Information for medical professionals 2018: Rehabilitation, part 2

Treatment and rehabilitation measures at Firda Physical Medicine Centre

A case study (this case study of a patient is put together from four different cases, for reasons of patient anonymity):

Your pain is primarily situated in the neck/head and neck/shoulder/upper part of the thoracic spine. Six years have passed since your traffic accident, in which your car was hit sideways by a large van. You were driving a Golf and you thought there was nothing coming from the right when you drove into a junction, your intention being to turn left. Half the car was in the junction, and your head, neck and eyes were turned towards your left as you were straightening the car. The van hit you on your right side, and you experienced a massive combination whiplash with a sideways and rotational movement of the neck and head. The impact was subsequently calculated to have happened at a speed of approx 50 km per hour.

You were left unconscious, and woke up later when lying in the ambulance on your way to hospital. The X-rays taken immediately upon arrival showed no fractures. A CT scan of the head showed up normal. You stayed in hospital for 3 days, and were then discharged with the responsibility for following you up transferred to your local GP and physiotherapist.

In the course of the next few years your pains and functioning level have varied. The immediate period of injury lasted approx 6 months. It took you some time to realize that you could not lead your life as before. You cut down on your social life, you let your husband and mother-in-law take over much of the housework, you worked less and less until you eventually, after approx 12 months, went on sick leave. You have tried numerous types of treatment, but without much relief. After several years of being on AAP (work assessment allowance), further neurological tests and MRI scans, you and your GP have together come to the conclusion that it would be a good idea to apply for disability allowance.

When you came to us for the first time you came across as someone who had almost given up hope of ever getting better. You had recently started taking new medicines which were supposed to remove the pain more efficiently. The problem was that you felt worn out and weak, and in addition you had gained 8 kilos in weight during the previous 2-3 months. This weight gain was similar to the one you experienced during your last pregnancy 8 years earlier, when your body had temporarily accumulated a lot of water.

This GP has tried to understand his patient's distress. He explained to her that he had tried everything he could think of, and up to several times each. He said that if she felt the need to speak with someone else he knew of a good psychiatrist who had experience of neck injury patients. The doctor mentioned that 'it might be good for her to talk about her problems'. She accepted the offer. After a delay of 3 weeks she received a letter in the post promising an early appointment in only 4 months. However, she forgot the appointment and then did not speak with her doctor about it again. The GP has since moved to northern Norway and our patient has not had any further contact with doctors about the problem.

She now receives a disability allowance and has 4 children between the ages of 8 and 18. Three children are still living at home. Her husband is a long-distance lorry driver on the Continent. He is away from home for 6-12 days at a time, followed by a period of one week at home. His rest times are the minimum required by law, and he drives as much as he manages. They need the money now that she is no longer a wage earner. Her monthly income went drastically down the day she went over to disability allowance.

She has received no compensation from her insurance company. Apparently it was her fault that the accident happened, as she had been 'inattentive'. The car was wrecked and the reduced amount of money they received on the car insurance was not enough to buy a new one. However, she can borrow the second car belonging to her parents-in-law. They smile about the way she uses their car for free on a permanent basis. The mother-in-law has recently retired. She comes over to clean the house once a week. She once worked as a cook, and when she makes food in her own house she invariably makes extra portions to put in the freezer, and brings them over to her daughter-in-law. This is a great help.

Upon examining this patient at Firda Physical Medicine Centre we concluded the following:

  • Woman, aged - -. Married with 4 children.
  • Recipient of disability allowance. Previous job - -. Higher education with a Master's degree.
  • Known trauma to the neck, serious traffic accident 6 years ago.
  • Hospitalized same day as trauma occurred. Has made many visits to doctors, examined by GP and specialists.
  • In-laws paid for Upright MRI in London, 2014. R: Cervical spondylosis. Exaggerated ventral glide C4-5, findings compatible with ligament damage to the upper neck region. Our second opinion of the images (seen on CD ROM) conclude with poor resolution, unclear areas between different tissue types. When we enlarge the images to get a better view of possible findings the picture quality is further exacerbated due to low pixel count.
  • We request the results of the Norwegian X-ray, cerebral CT and cervical MRI. All have the comment, R: Nothing noted. When we receive the MRI scan images we see that they show the whole neck, with no especial focus on the cranio-vertebral area. The neck is pictured only in a neutral position.
  • Our patient feels that her head is 'extremely heavy'. Because of the neck pains and headaches she has not been able to train as much as her physiotherapist recommended. The problem is that the exercises he gave her make her symptoms worse, and she often has to spend the rest of the day lying down. In periods she has been to see a chiropractor. He manipulates each time. 'My neck really cracks. And after each treatment my neck is quite floppy and I need to rest it, and then for the next day or two I spend a lot of time lying down.'

When we perform a passive tissue examination, as well as a passive function test, we come to the following conclusions:

  • As a result of the examination we find that the throat and neck muscles are generally atrophied. The patient is 168 cm tall and weighs 68 kilos at present.
  • During palpation there is soreness in the tissue of the arms, throat/neck and back (test done when lying on stomach, seated and in standing position). There is fluid, swelling, low tissue denseness when the muscle function is activated. The short cranio-vertebral muscles are difficult to localize and test. We are not able to create enough tension in the short muscles with for example a C0-1-2-3 rotation (passive and led active test). Flexing the area (increasing the stretch of the muscles) prior to the rotation does not help. We are also unable to work with a rotation and side bending C0-1-2 of the opposite side because of insufficient stability in the ligaments/muscles to obtain expected tension. I cannot stabilize C1-2 centrally. The atlas ring is probably hanging against its axis (LADI - lateral atlanto-dental interval).
  • The findings are compatible with a rotational instability C1-2, rotating mainly towards the left side. When testing rotation towards the right hand side we conclude there is subluxation. During rotation the atlas joint and axis joint surfaces on the left side appear to stick. When I stabilize the side glide (LADI) C1-2 during a led active rotation towards the right we come further without the sticking.
  • By rotating towards the left we conclude with a borderline full luxation atlas-axis. We palpate non-physiological gapping C0-1 on the right in a combined non-physiological side bending (towards the left) C0-1, together with a rotation atlas-axis in the same direction (left) that is compatible with luxation of the right hand side atlas surface on axis surface. When rotating to the left the patient experiences a numbness of the right hand side of her body, problems with her vision and she feels faint. Immediate nausea and tightening in the throat. After the examination she rests, and then comes the usual 'thumping pain with migraine-like symptoms'. The neck pain 'is there all the time, in varying degrees'. She has been through many neurological examinations for these problems.

This is a CT image of a similar patient. The CT was taken in London, a referral from Firda Physical Medicine Centre.
The findings here are consistent with a full dislocation on the right hand side atlas-axis. Residual contact amounts to less than 5%.

  • I am unsure about clinically testing the central cervical column. With such extensive findings in C0-1-2-3 I would be unable to distinguish possible findings in the function of tissue around C3-5, as the function findings from above C3 level are such that the muscles over all three neck areas are very much affected. This does not mean that there is no tissue damage C3-5, but it is difficult to assess at this point.
  • Due to these findings of function deviation C0-2, with symptoms, the patient has adopted a habit of poor posture with a forward bending thorax, enlarged kyphosis (lump) between the neck and head, and in the middle part of the thoracic spine, and with rounded shoulders. The shoulders slouch forward, rotating inwards. The tendon insertions to the long biceps and supraspinatus are sore, and the rotator cuff appears atrophied and with a stringy muscle quality. The patient cannot straighten the middle and upper parts of the thoracal kyphosis. The joints have become stiff due to lasting harmful strain. There is general muscle atrophy.
  • The long outer flexors and extensors in the neck are myalgic and very tight. The connections for levator scapulae right and left are especially myalgic and inflamed towards the scapule corners. To the front the scaleus group is shortened and tight, especially on the right hand side. If we had not known better we would have thought that these muscle groups were made of cartilage and bone, because of their extreme compactness and stiffness. They are so short that they effectively hold C4, 5 and 6 in a vice, pulled forward, without any ability to attain a neutral, segmental position.

Before tomorrow's follow-up I will confer with literature on anatomy. Among other sources of information we make frequent use of an anatomical app, ESSENTIAL ANATOMY 5.


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