A Surprising Cause of Pain in a Patient with Cancer: A Case Discussion

As clinicians it is crucial that we are aware of our blinders. 

Sometimes the obvious cause of pain isn't the actual cause of pain and we need to be willing to look past our first impressions.

This week I discuss the case of one of my patients (de-identified of course). He had widely metastatic cancer and a pain that I couldn't control with medication. Come find out what worked to relieve his pain.

Celebrating the heart-centered healer that you are,

Delia Chiaramonte, MD
www.integrativepalliative.com

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Coping Courageously: A Heart-Centered Guide for Navigating a Loved One’s Illness Without Losing Yourself is available here: www.copingcourageously.com 

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Transcript

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Welcome to the Integrative Palliative Podcast, where we help physicians and other clinicians master the art of integrative symptom management so they can wholeheartedly care for themselves as they expertly care for their patients. Welcome to the podcast. I'm Dr. Caramonti. Today we're going to talk about a case. This was a patient of mine. He was a man in his 20s with a very bad cancer. And his cancer had spread widely and was in his bones in multiple places, and he had had a lot of pain. So he got sent to palliative care, outpatient palliative care, to work on his symptoms and also his coping. He was a really vibrant person. And before he got cancer, he had been a weightlifter and he played the guitar and he worked outside and he was just a really kind of a tough guy. He was lovely, lovely man, but he was a tough guy. And so when he first came, he had pain all over, and we worked on managing his pain, first without opiates, and then with opiates, and then higher doses of opiates, and then rotating opiates. And we got his pain from his widespread mets controlled. And he was also getting active immunotherapy and he was doing pretty well, actually. His lesions had reduced in size, his energy was coming back, he was doing some work, he was playing his guitar again, he had someone that he loved very much that he was spending time with. But he came in one day and he said, Gosh, Dr. C, my shoulder hurts so much. All the other places that I knew he had met were not hurting on his current dose of opiate and some adjunctive medications. But his shoulder, his right shoulder, was hurting him like crazy. And it was really impairing his quality of life because he liked to lift weights, he liked to work outside, he liked to be active and do things. And this pain was really impairing his ability to do the stuff that he liked. And this is a guy who had been pretty tough when he had clear cancer pain. So he had mets in his bones that we hadn't adequately controlled his pain from, and he was being pretty tough. So I was impressed that this pain must really be significant if it was impairing him from doing his regular activities. In thinking about what could it be? Well, let me back up. First, we just tried to raise his opiate. Okay, fine, we'll just go up and see if we can control it. And it didn't. And he started to get more side effects. He was getting very constipated, he was getting more sleepy, which he hadn't been before. But this pain was not going away despite these increasing side effects. I rotated his opiates again to see if that would work. And it did not work. And he still had his other Mets and they weren't hurting on his dose of opiate, but this shoulder was really bothering him. So I took a step back to say, all right, what is this? Let's think about what is this? Let's think about the obvious things first. Has he had an injury? Is there a dislocation or a fracture? Is there a tendon rupture? No. And then of course the other obvious is is there a new lesion, a new metastatic lesion in the shoulder? So we did an MRI of his shoulder, and no, there were none of those things. His shoulder looked normal, looked completely normal by MRI. No lesions, no injury, no mets, nothing. But it was really impairing his quality of life. So I took a step back again to say, all right, what could this be? Could this be central sensitization for some reason? Central sensitization, as a reminder, is when the nervous system turns up the sensitivity to pain. Usually it comes after a chronic pain condition or an injury or some reason that somebody has chronic pain that starts as a legitimate tissue issue, but then persists as a neurologic issue. So that didn't totally fit because he hadn't had known chronic pain in the shoulder before. But it crossed my mind, it should always, always cross our mind when we're thinking about someone who has persistent pain and we're not sure why. But someone who has central sensitization is often feeling very anxious about the pain, perhaps has an uncontrolled depression or an uncontrolled anxiety disorder in general. Maybe they might have allodynia, so when you touch it, it might be incredibly sensitive where, you know, they feel pain where you're just giving touch. But he didn't have any of those things. He wasn't feeling particularly anxious about this pain. He just wanted it to go away so he could live his life. And he had been meditating, listening to guided imagery recordings regularly. He was playing guitar, he was spending time outside. He felt happy with his life. Obviously, he wished he didn't have metastatic cancer, but he was happy in general. He had social support in his life. So I didn't feel like it was central sensitization. It wasn't a good match for that. So it wasn't an injury, it wasn't central sensitization, it wasn't a dislocation, it wasn't a tendon rupture. What on earth was causing so much pain that high doses of opiates were not controlling it. And so what was left in my mind is not what you would typically think of in a person coming to a palliative care clinic potentially with a very advanced cancer, but the next thing to think about was a myofascial dysfunction, meaning something going on with the muscles or the fascia around the shoulder. The thing that was so striking about this is that the medications, the opiates that were treating his metastatic cancer lesions were not enough to treat this shoulder pain. So even myself, you know, I'm I'm pretty facile with pain and with myofascial dysfunction. I would have thought that if you had myofascial dysfunction in your shoulder and you were on a boatload of opiates, that it would have taken care of it. But the fact is it did not. And so I thought, well, you know, let me send him to a myofascial expert. So I sent him to an osteopathic physician who had expertise in myofascial dysfunction. She treated his shoulder and the pain went away. Really? Really, his pain went away. And this was a pain that we had been trying to figure out for probably six weeks at least. And it completely transformed his ability to live his life. So most likely he injured it when he was either working outside, he did work with large machinery outside, or when he was lifting weights. So the reason I wanted to share this with you is that we sometimes have glasses on that restrict our vision about what might be happening with a patient. So this guy with widely metastatic cancer on tons of opiates, the first thing is not going to be to think that he has myofascial dysfunction and we should send him to somebody with expertise in the muscles and fascia, we're going to think it must be cancer related somehow. But it was not cancer related, and the meds we were using for his cancer pain didn't touch this. It was the manual medicine approach that made him better. And it markedly improved his quality of life. So the reason to talk about this case is just to remind ourselves, widen your gaze. If something isn't working right, if something isn't getting resolved that you think should be resolved when you're managing someone's symptoms, take a step back and think again, what could it be? And widen your gaze. Because even I, in the beginning, just was not thinking that this was really kind of a simple regular person pain that could be resolved with a manual approach. And the other thing that I think is a great learning point for all of us is that high doses of opiate did not fix this musculoskeletal pain. And so that's important for two reasons. One, if you have a patient who has a pain that is not cancer related and they're on opiates and the opiates aren't working to fix it, think about could this be a musculoskeletal pain? But then the other thing that's important for us to know is we we know this, but boy, we really probably should not be treating musculoskeletal myofascial dysfunction pain with opiates. Because for me, this was such a pure example because he was already on opiates for something else. There was clearly no drug-seeking behavior at all. I was happy to give him all the opiates in the world because of his metastatic cancer. And despite all that, it literally didn't work. It didn't work for this kind of pain. A manual approach is what worked for this type of pain. So who can you send a patient to if you think that they're having a myofascial dysfunction issue somewhere in their body that is causing them pain or dysfunction? So the ideal person, in my opinion, is an osteopathic physician, a DO, who has extra training in neuromusculoskeletal medicine. So they have a separate board that certifies people who have extra training, a fellowship in neuromusculoskeletal medicine. That would be an ideal person to send your patients to if you have such a person in your community. They will almost certainly be running a practice that highlights the fact that they do osteopathic manipulative medicine, OMM, or osteopathic manipulative treatment, OMT, same things, just two words to say the same thing. If you Google that, Google OMM in your community, you will probably find the people that are practicing that way. Another option is some chiropractors. So not all, but some chiropractors practice manual medicine. So if you call the chiropractor or look on their website, if you call them and say, do you practice manual medicine? Some will say, Oh, absolutely, that's a big part of my practice. That would be somebody that I would consider sending a patient to. If they don't know what you're talking about, then no. Some physical therapists have expertise in myofascial dysfunction and some do not. I wouldn't send somebody to just a generic post-op physical therapy practice. You're less likely to get somebody there who's really facile with myofascial dysfunction. So that's the word that you can use. You could call up a place and say, do you guys do work on myofascial dysfunction? And if they say, oh, absolutely, then that would be a place. If they say, well, you know, we have exercises, then maybe I wouldn't send the person there. So it's really a good idea in your community to find a person or two, either an osteopathic physician with extra training, or a chiropractor who handles myofascial dysfunction, or a physical therapist who handles myofascial dysfunction. There are massage therapists who have expertise also in this area, and they can absolutely be a really important contributor to the team and helping a person who has myofascial dysfunction. So it's a good idea to have ideally, if you can find a DO plus a chiropractor, plus a physical therapist, plus a massage therapist in your community, then you can have a place to send a patient when you get a vibe of, oh, you know what, maybe that's what this is. So for this patient, at that time in his life, the most important person for improving his quality of life was that manual medicine physician. Without her, he couldn't have done all the things that were important to him. It was even getting hard for him to play his guitar just because of how you have to hold your body. And so the things he really cared about, which were guitar lifting weights and working outside, he couldn't do any of those things. And his time on earth was short. Those were really important things. So having that resource to send him to was more important than all the medicines that we had, honestly. So that's why I wanted to share it with you. Everybody was shocked that that was what got him better. So keep it in mind. If you see a patient who has pain that you can't control, just always run it through your mind. Could this be myofascial dysfunction? And hopefully you will have already looked in your community and have in your back pocket the people that you can refer to. And that is Integrative Palliative Care. Thanks so much for being here, you guys. I'll see you next week. Bye-bye. This podcast is brought to you by the Integrative Palliative Institute. 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