilitates healing, enhances strength -  and not just one thing: pain relief.

So, with that in mind, the top card, the next thing I need to know is what's keeping me from getting the top card back on top of the deck? By now you know I had a good sized disc herniation but that's only one piece of the puzzle. You also know that I had a pretty good sized wall around me, the wall of denial, that I had to tear down or at least knock a hole in it. I also have some other, pre-existing problems in my spine: joint disease and disc disease. So, Christine got a nice bundle of stuff to sort through. A 51 year old guy, who intermittently has the mind of a 12 year old, with a moderate to large disc herniation, multi-level joint and disc disease, lots of denial, trouble asking for help, highly competitive and her teacher. I can't imagine why this guy would be tough to work with, can you?

Christine did the right thing though by disarming me early on and getting the emotional issues out on the table. Then, she started the rehab program with the basics: jump start the muscles in my spine, get me moving and elevating my heart rate while controlling the compressive loads on my spine, and making sure I was not ignoring the pain and just trying to tough my way through it.

And, I'd like to emphasize just how hard it is for a clinician to feel ok with the basics; simple things. Just about everyone wants it to be harder (clients and clinicians). It makes you feel better as a client if the treatment is really complex as if you have a really tough problem - no wonder you feel the way you do. And, as a clinician, it's a great boost to your ego to choose complex treatment regimens with all sorts of stuff in them. It took me a long time to figure that out. I did a lot of stuff because it made me feel better about what I was doing. Of course, it helped people but why make stuff harder than it needs to be? William of Occam, famous for Occam's Razor, once said, "It is vain to do with more than what can be done with fewer."  Enough said.

The first several sessions were really tough for me physically and mentally. I had only about three drills to do and that seemed like it was too simple (see? - and I know this already). I had trouble getting on and off certain pieces of equipment because I couldn't control the movement well enough and would "nick" my nerve sending a nice electric jolt down my leg. I felt weak walking on a treadmill while being lifted up by the very machine I invented - the Newton (this is an anti-gravity machine that enables you to do more - walk or run - faster and sooner than you otherwise could because of an injury) . And, I don't mean I felt physically weak. I felt like a weakling; like surely I could do more than this yet if I tried increasing the speed past about 2 mph or reducing the amount of lift, my leg hurt.

One of the exercises on my list of things to do was to strap what looked like a blood pressure cuff to my abdomen and then lie face down on a table. I inflated the cuff until the needle rested on 40 mmHg. My job was to suck in my belly enough to reduce the pressure on the cuff and move the needle as far down the scale as I could. The problem was the needle didn't move. I figured that there must be something wrong with the device so I got up and traded it out for another one. This one didn't work either. So, I checked it. And, of course it was just fine.

What I wanted to do was something else, something that was harder, like lift weights or throw something. About the last thing that I wanted to do was to face my limitations. Every session, there they were waiting to greet me. "Hey, K - glad to see you! We missed you! Now, remember, you can't walk faster than 2 mph, right? Remember that? And, oh yeah, your spine muscles? They want you to know that they can't do anything right now." Man, that ticked me off but it also gave me a new sense of what it was like to be in that sort of position; a lot of respect and I think a dose of empathy blended with a little humility. Everyone at Sports Center did a great job though of giving me just the right amount of encouragement without coming across as sappy sweet. Most sessions, I left feeling a lot better: a physical and emotional boost. I wondered, "How does anyone get through something like this alone?"

If I felt my frustration start to simmer while I was trying to master the treadmill and the thing that looked like a blood pressure cuff, I reminded my self about the top card.  Just do the drills, focus, do them right. Just focus on today. Stop thinking about how you felt yesterday or the day before that, it doesn't matter,  or how you might feel tomorrow. Just work with what you have right now. And, that is by far the toughest thing for me to do. And, I work on it a lot. I talk to my self, my dog Spencer, I write about it, I read about it. I think it may be the key, the thing that really makes the difference, in getting well.

You might be wondering though, how I'm doing. Am I any better? Do I still wake up at night? What's my life like now?

Well, coming up in future chapters, I'll give you an update - a sort of diary summary - and fill you in on things like how my follow up went with Christine, Dr. White, Trish, and what I'm doing in my rehab, what my home life is like and the wins and losses I go through.

But, right now, it's time to teeter-totter (so, there you go - you know that at least!). More to come.

What's on my iPod?

Music is a great source of healing and inspiration for me. I often listen to these songs to help me when I'm down or need a positivity injection. I like some of them because the lyrics speak directly to me; I connect. Others, I just love the way the music feels - the texture of it. Hope you enjoy them.

Things That Go Bump in the Night

Chapter 11: Outside the Castle (Part 2)

"Roy, what's wrong?" I asked.

"I don't feel so good. This is what happens. I turn my head and it feels like it gets stuck and then I sort of...." and Roy's voice trailed off. His skin color was changing; turning kind of grey. He was sitting on the edge of an exam table and he started to sway a little. His chest was heaving.

"Roy, I'm going to help you. I need you to relax. Take a few slow, deep breaths. Ok? I'm going to help you get your head back to the middle but you have to stay with me, ok? All you have to do is just stay relaxed. Ok? Roy? Roy? Can you hear me?" I asked in a rising voice.

I remembered my friend Ed telling me once that the first thing you do in the ER is take your own pulse. I think I might have been breathing as hard as Roy was and probably was about the same color. I had never seen this before. I had seen dislocated fingers and shoulders where the joint was stuck and it couldn't move. But, never a dislocated head. I took my own advice. A few deep breaths.

"Yeah...ok....ok...I'm ok..." said Roy.

I stood behind him and placed my hands under his skull cupping the back of his head. I lifted up, felt something sort of vibrate up through my hands like a suction cup being pried off a glass window. In one easy move, I lifted up, hard, and turned his head to the left stopping as he reached the mid-point so he was looking straight ahead. We both just waited. He seemed a little calmer so I helped him lie down and elevated his legs. He was ok. His breathing was normal. I took his blood pressure; checked his pulse. He was ok.

"Roy - we have a problem," I said.

I met Roy from another therapist who had attended a lecture I gave on upper cervical spine instability. At the end of the talk, she came up to me and said, "You know, what you described in your talk is exactly like my patient and I have no idea what to do for him. I had never heard of this before and I just feel...well, I just feel really bad because he has been bounced all around the medical system. I just think you need to see him. Could you?" she asked.

"Sure. I would be happy to," I said while thinking, "We'll see if this is real or if this is someone who is trying to work the system for his own advantage." At the time, the Texas Worker Compensation System suffered from a lot of abuse. Employees with legitimate injuries were often mistreated by their employers while others scammed the system, feigned injuries, to collect a check and get back at the employers they disliked. It was a mess.

When Roy told me his story, I had a feeling he was telling me the truth. He was at work, carrying a plastic tub of dirty dishes in a commercial kitchen, when he slipped and fell striking the back of his head on the edge of a counter. It knocked him out. He was taken to the ER. His exam was normal as were his x-rays. He was given a few days off work along with some medications and told he would be ok. He would have a headache but would be ok.

He followed his doctor's orders and returned to work about three days later with a raging headache. He was doing ok until, once again, while carrying a bin of dishes, he turned his head to say something to a co-worker, and passed out, striking his head again on the edge of a counter. Off to the ER, a negative exam, and negative x-rays but this time Roy couldn't shake the headache and he had new symptoms: neck pain, pain in each arm, tingling, numbness and weakness.

After I put Roy's head back on, so to speak, I explained to him what I thought was wrong. "You probably have moderate to severe upper cervical spine instability which is why, when you turn your head, it feels like it locks. The two bones in the upper neck have ligaments that keep them together and these bones have an unusual shape compared to the rest of the spine. Kind of like two marbles stacked on one another. As you turn your head, one marble pivots and drops down but the ligaments keep it from dropping too far and also create tension to bring it back up into place. If you have torn the ligaments or even severely stretched them, which could have happened when you struck your head on the counter, one bone can slip out of position relative to the other and can't get pulled back up which leaves you stuck," I explained.

I called Roy's referring physician. He all but laughed at me. So, I called his case manager. She didn't believe me or Roy, for that matter. About the only thing I could do was build Roy a special cervical collar to keep his head still. I figured this would buy us some time until I came up with plan B.

It was only a few days until I needed plan B.

Roy came into the office for me to adjust his special collar. He said he felt like it wasn't holding his head still enough. But, he didn't look good. I said, "Roy, are you feeling ok?"

"Well, I've been sick for a few days. I think I got the flu or a bad cold or somethin' is all," said Roy.

"How often have you been sick since your accident, Roy?" I asked.

He paused, thinking. "Uhhh...gosh, I don't know...maybe a couple times a month or so?"

"Have you seen someone for this? A doctor? " I asked.

"Yeah. My family doc. Why?" asked Roy.

"Well, I'm not sure. That seems like a lot of illness; an unusual pattern. I need to call someone. Hold on," I said.

I called a neurosurgeon I knew well and luckily got him on the phone. I explained the situation, Roy's story, my findings, and he said, "Well, I would need to run some tests, do a scan, but it sounds like upper cervical spine instability to me. Yes. I agree, " he said.

"Would you be willing to see him? I know this is not the way these things are supposed to go but no one else is listening," I said.

"Sure. It's ok. He can get a second opinion. Just have him call the office," he said.

I explained the plan to Roy. Call the surgeon. Go see him.

The surgeon called me a couple of days later. "Well, I know why this guy has been feeling so crappy lately," he said.

"Really? Why?" I asked.

"He has a neurogenic bladder," he said in a matter fact way.

"How did he get that?" I asked. A neurogenic bladder is a condition in which the bladder fails to empty because it has lost the signals to and from the brain. It's a condition that people with severe spinal cord injuries, quadriplegics, can get.

"Well, his upper cervical spine bones are pressing against the spinal cord causing his bladder to shut down. Urine collects in the bladder and he develops an infection. The infection causes the symptoms of the flu with the elevated temperature. He needs surgery. Now. His spine is very unstable. He could die from this," he explained.

Roy got the surgery - not without a lot of wrangling and twisting of arms (and I nearly twisted some necks as well) - and the good news is he recovered, went back to work, and moved on with his life.

This is the story that popped into my head and helped me better understand Trish's philosophy. If you have enough instability in your upper cervical spine, like Roy did, creating pressure against the spinal cord that can shut down your bladder, is it possible then that a minor degree of pressure, as Trish proposed, could alter your pain experience or other functions? We, in medicine, agree that pressure on a peripheral or spinal nerve can create all sorts of problems. Pressure on a spinal nerve can create pain in a leg or arm, weakness, sensory loss. Why couldn't that also be true in your upper cervical spine?

And as far as quackery goes, here's my take on that. One of the most common definitions of quackery is, "a treatment of which the supposed benefits are unsubstantiated; treatment that has not been scientifically tested, that the scientific evidence for its efficacy is very weak, or that it has consistently failed scientific tests of its supposed benefits." 

If this is the definition, then shall we turn this lens on ourselves? On mainstream medicine? What about the the evidence against knee arthroscopy for patellofemoral pain? Or, the use of ice in the treatment of injuries? Or, the use of non-steroidal anti-inflammatory drugs in the treatment of knee pain? In each of these cases, science has shown the treatments to be ineffective yet we do not call the practitioners, who continue to use these treatments, quacks. Why is that? And, to take it one more step, look at the psychiatry profession. Is there any scientific proof that certain treatments are better than others? Is the psychiatry profession more art than true "science?" Is this why, in his outgoing message to the profession, the former president of the American Psychiatric Foundation was arguing against embracing evidence-based practice?

Remember, Louis Pasteur was largely regarded as a quack for his hypotheses on germ theory even after he proved it. Today, we herald him as one of the founders of microbiology. I suggest we all take a deep breath, step back, and start talking about what we can learn from each other to help all of the people in front of us who hurt, who suffer: who need help.

I'm grateful that I met Trish; that I had the opportunity to discard the armor, be open.  I can see that what she's doing has threads that weave their way into what I do and how I work. We have differences perhaps in theories and technicalities but I think our similarities are much greater than those differences. I've learned how judging others can overrule your judgement of what to do.

I don't understand everything that Trish does with me but I don't need to. I understand enough.

References:

Kettunen, J. A., A. Harilainen, et al. (2007). "Knee arthroscopy and exercise versus exercise only for chronic patellofemoral pain syndrome: a randomized controlled trial." BMC Med 5: 38.

Bjordal, J. M., A. E. Ljunggren, et al. (2004). "Non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, in osteoarthritic knee pain: meta-analysis of randomised placebo controlled trials." Bmj 329(7478): 1317.

Bleakley, C., S. McDonough, et al. (2004). "The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials." Am J Sports Med 32(1): 251-61.

Hubbard, T. J. and C. R. Denegar (2004). "Does Cryotherapy Improve Outcomes With Soft Tissue Injury?" J Athl Train 39(3): 278-279.

http://pn.psychiatryonline.org/cgi/content/full/36/9/3

Walk the Line

Chapter 10: Outside the Castle (Part 1)

I'm sure she knows...there's an artery in there...I could stroke out..right here...right on the table...it's too late! How much pressure is coming...I know she said not much...but my head..on this wedge...feels like it could break off...what if...should I...

At that moment, I felt a slight pressure over the area near the base of my skull on the left side. About as much as you might use to press in the button in the center of a door handle. A little rubbing and twisting,  a few more pulses of pressure, a sense of vibration. Nothing painful or uncomfortable. No cracks, snaps, or crunches.

"Ok, go ahead and sit-up," said Trish.

I sat up on the side of the table. I was leaning to the left several inches. I could feel much more pressure under my left buttock than right. Trish handed me my glasses and said, "How do you feel?"

"I'm leaning. To the left... a lot. I feel a little...I don't know...dizzy or woozy, I guess," I replied.

"You're straight," said Trish.

"What? No. No. I'm leaning. Not straight. I'm leaning to the left. Really? Straight?," I said.

Trish smiled. "Stand up and walk into the hall and look in the mirror," she said.

I stood up staggered into the hallway like Frankenstein just coming to life. I felt very off-balance almost as if I was just learning to walk. I walked or staggered up and down the hall a few times. My feet scuffed the floor. I gradually got my balance back but still felt tilted to the left. I looked in the mirror and saw I was straight. Straighter than I had ever been - at least in recent memory. What? What happened?

When I arrived at Trish Gregg's office that morning of March 22, 2008, I was fully clad in my mental and emotional armor. I had tried, really tried, to convince myself that I was open minded; that I needed to just listen, let Trish do her thing, and let go of any judgment or pre-conceived ideas of what a chiropractor would do; how it wouldn't be evidence based; it was some sort of quackery. But, honestly, as I got out of my car, I was about as guarded and protected as one could get. I'm impressed that I could get in her front door with all of that armor on.

Trish showed me to an exam room. She said she had to get all of her forms and tools together. She was looking around the room and then into another room. I thought, "Has she not done this? Why the disorganization?" Then, she said, "Sorry for the confusion but I haven't had a new patient in about 18 months so all the stuff I normally use in the first visit is scattered around between my two rooms. I'm booked through May. But, I have everything now." Eighteen months? How is that?

She asked me about my symptoms, how I got injured, other injuries I had had in the past. Did I have any other symptoms in other parts of my body? She did a brief "review of systems" - a screen for problems with organ systems or possible systemic diseases. She wanted to know how I was dealing with the effects of the injury. Was I sad, depressed? She gave me plenty of time to talk; didn't interrupt me. She listened.

Trish then explained to me the premise of her practice. She didn't treat diseases or injuries but rather helped the body return to as healthy a state as possible; encouraging the natural healing process. And, that healing included physical as well as mental and emotional components.

This all sounded fine to me. I felt a couple of pieces of armor fall to the floor.

"The problem is that the atlas, the bone on which your skull sits, is often out of place or tilted. This then places more pressure on the nerves that exit the skull which interferes with the healing process. In addition, in order to keep looking straight ahead, your body makes compensations in its position or posture creating tight muscles in some areas; increased pressure where there shouldn't be any. So, you may develop various aches or pains from this. I reposition the atlas, reducing the pressure and realigning your body to a more ideal state," said Trish.

I put the armor back on.

"The technique is not aggressive. I use very light pressure and you'll barely feel it. But, what we need to do first is a series of x-rays of your upper neck and a few measurements so I can figure out what is wrong," she explained. Trish paused, clasped her hands in front of her holding my file.  "I know you know a lot. And, it's ok if you want to disagree with me or argue or state your views. I understand that what I am saying probably doesn't make any sense to you. But, it's what I believe and it's how I help people."

She saw right through the armor. My training taught me that the ligaments between the atlas and axis (cervical bones 1 and 2) are some of the strongest ligaments in the body and that you could not just go around pushing the atlas into just whatever position you wanted. It just wasn't possible. So, this is running around in my head while I'm trying, at the same time, to be open and receptive.

"I know a lot about certain things and some things, I know nothing at all. I'm here to get well. I want to listen to you and be as open minded as I can be, " I said.

Trish took the x-rays and sat down in front of a lightbox with a protractor and what looked like a slide ruler. She started making marks, drawing lines, calculating angles on the films. After several minutes, she proclaimed, "You're a Type III."

"OK. Is that good or bad?" I asked.

"Well, it's not that. There are three types of upper cervical subluxations. Type I is the most common and fairly straight forward. Type II less common and Type III is fairly rare. But, it's something we can fix," she said.

After my balance returned and I could walk normally, I still felt like I leaned to the left. I was just certain that people could tell; that they would think I was trying imitate John Wayne. I felt relaxed though and my leg pain was less severe. I was really intrigued by the whole process and at the same time encouraged. I wasn't sure exactly how Trish was going to help me but I had this sense that she could.

"Now, in about three days, you may feel a lot worse. You may have more leg pain and feel sort of like you have the flu; achy or painful joints. It's a normal response and it won't last but I wanted you to know. Your brain is going to be processing a lot more sensory information than it has before which is why you might hurt more," Trish said.

I had this image of a water hose with a kink in it and all of a sudden it turns into this monster gusher spewing out pain impulses. Great. Should be a really fun few days. Why did I do this again?

Driving home though, something from a long time ago, from the early days of my private practice, popped into my mind. It was a patient whose problem suddenly helped me understand what Trish was talking about.

Everything made a lot more sense to me now.

Why Money Will Never Make You Happy

You probably have heard this before, about how making more money doesn't mean you will have more happiness in your life, but this article does a great job explaining why this happens. It's a longer than usual article, a little "science" oriented but worth reading - especially if you're chasing the dollar and finding each day to be less than you had hoped.

What Running Can Do