Monday, October 4, 2010

Physical Therapy

     As my readers can see, I have not posted a new article for over a month. Yet I am looking over the new flags that made hits on my website and also where some of these viewers came from. I feel I owe you a posting, so I decided to write a little about why I have been delinquent.

     I have been accessing the medical profession again from the consumer side of the desk. My elbow has been continuing to have daily pain from my melanoma surgery. I have had various types of strange pains starting about 2 weeks after the surgery. At first it was, I think, a nerve pain with hyperesthesias (extreme sensitivity to normal touch) over the area, and allodynia, which is accentuated pain from stimuli over the area. I saw a physical therapist at the Hand Clinic at the Medical College of Wisconsin. But she really didn't have much to suggest and showed me a couple exercises to try to stretch the nerves, and slapped some corticosteroids cream on the site and gave me an ultrasound treatment. But she said she was not allowed to get the ultrasound head very close to the relatively new incision so she couldn't really get to the area that was bothering. Even so I found the vibration of the ultrasound to be very annoying, accentuating the pain.

     This was very similar to therapy years ago for my knee and mostly what was done was modalities ie ultrasound, and electrical stimulation. That time zapping my quadriceps muscles with electrical stimulus while I was voluntarily contracting them was I thought extreme torture. And I did not complete that session. My knee slowly got better on its own.

     Since my pain is persisting and some of that hyperesthesia is better, but now I am having deep pain with motion and with hanging my arm down, I have decided to try therapy again. It is after all three months since my surgery. A friend from my Spirit Mind Body group gave me a name of a therapist at the Sports Therapy clinic near my home. After the first visit with him, I was very optimistic. I now think there are therapists and then there are therapists. He was great, treating my whole body, found some things that I didn't know could cause me trouble. Very thorough. and astute at picking up on what I told him about the nature of my pain. He found a lot of tightness in my neck and shoulder, and at the acromioclavicular joint in the shoulder. He also said I was lacking about 40% motion when turning my head toward the surgical arm. He said one of my vertebrae was turned on the other because of that muscle tension. so he took it upon himself to strengthen this out and release those tight muscles. Just with the first two sessions I was felling somewhat better in the arm.

     But then he started working on my surgical site and that elbow. He was probably too vigorous that first time. Within a day or two I began to recognize the pain; it was no longer strange or a stranger to me. I now had lateral epicondylitis, or tennis elbow. Somehow all that manipulation of the elbow had centered the pain and inflammation right on that lateral epicondyle. I had experienced tennis elbow before from playing tennis, but this one was created with the help of a surgeon and a physical therapist and it was a wing-dinger. But at least I knew what to do for this. I purchased a fresh new tennis elbow band and wearing it brought some relief. I have been wearing it much of the time since. My physical therapist was bummed out that he had caused a lateral epicondylitis, and stayed away from the elbow until about my 7th or 8th session. He continued to work on my neck and shoulder girdle. He is good, he identifies the muscles and performs maneuvers and asks me to move certain ways against resistance while he is isolating those muscles. My grip strength is lagging and seems to have plateaued at about 30% down from normal. We are able to record increases in neck range of motion, and arm range of motion after these sessions.  But then the next session, I have lost all that range of motion and everything is all tightened up again.  I have learned that therapy is an example of the cliche: Two steps forward, one step backwards. In fact it may sometimes be one step forward, two steps backward. Once I seemed to get a flare up of the arm pain after attending an Imax movie -- looking up. Once when I seemed to have moved backwards, the therapist took a history of my activities and we decided it might be me working a lot on my laptop, writing blogs and, -- I admit it, playing solitaire, or mahjong on line. So I have limited my computer time or else tried to steal the desktop machine which is more ergonomic from my husband, which is not always easy. So, indeed, you have not seen any blogs for a whole month.

     I am still occasionally taking steps backwards. I went to water aerobics on Saturday and had a different and very young teacher. Of course, the moves were different because of the different teacher and she did a lot of arm work with buoys in the water. I stopped using my bad arm about 2/3 of the way through when I saw this, and I iced it after, but still I was pretty sore the next day. My therapist says I must stay positive, so I will try. Thank goodness for tennis elbow bands! And I will get better; I know it. It is just a slow process.

     In the middle of this whole therapy thing, I did go back to see the plastic surgeon who operated on my arm. First let me go against rules and generalize that I think many surgeons (my son excepted) do not deal well with postoperative pain, particularly the pain that is different or more than expected.  He was not very interested in the neuropathic pain I was reporting to him when I returned to get the sutures out. This 3 month follow up was just as disappointing. He really didn't address the location, nature or degree of my pain. He put his finger on a spot on my forearm which was slightly tender, and brought up a diagnosis that I had never even heard of, called a radial tunnel syndrome, and he suggested I was creating it by wearing my tennis elbow band too tightly. He also criticized my therapist implying he was treating me appropriately.  He was otherwise showing off for the medical student that was with him. He also was critical of the report that my oncologist had sent him because she had decided that the total depth of my melanoma was only 0.48 mm which is very superficial. This depth would probably not justify as wide an excision as I had and would not justify a sentinel node biopsy. So he told me that we still do not know the depth. He still said we can't be sure and add up the depths, which of course would be 0.48 mm and 0 since nothing was found in the wide excision specimen. Just to make sure his student knew the degree of surgery was justified, he told me that we still had to be paranoid about this melanoma, that it could come back. Then he said,"Now, if you ask me do I think it has spread, I would say 'No.' but I do think we will never know the depth of this lesion, so I would class it as more advanced class of tumor than your oncologist did." OK, that's going to make me feel good and confident. Needless to say, I found this appointment very disappointing.

     In an unrelated experience, I wanted to write another tale of a medical interaction. Amazingly, my husband had a nevus removed from the bottom of his foot about a week after I had my melanoma surgery. A dermatologist in my clinic had been watching this lesion on the bottom of hubby's foot for about 6 months and just could not live with it there anymore. He was going to do a very shallow biopsy of it, but knowing how my depth was disturbed by the shave biopsy, my husband insisted that at least 1 mm of tissue be removed in the biopsy. The dermatologist said he was uncomfortable about doing this and so wanted to send my husband to a surgeon. He called me into the exam room to explain this to both my husband and me at the same time. But then he began speaking to me about my amelanotic melanoma. He related that he made the same "mistake" that my dermatologist made and shave biopsied an amelanotic melanoma on a young woman. He felt bad about this, but then he said: "But it really didn't matter, because her melanoma had already metastasized and she died of a brain met." Yes, he said that to me and I was still wearing the big bandage on my arm from having my melanoma removed. This was an example of the doctor talking with the doctor and his being unable to view me as a patient. He was in truth not very sensitive to the situation. I told this story to my water aerobic lady buddies, and they thought it was terrible. They wanted to know his name, but I refused to give it to them, because this dermatologitst was a good doctor. He was just having trouble telling between the patient and the doctor.

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