Case Study: Patient With Pain in a Paralyzed Limb

J.B. was in a car accident 26 years ago and is paraplegic secondary to a traumatic fracture in his thoracic spine. He has minimal sensation of both legs, with a bit more on the left side, and slight movement of both legs, again more on the left than the right. This is suggestive, of course, of an incomplete lesion of the spinal cord, although he is incontinent and reliant on his wheelchair, with no ability to walk. J.B.'s story, rough as it is, gets worse: He suffers from chronic, consistent, shooting pains in his legs, primarily on the right side, and nothing, including heavy medications, has eased his pain. In addition to the medications, J.B. has received physical therapy, adjustments, acupuncture and hypnosis, generally with little to no results. He was referred to me by his chiropractor in the hopes that he could experience some (or as J.B. said himself, "any!") relief.

To experience leg pain in an essentially paralyzed limb; we can easily understand how frustrating this situation could be for the suffering patient who feels pain in a non-functioning body part. We can also be overwhelmed clinically because, really, where do you start with a case such as this? Many of us, honestly, would "pop and pray" (I know I would have), hoping that a good chiropractic adjustment would have a positive effect, even if we did not completely understand why.

If the adjustment had worked, would we have explained our success as having uncompressed a "pinched nerve"? The mechanism would not be likely, considering the spinal cord lesion would supersede any local area of possible compression. J.B. had been adjusted dozens of times throughout the years, by his own estimation, so clearly the adjustment in and of itself was not enough to affect his symptoms.

This is the literal manifestation of my previous discussion on "Pain in the Brain" (Part 1 and Part 2), in which I spoke of the central realization of pain, specifically the alternative concepts related to phantom pain in amputated limbs or, as in J.B.'s case, paralyzed limbs. To summarize the premise of those papers, pain is, regardless of the stimulus (or lack thereof), a cortical event that can be affected by emotional states, chemical states and both afferent and efferent bombardments into and out of the cortex. In other words, we don't just feel a pain; we experience it with all its ramifications.

For any of us, I believe such a case as J.B.'s could be very difficult if, without any prior experience, we had to figure out where to start. Whether the patient is in a coma or has ankle pain, I believe we should have a consistent approach to any case that presents before us. With that in mind, I started his examination like I do with all my patients: At the top, and then worked my way down. Obviously, due to J.B.'s limitations functionally, some of the exam was minimized, but keep in mind that neurological systems are neurological systems and the evaluation of the body should always be consistent, with allowances made based on individuality.

Due to the fact that pain is centrally mediated, a good cortical evaluation, with all that entails in chiropractic neurology (optokinetic testing, careful cranial nerve evaluation, right and left hemispheric evaluation, and assessment of integration, to name a few), were primary. All examination of J.B. proved to be within normal limits (not withstanding his condition, of course), except for a hemisphericity of the left cortex and a pyramidal weakness of the upper extremity on the right. Due to the fact that his symptoms were worse on his right side, the left hemisphericity became very important, in that I had to wonder if on some level, this cortical imbalance was affecting his central realization of pain. (Before bombarding me with e-mails, rest assured that I will address hemisphericity in detail in my next article.)

If there were weakness of the right pyramidal muscles (the extensors of the right hand, such as the triceps and wrist extensors), then perhaps there were other central areas being inhibited that could themselves be having an inhibitory affect on J.B.'s perception of pain in his paralyzed limbs. As demonstrated in V. S. Ramachandran's book Phantoms in the Brain, sometimes the brain will "produce" a pain response to try to ascertain functionality of a limb; it's as if the brain is "looking" for the limb.

Ramachandran had a brilliant answer to this: He made a mirrored box whereby the patient could, with the use of the mirror as an illusion, "trick" the brain into thinking that the amputated limb was still there. The pain, miraculously, minimized and was eliminated within a matter of weeks. Perhaps with J.B., the loss of afferent bombardment of his lower extremities produced some loss of cortical integration such that there was pain and lack of function, not from the injury, per se, but from lack of afferent and efferent bombardment.

The next step was to find what stimuli, if any, would bring his hemisphericity to "normal," or in his case, strengthen the weak muscles. After much trial and error, I found that a tuning fork on the right hip and some mild but active contraction of his right hip facilitated the upper extremity - thus, at the very least, ensuring that on some level cortical integration had increased.

J.B. told me straight out he thought this approach was "silly," but being out of options, he agreed to try it for one week. He was pleased (as was I, of course) to report the following visit that he had experienced the best week of the past 26 years with respect to his pain. Though still present, the level of intensity and the duration of the episodes of pain were greatly decreased. He was surprised, he admitted, but extremely grateful and looking forward to whatever "crazy" stuff I recommended next.

J.B. remains a work in progress, and each visit is different from the visit before. The stimulus is literally changing visit to visit, since, hopefully, his brain is changing visit to visit. His pain is mostly gone now (I have seen him four times as of this article's writing), and we are now working on central stimuli to increase muscle firing. His previously "paralyzed" abdominals are now starting to work again. This does not mean I will get him to walk again, of course. Some neurological lesions are beyond current science's ability to repair. We may, however, get back some neurological function which was apparently not "dead," but simply inhibited or "asleep." This possibility, beyond even the resolution of his pain, is what chiropractic neurology is about.