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  • Angie
    replied
    Thanks Diane - I'll try two sessions over two weeks.

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  • Diane
    replied
    A bra could be a possible contributing factor.. but not unless combined with lack of variation in movement/static sitting positions/habitual carrying of a load over one shoulder etc.
    It shouldn't take any more than a couple sessions to sort out.
    Good luck with your write-up Angie!

    Leave a comment:


  • Angie
    replied
    Thank you for posting the above case.

    I've been considering trying to publish a case study on Notalgia paresthetica (NP) since a previous patient has been diagnosed with NP made by her dermatologist. She is mid 50s and describes the typical unilateral patch of pruritis. No pain.

    She sent me this link http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663387/ to read about it and asked me whether she thought manual therapy might be a useful approach. I felt pretty confident that it would. There has been one published case study here http://www.ncbi.nlm.nih.gov/pubmed/19948695 taking a manual approach. Although it discussed cutaneous nerves, ischaemia and entrapment, the approach is all ribs, thoracic vertebrae and muscles.

    This client is happy to work with me on this experiment and I was hoping for advice on the approach - any suggestions for outcome measures, cervical AROM, VAS?

    I have done a course on how to write a case study for publication. This attempt would fall into the category of novel treatment for what I think is probably a fairly common but unmentioned presentation. In the articles on this I've read so far it seems to be most common in middle aged women. There is no mention of bras contributing to the entrapment, as mentioned it's all about damage to the cutaneous branches of the posterior divisions of the spinal nerves. Any thoughts on whether tight bras might contribute to this condition? Much like tight jeans contribute to lat fem cut nn or tight boots to sensory neuropathy of sup branch of peroneal nn?

    I'd also like any specific advice about which nerves to specifically try to address e.g. dorsal scapular? This is so I can create a 'teaching point' for the article as it needs a reason to be published. Would it be possible to replicate this particular approach for clients. Suggestions on number of treatments over what time? Time to follow up? I was thinking six-nine months or longer if I get a lot of knock-backs from journals.

    Do you think it would be handy to include some nerve information/explanation for this client as a part of the case. Another teaching point? I include this as a matter of course for all clients but possibly best to use a structured explanation?

    Any suggestions welcome.

    Thanks, Angie

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  • Diane
    replied
    Good job!! :angel:

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  • Mikal Solstad
    replied
    Notalgia parestetica case in full:

    Subjective:
    64 year old woman complains of a stabbing, electric shock-like pain about 2 cm lateral to the spinous process of T4 the size of a quarter. The pain came on several years ago for no particular reason. Her pain has gotten worse over the years. No particular movements or positions provoke the pain, it comes and goes on its own accord, it seems, however, if she lies on her right side with her shoulder in a neutral position she can relieve some of the pain.

    She is socially disabled by her pain, afraid to travel and to attend social gatherings because of it. She rates it at 10/10.

    No pain in the neck, no neuro symptoms in the upper extremity, no red flags.

    Objective:

    AROM cervical spine is normal.
    AROM thoracic and lumbar spine is normal.
    AROM shoulders is normal.
    Long-sitting slump: Negative.

    Palpation: Dysesthesia and allodynia left side T4-T8, particularly prominent at T4.

    Working diagnosis: Mechanical deformation of a dorsal cuteneous thoracic nerve, most likely around T4. AIGS formation is likely given her spontaneous pain.

    Treatment 1:
    DNM for 20 minutes on her intercostal nerves and dorsal cutaneous ramii T4-T10.
    Her pain goes down to 7/10 after the treatment.
    Treatment 2:
    She came in today again, feeling better. The pain has not been as intense and has not come on as often.

    We did some DNM again, this time for 30 minutes. We also applied some tape to the skin in the area of pain and tried to drag it towards the mid-line.
    Treatment 3:
    She came in today, and was glowing.

    She now rates her pain at 2-3/10. The stabbing/electric shock-sensation now only comes 3-4 times a day compared to several hundred times previously. She sleeps better and now she has no pain in any sleeping position.

    We treated her intercostal and dorsal cutaneous nerves with DNM again. Applied tape again.

    I also gave her deep breathing exercises to mobilise the thorax and by extension her dorsal cutaneous nerves to be done daily.
    Treatment 4 (1 month and 5-6 days after the first treatment):

    She rates her pain at 0-0,5 now. It does not bother her at all. It's all but forgotten.

    We therefore worked on another pain problem she has (her knee).

    Whoppee!

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  • nari
    replied
    I'm wondering what position the hips were in while this person was supine. This is probably not known.
    Quite true, Barrett.
    We work together in the Fine and Rare section of a large second-hand bookstore; I think if he'd lain on the table so I could check his legs and the boss had come in - well - it could have been interesting. :angel:

    I suspect they would have pointed to the ceiling.....

    Nari

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  • Barrett Dorko
    replied
    Nari,

    I would think that the toe had a pathological process present and/or major contributions of chemically mediated nociception. Taping made perfect sense. Though sensitive, the nervous tissue in the region wasn't going to respond readily to ideomotion. Time and metabolic economy led to a less sensitive system.

    I'm wondering what position the hips were in while this person was supine. This is probably not known.

    Leave a comment:


  • nari
    replied
    Both DNM and SC can be highly effective according to what I have read here over 10 years.
    I still favour SC personally as it is something a person can do without assistance from another.

    However: (anecdote coming )
    A friend of mine was having major pain with his great toe and was swallowing analgesics to keep going. I suggested he tape it and told him how. Worked like a charm....

    Nari

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  • Barrett Dorko
    replied
    I've often found that therapists don't ask. I don't know what to do about that. It has been suggested that I ask leading questions. I defend what I say will be present, but I don't know what to do about the manner in which the question is asked.

    The thing about ideomotion as opposed to DNM is its counter-cultural nature. It also involves an awareness; a mindfulness and an acceptance of self management that DNM does not.

    Less is done by the therapist to the patient.

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  • Mikal Solstad
    replied
    Was my manner helpful? Possibly. The other questions I can not answer, because I did not ask them.

    Was my treatment defensible? Yes, I think so. That is all I can strive for.

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  • Barrett Dorko
    replied
    Well, had she planned these motions? Did the characteristics of correction accompany them? Was your manner helpful?

    Of course DNM is helpful and it makes perfect sense that it would be. Taping is defensible as well. I support those approaches and simply add this.

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  • Mikal Solstad
    replied
    She came in today, and was glowing.

    She now rates her pain at 2-3/10. The stabbing/electric shock-sensation now only comes 3-4 times a day compared to several hundred times previously. She sleeps better and now she has no pain in any sleeping position.

    We treated her intercostal and dorsal cutaneous nerves with DNM again. Applied tape again.

    I also gave her deep breathing exercises to mobilise the thorax and by extension her dorsal cutaneous nerves to be done daily.

    Barrett,

    I did not specifically try to catalyze ideomotion with her. However, during the treatment she displayed all kinds of movements with her legs, arms and neck.

    Leave a comment:


  • Mikal Solstad
    replied
    I've not yet watched her lie supine. During the treatment the characteristics of correction did not emerge. However, I noticed increased blood flow to the area of symptoms by increased redness of the skin during the application of DNM to her thorax.

    I will try to construct an environment where she can express her own ideomotor activity at our next appointment next week.

    Thanks for the tips and comments, they are greatly appreciated.
    Last edited by Mikal Solstad; 06-12-2014, 06:06 PM.

    Leave a comment:


  • Diane
    replied
    Originally posted by Diane View Post
    She was off the crutches and out of the brace after the first visit.
    Not because I'm so great. Because she'd been misdiagnosed.

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  • Diane
    replied
    Originally posted by Mikal Solstad View Post
    Thank you, Diane.

    I agree, it sounds like notalgia paresthetica.

    Would membrane stabilizing medication such as Gabapentin/Lyrica be of benefit considering the likely ectopic discharge?
    I don't know.

    I do know this: I treated a young girl once, with ankle pain, dxed as CRPS, four years post #. She was in a cheerleading squad as I recall. She had been on gabapentin and it wasn't working for her anymore. She came in on crutches wearing a blow-up ankle brace she'd been wearing for 6 weeks prior.

    She did very well with pain ed, skin stretching, deep breathing, some support for maintaining and using an internal locus of control in those instances where she was expected to haul equipment with all the others after she was spent from practice, when right then, what she needed to do was sit for a minute, focus and deep breathe to manage pain as it started to be noticeable, instead of buckling to social pressure and authority and putting off dealing with it until later, because of social context and expectations. I told her I had her back and if her teacher wanted to contact me I'd be more than happy to discuss the matter.

    I think I saw her three times, widely spaced. She was off the crutches and out of the brace after the first visit.

    Leave a comment:

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