“Ignorance breeds monsters to fill up the vacancies of the soul that are unoccupied by the verities of knowledge.” — Horace Mann
It was a typical September morning eight years ago when co-author Jim Heafner woke up with his right arm swollen and painful. He was paintballing the day before and took a few close shots to his right forearm, which caused some bleeding during the subsequent paintball matches. He assumed he had an infection and went to his primary care doctor to have it addressed. Due to the amount of swelling and bluish hue of his skin, his nurse practitioner recommended he go to the emergency room immediately for a diagnostic ultrasound. The imaging quickly revealed a four-inch blood clot in his subclavian vein. Jim was immediately referred to a vascular specialist who diagnosed him with right Venous Thoracic Outlet Syndrome (vTOS). Despite pharmaceutical measures, the blood clot returned and within days, Jim was scheduled to undergo an 11-hour surgery which entailed a first rib resection, subclavian vein graft, A-V fistula, and removal of his anterior and middle scalene muscles. The surgery was a success and in the following months, Jim resumed all activities with minimal shoulder pain or discomfort. He continued to have mild swelling in his right arm because his body rejected the subclavian vein graft that was placed during the surgery. As his surgeon artistically explained, "Jim, imagine your veins are like a detailed network of roads. Your subclavian vein, the major highway for blood transport back to your heart, is permanently closed. Fortunately, your body has many side roads, which are known as collateral veins. Since the major highway is shut down, the collaterals will help return blood back to your heart. There will be a little traffic for some time, but the collateral veins will eventually be equipped to carry all the blood back to your heart."
Little did Jim know this story of veins and highways would be his first, but certainly not last encounter with a vivid analogy used to explain a complex medical scenario.
Fast forward five years....
Jim is now living in Boulder, Colorado, and has been experimenting with several new workout routines. One of these routines requires repetitive handstand movements. About two weeks into his new routine, he began to experience pain and swelling in his right medial elbow. The swelling felt remarkably similar to his blood clot five years prior. Additionally, in his outpatient physical therapy practice, he recently treated a woman with the same complaint of medial elbow symptoms. This woman was eventually diagnosed with a medial elbow blood clot. Needless to say, blood clots are something that have earned a spot in the forefront of Jim’s mind.
Jim’s mind was immediately flooded with the potential causes of the new onset of symptoms. Right arm pain, swelling, upper body tension…a detailed differential diagnosis streamed through his brain. Ultimately, it didn’t matter! He could come up with 50 diagnoses, but all would have led directly back to the scariest possibility: the return of a blood clot.
After speaking with his physical therapy colleagues, Jim was reminded that pain is an unpleasant sensory and emotional experience, unique to every individual, associated with actual or potential tissue damage. After a few basic physical examination tests, the medial elbow pain and sensation of inner-arm swelling revealed significant ulnar nerve tension. Jim was reminded that the central and peripheral nervous systems are continuous. Entrapment of the peripheral nervous system can have a wide array of symptoms, occasionally even mimicking vascular symptoms. As one colleague stated, “The nervous system is like a garden hose. The hose is your nerves and the grass, trees, bushes and yard furniture are your muscular, vascular, skeletal and lymphatic system. With your recent onset of overhead activity, the hose wasn’t moving freely through the complexities of the yard. This ultimately caused the hose to become tensioned or compressed, limiting the ability to water the grass.”
“Pain is a unpleasant sensory and emotional experience, unique to every individual, associated with actual or potential tissue damage.”
The clarity of his colleagues’ words resonated with Jim’s current state of pain. He felt immediate relief, less fear and greater confidence about his diagnosis. Despite Jim knowing that recurrent blood clots after a first rib resection are minimal, he was blinded by the sensory and emotional aspects of the potential damage. His history and personal experience led to thoughts and emotions that occupied the rational side of his brain. The line of thinking his brain deemed most logical was a direct route to his past experiences. The last time he had similar right arm symptoms, the result was a four-inch blood clot in his subclavian vein, three surgeries and six days in the hospital.
What’s most important (and not uncommon) is that it wasn’t a physical intervention that jump-started his recovery. Jim’s reduction in pain and quick recovery from this “scary” situation was driven by his colleagues’ ability to effectively communicate in a way that settled Jim’s nerves—no pun intended! After temporarily modifying his activity and performing light exercise, his symptoms were completely resolved. According to the International Association for the Study of Pain’s definition of pain, pain can be experienced when the brain determines threat from both sensory information and/or emotional information. In the brain, these sensory and emotional ingredients are swirled together and baked in an oven stoked by context, memories and expectations. The end product is a lived experience the brain creates in response to real or perceived damage in order to protect and survive. In this story, much of Jim’s pain was driven by fear. Jim feared the potential tissue damage and associated hardships he could have if another blood clot appeared. Once that fear was alleviated by his colleague, Jim’s brain perceived much less potential damage and reduced the protective response of pain production.
Pain is a Matter of Perception Think about the last time you cut your finger or stubbed your toe. These experiences have a very specific context which conjures up associated emotions and feelings. When you cut your finger, you likely remember the object that caused the cut: a knife, a piece of paper or a piece of loose wood.
“The same event is perceived differently by each person, and even differently by the same person in different points of their life.”
You may recall a particular smell in the room or even the background noise of the environment. You may recall the time of day, the weather, whether you’d cut that finger before, the amount of blood, the degree of pain you felt and more. Finally, you remember the outcome. Did this event affect your life in any way? All experiences—even seemingly small ones—are a sum total of your senses, thoughts, past experiences, expectations, beliefs and more. Each experience is intimately connected to the emotion and context of your actions. If you’re a construction worker, you may experience cuts on your hands each day, which may diminish the importance of a single event. If you’re a violinist, a cut to your finger may be a rare and frightening experience, one that could affect your stage performance and limit your ability to do your job. The moral of the story is: context matters! The same event is perceived differently by each person, and even differently by the same person in different points of their life.
Don’t Be Afraid of Thought Viruses Jim’s thought monsters blinded him from the truth of his situation. In healthcare, these thought monsters, or “thought viruses,” as they’ve come to be known, can linger deep in a patient’s psychology for months, years or even a lifetime. A thought virus is a negative or limiting belief that originates from spoken words, learned information and accepted social contexts. Oftentimes, a thought virus is a generalization or a misrepresentation that was once drawn from experience but is now inaccurate because of its separation from current context, as well as the individual’s evolution of knowledge and understanding. These implications are very often intensified when the seed of a thought virus is planted by an individual in a place of authority or perceived expertise. In Jim’s case, as well as the cases of many others, the thought viruses are often irrational and unfounded by truth.
“A thought virus is a negative or limiting belief that originates from spoken words, learned information and accepted social contexts.”
As health and wellness providers, you can see the impact of thought viruses manifested both internally and externally in a patient’s words, beliefs, expectations, fears and even movements. A common example seen by physical medicine and rehabilitation professionals is a patient who perseverates on a “disc herniation” or “degenerative disc disease” based on their magnetic resonance imaging (MRI) findings. The patient ruminates on these thoughts because the internet, society, medical professionals and close friends have told them at length and great detail about the “dangers” of disc herniations and the constant pain of degenerative disc disease. The patient verbalizes fear of the tissue changes in their body and consequently becomes afraid to move. They’ve seen pictures of bright red discs “tearing,” “pressing,” and “bulging” into the spinal cord. They’ve heard stories of discs that are collapsed and vertebrae that are bone on bone. However, the simple truth is that disc herniations are extremely common and disc degeneration begins as early as the third decade of life. Statistics show that in large samples of pain-free asymptomatic populations, you are actually far into the minority of you don’t have them. In fact, disc herniations are often not the source of one’s symptoms, but instead a concomitant finding of often unnecessary imaging.