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Old 07-02-2009, 01:21 AM   #1
Frédéric
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Default migraines because of knee pain!

Ok, I just assessed this 19 y/o girl, a bit shy, with multiple symptoms, of pain mostly. I want to talk here about her case because she actually kind of fit a specific type of young adult I assess from time to time.

So I will give you a summary of her initial assessment and will invite whoever wants to comment on it afterwards.

She went back to school to study to become an esthetician and she's working part time in a grocery store. She is not normally doing any physical activity.

Priors (in french : ATCD)
hx of left side migraines w/phono-photophobia that started 2 years ago (she says it runs in the family)
No other health condition known

Hx : Last winter, she mildly fell on her right knee, it did not bruise. It was a bit painfull afterwards but the pain really only started after her conditionning class, a week later, during which she started to feel an important increase in pain to the left side of her knee. She can't recall what actually caused the pain to increase during the class. The pain slowly subsided but never completly disappeared. Then this summer, she started to have LBP, also to her right side. She underwent some physio at another clinic where she mostly received electrotherapy both to the back and her knee with no results. She then started to experience right sided migraines that follow her LBP. She also went to a foot specialised orthodic clinic that made her some foot orthodics. She has been wearing the orthodics for 2 months with no improvement.

The foot orthodics clinic sent us the patient for the migraine issue.

One of the first thing she said was that her knee was responsible for all her pain. Migraine included.

P1 = pain on both sides of the patella 3-4/10 she says it's constant but it is obviously not. I asked her during the eval if her knee was painfull in this or that position and she answered no many times

P1 increases with half squat, prolonged sitting w/ knee bent and standing still
decreases : if she moves.

P2 = right LBP in the area of L5-S1, can't really quote the intensity.
Increases w/ prolonged sitting/standing/school/work-lots of walking involved
decreases : don't really know

P3 = frontal and temporal burst pain, appears when the back pain is present for a while
decreases when she just puts her hand on her forehead.

I did not ask about any psycho-social issues as i felt I would have gotten an untruthfull answer.

Objective :

observations :Unexpressive. She moves quite like a normal person though, no antalgic attitude whatsoever

Knee : pretty much nothing wrong! that I've noticed at least. Looks/feels/moves quite like the other painfree one.

Hips : all tests WNL

Lower back : ROM : slight pain at end range of flexion and left side flexion is more painfull on on the R L5-S1 area but barely restricted

Neural signs are all negative
SLR and PKB : pretty symetrical aside from a slight complain of barely noticeble pain on the patella on both test.

PVIM's : pain and stiffness (I know...) in R L4-S1 flexion. That stiffness slowly decreased as I went up the spine. It felt like a muscular restriction.

P/A's slight pain and stiffness on L4 and L5 R side

Palpation : tension on the paraspinal muscle of the R side.

The rest is pretty much WNL.

Cervical : normal mobility and neural exam.
the only positives are : pressure on sub-occipital area, pinching of the SCOM and PIVM's of the cranio-vertebral area all produce a frontal pain.

Did not have time for ULNT, CPF is negative.

That's pretty much it.

If I had not monitored pain during the assessment I probably would have found nothing wrong with her.

So, I basicaly just want to know what you think of a case like this one. Would it fall into the Symptoms of Unknown origin categorie ?

Do you think her CNS is sustaining the symptoms with dowregulation maybe for some unknown psychosocial cause ?

I'm just trying to think out the, old meso, box here !

Thanks

Frédéric
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Old 07-02-2009, 01:29 PM   #2
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dear Frédéric
In this case I would really like to really like to look at her from a bindegewebsmassage point of view.
But this cannot be done....through the web
but... its "working principles" are fairly similar to elastic tape.......

How about putting a little tape on the effected "stiff" areas
By applying a small strip of tape parallel to the spine on both sides you might find she will have" a reaction". Maybe even a very positive one.

Esther
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Old 07-02-2009, 03:28 PM   #3
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Check out "Taping a knee" thread

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Old 07-02-2009, 03:32 PM   #4
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Diane also had a link to this site

http://www.medicaltaping.com/Medical...ing%20Concept/

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Old 07-02-2009, 03:34 PM   #5
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Frederic,
Sounds like alot of the patients I see, lately! I had a patient very similar but she presented at different times with the same complaints as your patient. Currently I am seeing her for migraines. I was able to manage her with alot of neurodynamic techs and alot of education.

You have to start somewhere. I would start with the education part. If she thinks everything starts with the knees then start there if you want. Was she tender anywhere? Was PKB in the s/l slump position? Any sympathetic changes? I have found that kinesiotape really helps there.

I would then move quickly to the spine. I also look at Thoracic (my bias!) spine and just check out what's up there. When you have time, check out all ULTT.

This could be a case of ongoing knee pain sensitizing the whole system resulting in mal adaptive changes elsewhere.

Just my thoughts.

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Old 07-02-2009, 03:47 PM   #6
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Quote:
Originally Posted by Erica View Post

This could be a case of ongoing knee pain sensitizing the whole system resulting in mal adaptive changes elsewhere.

Just my thoughts.

Erica

that is pretty much my guess too

The idea is now to de-sensitize it !

The neural mobs are all allready in my plan

I'm not too found of taping anything, but for DNM sakes, I might try it this time.

Thanks, I'll try to post back as I see her in the coming weeks
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Old 07-02-2009, 04:15 PM   #7
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Frédéric, her symptoms make total sense in terms of neural irritation.

1. History of headaches etc in family. She gets headaches two years ago.

Psychosocially there could possibility be a bit of a sense of inevitability she feels, maybe some doom associated with this.

Quote:
One of the first thing she said was that her knee was responsible for all her pain. Migraine included.
If this makes sense to her, then for some reason it makes sense to her nervous system. It might be that a particular flavour or pain perception/quality of the headache became much worse after the knee pain started.

2. Then about a year later, she fell, dinged her knee, later it got worse during an exercise class (did you ask if the class involved stair-stepping? Maybe while holding light weights?).

Quote:
she mildly fell on her right knee, it did not bruise.
Quote:
she started to feel an important increase in pain to the left side of her knee.
Do you mean, medial side of right knee?

3. Then later she develops back pain:
Quote:
she started to have LBP, also to her right side
OK, so the history is pretty straightforward. She's got pain, which developed in those areas in that order. Prior attempts to help, including some well-meaning but erroneous perscription of orthotics, have failed.

The mystery:
I would approach her as the mystery "novel" that she is and follow the clues. There are no "objective" (i.e., mesodermal clues) here, really - so you have to follow the ectodermal clues (her pain story, her pain presentation, her pain perceptions) instead. And they are not definite, so they always have to have wiggle room left around them. You have to accept that you will never know most of this stuff for sure. It doesn't matter much, what really matters, to her, is the pain, and to you, helping her to snuff it out of existance.

The setting:
Remember that the "nervous system" includes/contains everything that can sense, from skin cell to construct of self ( "I" -illusion).
1. It includes her family too (they are still in her brain map of her "self" and her "body," because although she's at an age where she's trying to separate out from her family, she is not yet an adult.) (Soon it will include you too. Try to help her sensory system become less confused.)
2. Also, the individuation part of the I-illusion (at least the necessary neuroplasticity of it) is often in direct conflict with the non-conscious, still emotionally bonded, bits of brain (and females have a lot more association cortex to deal with. It's a hard time to be a female, that age. Stressful. Easier for boys usually, I'm pretty sure).
3. Plus her frontal lobes aren't all grown in yet, so she does not yet possess full executive control of her life.

To me, this is all "bio-".

The plotline:
Her first pain shows up. It's a family familiar type of pain. It's the family headache. It's part bio, perhaps, but maybe there is psycho- and social- in there too (refer to "the setting" above). Maybe she hates having headaches (oh no - the family curse), or maybe in some weird way they feel reassuring at the same time (ah, I know who I still am, to whom I belong). I don't know about you, but to me that pain could also be spelled c-o-n-f-l-i-c-t. If they are period-related, they are likely chemically sensitive headaches, which means the rest of her peripheral nervous system may be sensitized to all the prostaglandins and whatnot that float around the body, cyclically.
Anyway, whatever the case, central sensitization of some sort may have been installed congenitally, which may be mixed with some peripheral sensitization of nerves around the outside of her head. We don't know that for sure, but the possibility exists and we must entertain it. In any case, head pain preceded the rest. That much we do know for sure. Then after her knee started hurting her headaches changed. Intensified. Got worse. Got more painful. Whatever.. darn that knee.

The plot thickens: sorting out the clues
Then she fell on her knee. Had it not been for the conditioning class she might have been fine, but something else happened - she developed, for sure this time - peripheral sensitization.

1. The reason I wonder about stairstepping is because the knee, or more accurately the neural structures around the knee, mainly saphenous if it's medial knee, might have been made vulnerable by the fall, then sensitized by repetitive movement in the class which involved hip and knee together.

2. The reason I wonder if she held weights, is because she would have had to stabilize with lats and abs. Overusing those two might have irriated her lateral cutaneous nerves and dorsal cutaneous nerves, plus all the ones that stream around through the body wall to the front of the hips, setting her up for back pain down the road.

If this is so (it may have been something such as point 1 and 2, or it may have been something else), her non-conscious brain lost its ability to down regulate. Simple as that. Hopefully just through inexperience.

Solving the mystery:
There really isn't any way to treat someone like her mesodermally, because there is "nothing wrong" - with any mesoderm, that is. But, there are still lots of things to treat.

1. Those nerves would be a good place to go. They probably would appreciate some care/feeding/oxygenation in the short term. Some tape maybe. It's important to stress that there's nothing magic about your handling or the tape, that her brain is doing what it's meant to do, and your treatment is just helping it to remember how to do its job..
2. It would likely be helpful to explain pain to her on some level she could understand. It might not sink in for awhile, but eventually she would have it to draw on. After all - she's going to be sharing that body with that brain for a long time.

When helping a brain to neuroplasticize its way out of pain, with manual therapy, there are some basic rules involved:
  • Let her brain lead the way during the actual contact
  • Lighter is always better than harder
  • Slower is better than faster
  • Lingering is better than jumping around
  • More space between visits is better than less space
  • The patient should report significant improvement each visit
  • Most patients will be "better", as in ready to discontinue, within a span of 3 to 5 sessions
  • Be completely happy for them and let them go off to live their life as a normal person, not as a lifelong "pain patient."

End of the story:
There really is never any end to the story. People move on, hopefully better, hopefully never just the same or worse, from your care. You want them to move on, in better (i.e., less painful) condition, and with a better understanding of being embedded in a "human anti-gravity suit", and go on to maintain a better, autonomous relationship with it. People will go out and will ding themselves again at some point, but hopefully your care has helped innoculate them against making a big deal out of minor booboos, at every level of their nervous system function.
1. You have impressed upon them the fact that neuroplasticity exists and is real. (This provides basis for hope).
2. You handled them well (in a boundaried and caring way) physically. This has helped them relearn pre-emptive interoception, reaquainted them with their own insular cortex (where body maps and limbic system integrate input) from 'helpless baby' mode on through to 'adult'.
3. Your matter of factness has reassured them that they are indeed normal, not some freak of nature who will require huge maintenance.
4. Yet, by treating them well, talking to them with care at whatever is their level of understanding, by not hurting them physically, or frustrating their brain defences by trying to push through them to get to the deepest bit of mesoderm right off the bat, you've convinced them that you recognize they are special nonetheless.

...........
The end.

PS: I just read Erica's post about the thorax. Absolutely, leave no stone unturned. Help her system downregulate itself everywhere, including the head and anything that could feed upward into it.
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Last edited by Diane; 07-02-2009 at 10:02 PM. Reason: My poor spelling
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Old 07-02-2009, 07:48 PM   #8
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Frederic,
I really can't add anything more to what Diane has posted. The chain of events, starting with the 'family history of migraine' is typical of a sensitised nervous system. The nerves are ready to react (or not) depending on the context of the situation; for example, some of the tests you did produced no pain when in (old) theory, they should have.
As others have said, look at ULNTTs and thorax.
Diane stated:
Quote:
There really isn't any way to treat someone like her mesodermally, because there is "nothing wrong" - with any mesoderm, that is.
That's your biggest advantage in improving her neural system responses right from the start.
All you have to watch is to assure her that there is nothing wrong with her muscles and joints and she is not to blame for her pain in the conscious sense.

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Old 07-02-2009, 08:26 PM   #9
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That was an excellent post Diane. I like it very much. Especially the list in solving the mystery. It really relates to the from meso to ecto thread by Jason.

About were she feel the pain on her right knee, I kind of made a lapsus or wrote to fast :

She fell on her lat side of right knee. mild pain there. After conditionning : increase of pain lat side of R knee. Over time, the pain is still present on lateral side of knee and also on the medial side sometimes. But that is her story. Over a more than 1 year period, I don't know how reliable that pain localisation is since she can't really pinpoint a specific location and she is not reliable on other subjective questionning. Like the constance of pain for instance. And well, that confabulation issue brought somewhere (causes confusion I think) by Barrett seams to fit her description in part.

Thanks very much
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Old 07-02-2009, 08:26 PM   #10
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Diane, you have a unique way of explaining things that make so much sense even with the most "complicated" patient.
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Old 07-02-2009, 09:57 PM   #11
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Thanks Erica, but everything I knew how to write for that post stems from the neuromatrix model. Which I forgot to mention in the post itself, so I'm back with the addendum.
Frédéric, glad it made sense. So might your patient, and so might a more ectodermal line of reasoning.
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Old 13-02-2009, 05:25 PM   #12
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Saw her today.

Smiles more, seems less shy.
I had asked her to find ways to decrease the various pain :

She isn't able to decrease her LBP in sitting regardless of her sitting positions
She did have somewhat less migraine pain last week while keeping her head sidebended on the right side as she writes (she as a tendency to normally do just the opposite she says).

She is pretty much pain free before the treatment.

Somemore assessment I did :

She now recall doing leg press when her knee pain increased
ULNT 1 decreased rom w/out pain right side (by 15°)
Tweaking with PF and IR, the SLR did reproduce some knee pain.
While supine, keeps her right leg slightly internally rotated.

Treatment today :

SLR+IR+PF mobs
med patella glides in a SLUMP and PKB-SLUMP position
some DNM lat side of knee

Some DNM lumbar with some neural tension in the leg (slightly)
Flexion L4-S1 in SLR gr3

C0-1 decompress
Flexion C0-1 with and without ULNT1

Exs : self SLUMP at home
self ULNT1 at home

Some nerve-pain education.

Painfree too as she leaves
did feel some slight pain lumbar and knee while doing some nerve mobs but it subsided right away

Seeing her beginning of next week, so will try to keep you posted on improvement.

Ciao

Last edited by Frédéric; 13-02-2009 at 05:28 PM.
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Old 13-02-2009, 08:40 PM   #13
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Looks like both of you are on the right track.
Interesting she has "swapped" sides with her neck position, but that is the nature of neural sensitivity, the perception moves around. When she can sit with her head in neutral, with comfort, her LBP should subside. Hopefully.
I'd look at the slight IR of her leg in supine and see if she can correct that; just touch the leg on the lateral side a few times and see what happens. Barrett considers this IR positioning important to resolve and I agree with that, clinically.

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