what would you do???....

[nari]

I saw someone briefly today, (brief because he wasn't my patient but the pain specialist's):

A 55 yo male, in a car accident 20 years ago with soft tissue injury/neck pain/low back pain. He had 2 years of intensive physiotherapy after the accident, with no useful outcomes. Attempts by PT to manipulate totally unsucessfull. Chiropractic had much the same result.
He has had to give up work due to pain (5 years ago). He has good home support, and social life when able.
Any yellow flags were not evident.

At present, he has no cervical spine flexion or extension, it literally does NOT move actively or passively. He has 50% LF and rotation, with pain at EOR. plus intermittent head pain; vague UL and LL pain; LBP (constant).
No neurological changes.

XR - static--> complete loss of cervical curves.
XR in Extension--> some movement OC1C2
XR in flexion--> zero.
Some retrolisthesis of C4 on C5. (mild)

Now the odd bit. He is unable to elevate shoulders without scapular retraction, which as a composite movement is strong and painfree.
No protraction of shoulder girdle at all. He reported he had never been taught 'scapular stabilisation'. Pecs are functioning.

Trapezii are relaxed in sitting and lying, bilaterally. Posture is OK.
No abduction of either UL beyond 80 degrees, limited by??? (not pain, not stiffness).
Flexion of both arms OK.

He is on MS Oxycontin, and has been for many years.
A flare means several days of severe pain, and the "cause" is arbitrary.

He has worked out a tolerable lifestyle after a lot of hard work on his part and by himself. He has accepted he will always have a life of pain, and days written off due to nearly intolerable pain.

What would you do? What might you offer this fellow?

I will post my decision on what to do next after a few replies!


Nari

[Diane]

Hi Nari,
Without yellow/red flags I would do a bit of exploring physically. Sounds to me like his neck flexors are 'off line.' I'd start up at the top with some very mild, subthreshold even, contract relax of the deep neck flexors (retrohyoid muscles), one hand supporting the top of neck, other hand taking his head passively a millimeter or whatever you can find into flexion, asking him to just tilt his chin toward his neck slightly, (important, no lifting of head up, JUST tilting of chin down) hold it there (but not letting go of contact with his head) for 7-10 seconds, or longer if it feels like he needs a bit longer to 'load' his motor cortex, then relaxing into your hand (but your hand hasn't allowed him to resume the startup position. Rest for a moment, then go for another contraction, asking tilt chin down into neck again, again your hand underneath supporting neck at OA area, other hand taking most of the weight of the head, and another rest, whereupon you should be able to feel quite a bit more motion available to you; take up the slack and go for a third round to lock in the new motion, so he has it functionally.

Help him roll to the side and sit up, supporting his head/neck just as if he had just had neck surgery (you don't want this function to go back off line again.) After he's upright, seated on the edge of the bed, ask him to bend his chin down to his chest. You should see a distinct increase of functional range available now.

He would need lots more careful neck work, for rotation, and probably some positional work combined with skin stretching for SCMs, scalenes, (ant, lat and post) which would open up the front of the neck and let the clavicles drop a bit, which would help his shoulder function become more normal I suspect. But that little regaining of nod function can help so much for starters.

Diane
PS: That was a little description of a muscle energy technique, or MET intervention.

[nari]

Thanks Diane - sounds like a great start, and I am a strong believer in what I call the nodders and shakers - small parkinsonian-like movements of the head on the neck.

Any more suggestions out there?

A gentle reminder: this bloke has been in pain for 20 years....

Nari

[pablo]

Nari,

You wrote:

"He had 2 years of intensive physiotherapy after the accident, with no useful outcomes. Attempts by PT to manipulate totally unsucessfull. Chiropractic had much the same result."

What was his previous experience with physio like? I'd find out more (you probably already have!) before I go into any hands-on work with him. How does he tolerate palpation?

What has he been told is the problem with his neck? The words may have been pretty powerful.

The fact that his neck doesn't move into flexion or extension at all suggests to me that it is fused or that there is a whole lot of muscle activity which is holding his neck rigid. Can he relax his neck at all (other than trapezii)? Maybe try surface EMG, sometimes it shows up all sorts of strange things. What about his breathing pattern? If he has some lateral flexion, it means that he has at least some facet joint movement into flexion because of the side flexion coupling, so it is less likely that his joints are completely stuck.

The shoulder girdle movements are odd, as you said. What limits his abduction? Do his scapulae move at all when he abducts?

What does his jaw do when he tries to move his neck into flexion? Can he do some protraction?

I'm just thinking out loud here. I'd try to tech him protraction of the head, and I also like Diane's suggestion if he can tolerate hands-on.

Pablo

[nari]

I think he is a reliable historian, but he reported that he attended physiotherapy DAILY for eight weeks..(!???) and then twice a week for 9 months. His experience was not exactly negative or nasty (more or less his words), but extremely frustrating.

Palpation is very well tolerated, anywhere. (clue?)

He was vague about the dx; talked about whiplash.

XR shows good IV disc spaces, apart from the mild C4 on C5 retrolisthesis.
Doesn't really looked like fusion...

He can relax the neck surprisingly well, and move it naturally when talking and gesticulating - except for any F/E mts.

I have no idea what is limiting abduction of the GHJs. he doesn't know either - he just says he can't. On passive movement I just grind to a medium hard endfeel stop - which in a way is a bit of a clue.....

Scapular movements to the limit of available abd //OK
Scap movements through flexion//OK

He can protract a little, and retract, without significant pain.

The requested movements did not reproduce his head pain.

He expressed, with some pride, that he has control, more or less, over his pain experiences.

Final clue.... I think someone from Ohio would understand this fellow!

Nari

[bernard]

Nari and all,

I'm surprised every day to see patients who are unable to lift up simply their shoulders. Many of them are obliged to carry some parasites movements with the desired ones.

As Pablo said it, a rigid spine without any signs of fusion may induce a constant muscular activity. It is sufficient to activate a bit of extensor + a bit of SCM to achieve this immobile position. A constant muscular activity may concern some accommodation pattern and in my view, pecs and Lats are perhaps responsible of some effect?

What is his job?
LBP => breathing?

My 0.02$ is working facing a mirror. It help the patient to find out the lost parts without a hands-on approach?

[nari]

I could not discern any active restriction on the pecs at optimal abd.

Something else was putting on the brakes?

His RR went up visibly when he thought we were going to do radical movements - otherwise: certainly less than about 20.

But RR is significant.

He had to resign from work.

I agree mirror work would be helpful and good homework...

I am still hunting for the most likely reason for the neck splinting???

Thomas and anyone else- come on in?

Diane - think homunculi..... :wink:


Nari

[bernard]

Nari,

RR? :oops:
Right Rotation?

[nari]

Respiratory rate...


Nari

[bernard]

:evil:

I must put a page with all these abbreviations!!!!

[nari]

Correction....

I am not particularly looking for a cause for the physiological neck splinting - but the origin...?

Methods of treatment approach are likely to be varied, with several options.

There is a bit of a denouement to this tale, but I'd love to hear more views.


Nari

[bernard]

Nari,

It would be so great if you give us the RR/pattern you observed with the patient when he thought to radical movements!

I conclude with your words that RR increased, Am I right?

[Diane]

Nari, did you ask him to hike his shoulders up and look at neck rotation to see if it increases? What do you mean, think homuncularily? Did you treat him with light hands on and let him find his own way of moving?
Diane

[nari]

Diane -

Because he could only elevate with strongly retracted scapulae, it tensioned all the nerve roots and did not alter neck rotation.
(That's my theory anyway).

Homuncularily.....what do you think his motor and sensory representations would be like with zero flex/ext of the Cx spine?

Bernard - I did not have time to investigate that unfortunately.


Nari

[Diane]

Nari,
Homuncularily.....what do you think his motor and sensory representations would be like with zero flex/ext of the Cx spine? Actually, my guess is it wouldn't make much of a dint in the homunculus, which has little representation of the neck for both sensory and motor.

So, rhomboids and mid traps are behaving badly?

Diane

[bernard]

Diane,

I think the man put an active but habituated muscular shield on his neck and a habituated protective reflexes before moving?

[nari]

Diane

As the representations for neck are relatively small, then if they became smudged through collars, pain or whatever, the owner would be worse off than if they were a large area?

Just a thought


Nari

PS - will write my version of what is the problem with this chap, the outcome of the first contact, on Friday...

[nari]

OK, here is my unproven theory of what happened and is happening to this guy...

I think he/his brain has forgotten how to flex and extend the neck. All movements below C7 are normal apart from restricted shoulder abd/ER.

He cannot read in the usual manner, because of the rigidity, but he has adapted to lifting the book towards his face. He protracts the neck as needed, and cannot retract. Compensatory movements abound - he is quite strong; his upper back looks like a weightlifter's.
So I thought that the representation of his neck was smudged severely, perhaps the 4 weeks he spent in a collar (which allows some rotation) has been imprinted for some reason, and remained.
His pain is constant, but does not worry him greatly; he said he was used to it.
Interestingly, he sat with his thighs widely abducted, and when I queried that he said it was the only tolerable sitting position that eased his neck.

He had been through a good deal of physio, as stated above, intense and long term; he said:'They threw the book at me.." When both the pain specialist and I tentatively suggested a trial of phsyiotherapy, he said, quite calmly: "I have been through so much physiotherapy, and promised so much in terms of outcomes, that I could not bear anymore disappointment; I have come to terms with myself, and to have that disrupted would be..." and he shook his head.

We agreed, and after some discussion, I offered what I would be thinking of doing if he did agree - body awareness, verbal stuff, some hands on (Note, Diane!) with the purpose of trying to inhibit his wildly overactive traps and lats and rhomboids. Neural sorts of things...and no promises of any kind.

I then left them to it, and was told later by the specialist that he was quite interested in following up on my offer. Both of us were surprised.

If he does, I will have to get to know him and then work out a sequence of approaches...

So I will have to really scratch the old cortex for this fellow - if he accepts.

Nari

[bernard]

Nari,

I think he/his brain has forgotten how to flex and extend the neck.

It may be called by some as a SMA (sensory motor amnesia) or an accomodation process (the same).

You have true terms. The fellow had forgotten but simply forgotten.