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Re: strange case of sciatica??
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Re: strange case of sciatica?? - July 25, 2001 8:35:00 AM
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JLymanM
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Joined: July 24, 2001
From: Washington, DC
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With the utmost respect... none of you is even close. The woman's pain is obviously psychogenic. No neurophysiologic or skeletal-muscular condition can explain the symptoms, particular the night pain. This is not to say that she is imagining it; rather, the somatic condition is *caused* by emotional factors, most likely repressed anger and anxiety.
The whole concept of chronic pain's resulting from structual injuries or abnormalities is unsupportable. For one thing, the inflammation that is routinely blamed for pain -- even pain recurring for decades -- is nonsensical. Inflammation is a restoritive healing mechanism, of relatively short duration. For another thing, it is a neurophysiologic fact that sustained compression of a nerve root will quickly result in diminished sensation -- not continuing pain. While injury or improper healing may lead to limited motion, it in no case results in chronic pain.
Please explore the work of Dr. John Sarno of New York University, paricularly his latest work, The Mindbody Prescription.
Best regards and good luck.
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Re: strange case of sciatica?? - July 25, 2001 4:30:00 PM
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pablo
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Joined: March 12, 2001
From: ACT, Australia
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Hi JLymanM,
I am not sure I agree with you that chronic pain resulting from an abnormality of structure or continuous inflammation is "nonsensical" as you put it. I can think of lots of examples where what you suggest simply doesn't hold water. For example, why do patients with osteoarthritis of the knee feel lots less pain after knee replacements? How does conservative treatment of say, shoulder impingement, decrease pain and improve function? Mechanically, it makes more sense than to say all chronic pain is caused by stress and depression. Granted, psychological causes of pain do exist, but to say that all chronic pain is psychogenic is as much nonsense as saying that all chronic pain is caused by pronated feet! And is pain due to cancer also psychogenic? I am not sure what the purpose of your post was.
Our job is to consider ALL the options, and work with the ones that we may be able to change. I work with a few psychologists, however they don't claim to be able to "cure" physical problems, and I don't claim to be able to "cure" patients' psyches. But working in combination there's a better chance.
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Re: strange case of sciatica?? - July 26, 2001 4:20:00 AM
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henryryry
Posts: 100
Joined: September 6, 2000
From: Brisbane, Australia.
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JLymanM and Pablo,
I was surprised to see this topic move to the top of the column again after so long. I probably would not classify her as a chronic pain patient, since I posted the message 4 weeks post her complaint (so more subacute still than chronic).
JLymanM: I would agree with you partly that she had psychogenic factors which I did not look too much into back then. Perhaps her fear of movement, the fact that she continued to get pain at night may have triggered off emotional factors, released the "unhappy hormone's" and caused hyperalgesia effect.
However, I would agree with Pablo's last statement that "working in combination there's a better chance." Putting the blame on a person's psyche without consideration of other factors is dangerous and may lead to further complication of the problem. Chronic pain involves psychological, social and biological factors as well, and they should all be examined. They may have differing contributions, but all need to be managed in the treatment of chronic pain.
The last I heard from her was that she had a blood test and was going for an MRI scan. I may give her a call tomorrow and ask her how she is.
Henry***
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Re: strange case of sciatica?? - July 27, 2001 9:08:00 AM
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JLymanM
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From: Washington, DC
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Well, perhaps I was too declarative in my remarks. I do agree that physiologic causes should be rigorously investigated and discounted before one assumes that the somatic pain (e.g. minute blood flow restriction initiated in the central nervous system) is psychogenic. I do distinguish between osteoarthritis inflammation and the inflammation that is alleged to occur in response to herniated discs. It is difficult for me to understand how static disc material -- even if it's protruded or herniated -- could cause persistent inflammation. Further, many patients have steroidal anti-inflammatory drugs injected directly into these presumably inflammed tissues with no result. I have heard it said that about 30-40% of patients' bodies "don't absorb the nerve block." What!?
Admittedly, my personal history renders me bias. I have had left leg sciatica since I was 15 (23 years ago). Based on the symptoms alone, I was diagnosed with a "slipped disc." The pain persisted and a CT scan was performed at age 20. Reviewed by two neurosurgeons and an orthopedic specialist, there was no slipped disc indicated. In what turned out to be an emerging trendy diagnosis at the time, I was told that I had spinal stenosis (keep in mind that I was only 20 years old!). The pain has become chronic and recently became unmanagable. An MRI reveals, of course, that I now have a slipped disc (who doesn't by age 38?). Despite my dutiful recitation of the history above (i.e., that the leg pain preceded the slipped disc), the osteopaths and orthopedic and neurosurgeons are certain the pain emminates from the long ago deteriorated disc (it is clear from the MRI that little or no fluid remains).
And this: the most pain free year of the last 23 was the one which I spent trapsing around the back roads of Central America with a fifty pound pack. Further, my leg *never* hurts while exercising -- even rigoursly; I can run, but I can't walk.
I think a PT who agrees with me or at least accepts the possibility that the genesis of the pain is psychological, could help the affected tissues break out of the bad cycle. When a PT proceeds on the assumption that there's inflammation or nerve impingement, etc, I just don't get better.
Oh... but we weren't talking about *me* were we?
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Re: strange case of sciatica?? - July 27, 2001 7:47:00 PM
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Sebastian Asselbergs
Posts: 1206
Joined: September 29, 1999
From: Barrie, Canada
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With regards to inflammation at the disc level:
One recent article: "Extradural inflamation associated with annular tears: demonstration with gadolinium-enhanced lumbar spine MRI" Saifudden, Mitchell, Taylor
Eur Spine J, 8(1):3409 1999
It may not make it easier to comprehend the process, but it seems to strongly confirm that inflamation indeed occurs at extra-discal areas - and when inflamation occurs, chronic inflamation is not far behind....
The fact that steroid injections are not very effective says very little of the presence of inflamation - too many other variables to make the conclusion that there is no inflamation. Granted, it is obvious that the mind/psyche plays a major role in health and recovery from injury, but to discard well-studied inflamation as non-existent is IMO somewhat radical.
Individual anatomy being what it is, as you all know: disc protrusion can press on any nearby nerve root - dermatomes can be screwed up often, as are myotomes. Some roots exit at a higher level, some at a lower. Bogduk and Twomey have shown some good examples of variations. In Henryyy's case, hip pain can be ominous, or just the psoas "acting up - maybe due to its direct attachments at L1-2-3 discs (amongst others). And there may be three or four interacting dysfunctions at work... After clearing the red flags, I'm with MCAP - movement and therapy and second and third opinions...
Any news from the MRI Henryyy?
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Re: strange case of sciatica?? - July 28, 2001 1:50:00 AM
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henryryry
Posts: 100
Joined: September 6, 2000
From: Brisbane, Australia.
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Well said Sebastian. I think with present knowledge and diagnostic skills, we do not really know where the pain is coming from. This is what they call the grey zone. As I said, perhaps there's an element of inflammation, an element of psychogenic pain.... I think within the next 10 years, science will tell us a lot more about pain mechanisms.
As with this lady, I called her on Friday. She stated that the physicians cleared any red flags, but were more interested in her back, even though she still did not complain of low back. Her MRI showed disc prolapse but without nerve compression. She stated that when she gets pain, her right hip clicks at the same time. Any ideas??
BTW, her pain is tolerable now and not inhibiting her... and best of all, she is still doing her Physiotherapy exercises!!
Henry***
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Re: strange case of sciatica?? - February 12, 2002 2:55:00 PM
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abrar
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From: Melbourne, Australia
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Henrry: have you tried traction/glides of the hip combined with massage in the hip adductors?? I had a similar patient to yours except he never had any spinal involvement.....on a subsequent x-ray we found he had Osteoarthritis of that hip.
Very weird is the fact that he got better everytime after treatment with massage (vigorous) and adductor stretches in supine.
Dunno sometimes the resolution is so weird in physiotherapy.
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Re: strange case of sciatica?? - February 13, 2002 3:47:00 AM
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henryryry
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Joined: September 6, 2000
From: Brisbane, Australia.
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Thank you for your suggestion abrar. It is definitely interesting the extent of variability in individuals... probably makes Physiotherapy more exciting and never boring [IMG]http://www.rehabedge.com/forums/biggrin.gif[/IMG]
Henry***
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Re: strange case of sciatica?? - March 13, 2002 12:23:00 AM
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chel_rm
Posts: 2
Joined: March 10, 2002
From: Baguio City,Cordillera,Philippines
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hi, i just wonder what is the ROM of the hip in external and internal rotation, does the pain worsen during weight bearing, is it relieved by rest? any history of trauma?Based on your PE, I suspect a hip pathology aside from the muscular involvement and i guess an x-ray , a/p view is warranted to confirm.
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Re: strange case of sciatica?? - March 13, 2002 12:28:00 PM
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henryryry
Posts: 100
Joined: September 6, 2000
From: Brisbane, Australia.
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Chel_rm... thank you for bringing up this patient again, because they finally found something worth treating.
She continued to complain of pain after cessation of Physiotherapy in the anterior hip region, but the physician kept dismissing it as been just "coming from the back." Surely enough, her condition regressed and she started feeling a sense of general unwell. the doctors then decided that it was time to get something done, and it ended up that she had kidney stones (so edvol's guess what right). Sure enough, take the stone out and she was pain free! (why didn't the physician just get it checked out in the first place??)
Henry***
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