Information for medical professionals 2018: Rehabilitation, part 3
Treatment and rehabilitation measures at Firda Physical Medicine Centre
Case study Part 2 continued:
Findings: During exaggerated passive side bending, right side C0-1 to left side, there is a probability of tissue damage to this joint (joint capsule and ligament close by). We also test an almost full luxation atlas right side on the axis surface during rotation towards the left. That is, the right atlas joint surface has a non-physiologically large rotation, and there is almost no joint contact with the right side axis joint surface below.
My initial thoughts are that the peripheral nerve C1 which emerges between C0-1, and the nerve C2 which comes out between C1-2 must be exposed to mechanical stress of some considerable force. Did the original trauma 6 years ago cause tissue damage to nerve structures in the area, in addition to local tissue damage to ligaments/capsules/membranes C0-1-2-3? This is a highly relevant neurological question.
Anatomical structures - ESSENTIAL ANATOMY 5:
Above we see the joint C0-1 right side (x-x). The text in the picture shows clearly the nerves which serve the short muscles. We are completely dependent on these muscles when training in the 'neck machine' (Multi-Cervical Unit). The question is, how easy is it to train the short, stabilizing muscles C0-1-2 when the nerves serving them are damaged? This is also an important neurological question!
We are still in the joint area C0-1-2, right side. Again, parts of the C1 nerve are made clearer. The nerve lies exposed in the far part of the atlas joint mass, see arrows. If the atlas mass rotates too far, and repeatedly pulls at the nerve, could this be the source of local nerve sensitizing? Does the nerve simply become over-sensitive locally, because we are unable to stabilize the rotation of C1-2?
Again, a branch of the nerve has been made to stand out - this is a brain nerve which has a communicating part going to the aforementioned C1 nerve. In other words, dysfunctional impulses from a possibly damaged C1 nerve may spread through the network of a brain nerve. In this case we are talking about brain nerve no. 12. Could the irritation/damage here be the cause of the patient's uncomfortable tongue? Also an important neurological question.
Above we see an important image. The outer part of the joint mass C1 on the
right hand side, massa lateralis, has been enlarged - see the two x's. In the example of this patient it moves too far forward and backward (see arrows) when he rotates to the right and left, and with rotation instability there is potentially too much pull on this brain nerve. The text in the picture explains which problems this nerve can cause when exposed to the wrong kind of strain (see double arrows).
We will now deal with the circulatory examination of patients. There are many veins and arteries that pass through the throat and neck, and so there are very many circulatory issues we need to be aware of. A few examples follow:
When there is a non-physiologically large rotation of atlas on axis, how does the neck and vascular system deal with it? With a rotation towards the left we see a greater accumulation of blood/stasis in the veins on the right side than during a comparable rotation to the right - check the left side veins.
With a palpation of arteria carotis externa above the division point of C3-4 we are aware of increased throbbing on the right side when there is rotation to the left, than we do during a corresponding test for the other side. What is the significance of this? If the neck is rotated too far (and there is rotation instability C1-2) could this lead to an arterial/venous tightening? There are numerous vessels going up to the head, so surely there will always be some open vessels that can ensure sufficient flow. . . But what about pressure changes in the vessels, not due to physical strain but rather possible constriction? Terms such as turbulence, emboli (clots), stasis and so on - could we here be dealing with potential sources of intima damage, infarct etc? These are important questions for the specialist in internal medicine and neurologist.
Here we see the artery and vena vertebralis, right side, where they come through the hole in atlas. They are shaped as a coil to be able to manage a rotation, in which there is great movement of atlas on axis - see the arrows.
However, if the side movement of C0-1 in the opposite direction is too great, in this case towards the left - combined with too great a rotation to the right, where the atlas mass presses the vessels to the back - can we be equally sure that the network contains sufficient slack?
The arrow pointing up - the skull bends over to the left. The long arrow pointing backwards indicates a rotation of C1-2.
If we go a step further in our assessment of a patient's condition, we take a closer look at vena vertebralis. The condylar emissary vein goes off just above the foramen. It goes in and out of the skull in a separate foramen. Again we are looking at a side bending of the skull-C1 and a rotation of C1-2 - see the 2 long arrows.
We carry these thoughts with us to the next image, below:
Here we take a closer look at the exit of the vena condylar emissary towards the vertebral vein. Is there an area of friction around this point? We bear this in mind when looking at the next images.
Now we have moved on to where we can see communication between vena vertebralis and the deep cervical vein. When I test for swelling (right side) in a vein in the throat/neck of a patient who rotates his neck and head to the left, is this the area we are at, or are we still a little further down in the system?
Is it significant that a vein in the throat/neck swells during a rotation of the neck? Even though it may feel swollen during palpation - do we know exactly where the vein is constricted, or not?
I have made use of a small part of the vascular system in my example. We have a corresponding situation in the arterial network, in the same area as this. But let us add some muscles to the veins, arteries and nerves:
Above we see m. Splenius Capitis, a muscle which attaches to the same area as caput, just in front of the aforementioned arteries and veins. The arteries pass underneath the muscles, the veins pass over them.
We add m. SCM: Here we see a new artery under the muscle (art. occipitalis), a vein on the outside (vena occipitalis).
And here we see the various parts together:
x - atlas, which is rotating too far on axis;
A long outer muscle, here represented by semispinalis capitis;
Arteries and veins by the atlas joint. The arrows represent examples;
Important stabilizing muscles for x (several small green crosses).
Please note: From Jan 1st 2018 we no longer accept credit cards. Only debit cards can be used.
User survey results
Question: "How do you rate the treatment you had at Firda Physical Medicine Centre relative to any treatment you had before coming to us?