Help me work this one through

[BB]

I evaluated a patient today as follows:

Middle aged father of one, construction worker

Injury: greater than a year ago had a fall resulting in a hyperextension injury of the cervical spine. He had immediate numbness of the arm.

His pain description-
squeezing pressure type sensation around the forearm just past the elbow which increases when attempting to reach forward
increased perspiration of that hand, occasional blotchy red patches
Pins and needles usually in radian distribution, but occasional in median distribution.

Findings
Posture-neck list toward involved side with slight rotation toward involved side, forward head, elevated and rounded shoulder in internal rotation and elbow flexed, also tends to hold the wrist and fingers in more flexion than the other hand

AROM-cervical rotation is very limited to both sides and increases the arm discomfort. Flexion ~50% limited and happens with compensatory sidebending, extension ~50% limited
Shoulder motion is very limited and causes increased crushing sensation in the forearm.
all are very guarded movements

Testing- positive tension for radian and median nerves (very positive for rad.)

Back to the person- he is very insightful in that he is aware that fear of movement has likely increased his guarding (at one point it was thought he had a bone fragment and was told to limit motion, this fragment has not been seen on subsequent MRIs)
He did not use any "angry" words, but was very depressed. He is afraid that his daughter will be embarrassed by walking with him because of his posture.

My treatment today:
1) Explanation of anatomy and nature of neural pain. ("nobody has yet tried to explain to me in this past year why my arm hurts because of my neck")
2) Diaphragmatic breathing
3) Gentle neural glides, passively first, then instructed active
4) Sidelying scapular protraction in pain free range
5) Mulligan mobs with movement for cervical Rot, and flexion
6) Cervical flexion in front of mirror in pain free range without compensatory sidebending

Response to treatment
Significant improvement in shoulder alignment ( He was very pleased with this)
Crushing sensation was happening at rest (Maybe too much to start with?)

OK guys, fire away with feedback.

Cory

[bernard]

Hi Cory,

Try the "neck and shoulders" of the Try it section?
Please send your comments after?

It can be done firmly and hardly without any pain!

[bernard]

PS: Add firstly some "active" work of the pecs and latissimus dorsi => adduction.

[emad]

Hi Cory :

good management :D
i would ask if cervical felxion :arrow: referr to the arm
cervical extension :arrow: referr

as you see ,you begin with cervical flex ,thus result in improving so i see you go on ,to mobilise in the direction of flex,then try extension.

you have not said about thoracic region , i think it may suffer stifness and pain ,which need some physiological mobilisation in all directions .

scapulothoracic articulation needs mobilisation ,which i think you have applied.
relaxation teaching of the elevatd shoulders ,to keep relaxed.

i think you will see very great result soon ,regarding the squeezing sensation you had reported , if you teach the patient to relax all his tewnsioned muscles,then the neurdynamic tests you have described positive will be improved soon.

cheers
emad :wink:

[rolf]

Hi BB!
Like your first steep rgarding treatment!
1.What have been done earlier regarding treatment before you saw him?
2.Is he working at the moment?
Zooming out, consentrate on changing his negative way of thinking(cognitive therapy)-READ Daniel Amens book "change your brain,change your life"Depression,increased deep limbic system,increased muscular tone,thoracic breathing pattern ,etc etc(sympathic reaction)Ask him how he know that his daughter is ambarrassed or it just one of his ANT(automatic negative thoughts)?
Zooming in,what about muscular spasm in m.scaleii ant and med.giving a decompression on parts of plexus brachialis?
RIN

[BB]

Hello, and thanks for your responses!

Bernard- thanks for the advice, I will use it and let you know!

Emad- Arm pain was referred with both flexiion and extension. He moved very slowly throughout both motions as is fearful of the motions.
He did have a sllight thoracic sidebent position toward the affected side. I did not notice it to increase with arm motion.

Rolf- His earlier treatment for most of the past year has been medication. He is not working as a result of this injury.
Interestingly, the physiatrist who referred him to me tried to get him into a physchologist, but this was denied, as was some kind of lidocaine patch that he had tried and gotten some relief with. This is interesting because, evidently they would have been willing to send him to a pain clinic instead of the psychologist and have let him to continue on narcotic meds of little benefit rather than the patches which helped?!
He is also being seen in OT for industrial rehab. The OT is concerned about it being too aggressive at this point, but it was such an ordeal to get him in that she is afraid to lose him.
He had one treatment of prior PT and apparently the therapist tried traction after which he had unbearable pain for 3 days.
Regarding his daughter, he heard one of her classmates yell that he was a hunch back. Kids can be so, so cruel.

I was hiking today (where I do my clearest thinking!) and had actually thought about how useful teaching to positively reinforce experiences would be, especially in the presence of depression. I think that he will be able to grasp this concept and make it useful.

Again thanks everyone! I will keep you posted.

Cory

[BB]

Update time,

Today some interesting things happened. First of all, the physician who referred this pt. did not like the fact that I cited "neural irritation" as contributing to the problem. He said that the EMGs were negative, thus no neural irritation could be present.

Does anybody have a reference regarding EMG studies in cases of neural tension? My thought is that neural irritation can certainly be present in the absence of damage that would be picked up by an EMG.

Anyway, he wants aggressive/progressive treatment without regard to pain.

So, the OT and I put our heads together. She directed the tasks. I helped him with his movement.

Reaction to last treatment:
-best night of sleep in a long time, followed by one of the worst.
-improved posture was maintained.
-he reported no real change in his overall pain level, but was not physically grabbing his arm from pain with reaching movement as he had previously.

Today's treatment
-Bernard-I tried the neck and shoulder treatment. It helped him to relax his shoulder but he reported no change in arm pain. I also added in similar fashion head movement (sidebend and rotation) to the painful side.
-I provided a sustained lateral glide of the ulna during a continuous reaching activity
-Sustained cervical glide during continuous reaching activity
-Manual assistance for scapular motion during a continous reaching activity.
-diaphragmatic breathing in standing incorporating head rotation. Breath in= move head to middle, breath out= rotate in a relaxed fashion

My impression:
I think that today he had much improved upright position of his head and neck and improved awareness and ability to correct when his shoulder began to guard.
When turning his head you could visible see sternocleidomastoid standing out. I asked if he felt he was putting a lot of effort into turning the head and he said no. It was more limited by pain. So, I assume the SCM was a guarding issue.
His emotional state was improved. He is very happy to be more upright and "normal looking."

Any feedback?
Any ideas on helping him sleep?
Any references on EMG and neural tension?

Cory

[BB]

I almost forgot,

Today I witnessed that he has a lip smacking "tick"

It is not a listed side effect of his medications.

Any ideas?

Cory

[emad]

Hi Cory;

Glad to know that progression.
you
but was not physically grabbing his arm from pain with reaching movement as he had previously
I think this what i predicted, this as you theached him relaxation.

Is it legal to NOT inform the physician what our findings,decisions...... i mean there in your country :?:

Of course you are right neural tension can not be picked ,except through using neurodynamics ,if you have to supply evidence of the neural tension , you can provide him/her with any evidence of ULTT which you will find postive ...so you do not need at all EMG,which is not reated at all.

The problem where are you :?: ,if every thing is performed legally ,within scope of practice , you can teach him what are your ideas ,here i can NOT teach them ,as they will perform physio,so no reference for me as :arrow: :idea:

New idea for me

to perfom treatment in a functional manner,excellent.

the issue of good night after treatment ,usually i meet,then pain :arrow:
what about performing neural mobilisation in the form of elbow ext RT+elbowflex LT.

cheers
emad

[nari]

I agree with emad - EMG is useful for education for patients, but there is not a logical reason to use it as a diagnostic tool; ULNT tests do that quickly.
However I am no expert on EMG; I hope Pablo will come into this thread with his ideas on the uses of EMG.

Nari

[BB]

Hello all,

Bernard- I apologize. I did not describe the relaxation treatment well. His guarding and shoulder holding definately improved with the relaxation technique.

His pain did not improve with movement-- do you have suggestion on good use of the same relaxation during motion--maybe look for tension to return as he moves and apply again at the that point of the motion?

Also, "moving the neck to the painful side," again poor wording on my part. I had him move his head toward his sore shoulder and arm (to the painful side) thus shortening the painful tissues.

Thank you very much for your advice and I hope that I am using it correctly!

I see this pt. again today. I will update again tonight.

Cory

[rolf]

Hi Cory!
what about m.scalenii on the painfull side?Increased tension here can limit ,aspesially rot. to painfull side,and hyperexstension!?Flexion can be ok!
RIN :wink: :wink:

[emad]

Hi cory :

You are doing very well ,i think , do not worry :D :)

the outcome will mainly depend on the patient cooperation.

to make the issue easy .
try the relaxation techniques on yourself , you will find new experiences with training which may help through patient education .
:arrow:
cheers
emad

[BB]

Update:

The day following monday's treatment, he had his least painful day he had spent in 9 months, and had the best night of sleep in that time period also.

Starting yesterday, the pain returned to its previous level. Bad night of sleep last night again.

Treatment continued today:
added- lateral mobilization of the radial nerve at the forearm (I liked the idea Emad!)
Strain counterstrain to scaleni (Rin, indeed the scalenes are involved. When they were shortened his hand symptoms decreased, SCM and pec major also join the party)
Taping of the elbow and wrist
Education, Education, Education--breathing, told him to watch a sudden increase in activity when he starts to feel better

Emad- I am in the US. Legally, I don't believe that I have to give a report to the physician....however, that is not very realistic for me to avoid this. 1) injured as a worker with case managers depending on the physician to direct care. 2) He is a provider of lots of patients for us and is likes to be very informed 3) I think that if he sees evidence that he will be more cooperative and is therefore my prefered route of action (I'm still looking for EMG info)

Cory

[emad]

Hi cory:

however the consumer his last impression was pain ,i think he is glad/happy, as now he feels there is someone knows his problems.

I would ask you ,did the patient report the pain is intermittent ,at least now is not continous , or the period of pain suffering decresad :?:

cheers
emad :)

[emad]

Cory
please ,i hope you can provide us a clear defination of

reach movements
i hope you can put that in the abbreviation category of the forum.


cheers
emad

[BB]

Hello all,

Firstly, I posted the EMG question on rehabedge and did recieve some references http://www.rehabedge.com/forums/Forum25/HTML/001161.html

Emad,
reaching forward--combined shoulder flexion and elbow extension, as if reaching into the refridgerater for the milk.

Regarding his pain-- I think it is tough to find if his pain has remained improved overall. His emotional responses and pain seem to be enough entangled that his dissapointment in pain increasing has likely amplified his perception of the pain.

Cory

[emad]

Hi all ;

Bernard :arrow: good reply :wink:

Cory ;

i took a look on the links you supplied,all no evidence , just a course :!:

i hope you can ask your physician a question :

If there is sciatica,can he assure that through EMG :?:

sciatica alsi a neural irritation, let us see his reply.

cheers
emad :)

[rolf]

Hi Bernard!
Your last "letter" was interesting!"A movment is never painfull!"
I do agree with some of your thoughts but isent it a problem to reduse a
the speed of a movment without focusing on the pain which might be the main problem in making this movment.
When my back aches i have to be in motion,it reduses the pain and its possible for me to" run the pain" away.I dont care as long as the pain isent increasing.
What about pain from the nervous system?
IT might be pain free during the motion but due to too much motion on a irritated nervous system ,you get the pain some hours after the event.
What cind of pain problem are you taking about ?
Could you pease give me an clinical example ,mon ami!
RIN :D :wink: :D

[rolf]

Hi bernard1
Thanks ,no i follow you,and i do agree with your statment"your convincing the patient that he can have all control over pain",BUT some patient can be so conserered on the pain itself
that they arent able to seall the positive painfree movments?

When it comesto my backpain its mainly a"physical" discproblem .
Emotional indused pain is "always" in my neck ,LEFT side.
I have it at this moment when iam writing this topic.Its gone after two minutes when i have left the "SomaSimple."
:lol: :lol: :lol: :lol: :lol: RIN
Have a nice weekend to all on the SM.

[nari]

Rin, if you believe your back pain is partly discal in origin, why do you continue to have pain? Do you feel it is chemical irritation, persisting? Does anyone know where 'discal pain' comes from?
If you pinch/compress a nerve it transmits all sorts of interesting forms of asthesias, but it does not cause pain. A leaking disc might; I don't know.

Then, your neck hurts when you sit at a keyboard...is it positional, do you think, or is it the forum that triggers off pain? :wink:

Cheers

Nari

[BB]

Hello all,

First of all, what a great learning experience this has been. Sometimes, the best way to learn is to do (learning ideas seems to happen in much the same way as learning movements....)

My patient cancelled his last appointment so no update right now. However, I hope to hear back from his physician tomorrow. I'll let you know how it goes. Who knows, maybe I can convince him of the need to support or refute what each of us are claiming and a research project on EMG and neural tension testing will ensue. Wouldn't that be a great turn of events!

Cory

[rolf]

Hi Nari!
When it comes to my lumbar back pain i think its a chemical irritation of the sinus intervertebrale nerve that suplies the outer 1/3 of the nucleus pulposus in the lumbar spine.ITs my theory!I have never experienced an irritation of the n.ischiadicus when i have this kind of backpain.I do get a cyfosus in my lumbar area and is a little bit in a flexed position.

Hey,today its no problem in the left side of the neck when writing,and it might be because ive just been sitting in the sun for an hour and relaxing.
RIN :wink: :lol: :wink:

[bernard]

Hello Rin,

As said Nari, your problem seems positional. Sometimes changing the height of sitting from a centimeter makes a huge difference?
The screen position is also source of pain! The line of vision must cross the 2/3 top of it!

If you lose the pain while relaxed it is perhaps possible to introduce an active relaxation at the office?

[emad]

Hi Rin:

sorry that you feel that pain.
i hope you can conquer that pain,it is easy for us.

Why not you post a new topic ,and we dicuss the issue more extensivley.

cheers
emad

[rolf]

Hi Somasimplers!
Thanks for beeing so conserned about my helth,but dont worry ,be happy!
For me pain is gift nowbody wants.Its a bad mate/friend .Its there to tell me a story ,giving me information about my mental and physical state of mind.
If i want to listen to it i do or i can just give a dam about it.I have it under control.I think its unnormal not experience pain.As i have witten earlier.The pain isent the problem its how you react to it!
Dont you ever experience pain due to stress(mental)og physicly indused?
My motto:Dont worry be happy!
RIN :wink: :lol: :D