Tuesday, 5 August 2014

Bilateral lower limb amputee rehabilitation - A Retrospective Review

The appraisal of functional status is routine in medical rehabilitation, including ambulation status after inpatient rehabilitation programs. [1-13] A review of the recent literature, however, failed to show reports of functional outcomes for bilateral lower limb amputation.

In 1984 a seven-year retrospective review of the population admitted to a major metropolitan rehabilitation center described the characteristics of patients with lower limb amputation. [14] The review, when compared with national surveys done one and two decades previously, [15,16] indicated an increase in mean age, an increase in the number of below-the-knee over other amputation levels, and an increasing number of amputees readmitted for bilateral prosthetic training.

Sakuma and co-workers reported in 1974 their study of 53 elderly patients who had undergone bilateral lower extremity amputations. [17] They found that 50% of amputees with preservation of at least one knee joint could become ambulatory with prostheses for self-care purposes. They also concluded that a rehabilitation program was beneficial for both users and nonusers of prostheses.

Also in 1974, Kerstein and associates reported their study of 194 major amputations over a ten-year period. [18] Of the total group, 23% had bilateral amputations. At the conclusion of a 22-week postamputation rehabilitation program, 80% of the patients were able to return home and 70% of all patients were able to walk with just the use of a single cane or without aids.

The purposes of this study was to document patients' functional results after bilateral lower limb amputation on discharge from an impatient rehabilitation program and at one month and three months after discharge. As the number of patients with bilateral lower limb amputations increases, there is a greater need to examine closely the efficacy of rehabilitation programs that have ambulation training as a goal. [14]

Patients and Methods

All patients with bilateral lower limb amputations who presented to a regional amputee rehabilitation center over an 18-month period (from July 1988 through December 1989) were selected. The outpatient records were reviewed retrospectively for the following information: Patient demographics, including age and sex, amputation levels, length of inpatient rehabiligation stay, and disposition on discharge; and functional mobility on discharge, at one month, and at three months after discharge.

The levels of amputation were defined as partial-foot, to include toe, Syme's, and transmetatarsal amputations; below-knee; and above-knee amputations. During the 18-month period, none of these patients had hemipelvectomy or hip disarticulation as their secondary amputation site.

Patients' functional status was examined on discharge and at one and three months after discharge in 41 cases; 20 were not included in this portion of the analysis because of transfers to acute care hospitals or loss to outpatient follow-up.

Patients' functional status falls into the following five groups:

* A limited household ambulator is a person who can use a prosthesis only in the home to ambulate independently and perform self-care activities. The distance for a limited household ambulator is less than 37 m (120 ft).

* A household ambulator can walk more than 37 m and performs all of the activities of daily living using prostheses.

* A limited community ambulator is a patient who can walk 152 m (500 ft), can participate in some avocational activity, but is not gainfully employed.

* A community level ambulator is one who can walk more than 152 m, engages in vocational and avocational activities, including driving with the prosthetic devices, and is gainfully employed.

* Although the wheelchair is used by all of them to attain greater mobility within the home or community, a person who uses a wheelchair exclusively for all mobility and activities of daily living is defined for the purposes of this study as a wheelchair user.


Over an 18-month period, 2,941 patients were admitted to a major metropolitan rehabilitation center. Of these, 314, or 11%, were admitted to the regional amputee rehabilitation program and 61, or 19.4%, had bilateral lower limb amputations. As illustrated in Figure 1, the most frequent level of amputation was below both knees (25 patients or 41%), followed by below and above the knees (14, or 23%), and above both knees (12, or 20%), with less frequency of bilateral partial-foot, partial-foot and below-knee, and partial-foot and above-knee amputations.

Of the 61 patients, 41, or 67%, were men. Ages ranged from 29 to 88 years, with the average age being 61.5 years.

Figure 2 shows the average length of stay on the impatient rehabilitation program, which for all amputations was 23.9 days and for bilateral amputations was 24.2 days, with the range being 3 to 78 days. The average length of stay for below-knee and partial-foot amputations was 37.8 days, although one patient's hospital stay was prolonged because of disposition problems, and the patient was eventually placed in a nursing home. The correlated average length of stay for this level of amputation was then 32.7 days.

Of the 61 patients, 47, or 77%, were discharged to home, 12 (20%) required transfer to acute care hospitals for medical or surgical complications, and only 2 patients were transferred to a nursing home for long-term care.

Of the 47 patients discharged to home, 17, or 36%, achieved a limited household level of ambulation at the time of discharge, 12 were dependent on a wheelchair for all mobility, while 10 attained a household level of ambulation. Only 8 achieved community ambulation of some level (Figure 3-A).

At the one-month follow-up, most patients were at the wheelchair level of function, with the other patients evenly scattered among the other categories. Further analysis of the data revealed that of those patients at a limited household level of ambulation at the time of discharge, 7 (41%) maintained their level of function and 6 advanced to the household level; 8 patients were lost to follow-up (Figure 3-B).

At the three-month follow-up, those patients who were previously walking at a limited household level regained this level. Most patients achieved limited household ambulation at three months (Figure 3-C).

The patients who were functioning at a higher level at the time of discharge were noted to maintain or improve their level of functioning over the three months. Those patients discharged at a wheelchair level were either lost to follow-up or remained at the wheelchair level. Few (3, or 8%) of these advanced to walking at some time in the three-month period.

Of the 17 patients with bilateral below-knee amputation (Figure 4), 6 (35%) achieved limited household ambulation at the time of discharge; of these, at the one-month follow-up some had maintained function but others declined. By three months, however, these patients had advanced to household walking and even limited community walking. Those patients achieving on discharge a high level of functional mobility were able to attain and maintain limited community and community ambulation during the three months.

Similarly, persons with below- and above-knee amputations (Figure 5) achieved limited household mobility on discharge and advanced to household walking, with few advancing to limited community and community ambulation; about a third remained at the wheelchair level.

Although most of the patients with above-knee amputations were independent at the wheelchair level at the time of discharge (Figure 6), some achieved a limited household level of walking and maintained this up to three months after discharge.


A review of the rehabilitation literature failed to elicity any recent information regarding the functional mobility outcomes of patients with bilateral lower limb amputations.

In this limited study, we found that person's with bilateral lower limb amputations deserve a comprehensive rehabilitation program to attain (and maintain) goals of limited household walking. Further studies should examine the role concurrent disease plays in determining the appropriateness for prosthetic management; the cost-effectiveness; and the longterm benefits, both physical and psychosocial, of attaining the highest possible functional level.

Wednesday, 30 July 2014

Chronic and overuse knee injury symptoms vague, nonspecific.

Chronic and overuse knee injuries will get any physician behind schedule because the cause is not obvious, Dr. Steven Anderson said at a meeting on pediatric and adolescent sports medicine sponsored by the American Academy of Pediatrics.

"The effects [of a chronic knee injury] are vague and nonspecific, and if you don't understand the causes, you're not going to be able to adequately treat them," said Dr. Anderson of the University of Washington, Seattle. An evaluation of chronic knee pain should include extrinsic factors (training and equipment) and intrinsic factors (muscle flexibility and alignment).

Inflexibility looms large as a cause of chronic knee pain in both children and adults, Dr. Anderson said. Possible pain generators in the knee include the subchondral bone, synovium, tendon, bursa, ligament, and apophysis. Tumors, infections, and rheumatologic problems should always be in the differential diagnosis of knee pain that presents without an obvious injury--athletes aren't immune to medical problems that are unrelated to sports.

Some common overuse knee injuries:

* Osgood-Schlatter disease. This condition is most common in boys aged 13-15 years. There's some debate about whether rapid growth makes muscles tight, but the majority of kids with Osgood-Schlatter have tight hamstrings and the condition occurs during times of rapid growth. Running with tight muscles creates additional tension on the tibial tubercle and is tantamount to driving with the brakes on," Dr. Anderson said.

Children with this problem will have history of pain and infrapatellar swelling as well as a tender and swollen tibial tubercle. Treatment means limiting activity to a pain-free level, controlling inflammation with ice, and stretching the hamstrings, quadriceps, calf muscles, and hip flexors. This should be followed by a gradual resumption of activity as symptoms allow.

* Patellar tendinitis. Also known as "jumper's knee," the pain gets worse with jumping, lunging, or going downstairs. The tenderness can be appreciated by palpating the proximal portion of the patellar tendon at its attachment site on the inferior patellar pole, Dr. Anderson said. If the patella moves around or tracks abnormally, a patellar stability brace or corrective shoe may be helpful.

* Plica syndrome. This is more common in adolescents than adults. When the knee develops, it starts as three bursal compartments. At the end of the fourth embryologic month, the walls of these compartments melt away so one compartment for the knee remains, but remnants of these walls remain as synovial folds or plicas.

There are three plicas: one above the kneecap, one over the anterior cruciate ligament, and one in the medial portion of the knee. These can become inflamed and thickened, which can cause snapping and popping. Inflamed plicas can cause anterior knee pain and can mimic a torn meniscus.

Plica syndrome is best treated with soft-tissue mobilization, ultrasound, or a knee sleeve with side support. If conservative measures fail, surgical resection is an option.

RELATED ARTICLE: Knee Assessment Cheat Sheet

Children with chronic knee pain may have one of these risk factors, or possibly more than one of them:

Anatomic Risk Factors for Patellofemoral Pain:

* Increased Q angle (15 degrees in a normal knee).

* Unusually high or low patella.

* Hypermobile patella.

* Knee bent outward or inward (bowlegged or knock-kneed).

* Twisting of thigh or lower leg (femoral anteversion or internal tibial torsion).

* Hyperpronated subtalar joint.

* Muscle insufficiency in quadriceps or hamstrings.

* Muscle tightness in quadriceps or hamstrings.

External Risk Factors for Patellofemoral Pain:

* Inappropriate exercise surfaces (too hard, too hilly too uneven).

* Inappropriate training such as excess speed, distance, or general overload.

* Improper shoes or poorly fitting equipment (bicycle seat too low).

Sunday, 27 July 2014

Neonatal rib fracture - Birth trauma or child abuse

Fractured ribs in the neonatal period have not been recognized in the past as a consequence of birth trauma,1-5 possibly because they are exceedingly rare or because they are often not clinically recognized. Although chest radio-graphs taken later in infancy would be expected to reveal evidence of healed rib fracture, they are infrequently done, and past fractures, if any, would go undetected. The finding of healed rib fracture during infancy would be more likely to raise the question of possible child abuse than of birth trauma. The following is a case report of rib fractures in a neonate believed to be secondary birth trauma. CASE REPORT

The mother was a 37-year-old woman who had two previous pregnancies, both culminating in first trimester elective abortions. Her past medical history was unremarkable except for obesity and mild hypertension not requiring drug treatment. During the pregnancy she developed mild gestational diabetes, which was controlled by diet. She had mild pretibial edema throughout the pregnancy, and at 35 weeks gestation she required bed rest to control the edema and her blood pressure. She did not develop other changes consistent with preeciampsia. Starting at week 35, she had weekly non-stress tests to document fetal well-being. These tests remained reactive.

At 38 weeks she spontaneously went into labor. Early first stage was uneventful, but at 6-cm to 8-cm cervical dilation, the baby developed some variable deceleration. During the second stage the fetus developed late decelerations, and the vertex failed to descend. Obstetric consultation was obtained, and the treatment options were discussed with the patient.

It was decided to attempt immediate delivery using vacuum extraction. The head was in the right occiput anterior position. After delivery of the head by vacuum extraction, shoulder dystocia occurred, requiring significant traction force to deliver the shoulders. The left rib cage passed under the symphysis pubis, and the thorax was flexed upward as the remainder of the body emerged. The child weighed 3300 g, and Apgar scores were 6 at 1 minute and 8 at 5 minutes. The newborn examination was done in the delivery room with special attention directed toward the clavicles because of the difficult shoulder delivery. The clavicles were found to be intact, and the remainder of the physical examination did not detect any abnormality.

Because of the mother's diabetes, the infant was sent directly to the newborn nursery, where blood glucose levels were monitored. Approximately 4 hours after delivery, the infant was sent to the mother's room, remained with her for 45 minutes, and then was returned to the newborn nursery. Two hours later, a total of 9 hours after delivery, the child was noted by the nurse to have rapid respirations. Examination by a resident physician revealed mild respiratory distress with tachypnea and tachycardia. Crepitus was palpable over the left posterolateral chest. No skin changes suggestive of trauma were found. Chest x-ray examination revealed 5 fractured ribs over the left posterolateral chest area (Figure 1). There was no evidence of pneumothorax or other skeletal trauma. Over the next 36 hours the child experienced progressively less tachypnea and gradual disappearance of the crepitus. Full skeletal survey failed to show evidence of osteogenesis imperfecta or any other abnormality of bone mineralization. Since the fractured ribs were not noted at the time of delivery, the possibility was considered that injury occurred sometime in the 9-hour period immediately following delivery. A review of the nursery nursing notes and an interview of the nursing staff failed to reveal any evidence that injury occurred as the result of an accident by the nursery staff.

The possibility of child abuse by the mother also had to be considered. Social service personnel were consulted, and they met with the mother reviewing the circumstances of the pregnancy, her prenatal course, social supports, and attitudes toward the pregnancy and new baby. The pregnancy had been unexpected and unwanted and the product of a mixed racial relationship. The couple had separated 3 weeks before the baby's birth. Although there were multiple risk factors for child abuse, the mother denied having hurt the baby, and it was the opinion of the medical staff and the social service personnel that she be allowed to take the child home. Over the next 12 months the baby had normal physical and developmental growth with no evidence of child abuse. The baby has been followed by both her primary physician and the department of social services. Follow-up x-ray films of the ribs at 3 weeks postpartum showed callus formation and no other evidence of trauma.

DISCUSSION A review of the literature reveals copious reference to birth injuries of the skull, clavicles, cervical spine, brachial plexus, and extremities, but little could be found describing rib fracture in full-term infants.(1,2)

Rubin(3) prospectively studied 15, 435 births over a 6-year period. He found 108 injuries other than cephalhematoma, an incidence of one birth injury for every 143 deliveries. Included were 43 fractured clavicles, 7 fractured humeri, and 1 skull fracture. There were no reported episodes of fractured ribs in his series.

Levine et al(4) retrospectively studied 13,870 singleton consecutive live births and assessed risk factors associated with fractures and other injuries. That fractured ribs were not reported in this large series would suggest either that a rib fracture is an infrequent occurrence or that it is often missed. Thomas5 reviewed rib fractures in infants under I year of age during the period 1969 to 1975. Of over 10,000 chest roentgenograms reviewed, he identified 25 infants with evidence of one or more rib fractures. These included one newborn and one infant at 3 weeks of age. The infant with fracture at birth had osteogenesis imperfecta congenita and died at 3 days. The infant with rib fracture at 3 weeks was a full-term baby weighing 5686 g and was delivered by mid-forceps.

Levine et al identified risk factors associated with fractured clavicle. One might also speculate those same factors being predictive of potential rib fracture. Table I shows the risk factors identified in the infants with fractured clavicles. A score of 5 or greater predicted a fracture in greater than 50% of the injured group. The delivery described in this paper would have a total score of 7, resulting in a greater than 50% chance of a fracture if the risk factor scale of Levine et al were applied.

There are numerous reports of fractured ribs as a result of child abuse. Leonidas(6 ) writes that fractured ribs are the third most frequent skeletal injury in battered children. The authors could find no reports that described abuse in the first week of life. In addition, almost all children with bone injuries from child abuse have other associated injuries. CONCLUSIONS A newborn infant was discovered to have five fractured ribs 9 hours after a vacuum-assisted delivery and moderate shoulder dystocia. The diagnosis of child abuse was seriously considered, but little evidence was found to support this explanation of the injury despite the presence of several child-abuse risk factors.(7-9) The mother's interactions with the child, as observed by nursing staff, medical staff, and social service personnel, were considered to be appropriate. That the child's subsequent development over the first year of life showed normal physical and psychological growth also argues against neonatal child abuse.

The injury is thought to have occurred during the delivery and was missed on the initial examination. The mechanical pressure exerted on the left side of the chest during the upward flexion of the body against the symphysis pubis is the probable mechanism of this trauma. In circumstances consistent with the risk profile as described by Levine et al (Table l)-that is, infant weight greater than 4000 g, shoulder dystocia, and mid-forceps delivery the authors suggest that a careful search for rib fracture may reveal that such an injury is not so rare as the literature would suggest.

In addition to the customary auscultation of the lungs, careful palpation of the ribs looking for evidence of crepitation would probably represent an adequate initial screening measure to rule out rib fracture. Chest x-ray examination is not recommended unless there is respiratory distress or clinical evidence on the physical examination of possible rib fracture. References 1 .Cumming WA: Neonatal skeletal fractures. Birth trauma or child abuse?

Wednesday, 23 July 2014

Lose weight to help ward off chronic pain

You probably already know that carrying extra weight can cause a variety of health problems.

"Obesity can result in hypertension, diabetes, enlargement of the liver with fat, and," says Michelle Eslami, MD, a geriatrician at UCLA Health System. "Obesity can be responsible for coronary artery disease too. It can also cause social isolation as getting out and about may be hard for obese individuals."

But one thing that you may not think about is that obesity can cause you physical pain. "Obesity may result in joint pain especially in the lower back, hips, and knees, as extra weight can put strain on these joints," Dr. Eslami says.

Weight loss and exercise play a huge role in the reduction of chronic pain. The good news is that research has shown that losing weight and exercising can significantly reduce your risk of chronic pain.

According to study findings, the more people exercise, the less likely they are to experience chronic pain. In addition, obesity was directly linked to pain, but exercising for one or more hours per week compensated, to some extent, for the adverse effect of a high body mass index (BMI) on chronic pain risk.

Getting started. Weight loss plus exercise remains the best way to reduce pain. Randomized studies suggest that as little as a five pound weight loss can have a huge impact on chronic pain.

While it's easy to tell pain patients to exercise more, starting an exercise program can be difficult. The problem is that people who are hurting have trouble moving, and if you have trouble moving, it can be difficult to lose weight and begin an exercise program. Start out by losing weight through diet and making lifestyle changes, as well as building core and back strength.

"Weight loss with calorie restriction, exercise (such as recumbent bike), or swimming to reduce the overall stress and strain on the joints can help ease the pain caused by obesity," Dr. Eslami notes.

Pain patients who are looking to lose weight can try joining a commercial weight loss program, such as Weight Watchers, which often provides counseling. People will often find that they are making simple mistakes that, when corrected, can accelerate weight loss efforts. Getting professional help can lead to dramatic weight loss and, if you can lose weight, you'll start to feel better.

If you are obese, it's important to consult someone who will work with you to design the treatment program that is best for you. You can successfully lose weight, and keep it off, with lifestyle changes, but doing it on your own is difficult. A health care professional who specializes in weight loss can help you determine what strategies will be most effective.

"Diet" doesn't have to be a four letter word. The first thing to remember is that no single diet is right for everybody. Try different approaches and don't give up. As anyone who has been on a diet can tell you, weight loss does not occur overnight, and a successful diet requires that you stick to your plan even though you may not be seeing immediate results. Make small goals for yourself. Instead of aiming for big goals, like 30 pounds, plan to lose just five at a time.

Another helpful suggestion is to eat protein for breakfast. This is one of the most effective ways to lose weight. It helps to fill you up early and prevent overindulging later in the day. Try an egg-white omelet, yogurt, or cottage cheese for breakfast rather than toast or cereal.

A third tip is to start your meals with vegetables or salad. Eat these at the beginning so that you fill up on the "good stuff." This can help prevent you from overeating the less-healthy, more fattening foods.


The US. Centers for Disease Control and Prevention (CDC) recommends these tips for weight loss:

* Substitute fruits and vegetables for higher-calorie foods.

* Eat high-fiber foods such as whole grains to help you feel full.

* Prepare and eat most meals at home.

* Switch to healthier foods, such as skim milk instead of whole milk.

* Eat only when you are hungry.

Saturday, 19 July 2014

Dual ostomies - Great news

My doctor sat in a chair, leaning towards me, with his elbows at his knees and his hands folded. He had bad news to tell me.

He explained that I would need surgery to remove my bladder and part of my colon. My choices were either to have surgery or to be reconciled to the possibility that my cancer would grow and prove fatal.

As I watched the doctor, I thought he was going to cry. I said, "Oh well, I guess it is my turn, as I have had a lot of good luck in my life." I leaned over to pat the doctor on the back. "Hey," he said, "I am supposed to console you, but you are consoling me."


It all started with a tiny drop of blood. I thought it was nothing, since I had no pain or other symptoms. I was examined by a nurse in the emergency room at the hospital and was told nothing was wrong. A month later malignancy was found.

In June, 1985, I had a hysterectomy. My uterus was loaded with cancer, and the cells had gone three quarters of the way through the wall. Therefore, I had to choose between radiation and chemotherapy. I chose radiation.

Radiation therapy was not too bad. I experienced just a little nausea, and the inconvenience of getting to the clinic in Palo Alto (a forty-mile trip every day for six weeks). I had to give up my golf and a few other activities.

Life Goes On

Everything was fine. My life went on as before. Then eight months later, the following April, 1986, I discovered another tiny spot of blood, and went back to the doctor. This biopsy was also positive, and more radiation was prescribed, to the limit I could take.

Radiation thinned the walls of my bladder and colon so much that the doctor said the tissue would perforate. He advised that my bladder and part of my colon be removed.

Pre-Op Consultations

An appointment was made for me to see a cancer specialist in San Francisco. He explained the surgery I was to have, using a plaster model of female organs. He was very patient and said for me to take all the time I wanted and ask all the questions I wanted.

Then, the enterostomal therapy (ET) nurse tried to show me the equipment I would use after surgery. At this point, I really broke down and cried. I refused to listen or to look at any of the equipment she had gathered to show me. With tears in her eyes, she gathered me into her arms and held me while I shook with sobs. She spent a great deal of time with me in the hospital later on. What a wonderful person and a great help she turned out to be!

Great News

Early one morning, while I was still in sort of a stupor after my surgery, I opened my eyes, and there was my surgeon, standing above me, smiling and rubbing his hands together. He said, "We examined you all over, and we did not find any more malignancy."

The significance of the doctor's broad smile and statement did not dawn on me until much later. I met several people who were told the opposite after their surgery, namely, that more malignant cells were discovered, and that they would need further treatment after their surgery.

I believe I had the very finest of care at Kaiser Hospital, even though there was a strike going on at the time. The nurses came running whenever my beepers went off behind me. When I was uncomfortable, they gave me a back rub and talked to me as though they were very interested in me.

In Praise of ET's

Of course the most important person was my ET nurse. She brought a huge minnor, which she stood on the floor, so that I could see what I was doing while practicing applying my equipment. She made me practice every day for about a week, even though sometimes I did not feel like it. As a result, I was able to take care of myself when I got home.

It is a comforting feeling to know that just about every problem you have with your stoma can be corrected by your guardian angel, your ET nurse. Sometimes you think you will lose your mind with a painful, unbearable itch, and she cures it in half an hour. I know it is not always that simple in all cases, but it helps to know that I can always depend on my ET, my friend.

Pearl A. Anderson is president of the Santa Clara County Chapter of UOA, and, as a certified visitor, is called upon often to see new patients. She and her husband of nearly 50 years have four children and ten grandchildren. She swims, gardens, and says she enjoys all the things she did before her ostomy surgery.

Saturday, 5 July 2014

Let's give pain the respect it deserves

A patient I'll call Bob Roan recently brought me a magazine clipping. "When the arthritis in Dolores Walker's ankle acts up," the article began, "there's only one way to get rid of the pain. She puts on her white sequined jumpsuit, slicks her hair back, and starts swiveling and snapping to the songs of Elvis Presley." The article went on to tell how the 43-year-old grandmother's Elvis act had enabled her to throw away her brace and cane.

I'm sure you're familiar with stories like this. They appear frequently in the lay press. The theme seems to be "mind over matter": If you pretend not be sick, you'll feel well.

My patient, Bob, has severe rheumatoid arthritis. He'll probably need a knee replacement soon. Despite his constant pain, he continues to do manual labor. He's kept his sense of humor. And he has nothing but contempt for the attitude epitomized in that article.

I share his contempt. I wish more people--especially physicians and nurses--did. Too often, the families of suffering patients tell them to "smile, you'll feel better." Or "snap out of it." Well, in a rheumatology practice, I see a lot of pain. My patients and I are tired of reading that illness can be pretended or laughed away. It belittles their genuine suffering. It hurts these people to walk. It hurts to get out of bed. It hurts to clean themselves when they go to the bathroom. They are weak, stiff, tired, and in pain.

Emily Sutton (I'm not using real names) comes to mind. Like Bob, she has severe rheumatoid arthritis. Her right knee was fused several years ago. She has a total prosthesis of the left knee; it broke and had to be repaired. She has chronic osteomyelitis of the right forearm secondary to failure of a total elbow prosthesis. She's had numerous operations on her hands and wrists.

When Emily sits, her right leg juts straight out, since the knee doesn't bend. Imagine the difficulty she has in using the toilet. Her right arm is almost useless. Imagine how hard it is for her to dress or brush her teeth.

Nonetheless, Emily doesn't complain a lot. She puts on a bright face and does her best to accept her fate. That includes enduring the well-intended advice of friends and relatives who tell her to smile and laugh and ignore her disabilities and pain. Emily is actually doing better than 99 percent of us would do under similar circumstances. These inane admonitions do her no favor.

Most of my patients don't use their illness for secondary gain, manipulating their families in order to get something. They simply want to be able to do what they used to be able to do. Homemakers want to be able to do housework. Those who work outside the home want to be able to keep on with it. They want to be able to drive, cut the grass, repair the car. When they can't, it's depressing.

Sally Austin is depressed. You might be, too, if you had Sally's systemic lupus erythematosus, coronary heart disease, and chronic pancreatitis. Because she has difficulty sleeping, she's always tired. She also lives with anxiety, perhaps because so much is expected of her.

Sally's family expects her to continue doing the laundry, washing the dishes, cooking the meals, and cleaning the house. She gets no sympathy or help from relatives, let alone from friends. She can't always manage to do everything, but she does what she can. In my opinion, it's more than her relatives would do in her situation. Telling her to "grin and bear it," as they do, not only is useless, it's cruel.

I tell patients in chronic pain not to look for sympathy. I warn them that complaints will quickly turn off spouses, siblings, parents, and children, not to mention friends and neighbors. I encourage them to suffer in relative silence, because complaining will only worsen the estrangement between them and their healthy families.

More than sympathy, these patients want understanding. Unfortunately, that's a scarce commodity, too. It's impossible to really understand severe, chronic, constant pain and disability without experiencing them firsthand.

I often talk with family members, trying to persuade them that their relative really is disabled and in considerable pain. This helps. Still, suffering is a lonely occupation.

It need not be a preoccupation, however. Certainly it's appropriate to urge patients to look on the bright side and to keep from fixating on their problems. But laughter doesn't stimulate T cells. Chuckling doesn't make cartilage grow back.

It takes a lot of courage to keep pain in perspective and get on with life. Joe Fielder, a young man with ankylosing spondylitis, had both hips replaced. Despite his obvious pain and stiffness, he continued working in a factory 60 hours a week. He had another problem, too-alcoholism, which I believe was related partly to his inability to live up to his family's unrealistic expectations that he laugh off his illness and conduct life as if he were normal.

Joe recently had to give up his job and is now living on disability. Around the same time, he quit drinking alcohol.

What patients like these need from their families, friends, and physicians is reassurance that their illnesses aren't their fault. They need to be reminded that even though they can't do everything they once could, they're still human beings worthy of our respect. Pain is an inescapable part of their lives. Let's stop their families from telling them to laugh it away.

Saturday, 28 June 2014

It never hurts to let patients second guess you

In training, we learn to ask patients all kinds of questions. But no one taught me to ask what may be the most important question of all: "What do you think is wrong?" I've found that even if the patient's answer isn't on target, it helps me address his concerns. And sometimes when I'm puzzled, the patient actually makes the correct diagnosis. Consider these cases:

Stabbing in the dark for answers

Over a three-month period I saw a 66-year-old woman four times. Her problem was pain in her left knee, but only at night. I could find little if any sign of arthritis, and everything else was normal, including blood tests and X-rays of her knee and hip.

Neither analgesia nor physical therapy helped. I considered depression or a family problem, but there was no evidence of either.

I was stumped. So I asked, "What do you think is wrong?" Without an eye-blink's hesitation, she responded, "I think I have cancer."

"Why would you think that?" I asked.

"I read in a magazine," she explained, "that pain that gets worse at night is often cancer-and it's often missed by doctors."

I was able to reassure her that she didn't have cancer, and she was visibly relieved. The pain resolved spontaneously over the next few weeks. I encouraged her to ask us immediately about anything in her magazine reading that distressed her. (I never did find the article in question. I certainly hope it didn't say what she said it did.)

Reading that paid off

I'd seen a middle-aged woman several times over the years for peptic-ulcer disease. She'd responded well each time, and I talked to her repeatedly about avoiding ulcerogenic substances. I had even drawn a gastrin level on her, which turned out normal. She was getting along reasonably well on [H.sub.2] blockers, but now she was back with what seemed to be a flare-up of the old problem. Discouraged, I broached with her the possibility of undertaking ulcer surgery.

She frowned. I frowned. Neither of us was happy with having to resort to such a procedure.

"Do you have any idea of what else might be wrong?" I asked.

"Well, I'm no doctor," she said shy. "But may I have hyperparathyroidism."

Hyperparathyroidism? Most of my patients stumble over medical terms with half as many syllables. I was surprised that she'd come up with a diagnosis so esoteric. But guess what" Although her serum calcium was in the high-normal range, it turned out she was right. She was a well-educated person who'd come across the disease in her reading, and-unlike the woman with night pain-had been able to steer me in the right direction. She responded well to parathyroid surgery; what's more, she's had no more ulcers.

Spotting a rocky diagnosis

A 51-year-old man came to see me with a rash. It was clearly fungal, and I wrote out an Rx that I said would resolve it within a couple of weeks or so. Two days later he called: The rash was worse. I encouraged him to give the cream more time. Several days later, he insisted on an appointment because he felt the rash wasn't getting better.

In fact, though, it was healing up nicely. Clearly he had something else on his mind, so I asked, "What do you think the problems is.?"

His answer took me by surprise: "I think I have Rocky Mountain spotted fever."

I asked him why he thought that. "Well," he said, "I grew up in the Rockies, and I've got spots. I guess I'm in real trouble." I listed the reasons he didn't have to worry about that illness. I told him again that the rash was fungal, explained once more what had caused it, and assured him that it would resolve. He calmed down considerably, and the rash cleared over the next two weeks.

Itching to live down guilt

I'll never forget the 83-year-old woman with a severe vaginal itch with no findings except for excoriations caused by her own persistent scratching. All tests were normal, all treatment was ineffective, and she was increasingly tearful and anxious. We both felt terrible.

Because I really don't know what to do next, I asked her what she thought was wrong. She knew exactly, and tearfully told me all about it:

"Soon it will be my 6oth wedding anniversary, and my family is having a big party for us. But I don't deserve it! I had sexual relations with a man before my marriage, and now GOD is punishing me with a sinner's disease. Everyone will find out!"

I tested her for CG and syphilis and presented her with copies of the negative results. We talked for a long while about childhood mistakes and how we had the rest of our lives to make up for them. I assured her that she had done just that-and more-by being a good wife, mother, and member of the community. Then I recommended warm baths each night, followed by a new cream. Over the next few weeks, the itching resolved, the excoriations healed, and her mood improved. Her anniversary party, I hear, turned out to be a joyous event.

Making a rash diagnosis

One way or another, it's always helpful to know what happened to members of the patient's family. Recently, for example, a patient I'd been following for years showed up complaining of chest pain. He'd had bypass surgery four years earlier, and had been doing fine. As part of my exam, I did an ECG, and still nothing seemed to explain the pain he was experiencing now.

The I recalled having heard something about the untimely death of his 39-year-old son. "Yes, he died a month ago-he had a heart attack," my patient said, sobbing. That told me what I needed to know to gently steer the conversation to the anxieties he had been burned with.

A large part of my practice is geriatrics, and that means a lot of funny little aches and pains. Many things start out with funny little aches and pains, and their initial similarity can make them hard to nip in the bud.

One of my older patients suffers from chronic back pain, and one day it was worse than usual. She insisted on being seen that afternoon. My front-office assistant agreed to squeeze her in between appointments, and when she arrived I put on my osteoarthritis hat for her. I prescribed treatment as though her musculoskeletal problem was acting up.

She seemed to be relatively comfortable with my conclusions, but as she was standing up to leave, she turned suddenly and asked, "So you don't agree with my diagnosis?"

"What's that?" I exclaimed.

"Two years ago, you treated my sister for shingles, and this is exactly the way hers started."

It was plausible, but there was no rash yet. If it was shingles, the rash might not show up until Day Three, and this was only Day One. I sent her home with office samples of a herpes zoster medication, and told her to start it if the rash developed. And that's exactly what happened. Her intuition--and my willingness to listen-had spared her a return trip to my office and perhaps a delay in tackling the real problem.

One Friday afternoon five years ago, just as we were about to close the office for the weekend, another woman called me about her 18-year-old son's abdominal pains. Could we wait for her? She was certain it was appendicitis.

It was indeed, and we had him in the OR within an hour. "Why did you think it was appendicitis?" I asked her as the surgeon took over. "I saw a case just like this on a TV show," she said.

I remember that conversation vividly, not only because she was so definite about the problem, but also because she was right on the money. Postscript: The son is now a regular patient of mine.

Yes, I know-sometimes you'll startle or confuse the patient if you ask what's wrong. You may get, "You tell me. You're the doctor." But along with all those great questions we learned in medical school, try adding my question for a change. I bet you'll be surprised, educated, or at least amused by the responses you get.