Case of the Week: Cervical Pain and Playing Detective | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Case of the Week: Cervical Pain and Playing Detective

I saw a recent headache and cervical pain patient that was a questionable rapid responder. 
Some reasons for this was
  • constant pain that does not abate in any motion, position, time of day or ADL
  • long standing pain for 2-3 years
The patient was very well adjusted and displayed very low fear avoidance, plus was very hopeful that with education, manual therapy, and repeated loading strategies, we would find a solution to her complaints. After 2 visits, there were no changes and she was very compliant with her HEP.

Next step after zero changes in pain intensity was Capnotrainer assessment. She was found to be overbreathing with a ETCO2 of 29 mmHg (WNL is 35 mmHg). We spent about 45 minutes trying to get an appropriate breathing pattern in supine, sitting, etc, that got her close to 35 mmHg. She eventually was able to do it with a slow and controlled exhale, but she kept aborting her exhales.

I followed up via email over the next week and she admitted the breathing techniques with the tongue at the roof of her mouth was very difficult but she was trying. I was hopeful despite when she was able to maintain ETCO2, there was still no change in perception of headache or cervical pain with motion.

The next session, I played a little detective and revisted her history. Usually, problem solving when patients are not responding goes in this order for most of my cases
  • review HEP, progress on end range forces
  • take HEP to unloaded position
  • Capnotrainer and breathing education
  • diet, sleep, general exercise advice
You could absolutely make the argument that the pillars of health should be counselled at each session. However, it's been my experience with most of my cases, adjustments to those are not needed. YMMV.

Getting back to breathing, the patient realized she was a mouth breather and practicing breathing with her tongue in resting position became increasingly difficult. I told her to practice as she felt comfortable, but did not want that to become a source of anxiety. In terms of sleeping, after reviewing her history, she had stated her pain was worst at night. This is what she admitted to co-sleeping with her two young children. She said she had actively been trying to break this habit for the past month and the transition has been difficult. Her sleep quality is "horrible" as she admitted.

We spoke about this, and I definitely was able to empathize as our first daughter was a terrible sleeper for 15 months. It absolutely affected our quality of life. I mainly listened to her complaints, and was careful not to judge, or even offer advice, unless she asked for it. After about 25 minutes of talking and joking about the difficulties of raising children, we left it at she would work diligently on it, as she realized she could no longer ignore her sleeping situation.

I plan on following up via email as it has been two months. In general, remember to play detective when your cases are not improving despite compliance with their prescribed HEP.

Keeping it Eclectic...

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