Articles Of The Week September 20, 2020

Much of the United States, Canada, and even areas overseas are currently blanketed in forest fire smoke. Could this affect people’s pain? Here’s a study that looks at the effects of tobacco smoke on pain and rest.

Effects of smoking on patients with chronic pain: a propensity-weighted analysis on the Collaborative Health Outcomes Information Registry – James Khan et al.

 

Another mention to the constant fatigue that many of us are likely experiencing in these days and times. This article continues to go into depth about the varying causes of lower energy and provides more tips on how to combat it.

Why You Suffer from Constant Fatigue and How to Deal with It – Mark Pettit

 

We all know that pain benefits from exercise in the long term, but only some of us might be aware of the short-term analgesic effect from movement as well. An easy assumption is that this is all an endorphin effect, but are there other mechanisms at play?

Exercise Induced Analgesia –Todd Hargrove

 

If you’re looking through these articles, great! You’re a research-conscious practitioner. As such, it’s good to point out the occasional limitations of the research that you’re reading in order to fine-tune your perspective. This article, for instance, looks at the need to adjust our experimental groups for low back pain-clients in order to create better date.

A need of subgroups with the large group of people with (chronic) low back pain – Hester de Bandt

 

Research into the causes of autism are a hot topic that many of us may not want to touch, but it’s ok to look at the scientific research objectively. In particular, we stumbled upon this new relationship while researching into hypomobility syndromes.

Researchers have identified a relationship between Ehlers-Danlos Syndrome and autism – Emily L. Casanova

 

Complex Conditions Does Not Mean Complex Treatment

 

As a student, I had the opportunity to complete a case study with a client who was living with Multiple Sclerosis.

Multiple Sclerosis (MS) is a chronic, inflammatory disease in which the immune system causes demyelination of nerves within the central nervous system. According to the World Health Organization and Statistics Canada, Canada has one of the highest rates of MS in the world: 2.9% of the population is affected. Fatigue, pain, weakness, spasticity, and paresthesia are common symptoms associated with MS.

I was excited to work on this case study, it was very difficult, in our student clinic or outreach settings, to have continuity of care with a client. To work with an individual every week, over three months, and observe the effect I was having, seemed like a great opportunity.

It also made me nervous.

I was only a student, not only that, I hadn’t received any advanced training at the time – no advanced techniques, remedial exercise, or homecare planning.  I asked my instructors to teach me some advanced techniques that would allow me to address the specific nature of the client’s diagnosis but was encouraged to proceed with what I considered to be a limited skill set. I lacked the confidence that I could make a difference.

I was not convinced but thought it was a good learning opportunity and, so, proceeded.

Help The Person, Improve A Condition

The client I worked with was in her 40’s, a mother of four. She had been diagnosed with MS 20 years prior but it had little effect on her life until the previous few years when she began to experience symptoms of drop foot. She started catching her toes on the stair lip and, by the time I saw her, she was using a walker. She had begun to make decisions that kept her from participating in her normal activities of daily living: driving, walking in winter, and trips with her kids.

At the outset, I had some challenges. I had only fundamental skills as a Massage Therapist and limited experience. The nature of a case study means it is limited in time and scope. Yet the condition itself is quite complex and can present many different symptoms. I took a very straightforward approach to tackle these challenges: listen, focus, and keep it simple.

I interviewed the client prior to starting the case study – partly to establish a baseline but mostly to understand what she wanted to address. Listening to her whole story provided context and direction for the treatment. It helped me understand what aspects of the condition were most affecting her life. Together, we identified what to ‘tackle’. 

It was important that was something measurable – not just because I was doing a case study but because the client wanted to understand the cause and effect of her efforts. Because of my limitations, keeping the protocol simple was necessary but it also turned out to be effective. The protocol used basic techniques like petrissage, tapotement, and stroking but it was applied consistently and regularly.

In retrospect, there were other aspects may have influenced the results. In choosing to participate, the client likely already felt hopeful and empowered, the regular break for self-care alone would be a change from her regular routine. Further, it provided an opportunity to get out of the house at a time when that was not easy for her. All of these aspects lie outside our treatment yet can have a significant impact on the outcomes.

Over the course of treatment, the results varied. The intervention used was a standardized massage therapy treatment approximately once a week for 12 treatments. The patient was assessed using the Multiple Sclerosis Quality of Life Inventory (MSQLI) (for the quality of life issues such as fatigue and pain) and measurement of dorsiflexion (as an indication of the degree of severity of drop foot).

The MSQLI is a comprehensive questionnaire that has been developed specifically for patients with MS and subdivided to include: health status, fatigue, pain, sexual satisfaction, bladder control, bowel control, visual impairment, perceived deficits, mental health, and social support. This self-administered survey takes approximately 45 minutes to complete. The raw scores of each section of the survey are scored, according to MSQLI instructions to determine the final representation of data. This case study, based on the patient interview, paid particular attention to Health Status, Modified Fatigue Impact Scale, and Perceived Deficits.

Most of the client’s symptoms improved steadily with a significant improvement in Perceived Deficits, meaning, the client felt she was developing the skills to cope with her symptoms. However, on three occasions, the ability to dorsiflex declined. 

Alarmingly, there were some new symptoms presenting at some points. Just past the halfway point of the treatment the client experienced the ‘worst spasticity of her life’. This was an extremely challenging point in the treatment.

Should I stop? Should I alter the protocol? Because of the random nature of Multiple Sclerosis, it was very difficult to determine how to proceed. On direction from the client, and with input from advisors, we continued. The overall result was positive, the client started with dorsiflexion of 2mm and, after 12 weeks, could dorsiflex 47mm. For her, it meant the difference between tripping and not tripping during her normal daily activities. Although she was not ready to return to driving, she had the confidence to attend a school trip to a museum with her children and successfully navigate the day with the use of a cane.

The important lesson for me was that a complex condition does not require a complex solution. Instead of employing advanced modalities or techniques, I listened, focused, and kept things simple by sticking to the basic principles of massage.

You can download the case study HERE if you’d like to learn more.

 

Degenerative Disc Disease Correlation To Pain Doesn’t Matter As Much As You Think

He came in with a look that resembled someone in grief.

I asked if he was okay and his response was a bit surprising.

“I was just told I have a disease which is causing my back pain, as a result, the pain may never go away.”

As I inquired more he told me the diagnosis was degenerative disc disease, which was causing his spine to shrink and as a result, it was causing the low back pain he was experiencing and would now have to seek treatment on a weekly basis just to deal with it.

This once active person (in his 50’s) was now disheveled because of this MRI diagnosis he had been given by another practitioner, he felt hopeless.

Why MRI Is Just One Tool That Should Be Used

Stories like this happen all too often with our patients.

They experience some sort of low back pain, (which usually they have never experienced before) and their doctor or other healthcare practitioner orders an x-ray or MRI and the results seem catastrophic. They are diagnosed with a “disease” or “syndrome” of some sort but aren’t given any really good information surrounding their condition.

While there is a possibility that disc degeneration (DDD) could be a contributing factor to their pain, it’s not as simple as just looking at some medical imaging to get a proper diagnosis.

There are several contributing factors including environmental factors, genetics, and associations with heavy physical work, lifting, truck-driving, obesity and smoking (smoking has been found as a risk factor for pain and DDD) found to be the major risk factors. However, these do not point to a clear pattern between degeneration and clinical symptoms.

Something that doesn’t get mentioned as often, is how this is also simply a part of normal aging. One systematic review points out some interesting facts to show just how much this happens. When looking at 3110 images of asymptomatic people the review showed: 

  • Prevalence of disc degeneration in people at 20 years old was 37% which increased to 96% in 80-year-olds.
  • Disc bulges occurred in 30% of people at 20 years old and 84% in those at 80 years of age.
  • Disc protrusions were 29% of 20-years-old and 43% of 80-years-old.

And all of these individuals weren’t experiencing any pain!!

Another study showed changes in the disc at multiple levels were more common in the elderly (in this case above 60 years) as well as other degenerative changes around the facet joints, ligamentum flavum, and disc bulges.

Even though degeneration has been seen in the younger population as well, there is little correlation between radiological findings and pain. Quite often people whose imaging shows major issues have no pain and those who present with minor signs experience severe pain.

Unfortunately, many of these people are referred for surgery (usually a spinal fusion) which eliminates motion and can lead to degeneration of adjacent parts of the spine. Another part of the problem here is this only addresses a symptom, not the cause and the surgical outcomes are not great. It is also important to note that 70-80% of people who have surgical indications for back pain or disc herniation recover whether they have surgery or not.

These surgical referrals usually happen because imaging has been used as a diagnosis, rather than just a tool used in the process. This isn’t to say imaging shouldn’t be used, but it should not be the only thing used. Overall we see the association between MRI findings and DDD are unreliable, so the importance remains on our clinical reasoning and of course, patient history as well as looking for any neurological deficits.

The Role Of Depression

Now that we understand DDD risk factors, it’s age-related changes, and correlation with pain there is another factor we need to look at. 

Depression. 

In a three year study looking at veterans who were asymptomatic with low back pain, they were given repeated MRI’s over this three-year span. The researchers made a point of not telling the participants the results of what they saw as they didn’t want the patients to alter their symptoms by becoming sensitized to trivial issues or amplifying their symptoms. 

Imaging findings varied, some discs were less severe, or even normal, and some became worse. The study concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings that may be risk factors for future back pain, however, protrusions were not a risk factor. 

But, the strongest predictor for low back pain was depression. 

Of those who self-identified (and were being medically treated for it) as having depression, their pain scores were greater at EVERY follow-up, whereas the progression of disc changes was only occasionally associated with new pain. Some of the participants also pointed out their activities were limited because of their depression. 

As we know (when reviewing the clinical guidelines of low back pain) bed rest used to be one of the main recommendations for those dealing with acute low back pain, but now exercise and movement is the far better recommendation. When we look at discs exercise does not affect them adversely and they respond well to long term loading strategies. 

So, think about that patient who comes in and is catastrophizing about the diagnosis they have just received. We know part of what we have to do is provide reassurance, in fact, this is a MAJOR part of what we have to do. Looking at all the information we have just discussed, letting them know that disc degeneration is a part of normal aging, there is little correlation between their diagnosis and pain (unless there are neurological symptoms) and quite often the issue resolves itself without surgery. Could we actually reverse their catastrophizing? Could we also assist this by encouraging them to exercise, even by getting them moving on your table to show that movement is safe? We know that exercise has great results in helping with depression and now we know it also helps with disc health, so aren’t these the things we should pay more attention to rather than focusing on MRI results? I’d say yes…and the research agrees. 

When You SHOULD NOT Treat Your Patients Thoracic Pain

When I was in physical therapy school, PTs in the States didn’t have direct access. 

I figured I needed to mainly focus on differential diagnosis of musculoskeletal issues and not worry about cancer or visceral referral pattern.  However, the States slowly has been adopting direct access for physical therapy and I also learned that regardless of having a referral, physicians don’t always spend enough time with patients to properly rule out other causes. 

The purpose of differential diagnosis is not to just identify a specific structure involved, but to also help determine prognosis, other psychosocial factors and to rule out serious pathology and identify conditions not appropriate for physical or massage therapy.

My patient was in her late 20’s and 6 weeks postpartum.  She had been having mid-thoracic pain and right scapular pain for almost 12 weeks.  Her physician sent her to therapy to receive manual therapy and strengthening. 

During the examination, I had difficulty reproducing her pain, but she stated her pain was worse at the end of the day after lifting, carrying and feeding her child all day.  She had weakness in her extensors and scapular retractors.  Even though I couldn’t reproduce her pain, I gave her some stretching and started some scapular stabilization exercises.  I figured her pain was from a sudden increase in lifting and carrying, sitting with her child and a change in her chest size.

Admittedly I treated her for 3 follow-up visits (with little change) before I realized what the problem was. 

On the third visit, her husband said: “I just don’t understand why the pain is always so bad late at night.”  He was more specific than she had been (end of the day).  The pain was late (10 pm) and often caused his wife violent vomiting.  That minute the lightbulb went on (and according to my patient I shouldn’t play poker because she knew!).  I asked her if she had ever had a White or light stool, she denied it, but her husband said: “don’t you remember the one when you were pregnant?”  She had a white bowel movement back when she was about 26 weeks pregnant!  She had denied pain anywhere else, but the minute I palpated her upper right abdominal quadrant she jumped off the table and reported radiation to her back/scapular area.

There it was….GALLBLADDER!  

She was admitted to the hospital an hour later and was in surgery 4 hours later.  The surgeon said she was days away from a rupture.

Quite honestly, I felt like an ass. 

I had seen her for 4 visits total before the husband had said the words that made gallbladder click in my head.  I realize she had seen both her Obstetrician and her Primary Care physicians prior to coming to see me, but that did little to make me feel much better at the time.  I had just started treating pregnancy and postpartum and couldn’t believe I almost missed something so important!  I went back and reviewed all my red flags and visceral referral patterns after this incident. 

I also share this story with every obstetrics in therapy class I teach.

Also, women and men often present differently with visceral referral patterns.  For gallbladder, women tend to have more vomiting than men.  Also, during pregnancy, the increase in estrogen leads to an increase in cholesterol in the bile and estrogen reduces gallbladder contractions.  The decrease in contractions leads to less bile leaving and an increased risk for gallbladder stones.  This can lead to severe pain and potential for infection.

Summary of Gallbladder symptoms:

  • Chills and/or low-grade fever
  • Dark colored urine
  • Jaundiced appearance
  • Light-colored stools
  • Nausea and vomiting (especially at night)
  • Stomach pain particularly after a high-fat meal
  • Right shoulder/scapular, mid back pain

We are never going to be perfect, but the goal is to learn from past patients and pick up on patterns faster the next time.  It also helps to share our experiences.  So keep these risk factors and symptoms in the back of your mind the next time your patient’s mid thoracic pain isn’t making sense!