The Weaker Half

No, this article is not about my place in my home. Recently, a patient presented to my office two weeks prior to hip-replacement surgery. He had suffered left hip pain for more than four years with no resolution, even after many therapies, adjustments, shots, medications and exercises. He came limping into the office with a walker and was in obvious major distress. Although he was rather advanced in years, you could tell just by looking at him there was still a strong man behind all that pain.

He was referred to me by another doc with the hope that we could maybe add something to the puzzle before his surgery. The patient came in, understandably, replete with a plethora of tests, exams and reports, all filled with interesting theories and possible solutions.

The interesting thing about the films was that they looked pretty darn good. There wasn't much degeneration of the hip on the X-ray, and the MRI of the hip and low back was essentially unremarkable. Yet, due to his pain, he was about to have (and was looking forward to) a total hip replacement in 15 days.

Down he went on the table, and out came the tools and toys of my office. Sensory examination revealed a generalized decreased perception to both pinprick and vibration on the right side. The loss was not just of the lower extremity, but of the upper extremity as well. I did some muscle testing and darned if his injured left side was strong in all positions, although painful on testing. When I went to test the muscles on his right side, though, there was nothing there. At best we could grade his muscles on the right side, on both the upper and lower extremities, as 4/5. His right side, to his great bewilderment and confusion, was his "good" side, so "why the heck was it weak?" he wanted to know. Lucky for me (and him), I had seen this type of scenario before and knew what I was looking at neurologically.

The body, in its infinite wisdom, always looks to achieve balance. Whether it's an aberrant vestibular system, an unbalanced musculature system or a dysfunctional respiratory system, the body will make physiological changes to attempt to normalize a deteriorating structure. Whatever we choose to call it, there is definitely "wisdom" behind our function that is striving for health and longevity.

This is my theory: When presented with a hypotonic side (whether because of cerebellar dysfunction due to a hemispheric imbalance or some other reflexogenic response), the body still will try, as will the patient, to maintain normal levels of movement and activity. After all, if we had not moved throughout evolution, we would not have survived - plain and simple. Based on the fact that we now have a side of decreased firing frequency, the body will now compensate with an increased firing of the good side. This is the example I give my patients: If you abduct your arm, your deltoid will contract and you can raise your arm to the side. This is a normal functioning muscular system. Now, if you do the same movement, but keep the arm abducted without lowering it, what will happen? You will start to have severe pain, of course. Why? The constantly contracted muscle is forced to go through glycolytic pathways due to the paucity of oxygen, such that the lactic acid (or hydrogen ions, whichever theory we currently are adhering to) will produce pain and the arm will need to be lowered and rested to allow clearing of byproducts. This also is a normal functioning system. Although the pain can be substantial, the simple act of lowering the arm and allowing it to rest and clear the chemicals will, most times, be enough to eliminate the pain rather quickly.

Now let's extrapolate this to our patient. He had spent years in constant, unremitting pain of the left hip. He had been adjusted, massaged, stretched, needled and Lord knows what else, all on that left side. Upon examination, though, it was evident that his hypotonic state was of the right side. The treatment protocol in his case was to leave that left side alone. We did not touch it, except for some very light effleurage to stimulate clearance of the pain-producing chemicals from his normal left hip. Treatment was directed to his right side only, with aggressive adjusting and stimulation of the right hip; a TENS unit application at home to fire up those muscles and promote a cerebellar response on the right side; and exercises and muscle-balance work to the right side. His first visit showed some promise, but still substantial pain. By the third visit he was 90 percent pain-free, and was discharged after the fourth visit.

He obviously never had his hip surgery on that left side. I do not see him often, due to the fact that he came to see me from Brazil. Still, he remains well and has really not needed much follow-up since his initial treatment. I have seen this scenario repeated over and over in many different patterns. The bottom line is to always assess what is there, not just the symptoms. I know we know this instinctively, and yet it's a great challenge not to try to fix the painful side, even when the painful side is not the true source of the pain.

For those of you who have followed my previous articles, I also have discussed RSD (reflex sympathetic dystrophy). The treatment for RSD also happens to be an opposite-side approach. The scenarios here are different neurophysiologically, although the presentation may be similar. RSD can affect any area or multiple areas and is vascular-based through the IML, whereas this muscle-balancing dysfunction seems to be more hypotonically based through the cerebellum. We will see weakness and sensory findings on the opposite side that usually are not present in the RSD case. This becomes important because the central ramifications of the adjustments one performs will vary based on the central area of effect we are looking for. In other words, the adjustment will vary whether we are focusing on ipsilateral cerebellum or the contralateral cord. This can be food for thought for a subsequent article, if anyone is interested.

Regardless, always assess both sides when dealing with a particularly stubborn hip or leg pain. You may be surprised at what you find. As always, any questions can be directed to me via e-mail.