Case of the Week 11-5-13: Win Some, Lose Some... then Win Some Again | Modern Manual Therapy Blog

Case of the Week 11-5-13: Win Some, Lose Some... then Win Some Again

Recently, I posted about knowing when to throw in the towel. This lately, has been for me 2-3 visits, instead of my customary 4-6 visits. This case seemed like the textbook cervicogenic HA, only it wasn't.

The eval was as follows:

Subjective: 24 yo female reports getting hit by a softball on her chin, forcing her head and neck into extension 7 years ago. She had daily HA that improved with treatment by a TMD specialist. She still had intermittent cervical and cranial pain, but not daily. In June of 2013, she was hit by another softball the same way and since then has daily HA starting in the occiput and radiating to frontal cranium. Sx are intermittent, but felt daily, onset only in the evening. Sx rated 8/10 on average. Nothing improves her complaints.


key: F = functional (WNL), D = dysfunctional, N = non-painful, P = painful, PDM = pain during movement, ERP = end range pain, LRF = lat rotation and flexion, MRE = med rotation and extension

flexion DP min
extension FN
Rot/flex Left FP Right FP

depression WNL, R> L early click on R

Rotation Left DP mod Right FN

LRF Left FN Right FN
MRE Left FN Right DP

Breathing: DN - sternal, lack of rib expansion

Myofascia: moderate restrictions in R > L masseter, B occiput and cervical patterns
Special tests: R shoulder HG IR, L HG flexion, cervical rotation L, all positive for R Brachial Chain pattern

Assessment: Signs and Sx consistent with chronic cervicogenic HA with TMD

To cover my bases, I made sure to hit on all the points of head and neck position effecting the mandible position, how that may irritate the subcranial area over time and reproduce the HA. I explained the forceful extension of her neck by a softball twice may have irritated that area, which was continuously under threat by her prolonged static positions at work. Just in case, I looked for a right Brachial Chain Pattern ala PRI, and found that as well. That was going to be my plan B after 2-3 visits if there was no change.

Visit 1: Did some light IASTM to cervical patterns, mandible elevators, subcranial shear distractions and instructed on use of a lumbar roll with cervical retraction for homework. There was no effect on her current complaints, which obviously disappointed her, but we both remained optimistic.

Visit 2: No change in her complaints, we performed the above, plus I instructed on balloon breathing to correct the right BC pattern. Again, no change in her complaints. I should also add that the patient and I, plus my intern had a great conversation, with little to no perceived threat, as she was extremely well adjusted. In general, there were no signs of central sensitization, and she had an amazing sense of humor. At the end of the session, I told her to add the PRI exercises for HEP; also, there should be a change within 1-2 days if it was going to work. At this point, I was still surprised, with her apparently compliance, great demeanor, that there was no rapid change.

Visit 3: The following week, she reported being worse after the last visit. This was within the 2 hour rule so I took full responsibility. For this visit, we really focused on her breathing, and I did some upper thoracic and thoracic manipulation. Again, her HA were completely unchanged. I apologized and felt like I had to be missing something. I told her that we would try the current program for 1 more visit and I would refer out if there were no changes. I casually mentioned that in cases like these, if it was a simple mechanical problem, there should have been some changes at this point. She asked what other options I may have for her. I stated there are several, including TrP injections, to which she said she'd rather have surgery (not a needle fan), plus referral for dietary consult as she may have something like a gluten intolerance.

She called the next day, stating she wanted to cancel her 4th visit and she was going to see a neurologist. I tried to call her wanting to make sure she saw someone I trusted and not see some big box that would just offer injections. I did not get a hold of her, but I felt like I missed something and that I should have been able to do more for a 24 yo female with HA.

The problem with having a good track record with difficult cases is losing what seems like a sure fire win. We all want to help people, and rapidly, but learn to trust your gut. I knew that despite my best efforts, there should have been some change between visits, much less worsening between visits 2-3. The patient could sense that as well, despite our great interaction, she knew something else should be looked at. Still, it bugged me and had me doubting my entire current approach.... was I not giving people enough of a chance? Should I have looked more globally?

I tried to put the case out of my mind, as it really got me into a clinical funk for about a week. One and a half weeks after her last visit, she called, stating she tried going gluten free, at my suggestion. It turns out since then, she has been completely HA free. In addition, her mother has a severe gluten intolerance, and no one had suggested testing despite the familial history. The main problem now was that her PCP, instead of sending her to a neurologist had her get a cervical x-ray. This apparently showed scoliosis and she suggested she see me before it turns into degeneration or gets worse. So now, the patient was completely symptom free, but because of the careless (but most likely well meaning) thought virus, I spent 20 minutes on the phone doing some pain science education. The patient really wanted to see me and I agreed to look at her movement symmetry (SFMA) and interpret her x-rays.

She came in today (11-5-13), and now for over 2 weeks was completely HA free except one incident that was traced to having a piece of gum that had gluten in it. Upon review of her x-ray, it was remarkably.... clean... the only finding was "mimimal" scolosis in the cervical spine, but was otherwise unremarkable... no degeneration, spurs, or any of the other things specialists worry about so much. I didn't have to explain anything other than "minimal" means just that. It was quite easy, and she was very relieved to hear of the other pain stats in regard to false positives, etc... in a "normal" pain free population. She was worried for days, since our phone call and her visit today, all on the suggestion that her spine may "degenerate" based on her x-rays... EVEN when she was completely asymptomatic.

Her SFMA revealed some of the same asymmetries we found on the first visit plus more in the LQ, and I suggested that we take care of them since she plays softball, bowls, etc... and she was happy to do so. In the end, this case went from

  • your basic textbook cervicogenic HA to
  • why the heck are there no rapid changes to
  • now we're HA free, but the doctor sent her in a downward spiral to
  • back to plain and simple movement assessment and cleaning up asymmetries. 
What a whirlwind! The moral of this story: Trust your instincts, most cases should modulate pain/symptoms rapidly, and certainly not worsen between follow ups. Sometimes it's just not neurobiomechanical.

Keeping It Eclectic...

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  1. Awesome case. Thanks for sharing, dr. E.

  2. Thanks! Wait til the next case! It was part 2 of what got me into a clinical funk!

  3. Cool win. Only question...why would a gluten intolerance kick in s/p traumatic softball injury? Seems odd timing.

  4. Yes, except she had HA before as well, only they were daily and worse after each injury. Possibly they triggered an initial chemical inflammatory process that was continued by some sort of reaction to gluten that kept the inflammatory soup going?