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Clinical Reasoning Typical cases are discussed there. The cases are brought by practioners.

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Old 22-09-2006, 03:51 AM   #1
EricM
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Default Harrington's Rod

We write on this site of cultural factors inhibiting the expression ideomotor movement. Some of us have even learned how to help others overcome this. I have been helping a young woman with another kind of inhibition to normal movement, a Harrington Rod.
In brief, she is now in her early 20's, a very bright college student. When she was either 16 or 17 she underwent the Harrington Rod implantaton to 'correct' a major thoracic scoliosis. I did not know her at this time, so I can't comment on the appropriateness of this type of surgery for her. I can can only assume the surgeon proceeded with her best interests in mind and hope that the outcome was as intended.
As an unfortunate consequence of the surgery she has been left with a 15 degree flexion contracture of both knees. Apparantly they were fine before surgery. They still do cause her some discomfort and she uses an elbow crutch to ambulate any significant distance. This isn't however why she came for physiotherapy.
About 2 years ago she developed right shoulder pain. This is when she first arrived for treatment. Nothing exceptional in this presentation, however this pain has proven remarkably persistent. More recently pain has spread to her left shoulder and neck. She finds it extremely difficult to sit in lectures for any prolonged length of time, similarly working at her computer is quite painful. She is most comfortable at rest.
She has full range of motion and all imaging has come back negative. She is definately not very strong, but as we know this has nothing to do with her pain. Attempts to exercise (lead an active life) of course has been difficult for her, because it hurts.
I do not find any indications of elevated central sensitivity or ramp-up type pain in her presentation. Although the pain is clearly taking its toll on her, she is remarkably pragmatic about it all. She demonstrates abnormal neurodynamics in all major upper extremity nerves and fluctuates between overt and covert symptoms.
What strikes me most is how this steel rod holding her spine still severely restricts her potential to move towards comfort. In spite of my best efforts to increase the adaptive potential of her nervous tissue I keep coming back to the fact that her spine isn't permitted to move, its the last stumbling block so to speak. Education, ideomotion, dermoneuromodulation, neural glides, they are all getting tripped up somewhere.

Has anyone else out there worked with patients with a presentation like this before? How can we help her? I have invited her to read here if she wishes.

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Old 22-09-2006, 04:07 AM   #2
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I realise that there are not likely going to be any easy solutions to this problem. I think I wanted to post though for the simple reason that this case reminds me how important movement of the spine is for us. Makes me wonder again why the heck anyone would want to spend countless hours training muscles in order to hold it still.

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Old 22-09-2006, 04:44 AM   #3
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Eric,

Thanks for taking the time to post regarding this situation. I am often asked about the potential for internal hardware to restrict motion as you describe. I say that these patients aren't typically part of my population and suggest others who see them search through the response to Simple Contact followed by ideomotion that they learn to elicit. So far, none of my usual students have followed up in any way. You, by the way, I don't consider a "usual" student.

Similarly, I am asked about patients with limited cognitive abilities. I say, "Go where they are and meet them there. Let us know what you've seen happen."

Again, zip.

Anybody else out there?
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Old 22-09-2006, 05:04 AM   #4
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Eric, does the use of the crutch have anything to do with the shoulder pain? Same side or opposite side? Is she right handed?
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Old 22-09-2006, 05:30 AM   #5
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Diane, while the crutch may contribute some additional abnormal stress to the shoulder I doubt it is all that important in this case. It permits a degree of mobility that otherwise might not be achieved, so it's important for her quality of life.

Barrett, I've been wondering about the implications of physical restraint. I should look through Scarry's 'The Body In Pain' to see if there are any insights there. I suppose the stress on the 'mind' must be enormous. Unlike cultural restrictions, there is never any opportunity for respite. While we may walk around town keeping our spines straight and our stomach's tucked in, we can go home and behave a bit more authentically, someone who is restrained cannot. I wonder what the premotor cortex would look like in this case? Confused?
I will maintain that we should be able to work with the inherent plasticity of the nervous system to create a system that can tolerate even severe, permanent restrictions to movement. It just might take a little longer.

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Old 22-09-2006, 06:17 AM   #6
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The testimonials on this The Neurology and Neurosurgery Forum are very interesting.
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Old 22-09-2006, 07:04 AM   #7
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This thread caught my attention rather quickly. My wife had Harrington rods placed in her back at the Scottish Rite Hospital when she was in 7th grade. She is now 27 y/o and has yet to have problems associated with the surgery and I hope they remains true forever. I can only imagine what a brutal surgery this must be. I suppose scar tissue could rear its ugly head sometime in the future, but surely this would have presented before now.
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Old 22-09-2006, 08:19 PM   #8
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Eric,

I work with scoliosis cases fairly often. I have some suggestions on what I would look at, please excuse my detours between ectoderm and mesoderm. When working with patients with rods we cannot change the loss of motion of the spine, but my goal is to maximize the respiratory mechanics. This patient sounds as if she is hyperinflated. What I mean is if she cannot breath effectively with her diaphragm she will be forced to meet her oxygen demands with neck muscles, this situation also leads to changes in rib cage position and shape, therefore leaving the scapulas in a dilemna of seeking a resting position( inhibition of ideomotor activity is soma speak). I think Diane would agree that this can lead to improper influences ot the nervous system. There are a lot of studies on the ill effects of hyperinflation so I won't list them here. My goal would be to get this patient to improve ability to exhale enough to allow for a Zone of Apposition on the next inhalation. I could foward you information on technique if you want. I know my comments will be met with scrutiny, but if she can breath easier then you may be able to achieve the other goals you mentioned above. This is one case where changes to the mesoderm have long lasting physiological changes.
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Old 23-09-2006, 02:43 AM   #9
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Thank-you Raulan,
I will look more closely at her respiratory pattern. I suppose this may be one important reason why a surgeon would try to straighten a severely scoliotic spine; to improve respiratory dynamics. Apart from cosmetics hopefully.

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Old 23-09-2006, 04:04 AM   #10
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Speaking of breathing, don't forget that abs are innervated by roots from T7 to T12. Those roots have to be able to move through the layers of ab wall. I asked about the crutch because of a tendency to tighten up through the axilla with downward pressure through shoulder depressors, leading to all sorts of weird suprascapular nerve or axillary nerve entrapments (among others) and funky subsequent scapular behavior.
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