Total Recovery, page 8
For centuries, the Chinese have studied the circulation of energy throughout the body. They have a deep understanding of how that subtle force interacts with the organs and other tissues in the body. The entire approach is designed to treat the roots, not the branches. Their knowledge in that regard is quite specific.
They have discerned, for instance, that around 3:00 a.m., there is a reinitiation of the energy circuit in the body. As it completes one cycle and begins another, the energy moves from the liver to the lungs. The most subtle blockages in the body can disrupt that cycle and, for instance, wake up a schoolteacher in the night.
If the body is struggling to metabolize hormones (stress hormones, sex hormones, thyroid hormones), it can be enough to disrupt the cycle. If energy from emotions (frustration, anxiety, worry) is being held in the body, it can keep the energy from moving through the body freely. In any of these cases, the energy of the body is imbalanced in such a way that, when the cycle begins again, there is going to be a problem. Waking up at 3:00 a.m. is not random; it’s predictable.
Prescribing a drug to force the body to sleep through the problem is overkill. It is like using a hammer when we should be using something much more refined. We should be treating causes, not symptoms.
Whenever possible, we should respect the influence a small intervention can have. Why do we assault the body when a more subtle solution would do?
INSURANCE AGENDAS
All too often, the reason lies in the medical system itself. The financial reality is that orthopedic surgeons are losing money every minute they are out of the operating room. The time they spend talking to a patient is minimally compensated.
After teaching graduating classes of medical students at Georgetown for almost 30 years, I can vouch for the fact that most aspiring doctors have chosen medicine out of a desire to be of service. They want to help others, and they genuinely care about their patients’ health. If their primary motivation was money, there are scores of professions that could have taken them more quickly to that goal with a far less costly education.
Despite their honorable intentions, most of those same students soon end up watching the clock and adjusting their practices to accommodate insurance compensation.
Insurance companies have no qualms about being in it for the money. Although they ostensibly want patients to be in optimal health, they would prefer not to pay for it. Every treatment, every office visit costs them money. In a perfect insurance world, they would be paid premiums without ever having to pay for any medical services themselves. Empty hospitals and empty doctors’ offices are best-case scenarios for insurance companies. So they limit everything as much as possible. They discourage long-term comprehensive treatments of any kind. Time is not valued, so doctors do not spend time with their patients.
The unblinking agenda of insurance companies in America is to strive for factory efficiency, narrowing everything down to one thing: a single issue, a single symptom, a single drug. They urge doctors to diagnose and codify the problem, provide an approved treatment, and move on. They want it fixed and done. And unfortunately, this bottom-line mentality, with no reference whatsoever to the health of the patient, has had an insidious effect on the way our doctors practice medicine.
Even if doctors wanted to ask probing questions, to consider other alternatives, to treat the whole patient, the influence of the medical insurance companies is like a riptide, constantly pulling them away from the time-consuming approach of comprehensive patient care. The insurance billing model works against it. The fragmentation of medicine through specialization works against it.
As a result, Western medicine is in danger of resembling the Indian fable of the blind men with the elephant. Each man considers himself an expert on the small part of the elephant he touches, without any idea of what he’s missing. Because none of the men communicate with each other or respect each other’s perspectives, they never realize how all the pieces connect. In some versions of the fable, they don’t even know they’re blind.
LEARNING TO LISTEN
With a private clinic like mine, doctors have the ability to opt out of that system. We get to work for patients, not an insurance company. We can create treatment plans based on their needs, not on what the insurance companies will cover.
It comes back to listening. Listening is one of the most important things we do for patients, and that takes time. Only through listening closely to our patients and taking time to do a careful, detailed examination of their physical condition can we come to an understanding of what has influenced their health to this point—what emotional, physical, infectious, or environmental blows they have endured; which ones have they recovered from; and which ones still linger, undermining their health.
When patients come into my office with back pain, I don’t ask, “How’s your back?” I ask, “How’s your life?” At the simplest level, what I do is pay attention to them. They are what’s important. I have a lot of specialized information, but I prefer to think of it as a shared exploration with the patient, a partnership.
Life is a struggle for all of us. So when I hear about a patient’s pain, I can easily relate. Most of the treatments and therapies I recommend are things I’ve tried myself. Before I hire a physical therapist for my team, I have them work on me. I want a deeper understanding—a body sense—of what they are like when they work with people. When I give supplements to my patients, they’re often things I take as well. If I recommend that someone goes on a fast, I can do it with compassion, because I’ve done it myself.
The better I can get to know the patient and the treatments, the better I can understand the nuances and sense the connections. We do not always resolve every problem or eliminate every pain, but a personal, comprehensive approach is the best way available to get the results.
No single approach can cure everything. All medical perspectives and techniques have successes, partial successes, and failures. It has always been my belief that integrating different medical traditions will ultimately lead us to a new and better medicine.
Pursuing that belief led me to cultivate as many specialties as possible, then to continually augment that knowledge—pouring over the latest research in medical journals, attending and participating in conferences, investigating promising new tests and treatments. Ultimately, I hired a team of experts to magnify our ability to help patients even more. With all that expertise, the best solution can be the most obvious one. As Freud famously said, “Sometimes a cigar is just a cigar.”
For a few weeks every winter, my colleagues and I spend alternate weeks offering medical aid to the people of Honduras. One year, Jeff Erickson, MD, one of the group leaders, came down with a bad case of bronchitis. After hearing him cough, I suggested that he take an antibiotic.
Jeff tried to laugh and ended up coughing. “I thought you believed in herbs and spices!”
“I do,” I told him. “And the herb-and-spice you need is Zithromax.”
LOOKING FOR CONNECTIONS
Treating chronic pain is never as straightforward as treating a bacterial infection. It requires a close evaluation of the setups, compensations, and consequences. A lot of pain generators have been triggered as a direct result of trauma to the musculoskeletal system, peripheral nerves, or the brain. Others have evolved from compensatory patterns that the body has developed to work around injuries, so it can continue to function. All of these generators modify the function of the central nervous system. Sometimes the process starts at the top, in the brain itself, sometimes in the periphery, but all of the pain generators result in neuroinflammation and, ultimately, neurodegeneration.
In Billy’s case, the mold exposure had poisoned his central nervous system. The result was excessive, chronic pain. Although I suspected that, somehow, each of the assaults and injuries had built up in his body—preventing healing and cascading into RSD—I had not yet found the underlying mechanism that would tell me how that could be happening.
For Emily, the pain began with a physical trauma. Both her leg and pelvis were shattered. She had nerve damage in her leg and a concussive brain injury. The compensation throughout her musculoskeletal system was her body’s attempt to alleviate the pressure, but it compounded the problem. Inflammation across the peripheral nerves and scarring along the sciatica stoked the pain even more. What if physical trauma could build up in the body, too, emerging into a condition that was much worse than its component parts?
Even if I could not yet identify the underlying connection between so many overlapping systems, comprehensive treatment was literally the only viable approach.
“You’re right to think not enough has been done for you,” I told Emily. “There is so much more we can do to restore your quality of life. If we use an aggressive integrative approach, with both conventional and alternative treatments, we will literally take the pain out of your body a layer at a time.”
Emily looked as if she wanted to believe me, but her experiences hadn’t given her much reason for hope. Listening from the side of the room, Todd was frankly skeptical. He had seen conventional medical doctors repeatedly let Emily down, but as far as he knew, “alternative practitioners” were unqualified pretenders. Any success they had with their bogus procedures was most likely a placebo reaction. It was not much better than hocus-pocus.
If the best orthopedic surgeons had not been able to help her, Todd couldn’t see any reason why I would be able to help. But I had caught his interest by listening carefully to Emily and recommending a comprehensive approach. This was the first time he had heard anyone do that.
“Will you ever be 100 percent back to normal? No. Your injuries are too severe,” I explained. “But you will be much more active and engaged. That feeling of hopelessness and powerlessness will be gone.
“Can we can decrease your pain medications, be smarter about which medications you need, and put you on much more solid ground structurally? Yes, absolutely. Can we reduce your pain? Yes. Absolutely. Can we relieve your PTSD and depression? Absolutely.
“More than one thing is going wrong for you right now. We need to address all of them comprehensively. If we treat you, the whole patient, instead of treating each symptom as a separate thing, the synergy will make a dramatic difference.”
“How can you do all that at once?” Emily asked.
“We need a team.”
For Emily’s structural issues and the disc degeneration in her spine, I would treat her with manual manipulation. Acupuncture would relieve her pain and help reintegrate all of her body’s systems. The physical therapist would work to improve Emily’s flexibility, range of motion, and structural integration. The trauma and long-term physical and psychological stress had impacted her brain’s ability to regulate her hormones. She was having hot flashes and sleep disturbances. The physician specializing in hormonal conditions would test and treat her for that.
We would also be using prolotherapy, an orthopedic procedure designed to stimulate the body’s natural healing process to repair the joints and ligaments that had been traumatized by the accident and surgeries. Prolotherapy involves the injection of a mild irritant into the tendons or ligaments. A 15 percent dextrose (sugar) solution is most commonly used. This creates a mild inflammatory response that encourages the growth of new supporting tissues that strengthen a weakened structure like Emily had. The principle has been applied since the days of the early Roman Empire in 500 BC to restore stability and flexibility.16
Our cognitive therapist would work with Emily using EMDR, a psychotherapy treatment designed to alleviate distress associated with traumatic memories by using physical cues, such as hand tapping and other sounds or movements. In conjunction with talk therapy, EMDR has been shown to help reduce PTSD much more rapidly and successfully than talk therapy alone.17 Without treatment, most people recover from a car accident in 12 months or less, but some people, like Emily, suffer in the throes of PTSD much longer.
In the year since her injury, Emily had gained 25 pounds and had been unable to lose it, so we needed to evaluate her nutritional status. Testing revealed evidence of abnormalities in her intestinal permeability. The testing requires the patient to drink a solution containing two sugars, lactulose and mannitol. The patient’s urine is then analyzed to see whether or not the sugars have been absorbed correctly.
As digested food passes through the long intestinal cavity, nutrients are absorbed through the lining into the body. The intestinal lining provides a barrier composed of many layers. It is designed to allow water and small molecules of nutrients to pass through and nourish the body.
Between the cells of the lining of the small intestine are highly complex channels known as the tight junctions. They act as gatekeepers, selecting which molecules can pass into the body and which should be kept in the intestines. As we are just learning, the capacity of the tight junctures to make those selections is finely tuned by our body chemistry.
When that capacity is disrupted, the tight junctures open too wide and allow larger molecules of digested food to pass through the lining into the bloodstream. The body responds to these molecules as if they were antigens and provokes an immune response.
When that happens, it is colloquially known as leaky gut. In Emily’s case, it contributed to the overall inflammation in her body and interfered with the absorption of trace nutrients that she needed to heal. To address this, we eliminated common food allergens such as gluten, milk, and milk products from her diet because they potentially boost inflammation. We also recommended supplements and probiotics to restore the health of her intestinal tract.
“While all of this is going on, all of us who are treating you will meet regularly to discuss your progress,” I explained. “We will all be aware of what’s being done by the other practitioners at every step of the way. We’ll be treating your mind and body as a whole.”
Todd smiled. He’d never heard of some of these treatments, but this approach just sounded like common sense.
Emily was ready to try the more comprehensive approach I was suggesting, but before we got started, there was one more thing I needed to ask her: “Do you want to walk without your cane and be pain free?”
WANTING RECOVERY
Very early in my residency, I once went to hear Elisabeth Kübler-Ross, MD, speak. She told an anecdote that I will never forget. As I remember it, she said she saw a patient who had been treated with chemotherapy for leukemia. The treatment had failed. His doctors had sent him to her, so she could help him come to terms with dying.
When she met the man, she asked him to draw a picture of his experience of chemotherapy. She projected the drawing on the screen for those of us in the audience to see. In the center was a nasty, menacing creature, representing the chemotherapy agents. Next to it, the man’s meek, mild cancer cells stood by helpless. Beneath the drawing, the man had written: “Thou shalt not kill.”
Questioning the man, Kübler-Ross learned that he was a devoted pacifist with a profound revulsion to killing of any kind. Rather than helping the man accept his inevitable death, she helped him reframe his attitude toward chemo. A few weeks later, he produced a drawing that showed he had changed his mind. Kübler-Ross sent him back to his doctors for another round of treatment, and his cancer went into remission, as she’d hoped it would when she saw his drawing. It depicted the chemotherapy agents not as monsters, but as monks, gently escorting the cancer cells out of his body.
The story taught me not to underestimate the power of belief. If a patient does not want to recover, they have the power to prevent it. Once I was seeing patients myself, I made a point to simply ask if they wanted to get well.
Emily, like most chronic pain suffers, found it hard to consider the idea that she might be able to walk without a cane, pain free, but she said she wanted to—without hesitation.
“And now for the bad news,” I told her. “Your pain medications are actually making things worse.”
I explained that opioids and benzodiazepines create problems, too, but chronic use of almost any analgesic—Tylenol, aspirin, Advil, Motrin—causes the hypersensitization of a number of pain receptors. Ironically, the end result of pain pills is increased pain.
Over the next 3 or 4 months, Emily discovered that, even with the right model, recovery from so many things at once was no walk in the park. Without the pain medication, everything hurt. All of the practitioners on the team explained that the medications had shut down her body’s ability to produce its own natural pain relievers, endorphins. Until her own pain relief system kicked in, pain would be her unwelcomed companion. She forced herself to go through the process, keep the appointments, and do what the doctors prescribed, and she had to do it in spite of a constant sense of doubt, suspecting every day that she was wasting her time.
When it was hard to keep going, she drew on the optimism of the staff at my clinic and the patients in the waiting room who told her of their progress. The staff was not suffering like she was, but we’d had the privilege of seeing patient after patient make steady progress back to health. We knew that it would work if she hung in there. For months, all Emily could do was trust in our certainty, because she couldn’t feel it herself.
In times when she was feeling the worst, she still recognized that “all of these people were trying to help me. I’ve never had that kind of support in my whole life. Think about it. When do you have that? It’s like having a big, supportive family encouraging you. But you have to be willing to go the distance.”
The long-term hope of something better was the only possibility that got her out of bed in the morning. It was the reason she hadn’t killed herself, even when she thought it was probably the only thing that would put an end to her pain. As the months wore on and the treatments didn’t seem to be making much difference, the idea that it might work was just enough to make her keep trying a little more.
