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Old 25-06-2011, 07:44 AM   #1
gollygosh
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Default I need advice

I don’t know if I have ever met an individual in this much pain, or maybe he’s just the worst that I’ve seen since joining Soma Simple. This is definitely a test of the information I’ve been trying to understand, and apply, so I’d appreciate advice.

Patient is 60 years old. He has had pain that originates in his neck, extends into his face, neck, and shoulders. He complains of his face, and neck “twitching all the time,” and his neck feels like it is “crawling”. His pain increases even when he thinks about moving

We’ve been going through the Explain Pain book. Emphasizing pain as an output from the brain to protect him from a perceived threat level. Emphasizing that the pain is now a problem—that there aren’t any structural concerns, and that motion is lotion.

Since even thinking about motion increases his pain, we started with a lot of deep breathing to improve oxygenation, and to give him a tool to use for relaxation, and pain control. His homework for the last 2-3 weeks has been deep breathing. Gradually I’ve had him mentally rehearsing tapping his toes without increases his pain. I tried having him gently open and close fingers(mental) and gradually these foot, and hand motions have increased. He can dorsi/plantar flexed through about 20 degrees of motion for 5-6 reps before he feels his neck tense up more. He can move wrists, and occasionally elbows.

As he was describing the tendency of his face to always move, and pull, I suggested that at home he experiment with letting his face go where it wanted to go—that this might be the body trying to correct it self through ideomotion, and has reported that his face feels calmer. I’ve used DNM along upper cervical nerves both anterior, and posterior, and he experiences a lot of warmth, but no lasting pain relief. I’m trying simple contact at his head in supine—again with a lot of warmth, and the other day his head actually turned about 20 degrees to the right in slow motion accompanied by much vibration, and feeling somewhat like an earthquake. He now notices a difference between the left and right side of his neck—right side feels tighter than left.

In attempt to progress his active ROM, I’ve had him start rolling eyes up and down, or left to right in supine with eyes closed. His head seems to track with his eyes—can’t dissociate the two movements well. My next “big” motion(s) would be to try moving eyes, and feet, and/or practicing these motions while sitting. I’m keeping repetitions to 3-6 with use of deep breathing to avoid increased pain.

I think the patient can recognize that he is gaining some motion, and his pain numbers have moved from all 8’s to 5-7. Am I moving in the right direction? What should I do next? What about time frames and expectations?

Geralyn
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Old 25-06-2011, 08:02 AM   #2
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Sounds like you're doing great with a tough case to me Geralyn.

I might want to know what the picture of "thriving" looks like to them, as described from their minds eye.

I might ask a question like, "If you woke up tomorrow without this problem, what would be the first thing that would be different." Their answer will be "I wouldn't hurt" but I would attempt to redirect them to a behavioral answer. "Yes, but what you DO differently?" I'd then try to tease it down to subtle characteristics. This will help them recognize the reduced threat situation when they see it/feel it.

I might then have a conversation about the last time they felt this way, if even for a short bit, to help them see that they do in fact have the capacity to improve from within because they've already shown signs of it in the past.

In subsequent visits, I might try to find out what would be their vision of "kicking ass." I might then advise that they in fact make a long term goal to kick ass in some fashion. The idea being to shift the focus from survive to thrive.

Just a few thoughts, but it sounds like they're lucky to have ended up with you.
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Old 25-06-2011, 08:19 AM   #3
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moving from "survive to thrive" is such a great choice of words. Thanks for the direction to aid the patient in self-assessment, and dreaming/planning.
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Old 25-06-2011, 09:20 AM   #4
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If you Google crawling face sensation there are a few threads and many helpless people being told about all manner of drug therapy, fairy tales, and misinformation.

As you are attempting to treat this gentleman's condition from a neurological based approach, he is in a lucky minority. I would still caution you to be alert to red flags indicating pathology. The vagus nerve communicates with other cranial nerves including the facial nerve http://upload.wikimedia.org/wikipedi...5e/Gray791.png
Here are some interesting papers I posted today. (I'm seeing sympathetics everywhere today, you'll have to forgive me.)

He will be even more lucky if the origin of his pain was simply mechanical deformation or chemical irritation and the movement therapy you are using averts him from centralizing and catastrophizing. It sounds like you are doing as much as possible. Thanks for sharing this interesting case study.

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Old 25-06-2011, 03:42 PM   #5
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I would support all the above suggestions, plus I would address the superficial cervical plexus. Good for you Geralyn.
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Old 25-06-2011, 06:06 PM   #6
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I'm with Karen. This is a nontypical pain pattern for a mechanical musculoskeletal problem and the first issue is whether there is some sort of underlying pathology here. I would need to hear more about what had previously been done in the way of differential diagnosis and his medical screening process in PT to be comfortable rendering advice. For his age and symptoms I would think questions in the way of screening for cancer and neurologic pathology would be primary. Any imaging done, etc? I'm all for treating patients but that's probably about Step 3 in the process where we can consider Step 1 is "does this patient belong in my clinic by having a mechanical/musculoskeletal problem? and Step 2 "if so, can I help them or if I'm unsure do they need referral first or in conjunction with treatment?" Just a rough approximation.

Geralyn, can you give some more of this type of background?
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Old 25-06-2011, 07:07 PM   #7
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I don't have anything to add in terms of treatment recommendations, but I will chime in on the possible need for further medical work-up.

This much pain in the head and face of a person of that age is medically alarming, and depending on his history, a 4-6 week course of treatment that results in only moderate improvement in his symptoms warrants referral to a physician, in my opinion.

The problem is when the referral is back to the physician who sent the patient, and they don't do anything about it.
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Old 25-06-2011, 08:36 PM   #8
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I will have access to his chart on Monday. I know that he has a history of x-rays and MRI of neck which were normal.

One of the other therapist asked me to treat this patient as she recognized that musculo-skeletal, and postural treatments weren't helpful( She has also started taking an interest in my personal copy of the Explain Pain book sitting on my desk, and I'm hoping she'll find a way to SS soon.. She is good about medical screening, so rather than spend a lot of time re-assessing, I made the assumption that red flags had been addressed. I'll have to review the chart more carefully, and get back to you.

Thanks for your advice. Sadly, at my clinic I am the go to person for persistent pain, and I have no non meso therapists to think things through with.

Geralyn
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Old 28-06-2011, 12:44 AM   #9
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I pulled my patient's chart. Let me say that I estimated his age way off based on his relatively youthful appearance. He is 73 years old(If any body needs an ego boost I'd be happy to estimate your age)
Recent MRI of the neck is negative. He has been dealing with this pain for "years"--had injections about 7 years with help, but resolution. Medical history includes HTN, and NIDDM, depression-- he is being medicated for all 3 if these conditions. He self-reports "rheumatic hands." I do not know if has had testing by a rheumatologist but I didn't see any RA mediations on his med sheet. He takes vicodan TID, and reports sleeping through the night with vicodan.--typically in side-lying. He does all the things he has to do to maintain house/yard but has no energy for other things. He avoids driving on the highway secondary to stiff neck, and would like to return to fishing or hunting. He is scheduled to come in tomorrow.


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Old 28-06-2011, 01:25 AM   #10
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Quote:
Originally Posted by gollygosh View Post
I made the assumption that red flags had been addressed.
I've made this mistake before for differential diagnosis. It won't happen again.
Glad to see some imaging has happened. Neurological screening questions for symptoms? Neurological exam? Seen a neurologist?
What do you think is the origin of his symptoms?
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Old 28-06-2011, 02:15 AM   #11
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My take is slightly different. Even if it is Cancer, he still needs help with that pain. No heat or US until imageing though. I can imagine some conditions rhabdomyslysis? for instance where motion wouldn't be much fun. Simple contact would be the way to go. Good Luck
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Old 28-06-2011, 02:35 AM   #12
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I will see patient tomorrow, and following his treatment talk to MD about neuro/health concerns. While pain is this man's constant companion he is sleeping okay(with vicodan), symptoms seem to be of such a long duration( with years of history) of history that I naturally assumed we were in some kind of repeat pattern. I feel foolish not having those answers but will definitely dig further. Thanks for the perspective.

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Old 28-06-2011, 02:41 AM   #13
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That's how we all learn Geralyn, don't sweat it.
You have the courage to put yourself out there and you (and we) are better for it.
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Old 28-06-2011, 04:32 AM   #14
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Not much more to add but have you tested his neurodynamics? ULTT, Slump etc?? Any head trauma? Headaches? Is he a smoker? Any significant weakness in his UE?
Keep us posted-interesting case!
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Old 28-06-2011, 04:36 AM   #15
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Link to "For I Need Advice." Reference material.

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Old 28-06-2011, 09:33 AM   #16
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nice thread!
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Old 29-06-2011, 02:13 AM   #17
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I saw my patient today. The good news is he describes the pain a 6 with the qualifying statement that it has been periodically worse since he saw me last.

He is carrying his body differently. In the past he has displayed a most uncomfortable looking symmetry with head straight ahead, no cervical lordosis, symmetrical shoulders without arm swing. Today asymmetry was noted in shoulder posture--right shoulder higher, less obvious guarding of head and neck movements. His platysma muscle was in an obvious contraction bilaterally--first time I've noticed that.

I took some time to fill in the some of the gaps in history. He reports having this neck pain intermittently for 25 years or more, but gradually it became a more constant complaint. He also recalls that even as young as age 8 he was prone to getting a crook on the right side of his neck "quite often". As previously noted he was given 2 pain injections about 7-8 years ago which were not helpful. This is his first encounter ever with Physical Therapy and he was referred by his primary care physician. I spoke to her on the phone briefly, but as she didn't have his chart in front of her, we are going to talk when she is better prepared--
hopefully on Thursday. I spoke to her about my concerns about this crawling sensation and suggested a neuro consult. The patient's psychologist recommended a neuro consult a couple of years ago, but the patient did not follow up on it.

The patient is seen by a rheumatologist 3 times a year, and symptoms in his hands are controlled by meds. His rheumatologist ordered the first MRI several years ago, and called it arthritis( I am assuming he differentiated this from the RA) and took no further action.

I have not done neurodynamic testing because I didn't feel like I could get any real information since literally active DF/PF increased pain. In the progression of ankle DF/PF with head motions I've been hoping to obtain some benefits to the neurodyamics , and hope to be able to progress in that direction. There was no asymmetry in initial MMT and I haven't explored that further.

As I worked with him today, I started with a skin test for the kinesiotape. If the tape is well tolerated, I am hoping to try Karen's tape technique on Thursday(thanks Karen, and I love the avatar). When he moved into supine today, I started with DNM at anterior neck, and then decided I really wanted to see where he'd go with Simple Contact. His deep breathing was more relaxed throughout the treatment. He was rotating his head to left and right--initially his right foot was pointing straight up in the air, and shaking with every motion gradually his leg relaxed in external rotation. Although I've heard about the Er'ed leg, I haven't really seen it myself until now. He really thought that I was moving him, and was very surprised that he was moving with less guarding. So WESS was present.

We ended with me stressing that the motion was generated by him, and practiced dissociating his eyes from his head while turning head from left to right. I am hoping to continue to expand his repertoire, and range of movements through this form of homework.

Jason asked what I think is the origin of his symptoms. Intuitively I think this is a stiff neck that the guy has been perfecting for years. In my mind the sheer length of time he's had these symptoms with little change in location, and behavior of pain makes me think there is nothing scary going on. Given that I didn't check those things up front makes me not totally trust my intuition. I am concerned about the "crawling" but at least in the face that has been alleviated some with my initial suggested to let his face move where it wants to move. I am going to push for a neuro consult, but I feel comfortable continuing treatment as long as he is compliant about getting to a neurologist.

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Old 29-06-2011, 02:04 PM   #18
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Hi Geralyn.
It is somewhat comforting that his symptoms are typical for him and unchanged. But just as physical therapists have good training and a good track record in screening for visceral disease, we can all benefit from talking about these issues from time to time.
I think this is a case where simultaneous treatment and referral is important.

When I said origin of his symptoms, I was thinking of the four origins of pain as well as distribution of his symptoms. What's your running list of hypotheses currently as to the source of symptoms?
We should first talk about pain origin and then reason our way through hypotheses.
Open to anyone reading.
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Old 29-06-2011, 06:01 PM   #19
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I'm going to admit here what you already know. I am so out of my league in terms of the vocabulary, and knowledge base to carry on this conversation. I have relied for years on intuition, which has moved me with Occam's tooth pick toward SS. I am struggling with communicating via blog, and am all in all in the middle of one huge learning experience. I am so glad to be someplace where I am not considered the go to person that I apologize up front for my inadequacies. Having said that, thanks for your willingness to remediate this therapist.

"When I said origin of his symptoms, I was thinking of the four origins of pain as well as distribution of his symptoms. What's your running list of hypotheses currently as to the source of symptoms?"
Currently I can remember 2 of the 4 origins of pain
1. mechanical deformation
2. chemical irritation
3.
4.
I have been operating under the assumption that his pain is due to mechanical deformation. That assumption doesn't totally account for the crawling sensation. But all of his other behaviors-- the facial guarding, the pain with distal motions seem to be related to protective spasms. As I type this, the crawling sensation becomes more, and more important to me--verbally the patient has said more than once " I can live with the pain, this crawling is really bad". So that would suggest a neurological origin( which I'm sure is on that list of 4 but not quite sure how to word it.)

I know there's a link out there for origin, source, and cause-- can you help me find it.

Geralyn
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Old 29-06-2011, 06:57 PM   #20
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I'll help, here is the thread Five Questions.

Thanks Geralyn for this case study. Did you Google - face pain skin crawling. It isn't an uncommon complaint. He could have had a seemingly inconsequential injury, or been born with cranial nerve defects that have resulted in chronic pain. Hopefully the neuro consult is a Sherlock Holmes type.

There is another skin crawling group who post and the majority report a varied size patch on the left shoulder with a tingle. itch or burn sensation. I myself get this and have noticed it for 4 years. They do report it occurring on face and legs.

Menopause symptom of skin changes accompanied by skin crawling sensation.

Some medications have a side effect that produces crawling skin sensation.

Skin Crawling can also be found in Dementia.

Thanks,
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Last edited by Karen L; 29-06-2011 at 07:14 PM.
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Old 29-06-2011, 11:14 PM   #21
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Karen, thanks for the link.

Yes, I've googled crawling face, and it looks that describes his complaint. If the source of se sation could be explained--or identified as benign, or appropriately treated I think he is perceived level of threat would decrease. If the threat is decreased, the pain output would decrease.
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Old 29-06-2011, 11:27 PM   #22
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Geralyn-
You are doing great. Your courage to step forward openly is the difference between someone who will grow and get better and someone who won't.

Four Origins of Pain
1/Mechanical Deformation
2/Chemical Irritation (temperature included here)
3/Ectopic Discharge
4/Central sensitization

Hypotheses could be named or essential diagnoses like: cervical radiculopathy, cervical myelopathy, brain tumor. They could be syndrome or nominal diagnoses like: mechanical neck pain with referred component.
If indeed his facial symptoms are related to his neck and shoulder area pain then we are dealing with a very atypical symptom pattern here.

I'd be interested in findings of a neurological screening exam including UMN tests as well as screening questions for visceral disease like for cancer or CNS involvement. This would help us determine what the origin of his symptoms was from a hypothesis standpoint as well as from a pain mechanism standpoint. A few targeted UMN tests could help with myelopathy and a ULNT could help with the radiculopathy possibilities.
With folks like these I'm cognizant that my differential diagnosis expertise is in appropriate screening and referral and not definitive diagnosis of things outside my area of training (like all medical professionals). So this seems an appropriate case for Neurology referral to me.

Does this help?
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Old 30-06-2011, 12:23 AM   #23
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Nice post JS.
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Old 30-06-2011, 04:44 AM   #24
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Neural Mechanisms of Persistent Pain

Professor Marshall Devor

The paradox of chronic pain, and its ultimate clinical solution, lies in the realm of neurobiology. Specifically, we need a better understanding of how neurons respond to injury. Accumulating evidence indicates that axonal injury triggers the generation of abnormal afferent discharge at ectopic sites in the injured primary sensory neuron. This ectopic hyperexcitability is an essential substrate of neuropathic sensation, both spontaneous and stimulus-evoked. Ongoing (spontaneous) neuropathic pain is due to spontaneous ectopic discharge. Since depolarization brings neurons to spike threshold, augmenting ectopic discharge, depolarizing stimuli such as mechanical displacement can augment ectopia. This brings about mechanosensitivity at ectopic pacemaker sites, the basis of pain on movement and on deep palpation. Allodynia and hyperalgesia are due to spinal amplification of sensory input from residual afferents in the injured nerve, and intact afferents in neighboring uninjured nerves. The spinal amplification process, known as "central sensitization", is maintained largely by ongoing ectopic discharge. (thepainweb.com)

Does ectopic discharge precede central sensitization? And if so should they be listed as 3 and 4?
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Old 30-06-2011, 04:56 AM   #25
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Quote:
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Does ectopic discharge precede central sensitization? And if so should they be listed as 3 and 4?
No, you can have all origins or more than operant at any given time.
I don't think we understand enough about how the whole process works to be 100% sure. Certainly there are people who are "pain researchers" who doubt central sensitization exists and/or can be the primary factor in a pain presentation - they usually are of the opinion that we just haven't found the right site to inject.
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Old 30-06-2011, 05:20 AM   #26
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I would consider ectopic discharges to be under the umbrella of neuropathic pain. Whereas central sensitization, according to the definitions set forth in the Kyoto protocol is

Quote:
Increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input
Ectopic discharges, by definition, are not "normal or subthreshold input" and thus can't be the same as central sensitization.

You could possibly have

3. central and peripheral neuropathic pain
4. central sensitization

If you want to narrow it down to three things, you could have 1 and 2 subsumed by "nociceptive pain". However, it wouldn't make sense to list nociceptive pain or neuropathic pain as an origin of pain. The point of the origins, I think, is to point to a neurophysiologic processes correlated with (and to it's antecedent stimulus), but not causing, the output of pain.

I think.
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Old 30-06-2011, 01:04 PM   #27
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Jon's on the right track, I think.

To me, an important question is, "When does central sensitization begin?"

I see no reason to assume that it doesn't begin immediately. When it becomes a real problem is another matter, but since education of some sort is our best defense against its growing, that should begin immediately.

Of course, this education should be offered by someone who knows what they're talking about.

Don't get me started...
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Old 01-07-2011, 03:04 AM   #28
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I saw my patient today. Pain remains at a 6, but patient is moving in a more relaxed fashion. As mentioned, I contacted the Dr. on Tuesday with my concern about the pain, and the crawling sensation-- which is really the patient's primary complaint. She actually called the patient in to re-assess him based on my phone call, but her first recommendation was to go to pain management. I told him that I felt it would be more appropriate to talk to a neurologist first, and I'm not sure what decision he is going to make. I spent some time talking to the patient, and we drew up a list of questions for him to take to the next physicians emphasizing that he is talking about 2 possibly different complaints, and that he is very interested in knowing where this pain came from.

Regarding testing: I assessed the ULNTT and they in no way influenced his pain.
I also assessed rapid alternating movements, finger to nose, finger tapping and this motions appeared symmetrical. I would consider his performance to be WNL, but haven't used any neuro testing enough to grade it accurately.
Visually I keep getting drawn back to his face-which pulls to left in an irregular fashion, and the platysma on the L which is typically contracted, but relaxes with Simple Contact.

I tried tape on SCM, and he immediately felt that all of the "pulling/crawling" in his neck seemed to be drawn to the tape, and somewhat decreased over the rest of his neck.

Did I mention that he can stop the crawling by placing his over his neck?

My impression right now is that pain in neck is secondary to the crawling. The crawling falls in the realm of the references on Google, and that the best I can offer him is pain management strategies.



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Old 01-07-2011, 06:08 AM   #29
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My impression right now is that pain in neck is secondary to the crawling.
It's probably more parsimonious to simply state that the crawling sensation is related to the chronic neck pain, in which case I tend to agree with you at this point.

I know that the "secondary to" phrase is what we medical folks always hear from our esteemed physician colleagues and read in medical charts, but it presumes causation, and I don't think we can make that leap with chronic pain problems.
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Old 01-07-2011, 07:28 AM   #30
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Geralyn,
You wrote:
Quote:
Did I mention that he can stop the crawling by placing his over his neck?
I guess you meant to write 'hand' over his neck?

I also would lump his symptoms together in the same basket of persistent pain and other features. Crawling sensations are often mentioned when people have long standing issues with chronicity. When and if resolution occurs, they tend to disappear over time simultaneously.

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Old 01-07-2011, 08:08 AM   #31
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I am reading this with great interest. I had a young (28?) woman come in today with pain all over, onset in 2008. She's seen an alarming number of docs, is seeing a PT. I'm assuming Explain Pain is a book and perhaps I should look for it. I am wondering about a lot of things. An elusive, yet undiagnosed condition? Is this an example of central sensitization? There have been various diagnoses - TMJ dysfunction, cervical spinal musculoskeletal whatever (which is what she's seeing the PT for) but none of it is a convincing reason for what she describes as pain all over her body.

This discussion - giving me vague ideas. What is simple touch? How can I find out more?

I am a massage therapist. Right now, I know a lot about what hasn't worked for her. She came looking for trigger point work, something I've done a lot of but don't think it is the right approach. Convinced her to let me do a very, very gentle 20 min. treatment (gliding & gentle vibration strokes) with the intention of calming the CNS, will repeat it again tomorrow & Sunday.

Am watching with interest your progress because of the similarity I see with the situation I've encountered - a lot of pain with no good obvious explanation and a very gentle approach & cultivating an attitude (?) of ease, mentally moving towards an idea of function. I didn't put that well, hope it was intelligible.
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Old 01-07-2011, 05:13 PM   #32
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Spontaneous sensations of any kind are manifestations of peripheral ectopic firing, are they not?

Explain Pain is indeed a book, a very good one. Alice, once you've acquired and read it, you would wonder how you could have done without it. It's also available from iTunes as an audible book.
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Old 01-07-2011, 05:34 PM   #33
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Spontaneous sensations of any kind are manifestations of peripheral ectopic firing, are they not?
That's a good question Diane. I thought ectopic firing was referring to the production of an action potential due to an increase expression of ion channels in the neuron, especially along it's axon. That would be in contrast to the production of an action potential due to the presence of an adequate stimulus (or the particular confluence of IPSPs and EPSPs) coupled with the usual expression of ion channels in the terminal buton.

This is a new area for me to explore. I found a reference--The tickly homunculus and the origins of spontaneous sensations arising on the hands.
along with this pdf, which looks promising.
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Old 01-07-2011, 06:08 PM   #34
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Thank you for those adds, Jon!
Upon reflection, I think any neuron you can name is probably bi-directional. Certainly sensory neurons seem to be: they respond to direction from more rostral zones and carry these out peripherally (e.g., production and maintainence of psychogenic rash), even as they carry out info-collection and deposition (their regular job) centrally.
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Old 01-07-2011, 09:35 PM   #35
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Originally Posted by nari View Post



I guess you meant to write 'hand' over his neck?
Nari
correct

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Old 02-07-2011, 06:20 PM   #36
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To me, an important question is, "When does central sensitization begin?"

I see no reason to assume that it doesn't begin immediately.
Or, at least, that it couldn't begin immediately. Yes, I agree.
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Old 03-07-2011, 08:08 AM   #37
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But how does one recognize it?
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Old 03-07-2011, 10:11 AM   #38
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First, one forms an impression from the interview. If things seem too hot to handle, I don't. Lots of times I try anyway, and sometimes it was only peripheral after all. If treating manually helps, then it's likely mainly peripheral. If it doesn't then it's central and there's no point in banging your own and your patient's head against a wall. Manual treatment won't make a dint in fibromyalgia, for example.
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Old 03-07-2011, 01:45 PM   #39
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I agree with Diane and I'm glad she mentioned fibromyalgia. I'm always asked about this.

I think it's important to determine how large a role position and use play in the tendency to hurt more or less. Since mechanical deformation is a peripheral problem, these are significant factors.
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Old 03-07-2011, 08:50 PM   #40
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I just saw a full blown Fibromyalgia case last night, so thank you for the reminders Diane and Barrett. I Did education for basic stress and activity and suggested aware breathing, as well she does some gentle yoga. I found her skin hanging loosely and seemingly without connection to her body. I was very challenging to massage her. There was one tiny little spot of defense on the right shoulder and everything else was paradoxically slippery.

She had Rheumatic/Scarlet fever when she was a child and has been this way most of her life. I wonder if her DRG's got messed up. Any way remembering manual therapy doesn't make a dint will help. I am still going to suggest Feldenkrais to her if she can do a bit more in addition to the yoga. I told her about watering the grass and breathing (I'll work in the treat angle next week). Social touch at this point is what I'm doing and so cognitive edu. Hopefully I won't trigger a migraine on her.

Geralyn there was a crossed hands paper around here recently Moseley and Iannetti both have done some mid-line studies. Since the man can alter his pain by touching the affected area it might be worth looking up the abstracts.

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Old 03-07-2011, 09:52 PM   #41
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These last few posts illustrate the difficulty in determining the difference between peripheral irritation and central sensitization. We discussed this a great deal in the "More Than Placebo" thread.

I think manual care can be used as a form of graded exposure in conjunction with education etc in cases of central sensitization such as Fibromyalgia. But I think more active approaches should go along with that.
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Old 04-07-2011, 02:05 AM   #42
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Jason - I'll check out the "More Than Placebo" thread.

Barrett - I've worked with a number of clients who have been diagnosed with fibromyalgia over the years, do short (20-30 min) very, very gentle massage treatments, the intention being to calm the CNS. They tell me it helps reduce the overall intensity of symptoms and frequency and severity of flare-ups.

To whom would you refer and what would be the preferred treatment?

And I've got a copy of Explain Pain on its way to me.
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Old 04-07-2011, 02:26 AM   #43
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Alice,

I would never suggest that the sort of treatment you describe wouldn't help, but in the world of PT I couldn't justify it to a third party payor.

I see people in pain for whom I can find movement toward correction. Without mechanical deformation as a primary origin I struggle - and I personally never found anyone near me I would send a patient.
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Old 05-07-2011, 01:46 AM   #44
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Yes, I understand. My clients pay out of pocket so third party payer isn't an issue.

I'm halfway through the Placebo thread. Wrapping my head around all this information, trying to make sense of it? What does it all mean in practice? That's some of what I'm hoping to figure out here.

If you struggle, I don't feel so bad then. For some, I'm the first person they see because I'm very accessible. Maybe I can help, maybe they need more or something different. It might be what I do with my hands, it might be information I pass on to them. I know my interaction has helped some folks get out of pain. I have other practitioners I can refer to - MDs, PTs. (I don't refer directly to PTs but can suggest.) Other clients have seen all sorts of doctors, PTs, alt med people. They've been through the gamut. At least the scary stuff has been ruled out - no cancer, dreadful diseases. Often I can give at least a little temporary relief and for some, that's better than nothing. I struggle when I can't be more helpful and feel inadequate. Then I think, well, other folks who know a lot more than I do didn't know what to do with them, either. I keep trying to learn, understand, look for that which is most likely to work.

I often think of Diane's description as a social primate groomer. I can relate to that. And also how I can more successfully shift from being an operator to an interactor.

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Old 15-07-2011, 09:02 PM   #45
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Default billing question

I have to address this question to the US PT's.

I taped for the neck pain the other day. The patient is cautiously optimistic, and we tweaked the position of the taping. (head to the taping from behind the ear while turned to the right from right to left, and from left to right while turned to the left)

Typically when taping I would bill for "strapping supplies, and then indicate the area--neck strapping. We keep tape in the department, for tape trials, but the patient is responsible for providing tape after the initial use of tape.

Strapping is defined as the use of tape to maintain/control the position of a joint, and as I my boss recently pointed out, there is no strapping charge for necks.

My bosses question: what are you trying to do with the tape?
My answer: I am using to tape to alter input over the patient's neck to provide the brain with novel input that will allow it to reassess the perceived threat level, and and hopefully decrease the protective spasms, and associated pain.
My bosses suggestion: It sounds like it can be billed as Neuromuscular Re-ed. She would like to know how others have addressed this billing concern.

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Old 15-07-2011, 09:18 PM   #46
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My patient feels that he is moving better. He feels that the crawling sensation may have decreased somewhat, but continues as a constant sensation. He believes the big change has been in his response to the crawling sensation, in that he realizes I don't think he is crazy. There is little evidence of guarding in his motion anymore. The motion in his platysma is constant except with use the use of DNM in supine with emphasis on the area over the origin of SCM, and over the C2 transverse process L versus R. The other day, he completely stopped twitching while we treated the anterior Cervical Plexus.( A first--and therefore in my opinion justification to explore this avenue a little longer)

Perceived level of pain now fluctuates between a 7 and a 4. There is little guarding in his ADL, and he reports getting more done with less distress. He has not yet gone fishing--which is on his list of goals.

Plan right now is to continue to encourage visit to neurologist(at this point the patient doesn't seem to visit a neurologist) and use DNM for 2-3 more visits. At the point-- if he only realizes relief of that motion with my hands on, then I can't justify further treatment.

Thanks for the suggestions, and the directions.


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Old 15-07-2011, 10:18 PM   #47
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Geralyn-
I think if you can't use the strapping code then 97112 Neuromusc Reed sounds good to me. I don't think it is particular regarding equipment or methods.
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