Case: 42yo F
Main complaint: constant ache CT Jctn > 20 yr Hx; NPRS: 6/10
also has constant whole posterior body stiffness; NPRS: 4/10
Sx agg
Cx: computer work, reading
Stiffness: highly variable; sitting and walking too much usually increase
Sx ease
Never goes away. Lying down. Heat sometimes helps
Review of Systems:
- ADHD (high functioning)
- Behavioral screening: neg
- Low grade systemic inflammation screen (NICE): neg
- Motor Control Abilities Questionnaire: positive (poor motor skill learning ability)
- No other co-morbidities
- Recent blood work: reported as normal
- Allergies: none reported
Family Hx:
- no DM, no CVD, no ID, no AI, dementia / Alz in parents & grandparents
Social Hx:
- Works full time: desk job. Has had ergonomic work station review
- Married. no children
- Physical activity: walking daily; hiking w/e; gym strengthening 3 x / wk with personal trainer (Sx with more)
- Pt noted that her physical activity did not help improve Sx, but was worse without it.
- Hobbies: reading
Birth Hx
2/12 premature. Emergency C-section due to pre-eclampsia. Neonatal intensive care for extended period. Walked very early. Minimal crawling.
Did not play sports as a child
Previous Rx:
Chiro (multiple practitioners)
PT: (multiple practitioners) Rx included: general strengthening and stretching; progressive loading; heat & TENS; manual therapy
Did get some mild temporary relief from manual therapy. Strengthening may have helped a little, but too much made things worse.
Chronic pain program: behaviorally based and encouraged increased physical activity (she did not enjoy this because she was already physically active and when she tried to do more her Sx increased. She stated that the program discussed depression with her so much she questioned if she was actually depressed and didn’t know it).
Observation
Chin poke posture
Sitting at end range Tx flexion
PA:
ROM:
- Cx flexion (functional range WNL)
- < 5° upper Cx flexion with most of the flexion occurring at the lower Cx
- Cx ext: No ability to extend the lower Cx
Pain provocation testing
PA (central)
- C6/7 reproduced Sx (main complaint)
Neurodynamic Ax:
- Slump test: overall range was moderately limited. Reproduced tightness in spine and legs, but did not reproduced Sx.
Myofascial Ax:
- palpation of paraspinal muscles reproduced spinal Sx
Primitive & Postural reflex screen:
- Moro: pos
- Trunk ext: pos
- Landau: pos
- Foot tendon guard: pos
- Supine creep: pos
- STNR: pos
- STNR-C: pos
Clinical Reasoning
Diagnosis
- Working Hypothesis: Discogenic pain C6/7; spinal and lower body myofascial pain
Mechanisms:
- The client may have a tissue loading mechanism of lower Cx flexion with poor control of lower Cx extension. This has placed strain on the C6/7 disc
- The client may have neurological dysregulation with altered posterior muscle tone
Causation hypothesis
- Possible cause: altered spinal tone and reduced upper cervical flexion
- Possible cause: atypical birth Hx and early life development
Notes: The above reflexes were selected in the assessment because they were extension based and were more likely related to the patient’s presentation. Specific motor control indicated, but not used due to poor motor skill learning ability. MDT was considered however the pt could not perform this.
Rx
- Education regarding the ADHD, neurological dysregulation and tissue loading
- Primitive reflex inhibition
- Moro extension x 10
- STNR sagittal and coronal x 10
- Postural reflex facilitation
- Supine Creep x 5
Post Rx response:
Pt had no Cx Sx or widespread stiffness after primitive reflex inhibition.
Patient advised to continue these exercises as needed
Follow up 6/12
Pt doing exercises every other day or as needed.
NPRS 0/10
Summary
Clinicians should consider Adult-Mild Neurological Dysfunction as part of causation in pts presentations. This case had widespread spinal Sx. No one gave her an explanation for her Sx and it was assumed by clinicians she would respond to general exercise and others assumed she had a behavioral condition when none was present.
Children do not usually grow out of neurodevelopmental disorders. They often carry them into adulthood. Neurodevelopmental disorders can often be treated with neurodevelopmental rehab such as:
- primitive reflex inhibition
- postural reflex facilitation
- midline coordination
- Specific sensory motor function
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