ChiroView Presents Marc Heller, DC - My Own Story On My Back More than 10,000 chiropractors are presently receiving the ChiroView Presents broadcast. Some of you, throughout this past year shared your personal clinical experiences. Mark Heller, DC did just that, and with his permission, I am sharing it with you. It is somewhat lengthy, but certainly worth it. One quick note. Many requested a copy of the Copenhagen outcome assessment tool. I hope you found that helpful along with the recent broadcast that provided some background information and instructions on how to score it. It appears many are interested in the different forms that Ižve put together. Some time ago I posted to the ChiroView Presents site a „consultation formū that I personally believe looks pretty good. If interested in a copy, just let me know and I will send it out as an attachment. By the way, many of you want to know if I have a good exam form. Ižve put many together over the years, but most „trash itū. I guess itžs because „exam styleū is a personal thing to each doctor and everyone likes something different. If you think you have a good exam form, then please consider sending it out to me as an attachment. And if it „stands outū, with your permission I will post it to the ChiroView Presents site and make it available to others. And if you have other forms you think are great, send them out for a quick look! By the way, let me know if youžre practicing in New Jersey. I have a question for you! So Markäthanks for sharing your story - My Own Story On My Back - Mark Heller, DC I am writing to share my experiences with my own back and buttock pain. This letter will be somewhat long, and includes my own experiences, what I have done, and my own musings on what causes what. March, 00- I am about to undergo an IDET, an intra-discal electro thermal procedure. The IDET is a procedure that heats up the annulus of the disc, to shrink the disc, seal up the holes in the annulus and kill the pain producing nerves. Itžs a fairly new procedure, having been around for 2-3 years or so. Unlike traditional disc surgery, the IDET is useful for axial pain, pain in the back and buttock. The IDET is an outpatient procedure, done under local anesthetic. Ižll be free of the pain of surgery within 7-10 days, but the healing process goes on for months. I probably will not know if the procedure has been helpful for at least a month, and I should continue to improve over 3-6 months. ( In hindsight, I was free of the severe pain from the surgery within one week, but my recovery from the surgical trauma was apparent to me over the next 3 months, as well). Ižve had some kind of pain in my left sacro-iliac region for about 25 years, with gradual onset. Ižve always had trouble with prolonged sitting or unsupported standing. Ižve carried back cushions into classrooms and theatres for 25 years. About 10 years ago, I started developing more L buttock pain. It waxed and waned, and was almost always present when I sat, especially in a car, for over 30 minutes. This pain does seem to extend down my lateral hamstring, at times, and I have extreme tightness of the L hamstring, L psoas, L piriformis, and L ilio-tibial band, despite daily stretching. I have had no true sciatic leg pain, no pain, numbness or tingling below my knee. I am probably a chiropractor because of my own back. I first saw a DC in Fayetteville, Arkansas, when I was 25. Dr. John Andre did help me, although my problem continued to be a chronic one. I donžt remember a specific trauma, but my back, specifically my left sacro-iliac area and L buttock, have given me trouble off and on for many years. I donžt respond well to side posture adjusting, which sparked my interest in low force methods, both within chiropractic, and more recently studying the work of the osteopaths, particularly the French osteopaths. I tried proliferant therapy, with some success to help stabilize my chronically subluxing SI. I have been helped by the osteopathic method of muscle energy manipulation, which corrects the SI and lumbars with low force slow methods. I have benefited from the rehab exercises of Janda, as my L psoas and L piriformis are chronically tight, and my gluteus medius weak, despite ongoing efforts to stretch and strengthen the involved ! muscles. Despite all of this wonderful work and many, many other methods, my low back has continued to be a problem, and has gotten worse over the last two years. Two years ago I began having frequent episodes (6-8 incidents per year), where I would bend forward, especially first thing in the morning, and have a sudden grab in my low back. I would then have 2-10 days of moderate to severe pain. I was helped by NSAIDS, and muscle energy manipulation and ice. If I could get adjusted a couple of times with muscle energy or other low force methods, the problem would resolve more quickly. I have had these episodes occasionally for probably the last 20 years, but they were few and far between, and resolved quickly. I originally thought of the pain as a muscle spasm, or a sudden subluxation, but have come to appreciate that they are more probably a sudden episode of leakage of nuclear material from the center of my disc through fissures out into the pain sensitive annulus. Gary Jacobs, DC, was the first person to suggest that my chronic buttock pain might be disc related. He was teaching McKenzie low back protocol at a rehab class, and asked for a volunteer. I went up, and he asked me to bend forward 10 times, and did this motion cause me distal pain. This did vaguely reproduce my buttock pain, and extension did seem to relieve it. I finally had an MRI last year, which showed a significant bulge on the left at L4-5. When I took this in to my friend and colleague, Jim Dunn, a neurosurgeon who is always pushing the envelope, he surprised me. He said, I donžt think this is enough information. I think you have an internally disrupted disc, and you need a discogram with CT scan for a definite diagnosis. This was not just for academic reasons, but because there was a new procedure that could help internally disrupted discs. 15 months later, I was finally ready to go ahead with the discogram. The discogram is a heavy duty procedure. Under local anesthesia, and with an IV of pain med, Versed, needles are pushed into the nucleus of the discs, at three levels in my case, to inject contrast material into the disc. The purpose is two fold. One, does the pressure from the contrast material reproduce the pain? If it does reproduce the pain, at what level is the pain reproduced? Two, the procedure is visualized on a flouroscope, and later better defined by a CT scan while the dye is still in the spine. As my level was L4-5, the discogram had to be done at the levels above and below, to see if they reproduced pain as well. The procedure was done by Mike Karasec, a neurologist in Eugene, He is a master, experienced at both the discogram and the IDET procedure itself. I was pain free as the dye was injected at L3-4 and at L5-S1, but I did have moderate pain on injection of L4-5. He then pumped a bit more dye into L4-5, which pushed my pain up to 8 on a 10 scale. Th! e dye pressure did not reproduce my sacro-iliac or buttock pain, just my back pain. Dr. Karasec says that sometimes the discogram reproduces the whole pain pattern, sometimes just the more axial portion. I consider myself lucky. I have a lesion that is treatable with the IDET. I am attaching my discogram results. It is truly an amazing study, and gives an incredible amount of definition and clarity to the discs themselves. MRI is a real advance over x-rays, but the discogram with CT gives the most information about the status of the disc. It is an invasive study, causes pain, is expensive, and obviously would not be worth doing if one was not considering further intervention. The interesting part about my discs is the comparison of the three levels. L3 leaks anteriorly, but this does not cause any symptoms, so is not really a problem. The L5 nucleus is somewhat bulged, but well contained, and the bulge is broad. Again, probably not a significant anatomical lesion. L4, on the other hand, has a single radial tear going out the left (the side of my symptoms), with a circumferential tear along the border of the annulus. From an anatomical perspective, this is the lesion of interest. This was also the level that reproduced my pain. The question that the discogram tries to answer is not only what discs are anatomically disrupted and how, but which discs are inflamed and cause pain. Herežs the key to the discogram. Its kind of in reverse, what you see on the right of midline is actually on the left side of the body. I cut off part of the scan, its missing a couple of frames off to the right. The six frames on the lower right are of L3-4 disc. Note the anterior leakage. The four frames on the lower left are of L4-5. Particularly note the one on the far left of this series, the second from the bottom. This clearly shows the central disc, and off to the reading right, the radial leakage, which then further leaks in a circumferential way. On the reading left, the „beakū is the needle track, where the dye was injected. The upper left 8 views are those of L5-S1, note the broad expansion of the nucleus, with no specific leakage to the extreme of the periphery. What makes me a good candidate for the IDET? One, I have maintenance of good disc height. If the disc is collapsed, the IDET is not a useful tool. Two, I am not too old at age 50. I guess I am really not young any more, but in relation to discs, Ižm not too old. The IDET is more successful on relatively young people. Third, I have a specific tear. The IDET works better if the lesion is at one level, and is a specific lesion, not a generally shot disc that leaks in every direction. Of course, one has to be able to reproduce the pain at a specific level, which also has a suitable lesion. Four, I am relatively thin. Overweight people donžt seem to get the same benefit from the IDET. The other factor is mechanical vs. chemical pain. If the small amount of pressure from the original injection of dye immediately causes severe pain, this means the annulus is chemically sensitive, or the area is extremely inflamed. These people have the best results with the IDET. My pain ! is more mechanical according to the discogram results, which means that Dr. Karasek had to inject more dye into L4 to create a more severe pain. This is probably consistent with the fact that I donžt have constant pain, but pain on prolonged sitting or standing. People with chemical pain get the best results from an IDET. How has this changed me as a doctor? For one, my own chronic pain of 25 years has made me hopefully more compassionate and understanding of my patientsž own pain. I really listen to what my patients have to say about their problem, knowing that on some level, they know more about their own situation than I ever can. I am aware of how much of my energy and time is taken up by my own back pain, from looking around the restaurant to find what will be a comfortable seat, to having to limit my sitting time in the movies or at the computer, to avoiding sitting on the ground at any cost. My own back pain and what I know about it, has changed my perspective as a doctor, as well. I always thought my own pain was from the sacro-iliac and from muscle imbalance, and maybe from joint problems in the lower lumbars. I was really surprised to realize how significantly compromised my anatomy was. I knew that I was a difficult patient, and I knew that I couldnžt seem to stabilize my sacro-iliac, despite the best of low force adjusting and good rehab exercise, and good nutrition. I think that I have historically separated anatomy and function, seeing my role as a chiropractor as one of helping correct function. I didnžt take many X-rays, and looked at arthritis and other anatomical lesions as secondary to the type of problems of function that I could help. Maybe this was the reverse side of the orthopedist who pooh-poohs or ignores pain that he canžt track to a specific thing he can see on an image. I am now much more appreciative of referred pain, knowing that my ow! n buttock and back of the thigh pain were coming from my L4 disc. When I was young and just out of school, I thought I could cure or heal the world, or at least my patients. As I get older and wiser, I see my role as more of a manager. We are all getting older, we are all falling apart, some slowly and gradually, some suddenly from trauma. I appreciate that I can help many people, but donžt beat myself about those whom I cannot help. I am constantly searching for new answers. It is an honor to be part of this path of constant learning. to clarify- one of the reasons I put my story and my discogram onto the net connection with other DCs, many of you whom I do not know, is for an educational purpose. Most of us, including me, are not always aware of what medicine has to offer for the kind of problems we see. Unfortunately, too many back surgeries are done for the wrong reasons, and with the wrong procedure, before manipulation and specific exercise are even properly tried. The key to my situation is the diagnosis. I never suspected a disc problem, for the first 23 years of my back pain. I never had weakness of the muscles, never had sensory changes, never had reflex changes. I had tight hamstrings, much more shortened on the left side, but never showed a true straight leg raise. My MRI showed a bulge, but as we all know, this is extremely common, even in asymptomatic people. Only the discogram made the diagnosis clear. My diagnosis is "discogenic back and buttock pain", meaning the disc is internally disrupted, leaking fluid, but contained. Thus the annular irritation, or irritation of the nerves of the annulus, is what is probably ( and hopefully, for me) the specific anatomical cause of my pain. It is probably also the factor that keeps my subluxing sacro-iliac recurring. As Michael Freeman wrote to me, this is not for run of the mill back pain. This is a test only for those patients who do not respond to what we do. We need to get out of an "us vs them" mentality. We need to refer, both to our own colleagues who use different methods, and to appropriate medical specialists when needed. There is plenty of pain out there, plenty of patients who need our help. Ižm now nine weeks after my surgery, and have many more thoughts on this process. April 17- 2 weeks out One, is that the procedure itself, and my body, are giving me lots of appropriate feedback. I was worried that I would not be able to be in touch with what was happening in my disc, and would be at risk of hurting, or reinjuring myself. Well, through stupidity, I could reinjure myself, but my body is giving me lots of feedback about what works and what doesnžt, at least for me personally. In the first few weeks, when I would sit too long, I would get reproduction of initially my dull achy back pain, and then later get sciatica, deep pain in my buttock and down to the back of my knee. These are the same pains Ižve had for a long time, and are obviously posturally related. The IDET seemed to temporarily make me less able to tolerate sitting or standing, especially the first week, and continuing now into the second week. I notice that I am better day by day, and have to be aware of how much I am lifting, etc. At first, it was obvious that I shouldnžt lift anything, lately I have to remind myself that I have a 5 pound limit, which technically goes up to 10 pounds after two weeks, but realistically, is gradually going up along a continuum. In relation to back braces, for me, the ideal combination is an SI belt, and then a soft brace supporting the lumbars. First, the SI belt, Ižve been wearing one of these for most of the last 15-20 years. I thought it was for my SI, and maybe it was. But I also suspect that a narrow, 2-3 inch support going around the ilium helps provide further bracing for the whole of the lower lumbar spine. My disc lesion is at L4-5, and Ižve always felt better with an SI brace on, even before I knew that I had a disc disruption. The lumbar support does provide some limitation of motion, and does provide a sensory feedback to the abdomen, creating a feeling of a supportive column. Tomorrow I go back to work part time. I am looking forward to this. I am not going to thrust for the next few weeks at least. Strictly low force, for me, and my safety. This is not a large change for me, I do mostly low force work anyway, although I will miss this tool, itžs a great opportunity to see how well the low force methods work. I was instructed not to exercise or stretch for the first two weeks. I found this advice impossible to follow. I know that I am supposed to rest and vary my position. I found myself doing simple feldenkrais style movements, in a very small range, probably after 3 or 4 days. I got so stiff from not moving. This may be my own fibromyalgic tendencies, or just stiffness from not moving. I quickly figured out what worked for me, what felt absolutely safe, and began to incorporate these, very gently. No actual stretching or strengthening, just micromovement, and keeping spinal neutral and stable posture. Further update, 3 weeks out. Ižve been working part time the last week. What a JOY, to be able to do what I do. Maybe it had to do with not being able to garden or bicycle. Anyway, I guess I really do love my work. Absence sure made the heart grow fonder for me. I donžt think I really appreciate enough the pleasure of what I do daily in my chiropractic work. I love the intellectual stimulation, the sensory feedback from my hands, the experience of being with and helping people, the satisfaction of figuring out a difficult problem. Whatever it is, Ižm glad to be back to work. My sitting tolerance continues to increase, Ižve been taking longer walks, just gradually feeling better. The uncertainty of still not knowing whether I am going to be better occasionally bugs me, but Ižm working to learn acceptance. Itžll be 4-12 weeks before I know whether I am really better, but I am optimistic. The other difficult part for me is the reality of continuing to limit my activity, now that Ižm not getting so much feedback from my body. Ižm visualizing my disc as repaired and healing, rather than thinking of my bad or shot or disrupted disc. One more clinical thought that may be useful to you and your patients. I got this from Craig Liebensonžs article in a late April or early may edition of Dynamic Chiropractic. People with low back problems are most at risk, first thing in the morning. Why? Probably because their spine is restored to its full maximum length thru imbibing fluid in the discs. In a bad disc, this probably acts like inflammation or swelling. Within half an hour of being weight bearing, the spine loses 50% of this extra length. So, for me, instead of immediately sitting down to drink my tea, read the paper, or sit at the computer, Ižve been going for a 20 minute walk or short ride on my bicycle trainer, immediately upon arising. I notice that I then have better sitting tolerance, after that motion. I theorize that I am re-shrinking my spine to its normal length. Ižve always thought that this imbibing of extra fluid overnight was a good thing, but the reality is that everyone who is stiff, i! s always stiffer first thing in the AM. The other thing Craig mentions is the risk of injury just after sitting for any prolonged period, due to creep. I am now 9 weeks post surgery. The surgery has clearly been successful with me. My early positive changes have continued. What a simple pleasure, putting on socks first thing in the morning without fear that my back would „go out.ū After 4 weeks, I noticed that I could lie on my left, involved side, for the first time in about 6 years. At 8 weeks, I sat comfortably through a movie, and my menžs group notices that I am sitting with less fidgeting. I actually stood unsupported at a party last weekend for about 15 minutes. Standing unsupported has been something Ižve avoided for at least 20 years. I still donžt know if I could do that for hours, or if Ižll be comfortable on long drives on long plane flights, but I know that I will continue to improve for the next 6-12 months. I still find that overexertion can cause recurrence of my symptoms. Ižve been trying to work up to a lower ab exercise, using spine stabilization principles, but am still not able to do this without increase buttock pain that lasts for hours. So, Ižm peeling back and doing easier ab exercises. June 14, 00 10 weeks post surgery. Went to a cranial, 4 day class, with plenty of sitting. Even with sitting with good support, and getting up frequently, and lots of workshop time, I still got flared up. Ižm not ready to sit for hours and hours, even with plenty of breaks. Its Wednesday now, and Ižm pretty well over the flareup. I am able to ride my road bike for 20-30 miles, or 2-3 hours without any problems, thank goodness for that. My follow up with Dr. Karasec was interesting. The main thing I got was a clearer picture of his theories of why the procedure works. The IDET, or thermal procedure doesnžt repair the tears or fissures. It „relinesū the tears or fissures. What does this mean? The heat causes a chemical change in the proteins, etc, which line the disc and the fissure. This chemical change strengthens the tissues, and makes them less susceptible to pain from either chemical reaction or mechanical pressure. I donžt really care that much how it works, the key is that it worked for me. They say that in well -selected cases, the success rate is between 50 and 70 percent. Ižm very happy to be among the successes. I hope my long updates are useful. My next follow up will probably not be about my own progress, but about what Ižve learned about how to conservatively diagnose, or at least suspect, disc involvement in our low back patients, and what Ižve found to work for it, short on a IDET. Marc Heller, DC mheller@mind.net Please remember to tell others about the broadcasts so they, too, can become a "member subscriber". All they need to do is click http://www.ChiroViewPresents.com. Cheers! Sig Sigmund Miller, DC 925.294.9800 x 11