Information for medical professionals 2018: REHABILITATION Part 1
Reflections on the treatment/rehabilitation of neck injury patients at the Firda Physical Medicine Centre
We now come to the business of how we work here at the Firda Centre in relation to the rehabilitation of patients suffering the consequences of one or more injuries to the neck. Before starting on a description of specific treatments and methods I shall attempt to show some of the thought processes we need to work our way through before arriving at these.
We wish to commence with a thorough diagnosis. The treatment measures chosen will be directed towards a reduction of symptoms felt, as well as the regeneration of tissue. To start with it is important to collate all available medical data from the various medical professionals that have previously been involved. The results of these examinations are important elements in obtaining as complete a medical and clinical understanding of a patient´s condition as possible. During the course of the ensuing rehabilitation work it may become necessary to pause and reassess the situation for possible further diagnostic measures, as the clinical picture may have altered or show itself to be incomplete. There is always a risk of complacency during any rehabilitation process, and thus ending up with a course of treatment that is incorrectly founded.
Patients with neck injuries do not form a homogenous group, and the clinical picture will vary between individuals. Hence, measures need to be tailored to each patient. Our focus is on different needs requiring different measures to be taken. We subdivide our objectives, prioritize these into the best sequencing, and assess which measures are needed to reach them. Again, I would seek medical cooperation in order to get the best results possible for each patient.
When we define our sub-goals a primary objective is the lessening of symptoms. Patients often suffer from a variety of symptoms, arising in different tissue areas and body parts, and which may be local or spread about. Naturally it is of paramount importance that we localize correctly the source of the symptoms. In our work the focus is on areas where there is possible damage and areas where there are alterations to function, which again may be the source of further pain. Where more than one injury has occurred, and on different occasions, then the areas affected will be at different phases of tissue damage and so accordingly we are obliged to adapt our measures. We refer here to reactions becoming chronic, whether these changes are directly in the tissue, or we have a case of neurogenic, peripheral or central sensitizing.
The period of time after the injury
The time aspect is vital. The sooner we have a correct diagnosis and effective measures can be taken, the quicker the patient will be able to get well or improve. We see an attitude in the health professions which appears to favour a "wait and see" approach. Literature on the subject indicates that 90% of neck injury patients will heal naturally. Thus we are left with 10% becoming chronic sufferers, with a condition that may stay with them for the rest of their lives. The big question then is: should we wait for about 12 months to allow those 10% to become obvious and then step in with relevant measures? Or, should we go actively in after an injury has occurred and with our medical knowledge do our utmost to try to ascertain who those 10% are, and so be able to contribute with effective measures as soon as possible? At Firda Physical Medicine Centre our approach is to get started with effective measures at the earliest opportunity.
Frequently we have arrived too late with diagnostic measures and we see that the overall health of these patients has worsened considerably since their injury occurred. They have registered a substantial worsening of their condition in terms of intensity and spread of symptoms and with a significant further weakening of local and general function. Pains in the neck may for example give considerable discomfort when lying down, which in turn affects the quantity and quality of sleep that person is able to get. She or he may try to compensate by sleeping during the day. Eventually the patient may lose control of their biological sleep pattern, and is left confused about when to be awake and when to sleep.
With symptoms and discomforts over time you rapidly lose general condition, there is a fall in heart and lung function and you become easily tired. You find simply functioning on a daily basis hard and may end up spending a lot of time just lying on the sofa. Your average day, which before was easy enough to get through, now becomes a physical and mental challenge.
How can we avoid this? The question is, again, how far we are willing to stretch our diagnostic capabilities for each patient. Is the medical help offered to neck injury patients adapted to work pressures and budgeting in our health service? Does our work at the Firda Centre help to alleviate the present below-par level of national assistance on offer, and do we contribute to raising the level of professional expertise available? If we are aware of more effective, albeit more expensive methods - which would give more precise diagnoses - who then has the moral and professional responsibility to decide that they cannot be used, and we must make do with the cheaper methods?
Do we at the Firda Medicine Centre recommend treatment involving symptom reducing medicine too readily?
How does heavy medication affect the regenerative ability of tissue? Is it being counter-productive when we are slow to diagnose accurately, recommend progressively strong medication, and subsequently attempt to make up for lost time?
We frequently meet patients who use strong medication. Why give a patient NSAIDs (non-steroidal anti-inflammatory drugs), Arthrotec, Sarotex, Neurontin, Paralgin forte, Fentanyl, Nobligan, OxyContin, Sobril, Temgesic, Tramadol, Zoloft etc (often a combination of medicines from different medicine groups, as in this random list)? The medication is often combined with repeated Botox injections.
How do I as a therapist feel about this? What is the reasoning behind giving these medicines and what is our therapeutic thinking? The best answer I can come up with is that I do not know for certain where the source of the pain lies, nor the exact cause of it. We camouflage this uncertainty with heavy medication.
Nerve impulse modulation
We are acquainted with various drugs and the development of methods for the modulation of nerve impulses. To a lay person like myself this would refer to a patient taking medicines that reduce their experience of pain following injury. Even though pain physiology is a very complex and essential field of work, I wonder about the following question: if you are in pain and the pain comes from the neck subsequent to a trauma, how far are we willing to go in order to reduce the body's ability to register impulses and pain? Do we know the consequences
for the future development of their physiology when we medicate expressly to override the functioning of the nerves?
In the fight to improve a patient's life with regard to pain, what happens when we are primarily taken up with altering the experiencing of that pain, and in so doing possibly neglect the mapping of the injuries themselves and possible regenerative measures?
Abnormal tissue sensation caused by medication
Unfortunately I could cite several examples of patients with abnormal tissue feeling or sensitivity. In this context I would like to mention focused shock waves, as in the latest Piezo Wave 2 Model. By using focused shock wave treatment we are able to stimulate tissue regeneration, to be dealt with more in depth later.
With Piezo Wave 2 stimulation the patient tells us his or her degree of discomfort by using the VAS (Visual Analogue Scale) from 0-10, where 10 equates to unbearable pain. During treatment a patient's level of pain will typically lie between 3 and 5. The area being tested here is paravertebral th. 1-12. The problem is that the patient feels no sensation! The strength of the apparatus goes up to level 20. At that level we have only a very short space of time at our disposal, and the patient barely notices that I am touching his back with the probe. When we double-check the method on a patient with no neck injury we get a VAS reading of 6-7 with the apparatus strength at 10-12.
The tissue is most probably so numbed that any attempt to rehabilitate and stimulate it is quite useless.
Stimulation to regenerate tissue
Here at Firda Physical Medicine Centre we think in terms of stimulation to regenerate the tissue. Internationally there appears to be an increasing movement away from treating back and neck injury patients with strong medication. Among other places we see this reflected in the work of the group of doctors in the American Association of Orthopaedic Medicine - www.aaomed.org.
The 11th International Conference on Tissue Engineering and Regenerative Medicine is to be held in Rome this October, with the theme: Redefining Health Care Through Regenerative Medicine. The staff at the Firda Physical Medicine Centre will be attending to ensure we are updated on the latest developments in the field, and so allow our Centre be at the forefront of diagnostics and rehabilitation.
Neck injury - an imagined condition
Many medical groupings in Norway claim that the majority of people with neck injuries simply imagine their condition because they suffer from psycho-social problems and personality issues, alternatively that they hope to gain a large amount of money as compensation in the courts.
Here a further important question arises: what then is the reasoning behind giving these patients strong and extensive medication if their injuries and pain are merely an illusion?
Are we, in fact, too quick to conclude that there are no clinical or radiological findings? Would our methods tolerate examination?
Atlanto-axial rotational subluxation/dislocation - worth worrying about?
Our Centre has addressed a number of important scientifically documented cervical problems to do with function, one of these being atlanto-axial rotational subluxation or dislocation. That is, when a patient rotates their neck and head and the first neck vertebra becomes partly or completely dislocated. If the patient has not first been tested for this condition, clinically or radiologically, then how can we presume that it is not there? Do the fixed and habitual faulty rotational positions differ? Should these two cases of rotational damage be diagnosed using different types of manual testing/radiological methods?
On what do we at the Firda Medicine Centre base treatment and rehabilitation?
We ask questions and check numerous medical circumstances thoroughly: symptoms and pains - precisely where, to what extent, duration, pattern etc; the patient's general condition; have all appropriate tests been taken and, if so, what were the results? Is it definitely a case of trauma? One trauma or several? The extent and force of the trauma? Does anyone know the condition of the tissue PRIOR to the latest trauma?
Has the patient's tissue been damaged? Is there any suspicion of damage to bone tissue and soft tissue? Can we arrive at the type of tissue that is damaged? Do we think there is a connection between possible tissue damage and the patient's symptoms? Are the symptoms similar despite there being different types of tissue damage?
A thought experiment
Let us imagine the following: there is clinical suspicion of damage to the segment C1-2. I ask myself, what is the nature of this damage - contusion, traction or a combination of both? Which structure is affected? Only a local one, for example lig. alaria, or an adjacent structure, like intima in art. vertebralis?
For what kind of dysfunction arises after possible injury? Are they local symptoms and pains following an injury to lig. alaria, or cerebral symptoms and deviations due to damage to intima in art. vertebralis? If there is local damage to the C1-2 area then the clinical examination/MRI of the C1 segment should be performed in a neutral position - alternatively, should it be done towards a provoked damage position? What happens when 'accepted scientific practice' holds that the use of MRI following whiplash is unnecessary and is not to be recommended, and that it amounts to a misuse of funds? We need to ask ourselves whether we actually wish to assess tissue damage to ligaments and vessels. For, if we do detect damage how will we be able to act on these findings? Would it be better for us therapists 'not to know'?
As a therapist I ask myself: Which clinical tests would it be useful to use? Do I have enough experience in examining neck injury patients? Am I sufficiently aware of 'falsely negative' and 'falsely positive' findings? To this end, how do I go about checking my work? Do I refer patients with neck trauma to radiological testing? Who asks the vital, clinical, pre-radiological questions we need answers to? Or, are radiological methods so broad and general that they may be used for all patients that have suffered trauma to the neck? Is the patient only radiologically tested for a set and limited number of conditions, and if these are absent will the conclusion of the examination be 'MRI scan cervical col. - Result: no findings'?
Who exactly assesses the images after a radiological examination? Only the radiologist? Does he follow only established and pre-defined radiological routines? What clinical expertise does the radiologist have in order to correctly assess the connection between clinical and radiological findings?
The time following trauma - changes in the tissue
How does TIME PASSED FOLLOWING TRAUMA affect changes of function in a patient's tissues? How do several trauma affect the consistency and strength of tissue?
In my experience tissue change following trauma is characterised by deposits of bone/cartilage and the presence of scar tissue and fatty infiltration, as well as other findings compatible with structure injury/tissue rupture, tissue atrophy and so on.
We often see the term 'degenerative changes'. What do we mean by this? Is there a difference in detecting cervical degenerative changes in a patient aged 25 and one aged 65? Do we differentiate between them?
Is there relevance in knowing whether 'degenerative' changes have happened fast or developed over time? Do degenerative changes at all constitute factual findings that are a consequence of trauma/tissue damage?
At Firda Physical Medicine Centre we think along the following lines:
Who wants to and is able to ask the difficult diagnostic questions?
Who has the courage to ask the difficult diagnostic questions?
Who will ask the costly diagnostic questions?
Who decides which diagnostic questions should be asked?
What are the possible consequences for those who ask the difficult diagnostic questions?
What denotes 'generally accepted knowledge'?
Who defines what is 'generally accepted knowledge'?
What do 'generally accepted methods' mean?
Which 'body' in Norway has an 'Approved' stamp on its choice and use of method?
What does a 'symposium' purport to be?
Who decides what is to be included in a 'symposium'?
Court cases to do with neck injuries
After having worked on 48 different legal proceedings and court cases I see a definite need for change. A patient should not need to go to court to fight for his or her rights. It requires resources of the person in question and of society as a whole. A court case will always produce a winner and a loser. Time, effort and money are usually wasted. There is a defence and an opposition. A huge effort is involved, and each side goes into a trench and prepares for battle. It is a case of those with power and those without: the powerful wish to sell insurance, and in the next instance they are positioned on opposing sides in legal wranglings. Justice and fairness - for whom? Does this constitute money and resources wisely spent in our society? Does it build a sense of community? Is it something we can all be proud of?
Who has the courage to go for a new strategy?
Who has what it takes to find more useful solutions for the individual patients involved and for our society as a whole?
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