BACKGROUND

This case study will present the application of osteopathic concepts managing spinal lesion patients.

Mr B. is an active 44 year old charity worker, he weighs 98 Kg and is 1.98 cm tall. A wheelchair user since a diving accident in 1994, which caused dislocation of C5/C6 segment resulting in an incomplete spinal lesion with functional level C6/C7 (American Spinal Injury Association “ASIA” scale A for functionality, B for sensitivity) and permanent quadriplegia.

He presented at the clinic complaining of left shoulder pain, described as a deep ache affecting the lateral aspect of the left scapula and the lateral aspect of the proximal 1/3 of the left arm. The clinical temporal profile was identified as being of sub-acute duration (4 weeks), with a sub-acute onset over 3 days after a gym session of weights.

The pain had a progressive character for the first week after the onset but was stable at the time of the first consultation. Aggravated by arm extension plus abduction and by lifting himself up to get out of bed or the wheelchair and relieved by rest and PK. The subjective VAS score was rated 7/10.

Past history of rotator cuff syndrome was reported, with first acute symptoms and diagnosis by US scan in 1999. Fluctuating ever since, aggravated now and then by overuse of the arm. Originally right handed, following the spinal lesion the dominant hand is now the left, which has the higher level of functionality. Mr B. drives over 15,000 miles a year for work and the most functional muscular group he relies on for his daily activity is bilateral rotator cuff and latissimus dorsi, which he keeps under constant training. At the time of the first consultation the symptoms were severely affecting his life in terms of independency levels and physical activity, keeping him off his weekly hand cycling and gym training activity. The patient looked stressed and concerned about his condition, as it was impairing his sociality and preventing him from interacting in his own environment as he normally would.

At examination a reduction of the left shoulder range of motion (ROM) was found in every direction, the left scapula was retracted and trapezium, rhomboids, levator scapulae and subscapularis on the left appeared hypertonic and tender to palpate. The muscle power testing revealed decreased strength of serratus anterior and latissimus dorsi on the left with the active contraction of the latter reproducing the symptoms as well as its palpation. Unaltered function of the acromio-clavicular and sterno-clavicular joints was found.

Clinical findings suggested the presence of an inflammatory process affecting the left latissimus dorsi to its distal attachment on the humerus with associated hypertonicity of the surrounding muscles such as subscapularis, serratus anterior and trapezium on the left. This was predisposed by the overtraining for functional aims, by the past history of rotator cuff syndrome resulting in weakness of the shoulder girdle and by the consequences of the spinal lesion. Moreover the repetitive transferring in and out of the wheelchair, which the patient was able to perform autonomously, had potentially concurred to the local tissue damage. The primary maintaining factor was represented by the patient’s continuous demand and necessity on these tissues.

OSTEOPATHIC CONCEPTS APPLICATION

On a short term basis the aims of the treatment were focussed on reassuring the patient and improving the functionality and fluid dynamics over the local tissues, decreasing the hypertonicity of the muscular components and therefore the pain. The biopsychosocial aspect had to be taken into account at first to preserve the maintenance of his social interaction, already partially compromised by the presenting condition. This had a primary role considering the complexity of the patient’s background and the necessity of preventing him from developing a chronic negative attitude towards the pain, being shown to be likely developed by patients with long term conditions (Lumley et al. 2011).

The local tissue treatment was addressed through soft tissue, myofascial release and trigger point stimulation techniques on the latissimus dorsi, subscapularis, trapezium muscles on the left and through muscle energy techniques (MET) on latissimus dorsi and serratus anterior. The patient was treated following these principles during the first consultation session which unfortunately was followed by 6 weeks of interruption due to a viral infection which kept the patient at home. At the first follow up session the patient still reported the same presentation of symptoms, as expected after the long break occurred, although he stated that after the initial treatment the pain had improved considerably for a day or two.

One complex aspect involved in approaching a patient with spinal lesion, is the necessity of taking into account the effects of osteopathy on the patient’s pre-existing condition and being able to prioritise the treatment goals according to this. Therefore it is particularly relevant to make explicit the strategies behind the clinical decisions, clarifying the reasoning process at the base of the therapeutic objectives (Thomson et al. 2011).

At the beginning the patient’s mobility difficulties represented an issue, as the patient needed a wider plinth to be able to get on it and this led to spend a couple of treatments on the wheelchair.

It was necessary to address at first the local tissues symptoms, which were keeping the patient away from his usual daily activity, being the cause for his diminished social interaction. Latissimus dorsi is innervated by the thoracodorsal nerve from C6-C7-C8 nerve roots and, in this specific case, still conserved 90% of its functionality. In a picture of spinal lesion with functional level C6-C7, latissimus dorsi represents the key muscle for undertaking the most of the daily activities, especially changing position and correctly using the wheelchair (Nyland et al. 2000). This is why the primary goal had to be focussed locally on the improvement of the muscle function, which would have allowed the patient to go back to his usual independency level.

The use of other osteopathic approaches such as indirect techniques of functional osteopathy could have been considered when addressing the aims of the short term treatment. It is claimed that functional techniques are suitable in cases of acute pain, where techniques with a more direct approach are likely to trigger extra pain to the patient (Boyling & Jull, 2004). Furthermore it would have allowed a gentler improvement of the range of motion of the left shoulder without stressing the already compromised soft tissues.

The short term management plan engaged with one of the basic osteopathic concepts of structure influencing function and vice versa (Stone, 1999). At this stage it was necessary to allow the impaired structures to recover in order to achieve improvement on the functionality. Hence the attempt to enhance the fluid dynamics over the affected area via soft tissue and articulation techniques.

A partial reduction of pain was achieved after 2/3 sessions, with visual analogue scale (VAS) scored 4/10 by the patient. This represented a satisfactory early result and the achieved outcome allowed to incorporate in the treatment the medium term goals.

These were addressed towards the improvement of the thoracic and lumbar spine mobility to achieve a better adaptation of the trunk to the left shoulder impairment, and generally to assist with the coping strategies developed as a consequence of the previous condition. In fact, all the posterior chain muscles appeared to be markedly hypotonic from the spinal lesion level downwards. The patient’s trunk control appeared markedly compromised and the thoracic and lumbar spine were evidently lacking in support, establishing a primary left concave thoracic scoliosis, compensated by a secondary right concave lumbar curve.

The treatment was therefore aiming to prevent the progression of the curvature (Weiss et al. 2006), addressing the segmental spinal restrictions via articulatory techniques and traction of the thoracic and lumbar spine towards a counter-positioning of the misaligned segments.

This intermediate phase lasted for about 4 sessions and led to a further reduction of the pain to a 2/10 VAS. An improvement of the mobility of the thoracic and lumbar spine was achieved, although the patient could not give reliable subjective feedback as he was almost totally unable to integrate sensory stimuli from below the spinal lesion level (ASIA B, Masry et al. 2006).

The approach to this patient’s case was relevant to engage with the osteopathic conceptual model of compensation of the body (Stone, 1999). It was remarkable noticing how the work on the dorsal scoliotic curvature helped in reducing the local symptoms on the latissimus dorsi, especially achieving a better scapulo-thoracic rhythm and reducing the hypertonicity of the rhomboids. In fact, a low degree scoliosis appears to be enough to alter the spatial arrangement of the patient’s body, leading to an asymmetric distribution of the trunk weight and to an active attempt to counterbalance the curvature, enhancing even more this asymmetry (Czupryna et al. 2012). In this specific case this process was made more evident by the pathological lack of voluntary contraction due to the spinal lesion.

The long term management plan took into consideration the adaptation of the physical activity/training of the relevant muscular groups and the educational guidance on the future self management skills.

After about 6 weekly follow up sessions the patient’s symptoms had considerably reduced and it was possible to introduce a home exercise program in the management plan. This should have customised the training for daily activity purposes and involved the patient’s family for the prevention of the recurrence of the symptomatology.

Within this specific case scenario the role of the patient’s wife was of relevance as primary caregiver at home. For this purpose they were asked to attend together for one of the following sessions, which would have allowed to teach and demonstrate soft tissue and articulatory techniques useful to alleviate the muscle hypertonicity caused by the overuse on those structures. Moreover it would have helped to increase the family awareness towards the fact that more help with daily activity may be needed over time considering the spinal lesion (Liem et al. 2004). Although it is arguable that the involvement of the carer could increase the level of dependance of the patient and therefore represent a potential yellow flag, it appeared necessary for the future home management. Moreover it was relatively unlikely to create an issue considered the strong independent attitude of the patient.

A relevant aspect linked with this case presentation was represented by blending together the patient’s everyday necessities, connected with the impossibility of resting his shoulder, and a home plan which should have strengthened and alleviated the latissimus dorsi at the same time. The involvement of the patient’s wife played a key role in the implementation of the management plan, in fact she was able to learn and safely apply basic MET techniques on the different components of the left shoulder joint, mainly focussing on latissimus dorsi, supraspinatus, scalenes and trapezium. The possibility of bringing home some useful tips from the treatment room helped to maintain the benefits of the treatment and to compensate for the daily demand on the left shoulder (Ludewig, 2003). The home exercise program was initially based on passive stretching positions of latissimus dorsi and rotator cuff muscles to repeat throughout the day. As soon as the symptoms improved, along with the patient self management skills, it was possible to add exercises with a resistance band. These helped in training the muscles on eccentric contraction, therefore improving their strength along with a more functional length of the fibres (LaStayo et al. 2003).

The patient attended a total of 9 sessions at the clinic over a period of about three months. By the end of the intervention the pain score was rated 0/10 with only occasional presentation of the symptoms after prolonged straining activities. The final outcome was satisfactory, although more attention could have been paid to the assessment of the breathing pattern and the diaphragm. Depending on the level of the spinal lesion, in a quadriplegic patient the respiratory muscle isn’t as supported as in the usual breathing mechanic by the accessory muscles of respiration. In this patient’s case the intercostal muscles were found to be inefficient, and a considerable effort was made by the sternocleidomastoids and scalenes during inspiration. The lower ribs were not expanding sufficiently to ensure a full descent of the diaphragm and an upper rib breathing pattern was present (McCool & Tzelepis, 2012) .

Addressing these elements during the treatment would have allowed a better engagement with the osteopathic concepts of dynamic of fluids and compensatory mechanism of adaptation of other components (accessory muscles of inspiration). Moreover the release of the hypertonic diaphragm could have improved the whole breathing mechanics, eliminating a potential concurring factor to the patient’s symptomatology. In fact, a correct diaphragmatic function makes the pump action and venous return from the lower body to the heart more efficient, achieving increased tissue perfusion. Hence aiding in reducing the local inflammatory processes.

The knowledge acquired from this clinical experience is deeply linked with the appraisal of how the body works in full integration of function from the different systems. The package of care offered to such a patient has to be underpinned by a concrete understanding of how various aetiological factors may influence the patient’s health, highlighting the importance of integrating the “little picture” within the broader complexity of a pre-existing condition.

REFERENCES

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