A Case of Sympathetic Neck Pain - Story and Context is Key | Modern Manual Therapy Blog

A Case of Sympathetic Neck Pain - Story and Context is Key






Today's Guest Post is a great example of how every patient has their stody and when it comes to Understanding Pain, context is key. Thanks to Dr. Dave Tilley of The Hybrid Perspective for sharing!

The other day I had one of the most eye opening experiences related to patient treatment and the impact of pain science education since graduating PT school. I wanted to quickly share the story.

In short, I treat a boyfriend and girlfriend both for cervical pain. The female I have been seeing for just about a month for a 3 year history of chronic neck pain with left sided radicular pain/numbness intermittently. She has been seeing progress over the last 6 treatments in terms of pain and radicular symptoms, although she still was having some left neck pain. The male I recently evaled 2 weeks ago after he elected to have a lower cervical fusion and I had only seen once. He unfortunately is in rough shape following his surgery and is dealing with a lot of sub acute pain/limitations.

On Monday, the female patient received results from a recent MRI, which ended up showing a mild - moderate C6/C7 disc bulge with foraminal narrowing. She said that her doctor was optimistic it wasn’t the worst case scenario and that with PT she could keep getting better, but the patient told me the appointment left her "unsettled" about the situation. She came to see me the two days later on Wednesday and said that randomly she has been doing worse. She told me that her pain was back up to a constant 7/10 (previous week 3/10 not constant) on the left side of her neck, it was worse in the morning after sleeping, and that she was getting some traveling pains into her hands again throughout her day (previous week not past shoulder). When I asked her about changes in her daily habits and if she had been continuing exercise for resets, she said nothing had really changed. She has been sleeping in the same positions, performing exercises every few hours that had been helping, and avoiding once problematic posturing.

When I asked her to show me her motion, she had definitely regressed quite a bit compared to the previous week. She had a large loss of motion with L rotation to 30 degrees, L SB to 10 degrees, and extension to 20 degrees, all with acute left sided pain 7/10 but no radicular arm signs. Due to her sensitivity levels, I wanted to start with some IASTM tone work and unloaded retraction progressions. Upon laying down on the table, she became very upset and started crying out of the blue. Confused, I asked her what was wrong. She then went on to tell me that the last weekend and previous few days had been so stressful that she was at her breaking point. She said that seeing her boyfriend (cervical fusion patient I recently evaled) in so much pain was horrible, and that she "felt hopeless because she couldn’t help him with his pain". She said that normally she is good about handling her stress levels but between her recent doctors report, her boyfriend having two really bad days, and her pain randomly coming back it was a lot to take.

This launched us into quite the conversation related to a lot of pain science topics. Over 20 or so minutes we discussed
  • Her boyfriend's natural course of healing and how he would get better with time/treatment
  •  The mechanisms of why we feel pain, perception of threat, and how tissue damage and pain level aren’t synonymous using phantom limb pain and other pain examples relating to her neck pain 
  • The science and neurochemical mechanisms (she asked for nerdy explanations) about how stress, fear, anxiety, and worrying about her boyfriend all were very real reasons with good research behind it
  • We also discussed possible reasons for why it could trigger her increased pain experience due to neurotag ignition, sympathetic drive, altered breathing patterns, and muscular tone 
  • MRI findings in asymptomatic patients related to spinal changes/disc bulges, and how she may have had that 2 weeks ago when she was seeing improvements
Following this discussion, she told me that it was incredibly helpful to hear and understand everything in relation to her increased pain levels and loss of movement. She said that she felt much better about the entire situation, and also felt better knowing that her stress creating more pain wasn’t all in her imagination. After I finished answering anything I could, she sat back up to gather herself and get some tissues. I mentioned to her some research I had read about TNE causing reduced fMRI activity in relation to a pain experience and increasing someones movement. Just for ha-ha’s I had her see if her motion or pain had changed. I kid you not, it instantly almost doubled for rotation and side bending to the left with much less pain. It was to the point that she screamed "Oh my god what just happened?!", almost jumped off the table, then started crying again when it happened. Her pain was still there, but it was a significant improvement. I was completely baffled. I hadn't touched her, done any exercises, or done anything related to treatment besides talk to her. After we shared our disbelief, we continued on with a few things and then she left very happy for a situation that I thought was going to be a massive roadblock for her recovery.

I have spent a lot of time in the last 2 years reading and trying to do a lot related to Therapeutic Neuroscience Education, but have never seen such a drastic example of how it changed a patient so fast. I’m still learning more every day of how to approach and fit it into treatment, but this story definitely made me more of an advocate for it with all patients.

Dr. Dave Tilley, DPT, hybridperspective.com

Keeping it Eclectic...

8 comments:

  1. I'm in my first year as a practicing PT and these patients are by far the ones who leave me frustrated. I have 2 in particular. Both have chronic pain, which definitely coincides with stress levels and both are very negative. In both cases, I've brought up the pain science perspective for treatment instead of a biomechanical approach. In both cases, they thought I was just calling them crazy and telling them it's all in their head. Any suggestions for how to go about talking to these patients? Or other posts you can direct me to for examples?

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  2. I can tell you 17 years out, chronic pain patients do not get easier, you only have more and better ways to relate to them and explain pain to them. While we know what helps them, we cannot make the same rapid changes to mindset and CNS vigilance as we do with the typical patient who rapidly responds. We know that education, metaphor, and graded exposure to movement helps, as does as acceptance and willingness to live with pain, instead working on function and therefore quality of life. These two resources I recommend to all, first for your patients http://astore.amazon.com/themanuther-20/detail/0985718625 - Why do I hurt, inexpensive and invaluable information, and for you, Therapeutic Neuroscience Education, http://astore.amazon.com/themanuther-20/detail/B00F3UC23K

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  3. St. Elizabeth HealthcareMarch 31, 2015 at 12:41 PM

    There is a certain element of psychosomatic pain in all physical therapy. It is tough to walk the line with patients between sympathizing and telling them it has to do with their mental attitude.

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  4. Thanks Erson! I just read explain pain which was extremely helpful and I read the NOI blog as well. I've given both patients these same resources but neither has taken the initiative to buy it. I guess you can guide the horse to water but you can't make them drink. Convincing people you can make changes without invasive procedures or popping a pill is such a challenge sometimes. I could go on about this forever. Anyways, thanks for responding. I love your blog, I read it everyday. Thanks for being so hard-working!

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  5. No problem, people need repeated exposure, and I agree, it is easy to get disheartened and lose patience. All you can do is your best, but I usually just tell people about the consequences of meds and irreversible surgery.

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  6. Hi Dr E, can you recommend some good journals regarding the influence of stress/anxiety on pain? Cheers

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  7. Therapeutic Neuroscience Education text has everything you're looking for http://astore.amazon.com/themanuther-20/detail/B00F3UC23K

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  8. I got a chance to talk to Lorimer Moseley at the San Diego Pain Summit a few weeks ago about just that topic: patients shutting down when you introduce pain science to them. His advice was to, first and foremost, treat the patient with respect and to "unleash the truth slowly." Simple but powerful. Also, anyone struggling with explaining pain might also take some comfort in this quick video clip, I know I did:

    https://www.youtube.com/watch?v=jIsF8CXouk8

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