I came through Ohio State at the peak of Woody Hayes’ career and although I feel it really shouldn’t be necessary, I guess I should explain that he was their football coach.
Anyway, the Buckeyes had a string of fine teams known for a grinding ground game that was fundamental, predictable and largely unstoppable. When asked why he didn’t pass the ball Woody would always reply, “When you throw a pass three things can happen, and two of them are bad”.
The diagnosis of reflex sympathetic dystrophy syndrome (RSDS) is something I see occasionally and I’ve listened to a few clinicians speak of their extensive experience treating this in specialty clinics. The basic message is this: “We don’t know why some people get this and others don’t. We don’t know which modality (blocks, electrical stim, exercise, biofeedback and many more) to begin treatment with. And we don’t know if any form of intervention will make the patient better, worse or have no appreciable affect”.
Listening to this, I’ve come away feeling toward modality care for this problem precisely the same way Woody felt about throwing the ball.
Like Coach Hayes, I would describe myself as quite conservative in my approach to this game. To me, this means providing potentially harmless care and remaining rooted in the basic sciences and the laws of physics. Difficult clinical problems no longer tempt me to wander down the pathways of so-called “alternative” approaches where anecdotal evidence is used to justify theories that make no sense.
Seated in front of me at a recent RSDS course was a young, lean P.T. and athletic trainer in obvious discomfort. After about a half hour she was literally grasping the left side of her head with her right hand and passively sidebending her cervical region to the right while actively depressing the left scapula. Clearly she was trying to acquire some length where she felt shortened and painful. She admitted to me that this really did not relieve her and that any sitting quickly brought on symptoms.
What I found interesting about her were two simple things; her dress and her breathing pattern.
In a warm room she wore three layers including a coat fully buttoned, and I saw her shoulders rise with every inhalation.
I began to think about how this situation was fundamentally different than the severe cases of RSDS including the allodynia and trophic changes displayed on the screen during class. I don’t think it was. I say this because the literature on autonomic function makes it clear that the sympathetics are highly involved in the ordinary flow of body reactions. It also is evident that the instinct of fear when unacknowledged will maintain sympathetic flow beyond its required time. Until that is dealt with it will keep us rigid and cold. The young lady in front of me is not yet in the throes of RSDS, but an insult to such a system, even a mild one, could tip her into the cycle of more obvious dysfunction. It would be like watching a shade of pink become a shade of red.
It seems that modality care, especially in its more exotic forms, is as risky as taking a football and throwing it where the opposition might catch it.
I prefer a running game. By that I mean I grind it out with an insistence on regular, deep diaphragmatic breathing, external rotation and abduction of the hips to induce neural slackness, and movements requested by the patient instinctively that elicit warmth.
This isn’t fancy or dramatic but it is guaranteed to move the patient in the right direction and it is very difficult for the patient’s illness to defend against.
I think Woody would have liked it.
“Sustained Sympathicotonia” by Irvin Korr in NEUROBIOLOGIC MECHANISMS IN MANIPULATIVE THERAPY (Plenum Press)
“Persistent Pain and Underlying Processes” and “A Simple Test of Autonomic Balance” by Barrett L. Dorko, P.T. (copies available from the author)