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Subocciptal Neuralgia??
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Subocciptal Neuralgia?? - September 9, 2003 5:46:00 PM
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sarty
Posts: 65
Joined: April 22, 2001
From: Florida, USA
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Hi everyone...long time no post [IMG]http://www.rehabedge.com/forums/wink.gif[/IMG] I am writing to get your feedback on an interesting case I'm dealing with. Former RN, female, 35 y/o, presents with diagnosis of myofascial pain and subocciptal neuralgia. Posture is poor with protracted head and protracted shoulders. aROM is limited by her shoulder and head positions and measures at about 50% of WFL. BUE strength is WFL (4/5).
She reports insidious onset of symptoms that have progressively worsened. Symptoms include "brain fog", and "lethargy" if she sleeps in her bed (flat). She sleeps in a recliner to avoid this. She also complains of a "pressure" that builds while she is in supine and cannot tolerate that position for more than a few minutes. Pressure is located in the sub-occipital area. Palpation reveals tenderness to moderate pressure in the scalenes, upper trapezius, levator scapula, sternocleidomastoid and sub-occipitals.
Vertebral artery test was negative, by the way.
Treatment so far has consisted of:
*McKenzie approach including loaded cervical retractions and loaded cervical retraction plus extension with hold of 45 seconds, performed q2 hours. Immediate effect is abolishment of "pressure", and soreness, but no change in any "fog" or "lethargy" that may be present.
*Posture training, with specific exercises to improve posture including scapular strengthening, chest/pectoral stretching, retractions, upper body ergometer (forward and retro).
*Manual therapy including suboccipt. release (result= "oh, that feels much better", but no change in lethargy or fog), kneading, manual traction, unloaded McKenzie retractions plus extensions. Results as above.
*Modalities prn: hp, US, Mechanical traction (unable to tolerate secondary to "pressure" and the supine position.
I'm totally lost. Her MD has suggested a botox(sp?) injection in the sub-occips. She believes she is not getting proper "circulation to the back of my head".
Her posture and rom have improved and I can decrease her soreness/pressure symptoms, but I cannot change the lethargy and foggy symptoms. Could she have some type of neurological or circulatory issue here? Am I missing something obvious? Any ideas would be appreciated. (The PT who assigned her to me has been kept up to date and thinks it probably is something beyond what physical therapy can fix.)
Thanks!
Jen, the PTA who used to post here all the time [IMG]http://www.rehabedge.com/forums/wink.gif[/IMG]
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Re: Subocciptal Neuralgia?? - September 9, 2003 6:26:00 PM
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PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
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As far as the foggy and lethargy complaints, there most likely is a psychosocial aspect. I have seen many women with this type of complaint, and much of it is the physical manifestation of tension and stress. Relieve the symptoms and you still have the cause, which usually is out of the scope of PT.
Not sure how the botox would work, but have seen corticosteroid injections into the suboccipital region work for persons diagnosed with "tendonitis" of the suboccipital musculature.
By the way, any trigger points to the temporalis musculature and the supraorbital area, just under the brow?
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: Subocciptal Neuralgia?? - September 9, 2003 6:47:00 PM
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Sam B
Posts: 73
Joined: August 6, 2003
Status: offline
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Hi Jen!
Some ideas to consider for you and the PT.
Headaches, if cervical in origin can start anywhere from as low as C4-5 on the same side. Sometimes when a patient has a mid/lower cervical problem eg painful disc, facet joint, it is very hard not to hyperextend the upper cervical spine, due to flexion positioning of the mid cervical spine from muscle guarding. So, you then end up with three problems.... the original mid/lower cervical problem ( she doesn't like supine lying/ traction in supine) an upper cervical irritation of the suboccipital tissues from extension loading ( the PT must check C1-2 and C2-3; C2-3 is THE classic headache generator) and then cervicothoracic junction problems, due to inability to turn the head fully for several weeks. When the CT junction gets crabby, enter the sympathetic nervous system and headaches get nasty/ symptoms become obscure.
I question a diagnosis of occipital neuralgia, unless there is an irritated occiptal nerve, or a C2 dorsal ramus syndrome. Myofascial pain... I still don't know what that is. Ischaemia of fascia tissues, collagen fatigue, local hyperalgesia due to peripheral/ central sensitization of tissue within a dermatomal/ sclerotomal pathway?... many, many questions on that for me.
Don't give up on her. Who else in the medical community can treat this but you? Botox is a band-aid and is a scary scary idea for a non-specific diagnosis. She may be frustrated/ depressed and anxious. The "fog" may be symptoms from the Tx spine or from mid-cervical. My bet is that it is upper thoracic in origin. Check that she is getting plenty of sleep, check psycho-social factors eg depression/ anxiety.Depression is common. But, you can still help her a lot!
Re-look at working her so hard in that gym. If you have a stiff/ sore thoracic spine, working scapula gropus will be uncomfortable, as her thoracic deep extensors just cannot extend her spine actively. Her traps and cuff are probably exhausted, so a UBE bike( uses a lot of isometric holding) may make her sore.
I think she needs to be completely re-evaluated again. Block out a chunk of time, look again and find the problem. Something will pop out at you!!
Cheers,
Sam B
[This message has been edited by Sam B (edited September 09, 2003).]
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Re: Subocciptal Neuralgia?? - September 9, 2003 7:42:00 PM
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Diane
Posts: 1510
Joined: March 9, 2001
From: Vancouver, B.C., Canada
Status: offline
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Just wondering; what is the front of her neck like? Does she have a tight set of SCMs? If so they might be pulling down on the mastoids, (which are attached to the occiput..) How long has she been sleeping in a recliner?
It might be redundant to point this out.. but there are carotids to think about as well as vertebral arteries..
I'd be very light, just skin stretching on the front of the neck, no pressure.
Diane
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Re: Subocciptal Neuralgia?? - September 12, 2003 3:16:00 PM
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Oaks
Posts: 11
Joined: September 11, 2003
From: Danville, Va
Status: offline
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I have been posting under ScottO, but lost that password, anyway
Recently, I had a woman sent to me with a dx of suboccipital neuralgia, she responded well for a short period after treatment, but continued to have symptoms of primary headache and subocc pain.After 4 visits with no lasting change, I noticed an increase in unilateral bulging of the temporal arteries, I reffered, her back to her MD with these findings, and it turned out to be temporal arteritis, was treated with predisone, and all of her symptoms were resolved after the injection. This mostly occurs in elderly women, but my patient was only 55, so she didn't fit the normal profile. I am unsure if this can cause brain fog, but it can strongly affect vision if not caught early. good Luck
ScottO
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Re: Subocciptal Neuralgia?? - September 26, 2003 6:53:00 PM
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Vtx
Posts: 1
Joined: September 25, 2003
Status: offline
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Hi Jen,
Your patient has a very interesting problem and i think you are a great therapist for being resourceful and reaching out to help this patient. Everyone has great point.i'm just tryng to add to their replies. Perhaps your patient should be seen by a good neurologist to check if she has spinal stenosis of the cervical area or possible Chiari 1 malformation.If you haven't heard of chiari, check online. Good luck!
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Re: Subocciptal Neuralgia?? - October 2, 2003 7:46:00 AM
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VagusX
Posts: 220
Joined: March 26, 2003
From: Savannah, GA, USA
Status: offline
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What meds is your patient on? Does she abuse psychoactive substances? Does she get any aerobic exercise?
Most likely your patient does not abuse psychoactive substances and was more of a joke. But see how she responds to giving her a fairly hard work for 20 minutes. She how she responds to that.
You could get mixed results. Improvments great! You could solve your problem right there and you may need to look into some vascular diagnostic testing. More fog then you may be dealing with some electropysiological changes in the brain or the MS aspect of the occipal muscles are creating symptoms. Or......a bunch of other things that the people above me said
Good luck
What ever happened to encouraging aerobic well being?
[This message has been edited by VagusX (edited October 02, 2003).]
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