The Power of Positive
by Maryann Brinley
Sometimes, the art of touch can be just as critical to a diagnosis as any medical history, biomechanical exam, laboratory test, X-ray, MRI or technological tool. This regular feature is designed to highlight cases from the files of UMDNJ physicians like David C. Mason, DO, acting chair, Department of Osteopathic Manipulative Medicine at the School of Osteopathic Medicine (SOM). Our narrative was pulled from his experience and written to protect a patient’s privacy so aspects of the story have been altered, but the truth is crystal clear: low back pain is one of the leading reasons why Americans go to the doctor.
ur patient, a 34-year-old mother of two, was experiencing sharp pain in the middle of her left buttock which radiated down her left leg. It was her first visit to my office so I was prepared to devote up to 45 minutes to this case. Returning patients see me for about 20 to 30 minutes. Her problem appeared to be sciatica for which there is no definitive diagnostic or radiological test. She had researched her symptoms online and had been hoping they would go away as quickly as they showed up. No such luck.
Two weeks before, after an 11 hour airplane trip which should have taken three, she put her foot on the floor while getting out of bed the next morning, and was suddenly in excruciating pain. It traveled down the entire outside length of her leg from the center of her left buttock. She could hardly move without wincing, felt worse when sitting down, and had become tired and frustrated by this tingling, shooting pain, which was only partly relieved by over-the-counter medicines.
Lumbar radiculopathy occurs when the nerve root in the lower back, which helps form the large sciatic nerve, becomes pinched or irritated. A herniated, slipped or ruptured disc in the lumbar or lower spine can also be the cause but I have to tell you, 85 to 90 percent of the people I treat for low back pain don’t fall into that category. Most of the time, the source of the trouble is in the muscles. And the great thing about osteopathic manipulation treatment (OMT) is that 80 percent of my patients feel better when they leave my office.
My new patient was under age 60, after which point in life osteoarthritis can become a concern affecting the back. She had no signs of premature menopause — estrogen is a factor in bone strength — and no other indicators for osteoporosis, cancer, or any disease that might affect bones. A non-smoker, she weighed more than 120 pounds (being underweight is an issue) and wasn’t of northern European descent (a genetic factor which would have added osteoporosis risk). Her bowel and bladder habits had been normal, complications which would have indicated that her situation might be more serious. By moving certain ways and putting herself into different physical positions, she had been able to lessen the pain’s intensity, a clue for me that her problem was muscle-related. Lying down with her hips and knees bent felt better than sitting or standing. Something was out of alignment, pinching nerves and causing inflammation.
One of the longest in the body, the sciatic nerve is formed by nerve roots that exit the spine in the lumbar and sacral regions. Unlike other muscles that flex the hip, the psoas is difficult to reach so you’re not as likely to stretch or exercise this muscle. Yet, when you sit too long — driving, at a desk, or in this patient’s case, wedged in the center seat of an airplane — the psoas tightens up. Over time, it can become shortened and will hurt whenever you stand up. The sciatic nerve passes through what is called the sciatic notch and continues beneath the piriformis, a muscle in the buttocks which moves the hip as well. Sitting too long on an uneven surface or with a wallet in your back pocket can aggravate this muscle.
Low back pain can be instigated by a traumatic injury but more often than not, micro-traumas or repetitive motions are to blame. Ergonomics is a factor. For instance, sitting improperly for too long at a computer or standing for more than two hours can lead to dysfunction just as easily as a single major accident or fall. It’s not lifting that 100 pound piece of equipment once, but picking a pencil up from the floor the wrong way too many times that will eventually get you into back trouble. What I discovered about my new patient while taking her medical history was that her back had been a little irritated before that fateful flight. The seat in her car was uncomfortable and she had been spending long hours driving to a hospital in Pennsylvania.
I performed a standard neurological exam to make sure her muscle strength was equal on both sides. I looked for any loss of sensation, and checked her deep tendon reflexes, which were normal. My orthopedic exam also included straight leg testing which helped determine that she didn’t have a herniated disc. I also did a Patrick’s or FABER test on her, which screens for pathologies of the hip joint. This entails flexing the knee to 90 degrees on the affected side while the foot rests on the unaffected knee. The pelvis is held firm against the exam table, a position which rotates the leg at the hip joint. If she had been in pain at that point, I might have suspected something other than sciatica.
What she had were muscle spasms of her psoas and piriformis leading to multiple somatic dysfunctions of her pelvis and lower extremities. I could make this pain get better or worse by mechanically putting her into positions that pinched the nerve. This pain was something I could touch and reproduce with my palpation. You can’t touch a herniated disc.
While testing for asymmetry and range of motion, I always ask the patient, “Where does it hurt?” and have them point to the spot. I’ll palpate the area assessing tenderness, edema (swelling) and spasm. There may be other tissue texture changes like warmth or ropiness, which occurs when a muscle is scarred or fibrotic (abnormally thick) from being in spasm or pain for awhile. She didn’t need an MRI. A real benefit to being an osteopathic physician is that we develop these palpatory skills. I have published a small study comparing my treatment of low back pain to that of another allopathic physician here in Stratford. We analyzed a year’s worth of low back pain cases — that’s about 40 percent of my patients. The MD sent 21 percent of his for an MRI while my number was under 1 percent. Yet, a thorough history and physical exam including palpation can identify the underlying cause. If you can demonstrate to the patient what that cause is and make them feel better before they leave, they are happy to skip unnecessary testing. In fact, my goal is to identify the cause at that first visit, immediately remove the muscle restriction causing the pain using osteopathic manipulation and help the patient stay better with an exercise prescription.
I demonstrated how she could stretch to relieve symptoms, gave her a handout with three regular exercises, and explained that muscle spasms and joint restrictions can return so she might want to see me again for a follow-up in one to two weeks so I could treat her again and re-evaluate. I also suggested yoga for its emphasis on symmetric stretching and Pilates classes because they focus on core body strengthening. Just giving medication to get rid of pain is never the answer to curing low back aches. All prescription drugs have side effects so you have to look at the risks as well as the benefits. Of course, sometimes I do suggest different pain relievers, anti-inflammatories or muscle relaxants depending on which type of tissue texture changes and range of motion deficits I’ve picked up.
Too many doctors look at a patient from across the room without ever touching them during a diagnosis. That’s a mistake.
A family practitioner, David C. Mason, DO, is acting chair of the Department of Osteopathic Manipulative Medicine at the UMDNJ-School of Osteopathic Medicine (SOM). A 1996 graduate of SOM, he was drawn to osteopathy because of its emphasis on holistic medicine. As a student, one of his teachers turned him onto the power of physical manipulation. He is certified in both family medicine and neuro-musculoskeletal
medicine. His book, 5-Minute Clinical Consult: Osteopathic Manipulative Medicine in Clinical Practice (Lippincott, Williams and Wilkins), co-authored with SOM physician Millicent King Channel, DO, will be published in March 2008.