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I had checked my referrals the afternoon before and stumbled across this; “Please see Mrs L, a 53 year old woman for management. She complains of persistent pain in her neck which radiates to the head and teeth, difficulty in movement due to radiating pain. Could you please provide regular physiotherapy to her to reduce pain and improve mobility.” The patients medical history; Chiari Malformation type 1 (surgery in 2014), stellate ganglion injection (right) 2015.
Baffled, I knew this was one for some research. I approached my senior, asking about his experience with patients post Chiari Malformation surgery, he looked just as baffled as I was. A Chiari Malformation, types I-IV, refer to a spectrum of congenital hindbrain abnormalities affecting the structural relationships between the cerebellum, brainstem, the upper cervical cord, and the bony cranial base. A long-winded way of saying the cerebellum herniates through the foramen magnum, causing similar symptoms that we would expect to see in a cerebellar stroke; headaches, ataxic gait, altered balance, nausea, dizziness, vision problems.
It was clear why this patient had to have surgery. She had undergone a posterior fossa decompression in 2014, which involved a sub-occipital craniectomy and a C1/C2 laminectomy. So, what that meant was careful palpation and no Passive Accessory Intervertebral Movements (PAIVMS) around C1/C2.… At this point I was feeling thankful I had done some research. The next day, I figured I would be seeing a patient with some post-operative neck pain and stiffness, what I didn’t anticipate was the constant neck and head pain of a year duration, bilateral shoulder pain, intermittent pins and needles/numbness in the right forearm complicated by nausea and vertigo, continuous hiccuping and burping. These symptoms left the patient housebound for the past year, and bed bound by 11am onwards, just enough time for her to shower and finish her breakfast. A few red flags later and I left the consultation cubicle to ‘photocopy her reports’, and buy myself some time to figure out how and where to start.
Once I had contacted her neurosurgeon who has been keeping a close eye on her and he ruled out any neurological concerns, I started treatment as you would with any other chronic pain patient. Problem list? Decreased C-spine range, ongoing relentless pain, headaches, assumed deep C-spine flexor/extensor weakness, combine that with no post-operative rehab or education and you got yourself a pretty severe chronic pain presentation.
Frustrated that I hadn’t seen any changes in symptoms, I approached my senior again, who has a knack with chronic pain patients. “Stop asking her about her neck” was the first thing he said, “Yeh, I know she’s chronic but surely I have to keep asking her about how it feels” I replied, “Stop asking her about it, and don’t use the word pain, at all. Ask her how her day was, ask her if she got out of the house.” My interest for chronic pain management kicked in. This was the reality of life for this poor woman, and she was convinced that it would never get any better than this. She had become so sensitized, with an increase in excitability of the spinal cord neurons combined with the theory that ‘significant headache may be produced by scar tissue surrounding the occipital nerves or by fibrous adhesions, binding neck muscles directly to the dura’ post surgery like hers.
Chronic pain patients, as clinically frustrating as they can be, are 10 fold more satisfied when little changes are seen. These patients aren’t crazy, the pain is real, much like we see in neuroplasticity for neurological recovery. Chronic pain uses the same tools, laying down nociceptive pathways and decreasing the pain threshold. I think we as clinicians sometimes discredit a patients pain when it doesn’t fit what we read in text books. So, I changed my management plan. Combining standard chronic pain approach and exercises, I focused on her quality of life and whole body movements. My first goal; “Walk for 3 minutes, 3 times this week” progress to “10 minutes.” After some therapy sessions, she came to see me, crying tears of joy, that she had left the house because she could walk for long enough to get her around the block and back home. Then, I tried the exercise bike and the theraband. Any whole body exercise that I could think of that didn’t focus on the fact that she had neck pain, seemed to help. I decreased the amount of cervical exercises she was doing and got her into our exercise class that she now attends twice a week for an hour.
It’s not the typical approach, but chronic pain is a complex entity and topic on its own, that needs to be considered in treatment. It is hard not to mention the words “pain” or “neck” in a session, but we found out that distraction from the problem was the lady’s best chance, and she needed to stop reinforcing those nociceptive neurological pathways. By no means to this day is she pain free, and there is a long way to go, but her Lyrica dose has reduced, and she can now leave the house and stay awake after 11 am. She smiles when she walks, and goes out to dinner with her husband like a normal couple. I would call that a triumph.
- Aghakhani, N., Parker, F., David, P., Morar, S., Lacroix, C., Benoudiba, F., & Tadie, M. (2009). LONG-TERM FOLLOW-UP OF CHIARI-RELATED SYRINGOMYELIA IN ADULTS. Neurosurgery, 64(2), 308-315. http://dx.doi.org/10.1227/01.neu.0000336768.95044.80
- Borisut, S., Vongsirinavarat, M., Vachalathiti, R., & Sakulsriprasert, P. (2013). Effects of Strength and Endurance Training of Superficial and Deep Neck Muscles on Muscle Activities and Pain Levels of Females with Chronic Neck Pain. J Phys Ther Sci, 25(9), 1157-1162. http://dx.doi.org/10.1589/jpts.115
- Chiari I Malformation Redefined: Clinical and Radiographic F… : Neurosurgery. (2016). LWW. Retrieved 10 May 2016, from http://journals.lww.com/neurosurgery/Abstract/1999/05000/Chiari_I_Malformation_Redefined__Clinic
- Deng X, e. (2016). Long-Term Outcomes After Small-Bone-Window Posterior Fossa Decompression and Duraplasty in Adults with Chiari Malformation Type I. – PubMed – NCBI. nlm.nih.gov. Retrieved 10 May 2016, from http://www.ncbi.nlm.nih.gov/pubmed/25701768
- Falla, D., Lindstrøm, R., Rechter, L., Boudreau, S., & Petzke, F. (2013). Effectiveness of an 8-week exercise programme on pain and specificity of neck muscle activity in patients with chronic neck pain: A randomized controlled study. EJP, n/a-n/a. http://dx.doi.org/10.1002/j.1532-2149.2013.00321
- Munshi I, e. (2016). Effects of posterior fossa decompression with and without duraplasty on Chiari malformation-associated hydromyelia. – PubMed – NCBI. nlm.nih.gov. Retrieved 10 May 2016, from http://www.ncbi.nlm.nih.gov/pubmed/10834643