A Common Conversation

I had a conversation with a patient the other day, one that I've had all too frequently in the past. The patient, someone with chronic neck pain, had gotten impatient with the length of time it was taking her to heal, and had discontinued care. Now she was back in my office, after visits to the MD, PT, and the radiologist.

"I finally found out what was wrong with my neck," she said.

"That's great," I replied. "What is it?"

"I have arthritis!" she said. "My doctor took x-rays." She pulls out a manila envelope and hands it too me. "Maybe if I'd known a little sooner, I could have gotten this fixed."

I left aside for a moment the concept, always a little odd to me, that somehow I wasn't her doctor. I know, it's a chiropractic thing.

"Yeah, you probably do," I said. I ignored the manila envelope. "Doesn't really make any difference, though."

"What do you mean?" she said.

"Look, Sarah, you're 50 years old," I said. "Of course you have arthritis, everybody does by 50. Arthritis is just a medical term for wear and tear on the joints, and if after 50 years you don't have any wear and tear, that would be the surprising thing."

She just looked at me, clearly upset that I didn't share her enthusiasm for her newfound diagnosis and her (real) doctor's "discovery."

"Here's the thing of it," I said. "Those of us who treat a lot of this stuff know that there is often very little correlation between what an x-ray or MRI tells us and the pain and symptoms patients experience.

"Heck, studies show us that 30% of the population is walking around with a bulging disk in their lumbar spine, but most of them have no back pain. I've seen x-rays that showed massive amounts of 'arthritis' and disks that are virtually missing in action, but those findings had absolutely nothing to do with the patient's pain," I said.

"That's why I rarely bother with x-rays or CT scans or MRIs unless I see a red flag when I examine you. In most cases, it's not worth the radiation exposure or cost, because the 'arthritis' isn't the source of your problem."

"That's not what my doctor said," Sarah replied.

"I know," I said. "Let me ask you this -- what did your other doctor do after he found the arthritis?"

"He prescribed some painkillers for me, and I've been going to see the physical therapist."

"Great," I said. "How's it working out?"

"Well, sort of ok," Sarah said. "The painkillers were giving me a stomach ache, so my doctor put me on a different pill, but they aren't really much better than Tylenol. The physical therapy really helped at the beginning, but it's not been doing so much lately."

"Ok," I said. "Here's the thing. The wear and tear you've got isn't really the problem. Chronic pain like yours rarely comes from a single source. It's usually 2, 3, or 4 things all going on at once. If you don't tackle all of them at once, you won't really find a solution."

From that point, I went on to describe a suggested treatment plan -- one that I would have implemented a couple of months ago, had the patient not withdrawn from treatment prematurely.

The problem with this treatment plan is that it requires some lifestyle changes. Regular rigorous exercise, not a few lifts and stretches under the supervision of a mildly bored PT aide. Changes in diet, giving up some favored foods.

These protocols do work for chronic, degenerative conditions. But for so many people, the mental/emotional pain of change -- even healthy change -- is greater than living with physical pain.

By the time I was finished, I could tell Sarah was still unsatisfied with me and my answers. I understand her reluctance. It is much easier to hang your hat on a simple diagnosis -- "I have arthritis" -- than it is to tell your friends "I have a metabolic/muscle movement pattern dysfunction with inflammatory overlays."

Despite my 30 minutes of explanation, Sarah left that day without making any further appointments. I don't know if I'll see her again, but it's likely that if I do, her condition will be that much more farther advanced and more difficult to treat.

Over the years, I've had many patients like Sarah. And sometimes they do come back, and often, with committed efforts on both of our parts, we make inroads.

Sometimes, it's just too late.