Will wonders never cease?


First, to answer my question, I hope not. They have not yet.

I see “wonders” almost every day in my practice. A “wonder” for me is when someone gets well, or perhaps better, against the odds. Seeing this firsthand in a health care environment is like having a toy for which the “new” never wears off. Maybe it is like going to a concert in which every piece tugs at your soul in new and exciting ways. I can think of lots of good metaphors. Anyway, the wonders never cease for me at work.

I want to introduce you to Roger. He works hard for long hours every day doing construction. He has a very strong work ethic that will not allow him to slow down, much less stop, with a health problem that is not directly life-threatening. Part of that is probably due to some strong parenting when he was younger, but there is also a family to feed. He simply cannot stop working, particularly in a right-to-work state.

Roger presented to the clinic one day with pain in his left shoulder. A careful history of the problem revealed a gradual onset of this pain that worsened with driving or other use of his left arm. After a directed physical exam ruling out some very serious potential causes of left shoulder and arm pain, it became apparent that the source of his arm pain was in his neck.

When pain radiates from the neck into the arm, something is hitting a nerve somewhere. Arthritis will not do that, nor will muscle strain. This was probably emanating from a cervical nerve root where it exits the spine. The things that can cause that include disc bulges and bone spurs, both of which can be troublesome.

I was concerned with the radiating nature of this pain because there are some bad things that can do that. We needed the missing piece of the puzzle, imaging, to be sure that conservative care was most appropriate for this problem. Consequently, we requested an MRI via the imaging center next door. I like using that imaging center because they do the “heavy lifting” with the insurance companies, and they treat our patients like customers. The radiologists are skilled and personable (you do not always get both attributes in the same people). They do good work and they are reliable.

I saw the films before I got the report. The films looked disastrous. Roger had three bulging discs, with the worst one at the level where the nerve exits that goes to the left shoulder and upper arm (the smoking gun). There was tight compression in the cervical spine at that level, which is what we call “stenosis.” Of course, doctors do not use the word “tight” when we can use the word “stenosis” because the latter sounds far more impressive, but seriously, this looked ominous on film.

My 21 years in this field have taught me, among other things, that we cannot always make a prognosis based on imaging. There are people who look doomed on film who do quite well clinically. I have seen others whose films looked quite innocent, but the patients for whatever reason fail to thrive with conservative care.

I had a chat with Roger and went over the films with him. We discussed treatment options. First, if we do nothing, we would expect him to get worse and possibly lose function of the left arm. That was an unattractive option. Second, this could be treated pharmacologically. Unfortunately, there is not a pill on the planet that will fix this problem. It can only be covered and masked until it gets worse. The current opiate crisis is a testament to the utter failure of this approach. Third, we could go straight to a surgeon, but that would be wholly inappropriate without trying conservative care first. Additionally, there is the possibility of injury, disability or accidents with anesthesia.

The fourth option, and by far the most logical, was to try aggressive conservative care first and reassess within four weeks. We look for at least 50 percent improvement by subjective and objective criteria to know we are going in the right direction. In the event we do not get the improvement we seek, we consider referral or co-management with an appropriate resource. Sometimes that is a surgeon or a pain management specialist.

Another factor for Roger has already been discussed. He could not just stop working. We were going to have to accommodate his work schedule and treat this at every opportunity we could create. This meant late afternoon appointments so we could decompress him on the way home.

We began treating this problem using a decompression manipulation technique called flexion distraction. This is a painless (in fact, it feels pretty great) procedure that creates negative pressure inside the discs. This technique can effectively reduce a disc bulge. After about 20 minutes of flexion distraction, we augmented the treatment with about 10 minutes of ultrasound.

Ultrasound is, as the name implies, high-frequency sound that is focused on the soft tissue around the joint we are treating. Those sound waves cause water molecules inside body cells to vibrate at the frequency we control on the machine. As those water molecules vibrate, they generate friction, which produces heat. Using this modality, we can raise the temperature deep inside body tissues. Not only does this feel good, but it also causes the tissue that holds us together to stretch better. Tissue that moves better hurts less.

We also got a traction set for Roger to use at home. It is simply a bag of water that hangs on a door facing with a harness that holds the head. It is a good way to supplement the flexion distraction that we do in the clinic, and it is not addictive.

We also discussed Roger’s sleeping posture. I typically recommend that people sleep in a side lying posture hugging a body pillow. The head should be supported by a firm pillow that is just tall enough to keep the head level with the mattress so that the neck is supported and held straight during sleep.

For acute pain, we use something topical with menthol, camphor or both with an ice pack for about 20 minutes. The menthol and camphor intensify the cold sensation, and the combination does wonderful things for blocking pain signals.

And now, back to the wonders that do not cease. Roger is dramatically better. Looking at the MRI, one would not predict success with confidence, but here he is, dramatically clinically improved. He is standing erect and has full use of his left arm. The pain going through the shoulder has diminished to the point of occasional soreness. He is going to do just fine, and he never missed a day of work.

I am daily thankful for a profession that allows me to see wonders. I am further thankful for my faith that allows me to know the Source of all healing. With Him, wonders truly never cease.

For this and other columns by Dr. Bob Hayden, please visit http://www.iriscitychiro.com.


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