The pain was literally all in my head. (Well face, which technically is my head)

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I like to think I keep up with the current evidence and trends in the “science of pain” (see what I did there) and I am definitely against anything that suggest the old chestnut “it’s all in your head” (subtext for your crazy and imagining your pain). I am also aware even with our best intent sometimes the “pain is a brain construct” also leads patients to think this is still the old “it’s all in your head” suggestion.

For the last month I have been suffering (my personal choice of words) from a severe face pain, which I have experienced in the past, but not this bad. The pain is deep in my face, beneath my left eye and into my front teeth and jaw. I am a frequent allergy and sinus sufferer (still my choice of words). Let me tell you, I understand pain, I know the current construct of nociceptive input being interpreted and the brain deciding, “yep!,here have some pain, you are in danger”.

My pain has taken several personalities over the last month, the dull ache, the sharp twinges in to my teeth (I went to the dentist, as I have in the past, it’s not my teeth), a gnawing sensation like a hamster having a good chew in my sinus, and pressure, lots of uncomfortable pressure. My symptoms have waxed and wained over the four weeks. After a serious session of two days of water boarding (aka salt sinus washes using a sinus was kit) I thought that the worse was over as I could sleep and not wake up all night (did I mention the pain was disturbing my sleep?)

Remember I’m a man, so going to a doctor in the first three weeks was never on my mind, I wasn’t at the about to die stage, so no doctor yet.

I have to confess the things that I tried and the things which gave me the most relief.

1. Water boarding, or the closest I ever wish to come to water boarding, two hourly sinus washing. I am amazed what lives up there.
2. Pressure to my sinus externally. Yes manual therapy, acupressure, what ever you want to call it. It feels great with the pressure on and a bit of deep rubbing, but once you stop the pain comes back in seconds. My wife just gives me knowing looks, as I sit with my index finger poked into my face.
3. Hot pack. I made a rice bag for the microwave. I am loathed to admit, number one best relief, the hotter the better ( I managed to avoid burning myself) the relief lasted up to an hour afterwards, enough time for me to get to sleep.( I think sleeping helped me cope with the daily pain.)
4. I started taking my Claritin (loratadine 10mg) and got some relief from the pressure. Blowing my nose frequently helped, but only temporarily.

5. Hanging my head over the end of the bed or lying on the couch with my head dangled upside down watching TV. (Our brains are amazing, because after 10 minutes you don’t realize the TV is upside down.) I got relief whilst in this position, I figured all the gunk stuck up there flowed somewhere away from what every was irritated up there in my head. Of course half an hour after getting up the pain came back.
6. NSAIDs, I overdosed myself at bed time, which allowed me to sleep, I tried to avoid during the day, as I am not a fan of medication.

 

Three and a half weeks in I spent a few hours outside walking in the cold, my pain got worse, the pressure increased and I felt back to square one. I also had some increase in life stresses, this seemed to be the straw that broke my tolerance for the pain. My wife was away traveling and I found myself on my own with my pain feeling sorry for myself. ( I truly think my mental state changed and hence my ability to cope changed.)

Yesterday I called an made an appointment to see and MD. I am not a fan of visiting the doctors, but off I went. Let me tell you I had a great experience and I am glad I went. (I know I hear a few voices shouting, you should have gone earlier.) I consulted with a float MD, who I had never met before. He was a 67 year old extremely pleasant MD who immediately asked me what my reason for coming was and how could he assist me. We had the usual chat about my accent (ETHOS) and he looked quickly at my electronic chart, smiling and saying “wow! We better listen to you, you don’t seem to need our help often.” At that point I knew I had met a skilled caring MD who understood that when patients like myself arrive for a consult we do so because we have a problem that is concerning us. He listened to my story and my expectations.

He did a quick exam of my ears throat and nose and listened to my chest. He didn’t press on my sinuses, be trusted that my accurate report of my own palpation.

He explained that he thought I had a severe inflammation of my sinuses, and that some antibiotics and a steroid would be the best initial treatment. I nodded and said that was my main reason for coming.

I have taken two doses of the steroids and one and a half days of antibiotics. The steroids seem to be working as my pain is already 90% improved, I know it will take a few days for the antibiotics to do their job. Today I feel a bit of pressure and sensitivity in my face, but have a positive sense that this is the correct treatment.

As usual the lessons I have learnt from the experience.

1. Maybe I should go to the doctors quicker, but I like to let my body try to work on getting better on it’s own.
2. Pain can be tolerable one day, but the same pain can be intolerable on a different day.
3. Sleep is important when you are in pain and feeling sick.
4. You do strange things to try to get pain relief.
5. Our emotional state affects how we cope with pain.
6. I DO NOT HAVE A HIGH PAIN TOLERANCE. I am totally intolerant to pain, I would prefer not to be in pain. I do have the ability to be tolerant if necessary in the knowledge that this is short duration and has a visible end point. I reached my tipping point at four weeks.
I closing the other driving force or me to go to the doctor was my wife sent me a Viber message saying “isn’t it time you went to the doctors?” I always ask my patients if this is the reason they have come for a consult. “My wife told me to come.”

Thanks for reading.

 

 

 

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When is a contraction not a shortening? Let’s talk about muscle contractions.

When is a contraction not a shortening? Let’s talk about muscle contractions.

1. The definition of a contraction is

• the process of becoming smaller.
“the general contraction of the industry did further damage to morale”
synonyms: • shrinking, shrinkage, decline, decrease, diminution, dwindling
• “the contraction of the industry”
• the process in which a muscle becomes or is made shorter and tighter.
“neurons control the contraction of muscles”
synonyms: • tightening, tensing, flexing
• “the contraction of muscles”
• a shortening of the uterine muscles occurring at intervals before and during childbirth.
synonyms: • labor pains, labor;
• cramps
• “my contractions started at midnight”       (Source: Google “definition of contraction)
But when it comes to muscle we have three distinct types of “contractions” concentric, isometric and eccentric. Only concentric contractions would fit the definition above of shortening. Isometric contractions keep a constant muscle length, whilst eccentric contractions are “oxymoronic” and actually have muscle lengthening, not shortening.

This issue was discussed in a paper by Faulkner “Terminology for contractions of muscles during shortening, while isometric, and during lengthening” he points out the contraction when pertaining to muscle does not indicate shortening but instead proposes the following definitions: The verb “to contract” and the nouns “contraction” and “contractility” need to be defined correctly in terms appropriate with long-term usage as “specifically for muscle, to undergo activation and generate force. Ref

So simply put a muscle contraction is when a muscle undergoes activation and generates force.

He goes on to propose that the terms concentric isometric and eccentric are also confusing and should be perhaps be replaced with the adjectives that provide the greatest clarity “shortening,” “isometric,” and “lengthening”.

It seems that these definitions have not been universally adopted and muscle contractions are still commonly referred to by concentric, isometric and eccentric.

The molecular magic of a muscle contraction.

Concentric and isometric muscle contractions can easily be explained by the sliding filament hypothesis which will be familiar to many who have studied muscle physiology. It was put forward by Huxley in the late 1950s and the involves the now well recognized, Z bands, sarcomeres, H bands,I zones, actin and myosin filaments. Ref (See diagram below) Ref

Interesting Tidbit: It is possible to have a concentric contraction of muscle even when you are dead and the sliding filament hypothesis still applies. This is of course known as rigor mortis, which develops several hours after death. It is interesting to note that once a muscle has undergone a shortening contraction, energy is required in the form of ATP to allow relaxation (normally created aerobically) obviously after death this is not possible and hence rigor mortis contractions can last for several days. the term “a stiff” indicating a dead body has it’s origin in rigor mortis. Ref

The big problem though is that the sliding filament hypothesis can not explain eccentric contraction and many of the features that they possess such as high force generation with low energy expenditure or the ability to generate a force whilst lengthening against a load. In recent year a large protein molecule Titin which connects myosin to the Z band and to actin has been shown to be highly elastic and have the capability of bonding to actin during the presence of calcium release during eccentric contraction. Work by Herzog has shown that Titin has both elastic and visor elastic properties when muscle is stretched passively, but when stretched actively as in the case of eccentric contractions Titin binds at the Z band end with Actin and acts like a rigid sprain creating high resistant forces in the muscle. This is a proposed mechanism for the high force generation and low energy expenditure of eccentric contractions.Ref
Ref2
Ref3

For those who have further interest in this hypothesis and the action of Titin during eccentric contraction, there is an interesting lecture by Herzog here “A new paradigm of muscle contraction.” Thanks to @sportstherapy56 Ian Brown PT, for pointing me to this great reference.  Video link 

Interesting tidbit number two: “Titin is the short name for an extremely massive protein molecule. The full-length scientific name of this protein molecule contains 189,819 characters and is considered (by some) as the longest word in not just English, but any language.” Ref
Click here for a link to Titin in it’s full glory. Ref

Interesting tidbit number three: a sarcomere is on average 3 microns (micrometers long) that is 3 millionths of a meter. The average human hair is 90 microns hence a sarcomere is 30 times smaller than a human hair. These are “magic” molecular force generating machines. (Authors comment)

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What have I learnt and why do we still teach and learn muscle actions?

So what have I learnt in my four day journey of trying to understand eccentric contractions? I learnt there is still much to be discovered about what happens at the molecular level during muscle contractions, especially where eccentric contractions are concerned.

Muscle contractions are fascinating, I wonder why we learn the “action” of muscles as though this reflects some sort of essential function. We seem to focus on concentric muscle contractions which reflect muscle action, yet muscle function involves all three types of contraction. I would propose that we would be better suited to learn the function of muscles and their synergy and role with other muscles. Eccentric contractions are just as common as concentric contractions, we call certain muscles extensors or flexors when they are able to control the opposite movement via an eccentric contraction. A prime example would be the quadriceps muscles during squatting or the hamstrings during walking and running.

There is far more to muscle than shortening.

Ancora Imparo (yet I am still learning) Michelangelo

 

To be continued…………………………. Thanks for reading. 👍

The beauty of vomiting (Emesis)

The beauty of vomiting (Emesis)

I know this seems like a strange title for a blog, but there is method in my madness, besides vomiting is a beautiful process, it protects us (and other animals) form danger. (Sounds a bit like pain)

On Wednesday I woke about 4 am with a infrequent but familiar friend “nausea”. I was on a five year no vomit streak (prior to that 10 years plus) yes I know I am bizarre keeping track of my vomiting. There is no sensation that I dislike more than nausea, because it signals the impending arrival of vomiting. As I stood up from my bed, I felt dizzy and sweaty, my pulse was racing, I stumbled to the bathroom, problem was my body wasn’t ready to vomit. It was just in the early phase of making me suffer the stomach pain, churning, head swimming, sweating, mouth watering and racing pulse that precedes emesis. It took 40 minutes before I did eventually vomit. (Is it just me, I always think I am going to choke to death during the build up, but am amazed at the process after it has ended?)

I felt so much better after I had vomited. Then I lay there pondering on the wonder of the human body and how it protects from danger.Ref

I did a bit of reading, nausea and vomiting are two separate processes which can occur independently. It is rare though to vomit without first being nauseous. (At this point I should mention Sheldon Cooper is probably wrong when he states what I am describing is “nauseated” rather than nauseous interesting blog here Ref )

So what I learnt from this experience (which has set my no vomit clock to three days) is that nausea and vomiting are autonomically controlled protective mechanisms, they have complex neurological pathways (still not fully understood). Just like pain they are protective, unlike pain they are often, if not always, short lived.

The other thing I pondered on was that I could not stop the process, once initiated it was on a path to it’s final destiny of emptying my stomach contents (emesis). I could not un-think my nausea or vomiting, just like you can’t un-think pain. (Not sure un-think is a word, but I’m sure you get my drift. I looked it up and it is, minus the hyphen)

I shall now wait for other people who become nauseated and eventually vomit to let me know if understanding the process, lessened the severity of the experience and decreased their suffering?

Of course I jest, but seriously understanding the beauty of vomiting, is just like understanding the protective beauty of pain. We can not un-think either process, but by understanding the process, we can assist in lessening the fear associated with each. I doubt if my “Explain Vomiting” course is going be a best seller.

It feels like my hip is “out”

This is a short article I wrote on New Year’s Eve on a flight from Minneapolis to Paris.

It is a self reflection of how my body said one thing whilst my mind said another.

 

Yesterday I woke up with a stiff painful right hip, after cycling on my fat tire bike for 2 hours in extreme cold and deep snow. I was fine during the cycle, but had to do lots of twisting and quick maneuvers, like sticking out my foot from the pedals, to keep myself from falling on the rough deep snow and ice.

I had no pain before bed and only felt pain in my right groin after doing my normal spin bike training.(maybe it was my normal spin session that cased the problem?)

After getting off my spin bike I got a twinge in my groin and I felt like my hip was stiff and restricted.
One could say “my hip felt out of place.” I ignored the pain and went up stair and showered. Later that day I took my granddaughter to the mall, on getting out of my truck I had a sharp pain in my groin and I had a hitch in my giddy up ( you know a funny feeling walking) “My hip truly felt out” (of course I know it wasn’t but I can appreciate why patients report this and why some therapists buy into this thought too.) I felt groin pain every step and my stride was short on the right, as my hip felt restricted. As my granddaughter looked round her shop, I did a bit of testing. IR was painful at end range, I was stiff in ER but no pain, no pain or restriction in flexion, but extension was painful and restricted. So I did a few loaded hip extensions via lunging, at which point my granddaughter wanted to know what I was doing. I felt like saying “grandpa’s hip is out” but I resisted.

Lunging helped reduce the pain and the hitch in my gait was less. (I had a McKenzie Directional preference, well at least according to their new definition). I did a few sessions of lunging, as we meandered round the mall. My hip felt better, until I drove home and got out of my truck, I had a sharp twinge of pain in my groin, as I climbed out and a hitch in my giddy up again.

Long story short, I popped four NSAIDs, had a cup of tea and did another hour spin without issues until I got off and had a sharp twinge of groin pain again and a return of my hitch walking. I did a few lunge stretches and got relief again. Before bed I took another four NSAIDS (my expectation was they would help me sleep, how could it fail, I primed myself for success?)

I woke early next morning, pain free and no loss of motion. My hip had “put itself back in place.” Yeh!

I get it, I understand why patients get distressed when this happens, our bodies are weird. I would have put good money on something being “out” if I was a lay person. I had loss of motion, sharp twinging groin pain, a feeling like my gait was affected and I couldn’t move my hip normally. It must all be quite frightening if this suddenly happens to a lay person.

What I also understand is that hurt doesn’t equal harm, I had control of my pain, my emotions and I knew that moving and carrying on my normal activities wouldn’t make things worse.
Pain is weird, so are our bodies, my hip was saying “danger danger Will Robinson”, I was saying “yep, got the message, but there doesn’t seem to be any danger, so it’s OK to shut the hell up.”

I also understand that this may not be the case in some patients. But perhaps being a positive caring understanding therapist for others and not giving catastrophic messaging like “your hip is out of place” may help then too. Plus, I used positive self messaging, simple exercise, kept moving and took a few NSAIDS ( a good placebo / pain relieving dose). I didn’t need clicking, taping, pricking, heating cooling or scraping. Problem is if you had done those things to me, I may have attributed my quick recovery to them. And there lies my concern, with jumping in with you favorite explanation and passive modality, you may also attribute my quick recovery to them.

 

It’s not Bio, Psycho, Social it’s “Biopsychosocial”

Let’s agree, humans are complex ecosystems that involve extremely complex interactions with multiple domains. The Biopsychosocial model tries to embrace the complexity and recognize that human suffering can not be reduced to a single physical cause response relationship. Pain and suffering are complex and involve complex interactions influenced by the physical the psyche and the environment the body exists in.  One complex whole……..Biopsychosocial.