What Éric-Olivier loves most about physical therapy is his ability to have the chance to truly learn about his patient beyond the body mechanics. Getting to know patients allows him to better tailor h...
Here is the story of another of my patients. For privacy, we will name him Mr. B.
This story shows how we are responsible for the words we choose and how sometimes complex problems don't always have a complex solution. The complexity sometimes lies in finding the proper "simple" exercise to help you find the path toward a pain-free life.
Mr. B is a middle-aged man who once was a national karate champion. This was during his twenties. While he was still teaching karate and working as a mover in his thirties, he sustained a terrible injury. He fell from a moving truck's platform on concrete with a heavy couch falling on top of his chest and neck. He was bedbound for multiple months following the accident due to a fractured vertebrae and multiple torn muscles in his neck and chest. This was over a decade ago.
Since then, Mr. B has seen over ten different health professionals (neurologists, physicians, physiatrists, physical therapists, chiropractors, massage therapists, osteopaths). He saw them all. Unfortunately, they could only provide him with minimal temporary pain relief and always ended by telling him that he was suffering from chronic pain and would likely have to live with it for the rest of his life. When I met him, he was on the waiting list for two more cortisone injections for his neck and shoulders.
When I met Mr. B for the first time, what I saw in front of me was someone in a lot of pain, but even greater than his pain was his distress and anxiety. We will address how this distress and anxiety had a large impact on how he was experiencing his pain. Mr. B had difficulty describing his pain since it greatly varied from day to day. He knew where it was, but the intensity and feelings of the pains were very variable and unpredictable. Due to the extent and variety of the different pains he was experiencing, we will list them.
- Constant neck pain (right and left) and sometimes shooting down to his shoulder blades.
- Recurrent migraines that would extend into his eye socket.
- Constant pain going from his neck to his fingers in both hands.
- Constant lower back pain, sometimes shooting down to the back of his thighs and buttock.
- Major loss of movement in all directions of the neck.
- Moderate loss of movement in most directions of his left shoulder.
- Intermittent tingling and numbness in his forearms and hands (worse at night).
- Intermittent tingling and numbness on the back of his thighs (worse when sitting).
- The most problematic symptom for him was that he would wake up with the left side of his face completely numb (he described it as coming back from the dentist). This was the worse for him since he kept waking up at night from the pain associated with the numbness. This prevented him from getting a good night's sleep for the last decade. He slept poorly and was apprehensive about waking up every morning since he knew he would start his day in pain.
To manage these, Mr. B was taking numerous strong painkillers and nerve pain drugs when we first met. He was also on the waiting list for a consultation at the chronic pain clinic in Montreal.
As debilitating as his pain was, something had an even more serious negative effect on his quality of life; his beliefs about pain and the distress they created in him. After asking him what had brought him into my office and a few more questions, I decided to put on hold my history taking. I felt that before diving deeper into his situation, some education on the meaning of chronic pain, something he had been labelled with for the last 15 years, was necessary.
During the initial 30 minutes of the session, the term chronic pain was used quite often by Mr. B. With the way he was using it, it seemed like those two words had a very negative connotation and nocebo effect on him. This pushed me to ask what chronic pain meant to him. I wanted to hear his own words to describe it. Here was his answer:
I was shocked to hear from all his previous discussions with the different health professionals, that this was Mr. B's understanding of chronic pain. We took the time to demystify this often taboo and poorly used term. It was primordial for the rest of our partnership that he understood what chronic pain meant. I don't want to dive too deeply into pain science since I will discuss it in a second article. Still, my main key educative points for Mr. B regarding chronic pain were the following:
1. First and foremost, and I cannot stress this enough, your pain is real. What you are experiencing is 100% real. There is no such thing as fake pain. Whether something is damaged or not is a different topic which leads me to my second key point.
2. Pain is not only present when something is damaged. A simple example to prove it is hitting your toe on the corner of a desk, we all know how badly this hurts, yet we both know that your toe did not sustain any damage for five minutes later it is no longer painful.
3.The last key point was the literal definition of chronic pain: Chronic pain is used to define pain that lasts or recurs for more than 3 to 6 months.(1)
Chronic pain is an umbrella term that is often used to describe pain that has been there for a long time (3-6 months). It doesn't mean it will forever be there; it only means that it has been there for some time.
Knowing this did not make his pain disappear, but it impacted the rest of our sessions. Even after learning that his pain was real and that improving his condition and quality of life was a possibility, it took Mr. B two months before he said he no longer was skeptical of the changes in what he was feeling and that he was certain that he was better and staying better.
For the rest of the first session, we started moving. Most basic neck and shoulder movements increased his pain to an 8/10 or more. Some of these movements also produced dizziness and headaches. After testing a few movements, we saw a certain pattern emerging, one direction seemed to increase most of his symptoms, and once the exercise stopped, the pain remained increased. In the other direction, his pain was increased during the exercise, but a few seconds after stopping the exercise, his symptoms seemed to want to return to baseline or slightly below what they were before the exercise. With this in front of us, we decided to pick one of the movements in the second direction. He went home with one simple neck movement, which he had to do ten times every hour for the next three days.
(Repeated cervical retractions or also known as chin-tucks as shown in the picture was the chosen exercise after our first session).
The main goal of this exercise was to allow his body to slowly relearn that moving wasn't always associated with increased pain and that maybe movement was beneficial for him. Over the years, he had become apprehensive of movements since most of them would increase his pain. He also became fearful after multiple health professionals told him he was fragile. (A word that I very, very rarely use). This is a normal protective mechanism. This is no different than never putting your hand on the stove once you've burnt yourself doing so once before. The body naturally shies away from painful situations.
Three days later, Mr. B came back. As asked, he had performed his exercise 10-15 times per day. We realized that although he was still experiencing roughly the same amount of pain, his neck had gained some mobility. Nothing incredible, but enough for him to tell me that he was now almost able to do his blind spots when driving without turning his whole torso. Enough to come back, as he said. It might sound benign for some of you, but this was an enormous improvement for Mr. B since he started believing that maybe, just maybe, there still was hope.
He no longer felt any pressure or pain in his neck when doing his exercise, which probed me to progress it in an attempt for further improvements. We decided to go with a second exercise by the end of the session.
We chose this exercise since initially when doing this movement only a few times, Mr. B complained of dizziness and his typical headaches with some neck pain, but once stopped, so did the symptoms, and better were his neck movements. After testing the movement for multiple sets, he was experiencing less and less of these unpleasant symptoms when doing the exercise. After doing it roughly 30 times, the movement no longer provoked dizziness or migraine. It seemed like this movement was working the body region that was the culprit for his recurring migraines and dizziness, as the more we were doing it, the lighter they were, as if it was reducing the problem.
Those were the words of Mr. B when he walked into my office during our 3rd session, which was a week after the 2nd visit. Here are the changes he experienced between the two sessions:
- No headaches/migraines since the last session
- No facial numbness in the morning when waking up
Mr. B was very emotional during the session as this was the first time in years that he had been able to have a good night of sleep and wake up without dreading pain in his face. It was also a big relief for him since the fact that he no longer felt these after only two weeks was proof that he had not imagined these "pains" for all those years, they were true.
The rest of the timeline was not always ups. There were some sessions where he came in saying that his pain was worse than the last week and that he was discouraged, but if we trace a line from the first session to the last, it was a positive tendency. We all have better and worse weeks, but the important is that the tendency is upward when you do the average. Over the next two months, we kept building on small and bigger wins.
By visit 7, his neck and shoulders had improved significantly. He felt in control enough of his progression and recovery that he asked me to now shift the focus toward his lower back. As mentioned previously, Mr. B was dealing with constant lower back pain, sometimes shooting down to the back of his thighs and buttock and intermittent tingling and numbness on the back of his thighs. We used the same approach as his neck and picked one movement that seemed to decrease his symptoms the more we did it. Again, the goal was to reassure him, allow his body to be confident with moving, and decrease his symptoms.
Mr. B expressed that he felt he was overall 80% better since our first session two months ago. Here are the changes since the first visit:
- It has been six weeks since he last experienced a headache/migraine or facial numbness.
- He no longer experiences pain or tingling in both his arms and legs.
- He now has intermittent discomfort in his neck and lower back instead of constant severe pain.
- He regained the complete range of motion of his neck, shoulders, and lower back.
- He now sleeps comfortably and, for the first time in years, feels energetic and able to attack every day the way he used to.
- He feels in control (and he was).
During this specific session, I proposed to Mr. B to go back to the gym for the first time in years. I knew this was something very important to him with his background, and I believed that it could have an amazing effect both physically and mentally for him. After explaining how to get back at it progressively and safely, Mr. B left with a workout program for him to train three times a week.
This session was our last session. Mr. B had now been training regularly for the last three weeks. During this session, Mr. B spoke, and I listened. Mr. B told me that he believed this would be our last session. I agreed with his decision. I asked why he believed so, and here was his answer:
I might not be perfect yet, and I likely will never be like I was before the accident. Still, I'm at a point where I'm happy and comfortable if I live the rest of my life feeling this way. I feel like I am myself again. I feel like I have control over my life and what I experience. I know what to do when my neck flares up. The same goes with my back. I am now back to being able to do those things that bring me joy in life, and more important than all, I can once again be the present father that I used to be for my daughters. I know where I am heading; I no longer wait in the gray zone, you heard my questions, and I received answers to my questions. I am in control of my life now.
Mr. B was one of the most challenging yet rewarding patients that I have ever had to work with. It is hard to believe that people we cross in the street live with such a large amount of pain daily. Too often, health professionals and people of our surroundings only focus on how the body moves, if it looks injured or not, to decide the extent of the pain one should experience. This is problematic.
Although not everyone goes through such terrific accidents, many will endure pain for many years and become labelled with chronic pain. This depicts an incredible story, but it also shows that there is always hope for improvement regardless of how long or how bad the pain you are experiencing is.
If you feel like you would benefit from an evaluation to identify and treat your pain from a health professional, you are welcome to take an appointment with me. It will be my pleasure to guide you and answer your questions.
For more information, make sure to read my other articles which you can easily find on my profile. To discuss the information disclosed in this article, feel free to reach out and let me know, I am always eager to learn. To do so, you can contact me by email at firstname.lastname@example.org
(Merskey H, Bogduk N. Classification of chronic pain. 2nd ed. Seattle: IASP Press, 1994. p. 1. [Google Scholar])