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September 2012

musica requitur sequitur: songs that must be played in sequence

Pandora_logoSince my shoulder surgery 4 weeks ago, I've been spending a lot of time developing software and listening to Pandora. The pain meds (oxycodone & hydrocodone) put me in a bit of a brain fog, limiting the effective breadth and depth of my thinking (and doing), but a reasonably well-defined coding task seemed ideally suited to my power of concentration ... and I've always found listening to music while coding helps put & keep me in "the zone".

The Pandora fremium online music service has developed such an accurate model of my preferences over the past few weeks that I've upgraded to Pandora One. The annual subscription version of the service has eliminated commercials and increased the length of time I can listen per day, and eliminates the pause and prompt asking "Are you still listening?" if I don't interact regularly with the site.

The one annoyance that remains is that there are certain songs that I believe should never be played without also playing the song that immediately follows them on the original album / CD. This strikes me as the musical opposite of a non sequitur - examples of which are virally proliferating as we slog through the U.S. presidential election season - so I propose the following name for this phenomenon:

musica requitur sequitur

DarkSideOfTheMoonAmong the examples I've noted over the past week [update: now augmented with examples shared in comments]:

  • Sgt. Pepper's Lonely Hearts Club Band / With A Little Help From My Friends (Beatles, Sgt. Pepper's Lonely Hearts Club Band, 1967)
  • Falling In and Out of Love / Amie (Pure Prairie League, Bustin' Out, 1972)
  • On the Run / Breathe / Great Gig in the Sky (Pink Floyd, Dark Side of the Moon, 1973)
  • Any Colour You Like / Brain Damage / Eclipse (Pink Floyd, Dark Side of the Moon)
  • Happiest Days of Our Lives / Another Brick in the Wall Part 2 (Pink Floyd, The Wall, 1979; contributed by Eric)

I'm probably dating myself with these examples, and by my uncertainty about whether contemporary bands are producing songs that are intended to flow so naturally from one to the other. Perhaps it was solely or primarily a trend of the late 60s and early 70s.

I'll update the list with additional examples as I encounter them, and would welcome any other examples anyone is inclined to share in the comments.


Arthroscopic shoulder surgery: biceps tenodesis, but not rotator cuff tear repair

Prior blog posts I've written about experiences with health challenges appear to have been helpful to others facing similar challenges. The following is a partial historical recounting of some problems I've experienced with shoulder pain, and some of the medical treatments (including surgery) that have been contemplated or applied thus far. I am not a medical professional, and nothing herein should be construed as professional medical advice. I am simply recording my own experience, in case it is of benefit to others.

History of Present Illness

Rotatorcuff_Gray412Sometime in May, I noticed that my left shoulder was becoming increasingly painful, and its range of motion was gradually decreasing. I can't think of any particular event that triggered or exacerbated the pain, but it suspect the problem was impacted by the combination of a significant increase in stress and a significant decrease of exercise during that period. I generally tend to avoid seeking medical help for problems, but by the end of June, the pain was so intense that I finally decided to see a doctor.

Diagnosis

Orthowashington_smalllogoFor the diagnosis and treatment of past orthopedic problems, I've enjoyed great medical care and attentive service with the physicians and staff at OrthoWashington (in Kirkland, WA), so I scheduled an appointment with Dr. Jason Boyer. After the examination, he said I might have a rotator cuff tear, and I could either get a magnetic resonance imaging (MRI) test to confirm or disconfirm the hypothesis, or try physical therapy. Given that physical therapy successfully resolved a similar problem I had with my right shoulder about 10 years ago, I decided to pursue that route, hoping to avoid the expense of an MRI and a more invasive surgical intervention.

Physical Therapy, Round One

Olympicpt_logo_OPTFor the next 3 weeks, I worked with Julie Lampson at Olympic Physical Therapy in Bellevue (a block away from the company at which I've been consulting all summer). Julie and her colleagues were very helpful in teaching me exercises designed to increase the range of motion in my shoulder without increasing the pain. Julie also suggested some ergonomic improvements to my workstation - more supportive seating and an external monitor, to improve my posture during long hours of computer work - which the company was very supportive in accommodating. Despite these changes, and diligently practicing the shoulder and posture-improving exercises between sessions, the trend of decreased range of motion and increasing pain continued. Eventually, Julie recommended discontinuing further physical therapy until or unless my shoulder inflammation could be brought under control.

MRI

Orthowashington_mri2I had an MRI performed on July 31. On the positive side, OrthoWashington uses an open MRI machine rather than the machines with enclosed tubes into which I've been inserted during past MRI procedures. On the downside, it was a rather painful procedure. The 45-minute imaging process requiring my shoulder to be virtually locked down into a position that became uncomfortable within 10 minutes and painful within 20. I've had lots of opportunity to use the pain scale over the last several weeks, and I would rate my pain at a 5 by the time the test was done. Fortunately, applying ice immediately after the MRI brought my pain down to a 1 or 2 very quickly.

The evaluation of the MRI of "Coronal T1, T2 and STIR, sagittal T2, axial STIR and axial T2" reported the following findings [with links inserted by me]:

ROTATOR CUFF: There is a high-grade linear appearing partial-thickness articular sided tear at the anterior attachment site of the supraspinatus tendon. The tear measures approximately 8 mm in transverse diameter and represents partial-thickness articular sided avulsion of the tendon at the level of attachment to the anterior footprint. This tear appears high-grade in nature but some of the bursal sided fibers remain intact without evidence of a complete/full-thickness disruption. The subscapularis and teres minor tendons are intact.

MUSCLES: Cuff musculature is normal with no fatty atrophy or edema.

BICEPS: Normal in morphology and position. There is fluid within the tendon sheath suggesting mild tenosynovitis.

SUBACROMIAL / SUBDELTOID BURSA: Findings compatible with mild bursitis.

ACROMION / AC JOINT: The AC joint images normal alignment with no significant arthrosis. There is a type II acromium. No subacromial enthesiopathic spurring. No thickening of the coracoacromial ligament.

GLENOHUMERAL JOINT / LABRUM: There is a type II SLAP lesion with fluid signal extending into the substance of the superior labrum with undermining of the long head biceps anchor, reference images 8 and 9 of series 4592.

BONE MARROW: No occult fracture or bone contusion noted.

IMPRESSION:

  1. There is a focal high-grade partial-thickness articular sided avulsion of the supraspinatus tendon at the anterior attachment site.
  2. Findings are suspicious for a type II SLAP lesion.
  3. Mild subacromial subdeltoid bursitis.
  4. Mild tenosynovitis long head biceps tendon sheath. Long head biceps tendon is otherwise normal.
  5. Type II acromium is present which can be associated with the clinical syndrome of impingement. There are no subacromial enthesiopathic spurs noted.

Given that physical therapy had proved ineffective at resolving my current shoulder problem, Dr. Boyer recommended diagnostic operative arthroscopy to examine the left shoulder, with possible surgical intervention including biceps tenodesis (detaching the biceps tendon from the shoulder socket and reattaching it to the arm bone), supraspinatus rotator cuff repair and/or superior labrum anterior to posterior (aka SLAP) rotator cuff repair. I agreed, and we scheduled the surgery for August 16.

Surgery

During the pre-operative consultations, I informed the physicians and staff of two possibly pertinent aspects to the arthroscopic knee surgery I had in Illinois during 2002. The first occurred in the operating room, after the initial dose of anesthesia, when they asked me to count backwards from 100; as I proceeded through the 90s into the 80s, I could sense a bit of a scramble in the operating room, but I don't remember reaching the 70s, so the dose of anesthesia eventually achieved adequate levels and I drifted off to sleep. The second occurred in the post-operative recovery room, when I awoke to the most intense level of pain I've ever experienced; I've never experienced [intentional] torture, but I believe I got a small taste of just how mind-altering intense pain can be, prior to the installation of a morphine drip pump (which seemed to take an eternity at the time). What started out as a routine out-patient procedure turned into an overnight stay, but by the next day, the pain was being effectively managed.

Radiolab_PAIN_SCALE_web_long_imageThis time around, the physicians and staff were prepared, and I don't remember counting down beyond 95. I was later told that they ended up using approximately twice the amount of anesthesia that would typically be expected for a person of my size. In the post-operative recovery room, I again woke up to intense pain; if the pain immediately following knee surgery was a 10, I would rate the pain after shoulder surgery an 8; once again, the staff here seemed better prepared to respond to this development, although it still subjectively seemed like another interminable period of intense pain. Eventually, my pain was brought under control, and I was able to be discharged home. [Aside: I highly recommend the recent RadioLab episode, "Inside Ouch!", exploring the art & science of developing and applying pain scales.]

During the followup visit 4 days later, Dr. Boyer told me that during his initial arthroscopic examination of my shoulder, the rotator cuff tear did not appear as significant as the MRI report had earlier suggested, and did not exhibit any evidence of recent trauma (i.e., the tear had likely been there for quite some time). He also noticed that even under anesthesia, my shoulder was extremely stiff. Recovery time - and the delay of subsequent rehabilitative physical therapy - would have been significantly increased if he had proceeded to repair the rotator cuff. Given his concern about the onset or exacerbation of frozen shoulder syndrome, and the importance of getting my shoulder moving again as early as possible, he decided it would be best to perform the biceps tenodesis and forego the rotator cuff repair. FWIW, an article in the March 2011 issue of the Journal of Shoulder and Elbow Surgery, entitled Superior labral tears: repair versus biceps tenodesis [also available here], provides corroboration for this decision.

I'll include a few arthroscopic images below [clicking on any image will bring up a window of a larger version of the image]:

Scan 122530000 Scan 122530001 Scan 122530002 Scan 122530003
Scan 122530004 Scan 122530005 Scan 122530006 Scan 122530007
Scan 122530008 Scan 122530009 Scan 122530010 Scan 122530011

Recovery: Managing Pain via Medications [or, "better living through chemistry"]

For the first week after the operation, I was taking

I set an alarm to wake me up to take the Percocet every 4 hours for the first few days. Around day 4, I tried sleeping through the night after taking the Percocet at 10pm, and awoke to intense pain shortly after 4am, so I continued using an alarm to stay medicated on schedule. I also found the maximum recommended dose of stool softener was not effectively relieving my constipation (a common side effect of the Oxycodone), so I increased the dose by one tablet daily, but spread them out over the course of each day.

When I had my stitches removed approximately one week after surgery, I was told that taking Percocet every 4 hours was putting me at risk of Acetaminophen overdose, and so was advised to shift to taking the Percocet at most every 6 hours, and continue using Oxycodone as necessary to fill in any gaps.

During week 2, my prescription of Percocet ran out, and I started substituting Oxycodone and Acetaminophen. Toward the end of the week, I started experimenting with 1 (vs. 2) Oxycodone every 6 hours during the day (but continuing with 2 every 6 hours at night). My Naprosyn was also running low, so I started taking 3 Ibuprofen every 6 hours during the day, and Naprosyn only at night. Dr. Boyer had warned me that taking non-steroidal anti-inflammatory drugs (like Ibuprofen and Naprosyn) may prolong the bone-healing process, but I decided pain reduction was a higher priority.

During week 3, I scaled back my nighttime medication to 1 Oxycodone every 6 hours, and started taking 2 Vicodin (Hydrocodone + Acetaminophen) and 3 Ibuprofen every 6 hours during the day. After a few days, I downshifted to 1 Vicodin + 1 Acetaminophen (plus the 3 Ibuprofen) every 6 hours during the day. Now in week 4, I've eliminated all narcotics during the day, and am planning to substitute 1 Vicodin for the 1 Oxycodone at night, hopefully eliminating the narcotics altogether by the end of the week.

It feels good to emerge from the persistent though variable "brain fog" that has affected my thinking (and doing) over the past several weeks. My power of concentration was diminished, as was my ability (or willingness?) to think deeply or broadly on the scales I typically like operate on. I haven't felt very much like reading or writing prose (or poetry) ... but, oddly, I have felt very much like reading and writing computer code, and although I may be self-deluded, I believe I've been fairly effective in programming a fairly effective graphical user interface for labeling results returned by a search engine operating in the medical domain [about which I still hope to write more in the not-too-distant future].

ColPaCThroughout this period, I have also made use of non-pharmacological tools. I was - and still am - icing down my shoulder religiously for 30 minutes every 2 hours with an oversized ColPaC reusable cooling pack borrowed from a friend who had successfully worked through some shoulder problems of her own. I have also found the DenTek Triple Clean Floss Picks to very helpful in maintaining oral hygiene with one hand. I have been sleeping in a Barcalounger in my home office throughout this period, which provides more support and protection while my shoulder is somewhat vulnerable ... and has made my medication schedule less disruptive for my wife.

Mindfulness_meditation_for_pain_relief_coverAnd while I hope that my current bout with shoulder pain does not (or, ultimately, will not) qualify as chronic pain, I have found relief and respite in Jon Kabat-Zinn's audiobook on Mindfulness Meditation for Pain Relief: Guided Practices for Reclaiming Your Body and Your Life. The mind-body stress reduction program promotes awareness, attention to and acceptance of pain: tuning in to the body rather than attempting to distract the mind from what is going on in the body. I believe this approach is applicable to other challenges involving "undesirable" mind-body states (e.g., fear, anger or sadness), and hope to continue the practice(s) regardless of whether and when my shoulder pain subsides.

Physical Therapy, Round Two

FlexLogo1About 2 weeks after surgery, I resumed physical therapy. Due to my impending return to full-time teaching at University of Washington Bothell in the fall quarter, I decided to switch to Flex Physical Therapy, which is about a mile from campus. At Flex, I've been working with Camille Porter, and although I'm still only doing simple pendulum-style exercises, similar to what Julie at Olympic P/T had shown me, Camille has started maneuvering my shoulder through gentle stretches, and has helped me regain considerable range of motion during (and between) the three sessions I've had there so far.

Prognosis

It's still too early to tell how much range of motion I'll eventually recover in my shoulder. I also can't say for sure yet how much my pain has been reduced, although during the day, even without the aid of prescription pain medication, it seems relatively minimal (except when I'm pushing toward the edges of my range during exercise).

I've heard from numerous other people that the key to successful shoulder rehabilitation is dedication to the physical therapy exercises, and so I have been practicing 5-10 rounds throughout each day. I hope to maintain this dedication once the school year starts, though my past experience has been that many important things - that are not directly related to classes - tend to fall by the wayside once classes begin. Pain, however, is a powerful motivator, so I hope to continue making good progress on restoring full functionality of my shoulder.

I don't know if this problem - or my experience with it - is as interesting to others as other health challenges I've written about, e.g., platelet rich plasma (PRP) treatment for elbow tendonitis and radiotherapy and chemotherapy for anal cancer. If so, I'll post one or more updates in the future.