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

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Old 26-06-2008, 04:35 AM   #1
Erica
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Default Interesting case of bilateral arm pain

Well, I thought I would post this case as I saw the patient today for the 1st time. I think this is probably one of the worst cases of neural tension, sensitized nervous system I have ever seen.

Briefly, 34 y/o male ex police officer -chasing a suspect 5 yrs ago on the beach, tripped over a wire and took a face plant to the left in the sand. Next day entire left arm was purple. Has seen multiple MD's, PT's-got stuck in the workman's compensation system. ALot of gaps in therapy and testing. Diagnostic testing fairly unremarkable-emg's revealed some median nerve damage-(he was unclear -didn't remember). Ended up having CTS surgery in 2005 with no relief. One MD wanted to remove a rib.

He presented to me with bilateral UE pain, pins and needles from the "ears into the tips of my fingers"-worse on thumb, middle and ring finger. Also, vice like migraines. Lifting his children, carrying things all aggravate. He also has the typical temperature and color changes-but not as drastic as previous. He has returned to school to study political science. He seems quite legit and motivated.

I won't list all the objective findings so I will be brief. Cervical Spine-fairly stiff with general hypomobility t/o. No repro of sx's with movement, overpressure or p/a vertebral assessment. Wickedly elevated left 1st rib-with repro of left ue sx's. Thoracic spine-p/a assessment-repro of sx's (bilaterally). Slump test-positive -repro of both ue sx's. SLR: also positive in that it reproduced the UE sx's. DF of the ankle made his UE sx's worse.

At the point, I said to myself -do I dare try the median nerve test? Well, I did-got the guy in the test position-did not do any sensitizing maneuovers- and his sx's were reproduced. I did not bother to test the other side or finish the other nn tests as I knew they would be positive. Strength was 3+ to 4 t/o UE. Grip was like 2#- he has note takers at school and uses voice activation for the computer.

Pec minor (B) was somewhat stiff and scalenes were all quite boggy feeling. I did a gentle skin stretch along the forearms just to test the sensitivity and his sx's were all reproduced.

He has had success with use of a foam roller, a home cervical traction unit. What has also really helped has been the use of the "Peter Edgelow" protocol as he describes it. I checked his web site-sounds like he has done alot with TOS. But I am not familiar with his work.

Today, I did alot of pain education and explained the whole neuromatrix theory to him. I told him that some gentle movement techniques would be helpful for him to do-he said he had tried some "Chi Gong" and it helped awhile back.

I thought I would try the mirror box at some point-but since his sx's are bilateral-it may screw him up. This guy's nervous system is so wound up that I am going to have to try baby steps to start. I have a few ideas on what I am going start with but I figured I would put it out to the group to see if anybody else has some suggestions as well?

Thanks!
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Old 26-06-2008, 06:08 AM   #2
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Whew, Erica. You have a challenge ahead. I've seen quite a few such patients in the pain clinic where even breathing near them reproduces the Sxs. Just kidding.
Just a few suggestions:

Try very gradual SLR, starting with minimal provocational totally passive lift and lowering?

Try DNM away from the UEs - perhaps on the thoracic/TLJ area?
What might happen if he strokes himself for a couple of seconds at a time and then, depending on outcomes, repeats this a few times more?

Try SC? No threats, no touching...

How does he manage dressing himself? That can be an interesting insight into the level of his fears/concerns about docs and therapists.


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Last edited by nari; 26-06-2008 at 06:11 AM.
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Old 26-06-2008, 02:44 PM   #3
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Hi Nari,
Thanks for the reply. You're not kidding-this will be a challenge. Good suggestions on the SLR and the DNM. Interesting question on the dressing. I will ask him. I think he will be ok. He seems to push through things. One other thing I forgot to mention was that WComp would not pay for pilates for him but they would pay for vocational training. So he became a certified pilates instructor. So in addition to the school, he teaches pilates part time.
Will see him tomorrow again.
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Old 26-06-2008, 03:43 PM   #4
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Erica, have you tried DNM for the T spine?
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Old 26-06-2008, 04:59 PM   #5
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Hi Diane,
I just saw him once yesterday for the Initial eval.-his history took so long and with my objective exam I just did some pain education. I will see him tomorrow morning and will try this.
Thanks!
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Old 26-06-2008, 07:44 PM   #6
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Hi Erica,
This is a tough one. Has anyone mentioned CRPS? Did he have a C-spine MRI?

I would think he's had at least one since his injury, what did the report say?
Regardless, this patient will likely benefit from a multidisciplinary approach.

I have a patient who suffered a very serious industrial accident and is in
a very similar spot as your patient. We found that a combination of acupuncture
and lower cervical spine adjustments (via a Pro-Adjuster instrument) has provided
substantial relief.

Erica, just out of curiosity, do you perform a neurological examination
on your patients? If so, could you describe it? Just curious, that's all.
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Old 27-06-2008, 01:23 AM   #7
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Sounds like several of my patients. I put them on an air mat (from Upledger) with whatever positioning gives the best relaxation and then look at their breathing. With a few patients, just moving a finger or a toe will produce a pulling sensation. Lately I've been trying rotation of the skin/muscle mass around the long axis. I try to work just proximal to the symptoms. (Thanks, Diane)

In the neck, I use ant-post sliding of the skin/lateral muscle mass (depending on how deep I want to work) combined with "letting the air out" exhaling to loosen the scalenes.

If he's been using Pilates, I suspect he is very good at holding on. Maybe not so good at letting go.

I progress to eliminating the air mat, flattening the table, increasing costal and diaphragmatic excursion in both directions--caudad first. Also arm abd / ext rot and elbow ext in full supination, full pronation. In any order. If the toes are scrunched, then they, too are treated. Just straightening the toes can produce wicked pain at a distant site.

Thanks again to the contributors here, I'm adding periods of ideomotor movement, when I can detect it.

Hope this might help.
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Old 27-06-2008, 03:41 AM   #8
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Luckbox and Mary, thanks for the replies. He did have a c-spine MRI awhile ago-he wasn't sure of the exact report-but he said he had a herniated disc at c2-3-which seemed kind of odd to me at that level-he really did not remember. I mentioned CRPS to him but no one else had. I do perform a neuro exam -the extent of it depends, obviously on the patient. With him, just listening to his subjective-I had a funny feeling all of his neural tension tests would be positive. Reflexes were hyper. He did not have any major myotomal deficits-but he was weak. I could have done cranial nerves but did not have time. Sensation was a little off-but given the chronicity of his problem- I believe his alarm systems need turning off and that he doesn't have any sinister pathology going on.

Mary, thanks for the suggestions-I know some of the diaphragmatic breathing he did in the Edgelow protocol was helpful.
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Old 28-06-2008, 03:04 PM   #9
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Saw him yesterday and the day before he had a taken his twins to the doctor for some shots and he was somewhat flared up b/c he had to hold them alot while in the office.

I did some DNM on the thoracic spine-what I thought was real gentle work seemed to bring on his sx's - so I lightened up and it was better. Guess I need some more practice (talk about a challenge!) His skin is so thick back there-you can't even pick it up. I also did some basic low level maitland on the t spine-which was fine, worked on the rib a little and did some SLR's-very passive. I took his leg about 30 degrees and his sx's started up. I reduced the range and he was fine. In the end, I did not flare him up-which to me, was a success.

We were talking about the Edglelow program and it seems very "butleresque" with a smattering of Feldenkrais. Is anybody familiar with it?
Thanks!
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Old 28-06-2008, 03:23 PM   #10
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Quote:
His skin is so thick back there-you can't even pick it up.
That's a big clue to me that his dorsal cutaneous nerves likely need more DNM, rescue, resuscitation... If they can be helped to breathe better, chances are higher that his pain and/or sympathetics might downregulate some day. The lighter the better. Get out a picture of the T2 dorsal cutaneous nerves and note how extensive they are. If you don't have much time, focus on them in particular.
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Old 29-06-2008, 03:11 PM   #11
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That sounds right Diane. He was so wound up back there. I see him tomorrow again and will spend some more time on that.
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Old 29-06-2008, 04:23 PM   #12
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Something I've started doing lately (as I get bored with one way of doing something I move on to another..), is a grasp technique. It won't kill the hands because the hands don't move or press, they just grasp. Good for back areas where there is so much cutaneous congestion the skin feels like thick hide.

Fingernails must be short short short. Finger tips go onto spinous processes. Hands settle onto the skin over the paraspinals. Wait for skin to stick to skin. Then, slowly and carefully, see if you can lift just the skin layer up. It can become a little game you can play with your own brain, "how slow can I do this"? The slower the better, because the more you can not be a threat to the front part of the patient's brain, the better it will "feel" to the patient, and the more isolated the bits that automatically register the contact as potential predation, will become. If you go slow, but hang in there, the skin will soften eventually. You have to be able to maintain this for as long as 5 minutes, even longer, as long as it may take, each side, without moving, your own kinesthesis focused 100% on taking up slack as it makes itself available.

I have found that this can tame the cutaneous output of the T spine, never any need to pop it or twist it or do anything for joints that are supposedly misbehaving deep within.
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

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Old 29-06-2008, 11:26 PM   #13
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Nice idea Diane. Will try it and report back. I have a funny feeling that it will take more than 5 mins with him!
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