No Hypothesis !

[emad]

Hi all ;

I encountered a 48 years women ,i have no clinical hypothesis to reason her complaint ;

Pain surrounding the base of the skull on both sides since 25 days ,near the
C1 , this pain is severe in morning !

Suggest me any clinical reasoning procedures .

tension headache ??

Regards
Emad

[Diane]

Pretty wide open question Emad.. have you got a history?

[emad]

Diane ;

No past history of the cervical region .

Her job is ; teacher .

physical examination ;

Cervical flex/ext revealed no pain
side bending no pain
rotation no pain
ULTT no pain ----


i palpated that area finely , no tenderness or pain , she said just pain in the morning , or when i sit in the front of the TV long periods.


I do not find any examination/evalutaion test/procedure to apply

Regards
Emad

[Diane]

What about present history... ? Onset? How long? Gradual or sudden?

[emad]

Diane ;

onset since 25 days , she visited a doctor gave her drugs , no progress ,then he ordered x-ray , he told her there is degeneration between cervical vertabrae .

I asked her what does mean degeneration for you ? She replied means all my vertabrae will crack down when i reach 60 age .

I asked , do you think this degeneration is dangerous issue ? she replied of course , it is very dangerous , this what makes me afraid .

By the way , she puts on a collar as advised her doctor !i asked her do you feel better with that collar , she said yes , espicically , when i come back from work tired .she pputs it 2 hours daily , one in morning , the other is in the second half of the day .

i do not think the collar is the cause of the current complaint .

Regards
Emad

[Diane]

What was the nature of the onset? What is the patient's narrative?

[emad]

Diane ;

She had not that pain before the onset , so that i think it is sudden .I assume that .What is your view ?

i mentioned before that all that pain since 25 days ,.

Emad

[nari]

emad, we cannot really give a view without knowing more about the nature of the pain.
We can assume that it is related to a static posture - after sleeping at night, and watching TV for a long time. But that is just an assumption.

What, if anything, makes it go away?

Does it wake her at all during the night?

Have you actually seen her when the pain is present?

I don't think tension headache, if such a thing exists, is the reason. That assumes the muscles are tight and cause the headache, whereas it has been shown that the muscles are OK and become tight as a result of the pain (which is the usual response in all cases).


Nari

[Diane]

Emad, I'm interested in her story. Where did this pain come from? What's her take on it? I want the subjective history. I want the details surrounding the onset of this particular pain.

[emad]

Diane & Nari ;

I saw this woman since 2 times in the last week .

During sleep no pain , she does not wake up from sleep because of pain .
when i asked her about headache and drawsiness , she replied yes , she sometimes feels it , which was not experienced before the current complaint .So that i tested the Vertberobasilar artery , by applying rotation to one side for 10 seconds , there was no pain accompained .

Regarding the pain nature , she could express about it , just saying when i wake up from sleep , i feel pain which is surrounding whole my neck , even i can not breath efficiently , as well when she takes showr , she can not breath very well , she added i got my hair cut because of that pain .

She is hypertensive patient , under drug therapy .
Nari,
As i was examining her , when i touched the cervical region near the C1 , there was no pain , as i sat to my desk narrating with her for 15 minutes , she said as i am speaking to you i feel pain as i sit for long period .i asked her do you consider this pain is 24hours , she said no no , if it so i can not live .

As well, she visited me putting on a skirt around her neck , she feels air drafts worsen her pain , also we are winter season here ,so that she says i am afraid of air drafts .

Diane ;
The nature of pain is like tightening feel surround the C1 &C0.

Regards
Emad

[Diane]

Emad, what I want to know is, the details surrounding the first time she experienced the pain. How long ago, how did she first notice it, what was she doing, what happened, was it insidious, did she move awkwardly, what was she doing at the time.. that sort of thing is what I'd like to know. That is the subjective history.

[emad]

Diane ,that is okay ,you are asking about the intial onset of the pain .if it was gradual or not .

She will visit me in 3 days , so that it will be better to be clear in my questioning ,because this woman is speaking a lot , she takes me between different issues .

I think she will say , i detected it when i wake up from sleep .

Okay .


Emad

[nari]

emad

Have a think about the NOI thread from the Norwegian PT to which you responded, quite correctly.

Don't you think your lady might respond to some careful neurodynamics as well? She seems to have all the indications of a sensitive system....

Nari

[emad]

Nari ;

Of course , there is CNS sensitivity , i can not rule out this aspect of any pain patient .

I have seen her 2 times , i described her ;

Breathing ex.
physiological mobilization of neck rotation gently 3 times .
neural l glides ex of both upper limbs .

I avoided any flex/ext ex


But , no progress.

Regards
Emad

[nari]

emad

Why avoid flex/ext????


Nari

[emad]

nari ;


i thought this would aggravate the pain .

i can not remember which is more painful extension or flexion ,however i think i would ask her to perform flex to relax extensors .

Regards
Emad

[nari]

emad

I'm confused...initially you stated that Cx flex/ext was painfree.
Has that changed?

Have you tried upper limb neural movements together with some cervial flex/extend or lateral flexion? In supine?

Nari

[emad]

Nari ;

I am doing all neural techniques from sitting position , what i did had not aggravate the pain .

I am sure , the ext/flex of cervical was pain free ,but i prefered not to perform it as mobilisation , as well i feel the cervical extensors are tight .

Regards
Emad

[emad]

Diane ,Nari ;

This lady visited me today , there is a postitve 25 % progress .

First time she experienced that pain was since 2 years , the course of the problem was gradual as she said .Concerning the pain nature , she could not expresse the issue in words except headache at my head base , she added before i came to you i was okat , after i went out in the street , the air drafts created my pain and headache .

Regards
Emad

[Diane]

So she's had the pain two years, it had gradual onset, and it got worse in the last month. For no particular reason. She thinks the drafts created the worsening. (Hmmmnn... another case for the weather thread?) (Just kidding Emad.)

I'd send her to the MD if I didn't get anywhere with her within a couple visits. Maybe she has something that should be MRI'ed. I don't think the collar is of any use whatsoever.

[emad]

Why MRI ?

What are your hyposes?

Regards
Emad

[Diane]

Just a hunch, a wild guess, a cautionary tale. Space occupying lesion (non-malignant) at base of brain, cerebellar. Saw one once. (Not my patient.) She had horrid occipital headaches that worsened over the course of a year until finally she began to feel weak and demonstrate slight ataxia. At that point, MRI found a tumor, she had it surgically removed and became normal again. It's one of those zebras one thinks of when one hears hoofbeats.

It's much more likely that your patient has some sort of treatable headache that will go away with some neural flossing (a horse, not a zebra). I'd mentally target the occipital nerves from C1.

[emad]

Diane ;

You make the issue so complex , however , before the last atttack of the headache she was normal , it is not stable condation of the whole course of the 2 years .

I will ask her more questions , before thinking of that shift , if you have more questions let me know .
I like to say there one marker rule out your hypothesis , she has that pain only in morning !

Is there a more reliable marker/sign/symptom could lead me to this move .

Regards
Emad

[emad]

Diane :

you are encourging me to throw her like a piece of meat to a very hungry lion , those are medical care system here and surgeons .

Consider that we are in the desert , we do not have reliable radiliogist s reports ,no competent MDs or surgeons .

I can not forget that old surgeon whom i was addressing his shoulder , narrrated with me about his experience in surgery about tumor cases , some neurosurgeons do operations not indicated .That is what all surgeons do/practise in my town for all cases .They are called butchers ,sorry for that word ,but that is truth .

Regards
Emad

[nari]

emad

A lot of people feel that drafts cause pain to start; apparently there is a tiny grain of truth in this, some people are afraid of moving air in a room or outside. Both my mother and mother-in-law were afraid of 'drafts' in a room....

At this point, ask her if she would change her pillow at night - try a rolled towel or a softer pillow, or something - just a change. Morning headaches seem to be related to what has happened to the system over the previous 8-12 hours.

Nari

[Diane]

Emad, you must have missed this sentence: It's much more likely that your patient has some sort of treatable headache that will go away with some neural flossing (a horse, not a zebra). I'd mentally target the occipital nerves from C1.:cool:

No way am I saying you should throw her to lions. :eek:
I am saying, try to be differentially diagnostic. ;)
Stay aware of biopsychosocial factors (is her headache associated with a spouse/person she has to deal with?), try/test Nari's idea, try flossing, try hands-on, try checking her further down, shoulder girdle maybe, for possible contributing factors... try stuff. :rolleyes:

[emad]

Hi Nari ,Diane ;

Thanks , i will see her in 4 days , as she visits me once weekly .

Regards
Emad