First, I want to know what the client has to say. Not a simple selection of a happy or sad face on a lleon a chart.
In 2016 we were commissioned to create two documentaries.
One on Case Management and the second on Bullying.
Pathology for Lady 3
One on Case Management and the second on Bullying.
Pathology for Lady 3
Lady 3 was is a very pleasant 60-year-old, right-handed, Caucasian, female who presents with a complaint of what she describes by her, "trigeminal neuralgia".
Her therapist told me a previous health care professional told her she had trigeminal neuralgia.
Her medical history shows a slip and fall from the side of a mountain which occurred approximately 4 and half years prior while hiking in her home state.
Lady 3 stated she had hired a person to assist her on the hike. She reported the person went off on their own and did not help her after the fall.
She reports that she struck the back of her head and both sides of her head but did not lose consciousness. She appears to be able to recall most of the details of the event.
Lady 3 states that she ambulated home and did not seek medical attention at that time.
She was subsequently seen by a neurologist approximately 3 months after the event secondary to complaint of headache, but was cleared and required no medical intervention.
She reports that she was able to hike for approximately one year before she began to experience head and neck pain.
She was then seen by a Chiropractor.
She was referred to my office approximately 3 years from the date she last saw the Chiropractor. She had feelings of feeling general malaise toward the Chiropractor.
Her primary doctor drove her to my office where she reported the following.
She stated the Chiropractor first treated her with a "drop table" before treating her with a spring-loaded tapping device.
She also stated the chiropractor came from behind her unexpectedly and used the device two times.
She claims the onset of this pain was immediately following chiropractic intervention with the spring-loaded tapping device.
This device is commonly used by Chiropractors as a quick, low-force impulse to spinal joints with the goal of restoring motion to a targeted joint.
A potential explanation for the delayed pain “may” have been;
There is the possibility that Lady 3 could have sustained injury from the accident that did not manifest until the pain was triggered a year later with a head or body movement or the tapping device.
The referring doctor brought Lady 3 to my office in San Diego, California.
She had heard about my technology and wanted me to use it with her patient.
Lady 3 displayed continuous shaking as one with Parkinson’s. I was told by the referring doctor and her patient this was a reaction to the lithium she was on.
While reviewing the doctor’s information, Lady 3 fell to the floor shaking legs, arms torso and head. I asked her doctor what caused it. She told me her medical records called it emotional.
Were her actions emotional or could this have been triggered by seizure or some other challenge. I couldn’t get an answer that provided support.
There are a variety of tests that can be run that lead to a proper diagnosis of emotional challenges. These tests are usually performed by a Neurologist. I referred her to a Neurologist at Grossmont Hospital for testing and consult.
I asked Lady 3 if she had gone to or been taken to ER during or following one of these attacks.
She answered yes but followed that by telling me they would make her wait for prolonged periods of time and never took her seriously.
I asked her to call me next time she was sent or went to ER and I would meet her there.
I met her in ER about a week later.
She was setting in the waiting room of ER crying with the pain.
I asked her why she went to ER. She told me the pain was unbearable. I asked her if she had the fell to the floor shaking. She said yes.
I spoke with the reception in the ER as to why she was sent to the waiting area am why she had been there so long. She told me Lady 3 said she had a headache.
I called Lady 3 to the reception desk and ask her to tell them what she told me. Again, she said it was a headache.
I explained to the supervisor how she fell hitting herself in the back of the head and on both temporals. I explained her shaking and falling.
They took her right in.
Lesson learned: Emergency Rooms take the worst cases first. A headache is subjective pain most often treated effectively with OTC drugs.
While I sat with her inside the treatment area, she started shaking violently and fell to the floor.
The nurse started lightly nudging Lady 3 with her foot her telling her to get up and stop acting like that.
She finally got a shot for her pain and I drove her home as I didn't want her driving in her present state of mind.
Communications between Doctors and Therapists
At the time Lady 3 was referred to me, she was currently seeing a number of other doctors, therapists, a NUCCA Chiropractor, an acupuncturist and naturopathic practitioners. There were no communications between her practitioners.
When you have five or more practitioners working on a single issue, you need communications and coordination between the doctors.
Never assume each doctor's notes magically show up in a common place where they are automatically updated on your current condition. There are HIPPA requirements that each medical doctor must follow. Sharing information is forbidden without the patients written approval.
There were no communications between the doctors so I asked Lady 3 to write a letter of introduction that would introduce me to her doctors and give them permission to share their information with me.
I set up meetings and conference calls with each. I wanted to know what each practitioner is doing to determine her injuries, root causes of her pain and what they were doing to help reduce or eliminate Lady 3’s pain.
I wanted to know who has scans (MRI, MRA, CAT, PET, SPECT, EEG etc.) and how we can use our combined professional talents together to form a comprehensive team with one common goal.
Lady 3's handwriting was challenged but she did put me on the telephone with some of her doctors and therapists.
Only one of the medical doctors had ran tests which included a comprehensive blood test and I found where an MRI had been taken.
I could not fine where any of the doctors I spoke to gave her the diagnosis of trigeminal neuralgia.
There are a variety of tests that can be run that lead to a proper diagnosis of emotional challenges. These tests can be done by a neurologist.
I ask what type of testing had been done to prove the emotional behavior.
I set up a personal meeting with the head of neurology at the hospital that had ran her previous MRI. That will be discussed in the next section.
I asked to see copies of her medical report and MRI report and noticed it was labeled unremarkable. All future references were stating Emotional.
The MRI had come back unremarkable meaning the radiologist is saying that the study or finding is either “normal” or has abnormalities that are of no significance to the patient in that situation.
My next question was, if the pain is emotional, why wasn’t she referred to a psychiatrist or a psychologist who could help her with the emotional challenges.
Mapping Lady 3’s Pain
Without documentation suggesting trigeminal neuralgia diagnosis, I worked with this as a pain management issue until I could find additional support regarding injury during the fall or from the previous Chiropractor. I wanted to speak with the Chiropractor to get his thoughts of her statements regarding the use of the spring-loaded device.
I was hoping to speak to the chiropractor to see if he had any x-rays or other images. I asked Lady 3 to obtain permission for me to speak with the Chiropractor and she later told me he did not return her calls.
Even with permission to speak to me, the Chiropractor did not return my calls, nor the calls from Lady 3.
I asked Lady 3 to trace with her finger the area where the Chiropractor used the spring-loaded tamping device. She pointed to area “A” and “B” in the reference charts.
Part 2: Identifying Pain (Emotional vs. Physical) and its behavior
Lady 3 frequently complained about the burning, searing pain in her face.
Atypical facial pain (ATF) is at times accompanied with burning and continuous in nature, and may last for many years.
Terms Lady 3 used to describe the pain
When I would ask Lady 3 to describe the pain, she would use terms she could identify with such as “It feels like fish sloshing in my veins radiating the pain in these areas” as she would trace the areas with her finger.
She would use other descriptions such as “It feels like someone is dragging thrones across this area” as she would trace that area with her finger on her face and scalp.
At times, she would tell me the pain was so severe she could smell the burning.
The areas Lady 3 traced followed the pathways of the facial trigeminal nerve pathways through V1, V2 and V3 with great detail.
Part 3: Identifying Pain
As I mention in the graphic above, pain is subjective.
Two people suffering from the exact illness and pain may show completely different numbers on the pain scale. In other words, one person and have no additional challenges with pain another person with the same pain symptoms are complaining of major pain from a variety of additional symptoms.\Electroencephalogram (EEG)
An electroencephalogram (EEG) can be utilized to detect electrical activity in your brain and body by applying small electrodes attached to your scalp or body.
The brain and body communicates via electrical impulses that are active all the time, even when you're asleep. This activity shows up as wave (or frequency) peaks on an EEG recording.
(www.mayoclinic.org/tests-procedures/eeg/basics/definition/prc-20014093) Pain can be brought on by emotional events as well as injury. This type device is utilized by hundreds of universities, hospitals, and research centers to utilize these solutions for measuring health, performance, and behavior.
The electroencephalogram supports the following signals.
Electrophysiological Peripheral (Q)EEG GSR/ Skin Conductance sEMG Temperature ECG Blood volume pulse EOG HRV SCP Respiration ERP Sp02 P300 Force Accelerometry EEG
Electroencephalogram (EEG / qEEG) Training
I received two Certifications in training and application utilizing the electroencephalogram (EEG / qEEG.) One in Biofeedback, the second in Neurofeedback.
The training I attended is approved by the American Psychological Association to sponsor continuing education for psychologists.
My first challenge was to attempt to reduce the pain.
I use a duel approach to review pain.
First, I want to know what the client has to say. Not a simple selection of a happy or sad face on a laminated chart.
I have the client describe to me how, when and where they get their first hint of pain. I ask them to describe th behavior of the pain. Is it a tingle or a jab sensation and where it did they feel it, how long between the timing of the first tingle until the pain manifested and where it manifested. What were they dong when the pain started, etc. Did they experience an anxiety attack, in incident, an accident? Was there peaks of high stress? Was there movement in muscle groups?
Second, I use a special software program I designed and had developed which measures 7 measurable elements of pain in qualitative and quantitative recordings. I run this software through a electroencephalogram (q)EEG on key areas of the scalp and body.
These recordings compare measurements between location of pain and matching with areas of similar activity in supporting areas of the brain. Nerve or pain response usually shows in behaviors and patterns and often it can be mapped and matched.
Emotional Pain and Physical Pain have different fingerprints making it easier to determine which is showing on the monitor.
While running the assessments, I utilize the data received from the output to determine a signal set that would help reduce the pain.
I deliver these signals digitally, embedded in relaxing, soothing music.
The challenge is Lady 3 was unable to listen to any type of sound nor could she handle the pain of anything touching her head.
I had to reprogram the signals to perform above and below the hearing range and find a different delivery method for the signals
Lady 3’s referring health care practitioner, and myself were able to watch the intensity of the pain reduction. Lady 3 was in front of the monitor and could not see the activity on the computer screen.
To verify, Lady 3 would tell us when the pain was diminishing. This helped us verify how well the signals were working and how I needed to adjust the signals that were needed to perform more efficiently. Lady 3 would keep us informed to any improvement or lack of improvement. Here tremors would often diminish or stop during the protocol.
Lady 3 responded quickly, and according to the client and the reading from the assessment, a great amount of the pain was temporarily reduced from the skull and back of head by as much as 68.3%.
This procedure does not remove or resolve the root of the challenge. It only brings temporary relief while we work to locate the root of the problem.
This was the first time the client had even temporary relief from the pain and would come to the office almost daily for pain relief.
With Lady 3’s permission, we were able to obtain Lady 3’s medical records, including MRI / MRA and Other Available Imaging Hospital Diagnosis and the MRI.
According to the hospital that ran the MRI, nothing conclusive was obtained from the MRI.
The radiologist is saying that the study or findings were unremarkable, meaning her conditions were considered either “normal” or has abnormalities that are of no significance to the patient in that situation. The report said Lady 3’s pain was emotional.
Studies have shown that chronic pain may be caused by physical injury and can also be caused by stress and emotional issues.
Pain is real regardless if it is emotional based or physical based. The good news is, Emotional Pain and Physical Pain have different fingerprints.
Tools Utilized Making the Emotional Diagnosis
Magnetic Resonance Imaging (MRI)
An MRI is a noninvasive medical test that physicians use to assist in making and diagnosing medical conditions.
An MRI uses a powerful magnetic field, radio frequency pulses and a computer to produce detailed pictures of organs, soft tissues, bone and virtually all other internal body structures. (Source: https://www.radiologyinfo.org/en/info.cfm?pg=bodymr)
Lady 3 told me of a neurologist in Montana that prescribed an MRI. I asked her to contact the doctor and have him send a copy. I never received copies from the doctor in Montana.
Visit to Hospital Neurologist
To get a better understanding of the MRI from the hospital where the MRI was taken. I scheduled time with the hospital Neurosurgeon, a highly respected neurologist in San Diego.
The purpose of this discussion was to review the MRI, discuss the emotional diagnosis, review pain scores, see what medical options would reduce or eliminate the type of pain Lady 3 was experiencing.
Please allow me to say I have utmost respect for this neurologist. He is very thorough and precise.
Together we looked at the MRI. He asked me to show him what I see that he doesn't. There was nothing on the MRI to show a challenge.
My problem is,
It pays to know what you are looking for when tit comes to brain trauma.
In this case, why are we taking the MRI if the area hit isn’t showing up on the MRI?
What do we want learn from this MRI?
Do we want to do another MRI that gets us a better view of the brain stem?
Most importantly, someone should have asked where the patient hit her head. That might be a good place to start.
Was this a routine ten minute MRI with no goal or thought put into it?
The conversation led to the pro's and con's of nerve blocks and devices that could be surgically implanted to help eliminate pain.
We made no new inroads from the visit.
Neither the neurologist nor I could see anything of substance on the original MRI taken at the hospital.
Reviewing the MRI
When we returned to my office, my thoughts were;
the neurologist I had met with is one of the best neurologists in San Diego.
I greatly value his judgement.
He reviewed the MRI with Lady 3 and could not see anything obvious beyond emotional.
The duration of the procedures (the time it takes to do an MRI) can vary but the average time is 45 minutes to one hour. The images are taken in sets lasting up to 15 minutes for each set. https://radiology.ucsf.edu/patient-care/prepare/mri
Lady 3 told me the MRI the hospital had taken was completed in about ten minutes which is rather abbreviated considering the time it takes to run a single set.
After reviewing the hospital MRI, they were right. The information provided did not give detail of the areas Lady 3 had hit her head.
Part 4: Planning for the New MRI
When you do any procedure, it is imperative you have a plan. You have to know
Answer these questions and you can create a request that will point you in the correct direction. Now, we can plan your MRI, MRA, X-Ray PET, SPECT, CAT etc.
When you want to take a picture of your garden, don’t take a picture of your neighbor’s house. It helps if your garden is in the picture.
Where was the Hospital plan for the MRI?
If you don’t know where you are going, any road will get you there.
The ideal situation is to get an image of the correct area and have great clarity of image.
The image quality of the MRI is continuing to improve.
The image quality of an MRI depends on signal and field strength.
The Hospital took Lady 3’s MRI on a 1X Tesla machine. At the time they ran the MRI, newer models of the MRI machine was available. These models were in 3x range. The 3X Tesla machine has a much improved signal than a 1X Tesla machine. The 3X Tesla images can provide a much clearer, vivid image and can often be done faster, decreasing overall scan time.
A newer unit, the 5x Tesla is available at certain research centers but not in general use at the time we were working Lady 3’s case. The graphic below is from Shields MRI website explaining the difference in definition and resolution of the 1x Tesla and the 3x Tesla.
Part 5: Pathology Potentials
Re-creating the accident.
When Lady 3 would trace her pain, she would always point to the ganglion and track the pain across her facial nerves, including the occipital and parietal lobes.
(1) She would describe the hit to the back of her head and describe the pain.
(2) She would point to an area around her ears and describe and trace the pain with her finger.
(3) She would describe the smell and burning in her mouth.
Lady 3 decided to have nerve blocks.
The doctor that we interviewed had suggested cutting the nerve in order to stop the pain. The challenge was, that nerve runs throughout the facial nerves, the gums, jaw, scalp and neck. Lady 3 chose to have nerve blocks hoping it would numb the pain. However, between one and three months then she would need another.
The only doctor to have a real handle on her pain was her pain doctor. He and I invested a lot of time reviewing her pathology.
In a staff meeting with our team, we decided to request a new MRI. We decided on how to write the instructions for the MRI.
One common thread to the areas she would track as she would describe her pain and trace with her finger.
It would always take us back to the Parietal and Occipital lobes and facial nerves. We considered her facial movement, the supraorbital nerve and the supratrochlear nerve. See Image 1 above.
I needed to know what was going on with the trigeminal and any other challenge that would mimic the trigeminal neuralgia.
Some of these challenges include:
We looked at the fall she experienced, where she hit and how she hit.
Lady 3 explained 1. she landed on her buttocks, 2. immediately slammed the back of her head into the rock 3. hit her head on each side with force.
We took our attention to the potential impact areas of the fall.
We labeled the model then considered what organs, vessels, skull and brain-stem could have been involved in the fall and how they could have been affected by the behavior and intensity of the fall.
Considering Lady 3 had hit her head in the back, my hypothesis was the major impact was her neck.
The Brain Stem.
A hit to the neck could have affected the brain-stem therefore challenging related bodily functions and behaviors.
We had to consider the medulla oblongata. The medulla oblongata helps regulate breathing, heart and blood vessel function, digestion, sneezing, and swallowing.
This part of the brain is a center for respiration and circulation. Sensory and motor neurons (nerve cells) from the forebrain and midbrain travel through the medulla.
These challenges were not an issue on her doctor’s assessments.
The Pons made more sense as the Trigeminal nerve has two ports in the pons.
Had she hit the medulla with such force, chances are she would have died since the medulla controls much of the automatic processes.
At that point, our attention became very focused on the Pons.
The graphic to the left will show the trigeminal gateways on either side of the pons.
Part 6: Delayed Pain or New Injury
This area also coincides with the place she was struck with the spring-loaded device by the chiropractor. (See areas marked “A” and “B” in Image 1.0)
We decided to have the order an MRI and an MRA prepared for the following reasons. We selected the following locations for a new MRI
1. Lady 3 would always trace areas V1, V2 and V3 when showing me the areas of pain. The areas Lady 3 was struck with a spring-loaded tamping device were V1 and V3, labeled as “A” and “B” as shown in Appendix A / Image 1.
2. Nervous system injuries such as traumatic brain injury (TBI) as well as stroke can be debilitating to the injured party.
3. What do her symptoms mimic? In other words, what other than trigeminal neuralgia could her symptoms represent?
Her other medical doctors and health care professionals were looking at her blood, neuro chemicals, acupuncture, massage, and psychologist consultations.
Since the imaging did not include the location(s) where she hit her head, nor the areas where she was experiencing the pain I decided to ask for an MRI and an MRA. I got the prescription with the special instructions I requested written on it.
An MRA can find problems with the blood vessels that may be causing reduced blood flow such as a bulge (aneurysm), clot or buildup of fat and calcium deposits, (stenosis caused by plaque) in the blood vessels, blood flow and the condition of the blood vessel walls can be seen.
Therefore, obtaining an MRI and an MRA would give us a comprehensive information that would give us direction regarding arterial damage.
I wanted a 3x Tesla or better and specific instructions for the areas of injury were included in the instructions and prescription for the MRI and the MRA.
We found a 3.5 Tesla in near the client's home which also happened to be one floor below the offices of one of our medical doctor’s.
This particular imaging center has long history serving our regional medical community and were highly recommended to us.
I hand carried the prescription to the imaging center and reviewed the special instructions with the radiologist.
I picked up the images and immediately found challenges as they did not contain the areas requested on the prescription.
The Radiologist and I had a very animated discussion in the hallway.
His supervisor came out asking if she could be of assistance. I showed her the order and I showed her what we had just received.
She told me she would do it herself and she came back with the correct imaging.
There it was, a lesion in the Pons near the gateways to the trigeminal nerves.
Armed with the new evidence, I scheduled her with the University neurologist.
These results are excerpts from the Neurologist report which is on file at the BT offices.
Patient presents with complaint of facial pain which exists in all 3 divisions of the trigeminal nerve bilaterally but also includes posterior areas of the scalp which are not innervated by the trigeminal nerve.
Although she uses the term, "trigeminal neuralgia", liberally throughout my encounter with her today her presentation as far more consistent with that of atypical facial pain. No spasm is noted.
The only radiographic findings which might correlate with her complaints is that of a central pontine lesion for which there is a fairly broad differential including, but not limited to:
Given the extremely high risk of biopsying such a lesion no definitive histologic data can be readily acquired. Therefore, the best option for her, at this time, would be to remain on-an MRI surveillance program with the next MRI to be acquired with and without gadolinium contrast in approximately 6 months. I have advised her to return to see me at that time with those studies in hand.
We scheduled the follow-up appointment with Loma Linda, and the follow-u