Although I truly appreciate all the work that has been done in the pain sciences world, it still isn’t enough to help guide our clinical decision making process.
I have unanswered questions: which patients are the best candidates for pain education? How soon should a change occur? How much of a change is enough to warrant a positive response to pain education?
Earlier this year I had a younger lady who finished her military career enter my doors. She had been serving in the Air Force. She had been in Iraq and Afghanistan. She did field work in Delaware. She returned to Michigan because this is where her life began. Her parents were gone. Apparently her Dad was a mean drunk. Her Mom was psychotic. This patient basically raised her siblings from the age of 11 – figuring out what to eat/cook… making sure they all went to school… protecting them as much as possible from their Dad. Her Mom committed suicide a few years ago. This lady experienced a divorce a couple of years ago. She sought out services because she had ongoing back pain for about a year. She had been seeing a chiropractor for 9 months (with no results). She did field work in Michigan testing lake, pond and river waters. The job was quite strenuous and required hauling buckets and gear 2-5 miles: at times without a 4-wheeler… many times without a dolly. She had been missing work due to her back pain. She was also feeling more and more fatigued which she related to being sick and tired of hurting.
My initial critical thinking was focused on a few things. It seems she had persistent back pain that had not responded to conservative care. As I thought about pain science and pain education, she had months and months of being told the anatomical reason for her back pain. Her psychosocial history indicated yellow flags.
Probably not surprising to most of you, the examination process was boring. I found no objective findings. I didn’t see any red flags. I took a mental deep breath and spent some time educating her about pain. She was a really good thinker and asked great questions. Because of her psychosocial history, she had an active professional helping her with her past. We came up with a game plan.
On her third visit, as I was working with her, she experienced some unexpected knee pain. She also reported that she was beginning to have ankle and shoulder pain during the day. I didn’t really comment or address this.
On her fourth visit, my alarm bells were clanging in my head. I was not finding anything objectively and she was reporting increased back pain, multiple joint pain and increasing fatigue. Nothing was making sense. I felt like kicking myself for initially connecting dots and making the assumption that she had persistent pain which hadn’t been addressed with pain education. On this visit, I spent time regrouping: what had I missed… what didn’t I ask? One piece I missed: in Delaware while doing her field work, it was very common for her to come home with multiple ticks on her body. About 2 years ago, she had a bite get infected. She received treatment. She never had any bloodwork done. Lyme disease needed to be ruled out. I contacted her primary care physician with recommendations to rule out Lyme disease.
She tested negative. Her primary care physician saw something in her lab work. She was referred to a rheumatologist. The rheumatologist had more lab work done and was confused. Nothing was adding up. I still don’t know exactly what led to a whole new chain of thought pointing into a very different direction, but oddly, drinking water became a factor. The end of the story: this patient’s symptoms were due to heavy metal poisoning from the city water. Our city has really old pipes and has had known water problems. Construction had been going on for the last year and I guess water was being diverted into older pipes when other pipes had to be closed for construction. It seems what’s happening in my lil’ city from a political perspective is what happened in Flint. The water has high levels of iron and lead. As I think about our practices, heavy metal poisoning is not some typical diagnosis we will see. This isn’t even on our radar, or on any medical professional’s radar, as an immediate diagnosis.
She has maintained contact with me and she is doing much better now. She quit drinking the water. She’s fighting the fight to get the city to communicate and address the water problem. The last text that she sent me was that she went mountain biking on DTE Energy Foundation trail and felt great. For the first time in a year she felt like herself.
As I reflect on this patient and my experience with her, I think of two things: who are the appropriate candidates for pain education and what is the expected response after educating about pain?