Looking Beyond Where Pain Is Felt - Medical Frontiers | NHK WORLD-JAPAN - NHKニュース

A Japanese doctor takes an innovative approach to unexplained neck and shoulder pain. Treating nerves in the wrist or elbow can help. We look to new research for clues to where pain really begins.

Around 1 billion people worldwide are estimated to live with shoulder pain.

Roughly 200 million people suffer from neck pain.

Yet for some, the cause remains unknown - and treatment brings little relief.

When I raise my arm, it hurts around here in my right shoulder.

by targeting nerves somewhere else entirely: the wrist or elbow.

The pain in my fingers is gone, and I can raise my arm. I was amazed.

This patient's shoulder pain made it difficult for him to raise his right arm fully.

It's gotten so much better. I'm glad I had the operation.

The results have been published in a US medical journal, raising hopes for a new treatment option.

And technology being developed in Japan is making previously hidden nerve activity visible.

looking beyond where the pain is felt, to uncover where the pain really comes from.

Many people suffer from neck or shoulder pain.

In some cases, compressed or damaged nerves are the cause.

But examinations of nerves in those areas do not always reveal abnormalities.

This can make it difficult to determine a course of treatment.

Hand and arm specialist Hagiwara Yusuke sees nearly 3,000 patients from across Japan every year.

It feels like something is pulling on my left shoulder.

When you tilt your head to the side, you feel a tugging sensation?

This man has severe pain extending from the left side of his neck to his shoulder.

But rather than examining this area, Hagiwara focuses on the hand and elbow.

I'm going to examine you now. Does this hurt?

- It hurts a little. - A little? Around here?

He presses and taps the patient's wrist and elbow to check for any discomfort or tingling.

So, you feel a little tingling here.

Hagiwara is examining the nerves that run through the patient's elbow and wrist.

This is a cross-sectional image of a left elbow.

The parts circled in yellow are the nerves.

Normally, as the body moves, nerves glide smoothly between surrounding tissues, such as muscles and bones.

But stress on a nerve can cause inflammation, which may make it adhere to whatever is around it.

This can prevent it from gliding smoothly, causing the surrounding tissue to pull on it as the body moves, possibly leading to pain.

You seem to be hurting quite a bit. I think injections in the wrist and elbow should help.

To treat the man's neck pain, Hagiwara first gives him an injection in the elbow.

It contains an anesthetic mixed with saline.

He inserts the needle while checking its position on an ultrasound monitor.

The parts circled in yellow are the nerves.

Hagiwara injects the fluid where a nerve running through the elbow is believed to have adhered to muscle or other tissue.

The injection creates a space around the nerve.

He repeats the process, gradually freeing it.

We've now separated the nerve from the surrounding tissue over a length of about 6 to 7 centimeters.

I think that alone should make your neck feel a little better.

He also injects the fluid into the patient's wrist to release a nerve from the tissue around it.

The entire procedure took about four minutes.

Put your arms out in front and raise them.

Now extend them to the side, palms up.

How does it feel when you move your arm?

Hirose Tatsuya was treated by Hagiwara three months ago.

Before that, his right shoulder hurt so badly that he couldn't sleep at night.

This footage was taken before the treatment.

He couldn't raise his right arm fully.

It was unbearable. I also had a stabbing pain, like being pricked with a needle.

Before the surgery, this was as far as I could go.

To treat Hirose's severe right shoulder pain, Hagiwara operated on his elbow.

He had separated nerves from muscle and other tissue they had adhered to.

The surgery brought relief, and Hirose could raise his right arm with ease.

I can do things I couldn't do before.

I had surgery just before my grandchild was born.

I asked Dr. Hagiwara whether it would allow me to hold the baby. He said yes.

Some patients improve without injections or surgery.

This man continued to suffer severe pain in his arm and shoulder even after treatment following a traffic accident.

Hagiwara immobilized his wrist with a brace to reduce pressure on nerves.

Immediately afterward, he was able to raise his right arm, which had earlier been difficult.

Hagiwara's team studied the effects of treating the elbows and wrists of 56 patients with shoulder pain.

In six of them, the pain was reduced simply by wearing a wrist brace and resting the elbow.

providing relief and improving shoulder range of motion.

The remaining 27 underwent surgery.

They all had a significant reduction in shoulder pain and improvement in symptoms such as difficulty raising an arm.

Every patient who took part in the study benefited.

Hagiwara and his team reported the results in 2022 in a medical journal published by the American Society of Plastic Surgeons.

The study was named the best paper of the year.

Dr. Hagiwara, welcome to the program. Thank you so much for your time today.

- Nice to meet you. - Nice to meet you, too.

So doctor, how did you come up with this initially? Or how did you make this discovery?

I specialize in treating patients with severe, intractable pain.

I treated the wrist, believing that the pain was coming from there.

Not only did the pain go away, but patients were able to move their shoulders again.

These experiences formed the basis for my approach.

Nerves in the human body don't run as individual strands.

They're bundled together and form a complex network that goes all the way to the fingertips.

We know that when a larger nerve is damaged, smaller ones running nearby can also be affected.

Hagiwara proposed a concept called "Parallel Crush Syndrome" in his paper.

Many nerves run through our arms, including three major ones.

Hagiwara suspected that damage to a nerve in the wrist or elbow could affect others running alongside it.

He thought this could cause pain farther away, in the arm or shoulder.

However, there may be another possibility.

Pain has long been thought to travel from the center of the body toward the extremities.

Hagiwara has reported that it could actually move in the opposite direction, due to nerve damage.

Problems in the hand can lead to elbow pain.

Trouble with the elbow can cause your side or shoulder blade to hurt.

When both the hand and elbow are affected, even the neck can start hurting.

So my approach is to start at the hands and elbows and examine them closely.

Hand surgeon Francisco del Piñal has treated a goalkeeper for Spain's national soccer team.

He is one of Europe's leading specialists and is among those who see promise in Hagiwara's approach.

the pain can be located in another area. So that's very interesting.

The topic has been something of a dark area for surgeons.

We are trying to answer questions that 10 years ago, nobody would have put forward.

Nobody would have asked those questions.

Hagiwara has a way of examining whether shoulder pain originates from nerves in the hand.

We asked him to evaluate discomfort in Erica's right shoulder.

Extend your arm and pull back your fingers with the other hand. Remember how tight it is here.

Now do the same on your left side and compare. How is it?

The right side is tighter? Keep this feeling in mind.

Hagiwara uses two simple tests to check the median nerve, which runs through the center of the wrist.

It passes through a narrow tunnel alongside the tendons that move the fingers.

Hagiwara says that if it's compressed there, symptoms may appear in the arm or shoulder.

First, Hagiwara examines Erica's wrists.

Bend your wrists and compare the lines.

Even though you're holding them the same way, the creases on your right wrist...

- You can hardly see any of the lines there. - It looks like there are fewer of them, right?

The creases on Erica's left wrist are more pronounced.

Hagiwara says this could indicate that a swollen ligament or tendons in the right wrist are compressing the median nerve.

Next, he presses the center of the wrist with his thumb for 20 to 30 seconds.

If this causes tingling or pain in the fingertips, he suspects swelling in tendons or an abnormality in the median nerve.

It's been about 30 seconds. Do you feel any tingling in your fingertips?

which could be causing the discomfort in her shoulder.

He recommends a middle finger exercise to relieve the compression.

It involves placing one palm flat on a table and spreading the fingers apart.

The opposite hand is used to hold all the fingers still except the middle finger.

This finger is slowly brought toward the ring finger and held there for about six seconds.

Then, it's moved in the other direction, where it remains for another six seconds.

It's actually quite difficult to do.

That's probably because you don't normally use this muscle much.

No, I feel like I've never used my middle finger.

This exercise is continued for three minutes.

That's 3 minutes. You must be tired.

Let's check the stretch that felt tight before.

Turn your hand outward and pull your fingers back like this.

- It goes farther than before. - Yes, it does. And this feels smoother too.

Hagiwara believes that moving the middle finger sideways reduces swelling in the tendons that are compressing the median nerve.

He says this eases discomfort not only in the wrist but also in the shoulder.

I feel great. It felt very much lighter than before.

So you're saying that just doing the middle finger exercise could be a solution to my shoulder problem?

Hagiwara also teaches these exercises to patients during appointments.

My right shoulder... It hurts around here.

The patient has been suffering from pain in her right hand and right shoulder for about six months.

Move your middle finger toward your pinky.

Hagiwara has her do the exercise for three minutes.

How about the movement that hurt your shoulder before? Is it still painful?

Yes, but I feel like I can move farther now.

It was the only treatment she received that day.

I was surprised I could raise my arm all the way up beside my ear.

He said I can start knitting again, which I'm looking forward to.

gathering more evidence with the aim of bringing this new treatment approach to more people.

There are so many people suffering from neck and shoulder pain in Japan and around the world.

If we change our perspective, we may find the cause elsewhere, such as the wrist.

I hope we can broaden our focus to look at how nerves in different areas are connected.

That could help us unravel the mystery of pain in the human body.

I wish there were more doctors like you. And thank you for thinking out of the box.

Nerves carry information through electrical signals, allowing us to feel and move.

leading to symptoms such as pain extending from the shoulder to the hand or from the lower back to the foot.

Identifying where the disruption occurs could help pinpoint the cause.

But these signals are extremely faint and pass by in an instant.

They can be detected from the surface of the skin, but not well enough to precisely locate abnormalities.

For more accurate measurements, electrodes can be inserted directly into the body.

But this is rarely done because it places a heavy burden on patients.

For over 20 years, Kawabata Shigenori has worked with Japanese companies to develop a device that visualizes nerve activity.

This is the neural magnetic field measurement system.

It can measure extremely weak magnetic fields generated by nerves and the spinal cord.

The device detects magnetic fields generated when nerves transmit electrical signals.

When electric current flows through a wire, a magnetic field forms around it.

The same thing happens in nerves. Electric currents flowing through them produce these fields.

The magnetic fields extend outside the body.

Kawabata believed that capturing them would make it possible to accurately track the flow of electric currents through nerves.

Highly sensitive magnetic sensors arranged over an area 15 centimeters long and 19 centimeters wide detect the magnetic fields.

The part of the body being examined is placed over the magnetic sensors.

Nerve activity in the neck will be measured.

To examine the nerves there, electrical stimulation is applied to the inner elbow.

The stimulation travels through sensory nerves in the neck to the brain.

The device detects the resulting changes in the magnetic field to check for abnormalities.

The procedure is carried out in a special room that blocks outside magnetic interference.

We'll begin the stimulation on the left side.

The process takes about 10 to 15 minutes.

A computer is used to monitor and analyze changes in the magnetic fields.

The results are shown as waveforms that represent electric currents traveling through the nerves.

These are from a patient with a nerve abnormality in the cervical spine.

Starting at the bottom, the waveforms weaken partway up.

Compared with a healthy person, the abnormality is particularly noticeable between the fifth and sixth cervical vertebrae.

With measurement intervals of only about seven millimeters, the device can detect nerve abnormalities with high accuracy.

The waveforms can be superimposed on images such as X-rays to visualize the movement of electric currents.

This footage is from a patient with a cervical spine problem.

The red disappears between C5 and C6.

These images show the flow of electric current superimposed on side views of the neck.

On the right is a person with a healthy cervical spine.

The red can be seen traveling from the bottom to the top of the neck.

But in a person with an abnormality in the cervical spine, the current disappears partway up.

The system can also measure other parts of the body, including the lower back and wrists.

I hope this device will help some patients receive a more accurate diagnosis.

This could lead to earlier, appropriate treatment and better outcomes.

Kawabata is continuing his work, aiming to put the system into practical use in the near future.

revealing that the true source of pain, may lie, somewhere unexpected.

So where might the answers be found?

Sometimes, they begin by listening closely – to the patient, to the symptoms, and to the clues the body might be giving us.