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Treatment Tools

By Debbie Roberts, LMT

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Should They Stay or Should They Go?

No, I'm not talking about that song from The Clash. Let me begin by telling you that the client we will discuss had too many correlating tests and symptoms to stay. Based on this client, we will be taking a look at vertebral artery stenosis or insufficiency and the risk factors of treatment. We will discuss some of the signs and symptoms that just might make you want to play this tune in your head when a medical massage type of client comes walking in your door. More clients and more doctors are recognizing the words medical massage. Although that is great, it certainly comes with an entire set of specialized expertise that doesn't necessarily mean a strong sense of palpatory skills.

Should you treat or should you delay treatment or should you not treat at all is the biggest question for a therapist that states they do medical massage or any specialty massage that has the goal of relieving pain. It is truly imperative that the client get a full medical clearance in order for you to safely perform medical massage that would include stretching, soft tissue manipulation, isometrics, or traction, if necessary.

Should They Stay or Should They Go? - Copyright – Stock Photo / Register Mark In talking with another colleague of mine, we both agreed that the longer we have been in the massage therapy profession the less anxious we are to jump right in performing manual therapy without first knowing the complete history of the client and making sure the doctor knows the type of therapy the client is about to receive. There are a ton of unusual circumstances that seem to seek out our help these days. And the client situation we are going to talk about in this article was no different.

She had been referred to me by a friend. Over the phone, she stated she was having left neck pain and occasional headaches that weren't getting any better with either physical therapy or chiropractic care. She had hopes that a medical massage might help. Sounds simple, doesn't it? Maybe soft tissue issues with the scalenes, trapezius muscles, or the SCM? When she presented with her reports and history, and I performed a cervical assessment, it became alarmingly complicated. So much so, I didn't treat, I wrote a report for her general physician, neurologist, and chiropractor asking them to make sure she could receive medical massage therapy with light traction.

Here is what set this all in motion. Her reports raised significant concern for manual therapy without medical clearance and this is only the impression of the report, not the whole report.

First, there were spinal biomechanical alterations noted in the C spine. Second, intercalary bone formation at C3,4,5,6 disc levels. Third, posterior osteophytes formation is suspected at the C6 disc level. Fourth, spondylosis, unconvertebral arthrosis and facet arthrosis in the cervical spine more prominent at the C6 level. Fifth, osteopenia advanced for her age. And sixth, the neural arch of C1 seemed incomplete.

Her lumbar report stated that they saw atherosclerotic calcific plaguing present within the abdominal aorta. It also stated she had baastrups kissing stenosis of the lumbar spine. Spondolosis and arthrosis at the lower thoracic and lumbar spine most prominent at L3. Also, spinal biomechanical alterations noted. Red Flags: The calcific plaguing can be happening in any artery and the aortic artery has a branch to the left vertebral artery.

Definitions you need to know

Intercalary bones are common discal ossifications that are usually triangular in morphology, found in the anterior annular fibers of an intervertebral disc, and are thought to be degenerative in aetiology.

Osteophytes, commonly referred to as bone spurs or parrot beak, are bony projections that form along joint margins. They should not be confused with enthesophytes, which are bony projections that form at the attachment of a tendon or ligament.

Unconvertebral arthrosis is a term used to describe a specific form of osteoarthritis affecting the unconvertebral joints, more commonly known as the Luschka's joints, located along the cervical vertebra.

Facet arthrosis is a term used to describe how the joint cartilage deteriorates – and joints depend on this cartilage to stay lithe and mobile.

Cervical spondylosis is a general term for age-related wear and tear affecting the spinal disks in your neck. As the disks dehydrate and shrink, signs of osteoarthritis develop, including bony projections along the edges of bones (bone spurs). Cervical spondylosis is very common and worsens with age. More than 85% of people older than age 60 are affected by cervical spondylosis.

Osteopenia refers to bone density that is lower than normal peak density but not low enough to be classified as osteoporosis. Bone density is a measurement of how dense and strong the bones are.

Baastrups syndrome (also referred to as kissing spines) results from adjacent spinous processes in the lumbar spine rubbing against each other and resulting in hypertrophy and sclerosis with focal midline pain and tenderness relieved by flexion and aggravated by extension.

According to an article written by the American Heart Association, abdominal aortic calcification deposits, detected by lateral lumbar radiograms, are a marker of subclinical atherosclerotic disease and an independent predictor of subsequent vascular morbidity and mortality.

Why I Said No

First, I asked the question why physical therapy hadn't helped. Physical therapy was able to relieve her headaches but not the left sided neck pain. Red Flag: Left neck pain since July and it is now January. Why?

Second, she relayed she had been having vertigo for the past two months that had not been discussed with any of her three medical professionals, only the physical therapist. She had an incident during physical therapy and the physical therapist performed a maneuver that helped. However, she experienced nausea and vomiting for about four hours that evening. She also stated that the vertigo could happen at rest and/or always seemed to happen when she turned her head to the right.

Red Flags: Only one out of four of her medical team knows she is experiencing vertigo and this needs medical clearance. The vertigo could be brought on at rest. The vertigo also happens when her neck is turned to the right. Is she impinging a nerve, artery or vertebrae?  And why nausea and vomiting after the physical therapist relieved the vertigo?

Third, she says she feels like her head is fuzzy all the time and she can't think. Red Flag: Just ask the question why? Why is there less blood supply going to the brain? Maybe she has a subluxation. These are questions for her neurologist or chiropractor.

Fourth, she is describing auras without headaches. Like she can see or experience a big circle sometimes. Red Flag: Experiencing auras without headache is typically a vascular migraine symptom followed by a headache. This is another question for her neurologist.

Objective findings

She is standing with her whole body rotating to the left. From the frontal view, her head is tilted more to the left. Her left eye looked more strained than her right eye. When I asked her to cover her left eye, her vision was more blurred on the right. When I asked her to cover her right eye, her vision remained clear. Flexion of the cervical spine was without pain or discomfort. However, extension of the cervical spine made her dizzy and gave her a sensation of an attack of vertigo. There was discomfort on the left side of the neck when side bending to the right. She had more cervical ROM looking to the right than she did looking to the left and there was pain on rotation to the left. Slight palpation of the right occiput and suboccipital muscles made her feel like she could experience vertigo and it was exquisitely painful. Red Flag: Left eye strain and the difference in vision when covered. Extension of the cervical spine just slightly made her dizzy, to close to a positive vertebral artery test.

Here is the question of the day: Does she have the potential of vertebral artery insufficiency or stenosis? And how many red flags should you ignore? Answer, none. She needs medical clearance.

Let's look at the signs and symptoms of vertebral artery stenosis or vertebrobasilar insufficiency. First, what is vertebrobasilar insufficiency? The vertebrobasilar arterial system is located at the back of your brain and includes the vertebral and basilar arteries. These arteries supply blood, oxygen, and nutrients to vital brain structures, such as your brain stem, occipital lobes, and cerebellum. A condition called atherosclerosis (which she has) can reduce or stop blood flow through the vertebrobasilar system. Arthrosclerosis is a hardening and blockage of the arteries. It happens when plaque that's made up of cholesterol and calcium builds up in your arteries. The buildup of plaque narrows your arteries and reduces blood flow.  Plaque can completely block your artery over time, preventing blood from reaching your vital organs.  This can occur in any artery in your body.  When it occurs in the arteries of your vertebrobasilar system, it reduces blood flow to structure in the back of your brain.

The symptoms of vertebrobasilar insufficiency vary depending on the severity of the condition. Some symptoms may last for a few minutes, and some may become permanent.Sypmtoms might include:

  • Loss of vision in one or both eyes.
  • Double vision.
  • Numbness and tingling in the hands or feet.
  • Nausea or vomiting.
  • Dizziness (vertigo).
  • Slurred speech.
  • Changes in mental status, including confusion.
  • Sudden, severe weakness throughout your body, which is called drop attack.
  • Loss of balance and coordination.

Conclusion

She took the report to her chiropractor and he performed a more extensive test for vertebral artery insufficiency. At this time, he didn't believe she had this, but during the exam he did say to her, "no wonder you are having all these symptoms as you are incredibly subluxated at C2 and C3." I got the call after her adjustment and she said it is amazing how clear she felt, with less pain and thanking me for taking the time to do the report. She is also taking the report to her neurologist. There may be more medical tests necessary to clear her for medical massage. Moral of the story: Trust your insight before applying your hands.

Last Definition

Insight is the capacity to gain an accurate and deep intuitive understanding of a person or thing.

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