Sometimes the Hospital is the Worst Place to Go
Sometimes a trip to the hospital for unrelenting back pain can take a person down the road road. Ineffective and dangerous treatment is the wrong treatment. Sometimes it happens because they’re looking at the wrong map! Over the years, I’ve seen dozens of people who went to the hospital with back pain, and came out without a real solution, on heavy drugs, with bad side effects.
The Wrong Map Leads Down the Wrong Road
Sometimes back pain is caused by a fracture, an infection, a tumor, an acutely herniated disc. That’s when X-rays or MRIs get right at the problem and the right treatment happens. That’s when you want to see a neurosurgeon or orthopedic spine specialist. And I refer to docs like that every week. X-rays and MRIs give us a map of the territory. But they are not the territory. They tell us specific and limited information about the person and his or her back. And sometimes they miss the issue. The trouble is when we think the map IS the territory. ‘The X-ray shows you have arthritis’. That must be the problem, because it doesn’t show anything else. If the pain is severe and unrelenting, that’s when the provider goes down a dangerous road and starts prescribing heavy meds, which don’t get at the problem.
Mrs R was an example of a case just like that.
She is a physically frail and mentally sharp woman in her 70s who survived the Nazi death camps and other terrible hardships and had been happily living with her children and grandchildren. She was admitted to rehab in misery after roughly 4 weeks of going in and out of the hospital because of back pain.
She had a mild fall at home. Her back hurt and in the emergency room was told there was no fracture and was sent home. Her pain persisted and got worse. Prior to the fall, she had been walking freely around the house. Now she couldn’t walk 5 feet. Her family brought her back to the Emergency Room where she was prescribed some percocet. That helped with the pain and they sent her home. Her condition deteriorated–she wasn’t eating well, barely getting out of bed, very unhappy. Back to the hospital and this time she was admitted. Had an MRI, given a diagnosis of ‘arthritis’ and ‘spinal stenosis‘ and started on a long-acting narcotic patch called Fentanyl. Her pain was better and she was sent to rehab.
On arrival the problems were many: her pain was only better when she was lying in bed like she had done in the hospital. When she tried to move she cried and she refused to participate in physical therapy. And was she wasn’t eating, felt exhausted and was losing her will to live.
Does Arthritis Really Cause Acute Pain?
Let’s get real. Osteoarthritis of the spine or other joints is a chronic process. When arthritis is the main cause of pain, it’s usually a gradually worsening problem. When someone has a fall, and suddenly develops pain, it’s hard to blame it all on arthritis in the joints. Look soon for another post on this site for more information about how ‘arthritis’ suddenly gets worse after a fall or trauma. There was more to her picture, and it wasn’t being treated by the narcotics. And from what I could tell, the narcotics were causing depression of her mood, constipation, loss of appetite. She was wasting away in front of her daughter’s eyes.
A Careful Exam Says More than a High Tech Test
My dad was a pediatrician. When I went to medical school (and for years afterwards) he kept telling me, ‘It’s all in the history and physical exam’. That’s not the way we train these days. The art of a careful a neuro-musculo-skeletal exam seems to be getting lost….
When I examined Mrs R it was clear that her pelvis was assymetric. The left ‘wing’ of the pelvis was jammed upward and forward. There were a whole set of associated muscle imbalances and spasm that were painful and correspond to the pelvic change. And judging from the ‘texture’ of her tissues, a detailed description of her fall, and the fact that she landed on her left lower pelvic bone, these changes were a result of her fall and could be the cause of the pain.
Low Tech. High Touch. Thinking, Feeling, Knowing Fingers
I treated her with osteopathic manipulation. A very gentle hands-on approach to enhanced fluidity and mobility of the ligamentous articular system, release spasmodic muscles, re-establish skeletal aligment, reduce soft-tissue swelling, and inhibit excitable neuro-muscular reflexes. Her pelvis shifted nicely and there was much greater ease in her lumbar and pelvic area.
She felt more comfortable almost instantly. We tapered her off the long-acting pain patch. We spoke about her beliefs and fears about her condition. She was invested in the fact that she had been unable to get around for a month and didn’t believe she was going to get better. She believed her life was over. We talked about the fact that we were doing things differently and getting her off the heavy medications.
A few days later, she was walking 25 feet with the walker. We did one more treatment the following week. She was participating in physical therapy and making slow but steady gains in her walking and transferring. Appetite improved and her bowels were working better. She gradually walked out of the rehab, without any pain medication.
The Integrative Model
Integrative Rehabilitation Medicine stands on the foundation of orthopedics, neurology, rheumatology, and other specialties. It looks at the complexity and interrelationship of the whole body-mind system. Click the link to my site if you want to come in for an eval, or set up a teleconsult and lets talk about your road to healing.
4 thoughts on “How to Find Your Way Home from Debilitating Back Pain? Get a Better Map.”
Great story. It raises a question: Is it erroneous to assume that pelvic obliquity would be detected in a standard PT eval, particularly in the case of low back pain? Assuming that it is, then how is the approach you described unique to holistic medicine, when it comes to treating back pain? Perhaps a patient with arthritis in her back would not normally be referred for PT? Why was she perscribed heavily sedating pain medication without being referred, first, for OT/ PT evals? is Is this the point of your post?
This brings me to another important point that you indirectly highlighted. The central role that occupations play in maintaining the will to live. And the impact of loss of participation on a patient’s prognosis.
In summary, your story elegantly points to the need for better communication between health professionals, with an eye towards promoting the ( holistic, therapeitic and essential) roles of PT and OT in the management of chronic pain and the long term health and wellness consequences of traditional – integrative approaches to the management of chronic pain.
Great comments. Thank you Ms Sternbach. I agree wholeheartedly with your assertion that a highly-skilled OT/PT can make the difference between dysfunction and function. Unfortunately, in my experience, most PTs and OTs don’t have the skills necessary to make and treat subtle biomechanical, neuromuscular, and autonomic dysfunctions that can give rise to pain. In the case cited here, the patient WAS seen in therapy. But they basically used a little heat, encouraged her to walk, did some basic stretching and strengthening exercises. These things are good, but for her they weren’t enough. To be clear, there are many PTs and OTs who do indeed have advanced skills in manual therapy, and I maintain close relationships with them and refer to them often. But it seems that many of your colleagues, especially those who practice in hospital and inpatient settings, don’t have the skills.
Why don’t inpatient therapists have manual skills? I don’t know for sure. It seems that the current payor system rewards therapy that is directed toward ‘functional outcomes’. Many therapists don’t really understand how a manual approach can not only be documented and billed within a functional outcomes approach, but can facilitate more rapid recovery. This case study is a case in point.
Part of the problem may be a misunderstanding of the principles of evidence-based practice. I’ll talk about that in another post. Briefly, the idea is like this: ‘evidence-based medicine’ was meant to enable the stratification of evidence by quality, to enable the best decisions about how to treat a given patient. The misunderstanding seems to arise when there is a lack of evidence to guide treatment in a given case. The assumption is often, “we have no evidence, so we can’t do that”. Even worse is the distortion that goes something like “lack of evidence of efficacy means evidence of lack of efficacy”. More on this later.
Thanks for your commnent!
“Even worse is the distortion that goes something like “lack of evidence of efficacy means evidence of lack of efficacy”. BINGO! This is a huge problem and I’ve been looking for this– an effecive, yet succinct way to express this exact sentiment! (I’m adopting it.)
Glad I found this site. Looking forward to reading more.
Wondering if the osteopathy you practice is also sometimes referred to as ‘biodynamic cranial osteopathy’. Or is that different?
I’m glad it is helpful.
Osteopathy is a broad approach with many aspects to it. I am trained in the biodynamic model and it shapes my thinking and therapeutic approach. But biodynamics is not something distinct or separate from the rest of osteopathy. It’s a way of working with the whole person osteopathically.