Rare Diagnostic Case of the Month: Notalgia Paresthetica

The next time you buy an orthopaedic textbook take a look at the chapter list. You will probably find the shortest chapter to be on the thoracic spine. With that said the list of differentials  for T Spine and interscapular pain is usually short for most manual therapist. This is why although perhaps rare, reading about Notalgia Paresthetica sparked my interest.

What is it?

Notalgia Paresthetica (A.K.A Hereditary Localized Pruritis, Posterior Pigmented Pruritic patch and Subscapular pruritus) is a sensory neuropathy which involves dorsal spinal nerves. The neuropathy usually first presents itself with extreme itchiness and then may progress to pain, paresthesia, hyperesthesia and eventually a hyperpigmented patch of skin.

What causes it?

The flaw in research regarding NP is there are multiple causes which are purposed. Most studies looking into NP denote one specific cause and only investigate that particular pathophysiology. NP has been deemed to be due to hereditary conditions, chemical toxicity, increased dermal innervations and spinal nerve pathology either due to trauma or entrapment.

The hereditary and toxicity notion is often dismayed because of the rare reports and anecdotal evidence. However, there seems to be a strong correlation with spinal changes and NP.  Firstly, dorsal spinal nerves in the upper thoracic spine appear to pierce the Multifidus in a right angled manner. Such an anatomical position leaves the nerves exposed to trauma and easily being impinged.

In addition, recent small cased studies have found the majority of NP patients to have some form of T Spine pathology (7/10 & 9/12). These pathologies consist of degeneration, bulging disc and past history or prior upper back and neck complaints. Interestingly enough the dermatological pattern of patients symptoms correlated with their imaging findings. For example if a patient presented with symptoms from T1-T3 it was found they had degeneration in this particular area. In addition, these findings were discovered by a radiologist blinded to the patient's complaint.

How do I treat it?

Multiple forms of treatment have been performed on NP patients. Majority of treatment options consist of dealing with hypersensitive nerves and skin. These options are limited to paravertebral nerve blocks, epidural injections, topical creams, acupuncture and botuline toxin injections.

However, what does one do when these forms of treatment are not at their disposal? How do you treat an area which is to painful to even touch?

A recent experimental form of treatment has been published. This treatment is based on the premise that NP may be due to the long thoracic nerve being injured. Thus with such an injury the Serratus Anterior is dysfunctional and now needs to be rehabilitated.

In this particular study subjects carry out Electrical Muscle Stimulation (EMS) of the Serratus Anterior.  Although results were recorded anecdotally, an improvement of 70% was found in some subjects.
More importantly this study provides insight into options for rehabilitative practitioners into treating NP.

Consider the following: If the Serratus Anterior is dysfunctional then the scapula may be positioned in a slightly retracted manner. The Trapezium and Rhomboids are now pulled under tension. This tension may apply traction or impingement to dorsal spinal nerves. This ideology may purpose a relationship between NP and Serratus Anterior dysfunction. If such a relationship is proven then this gives a rehabilitative premise for manual therapist to work with NP patients.

Additional research has also attempted to show analgic effects of using transcutaneous electrical nerve stimulation (TENS) amongst NP patients. However, results of this study were minimal displaying 30% improvement at best.

In addition, if one does find a correlation of T Spine pathology with an NP patient they should focus on the actual pathology. Degenerative changes could be treated with glucosamine supplementation and disc herniations with Mckenzie exercises.

So Remember

-Attempt to discover the cause of your patients NP.  Consider taking radiographs.
-Work with other professionals such as dermatologist to relieve symptoms such as pruritis.
-Incorporate Serratus Anterior rehab exercises into your treatment plan.
-Attempt to re-educate nerves with EMS and numb them with TENS.
-Focus on the actual T Spine pathology such as a herniated disc or degeneration which may be causing symptoms.

In summary manual therapist should be knowledgeable in the diagnosis of NP. Knowing such a diagnosis allows one to consider it in their differential list. Furthermore, NP allows us more insight into other causes of neuropathic pruritis which is often forgotten and not known about. Dr. Wayne Button, BSc, D.C

References:

SAVK, O., & SAVK, E. (2005). Investigation of spinal pathology in notalgia paresthetica Journal of the American Academy of Dermatology, 52 (6), 1085-1087 DOI: 10.1016/j.jaad.2005.01.138

Raison-Peyron, N., Meunier, L., Acevedo, M., & Meynadier, J. (1999). Notalgia paresthetica: clinical, physiopathological and therapeutic aspects. A study of 12 cases Journal of the European Academy of Dermatology and Venereology, 12 (3), 215-221 DOI: 10.1111/j.1468-3083.1999.tb01031.x

Wang CK, Gowda A, Barad M, Mackey SC, & Carroll IR (2009). Serratus muscle stimulation effectively treats notalgia paresthetica caused by long thoracic nerve dysfunction: a case series. Journal of brachial plexus and peripheral nerve injury, 4 PMID: 19772656

Savk E, Savk O, & Sendur F (2007). Transcutaneous electrical nerve stimulation offers partial relief in notalgia paresthetica patients with a relevant spinal pathology. The Journal of dermatology, 34 (5), 315-9 PMID: 17408440

Diabetes: The alarm clock that wakes you up in the morning

The alarm goes off loudly and stirs my slumber. Anxiously I slap the button and bring the room back to silence. I do this knowing I will fall back asleep only to have the beginning of my day depend upon my back up alarm. Soon enough the alarm attacks and makes its second attempt to get me jump started. Shamefully, it is the third alarm who is the victor. I now arise from the bed knowing this was my last alarm which I have set.

For years I have felt plagued with guilt knowing I start every day with this protocol. However, after reading some of the newest research I find myself not only disburdened but also somewhat health conscious.

Need another reason to fall back asleep?

Within the last decade studies have shown a correlation between type 2 diabetes and sleep deprivation. Since the 1960's, the percentage of the population which obtains <7 hours of sleep a night has more than doubled (15.6%-37.1%). Oddly enough a similar pattern has been observed as well with the populations rise in Type 2 diabetes.

Scientist believes this may be due to a hormone called Leptin. After eating a meal Leptin will be released by our fat cells. Our brain will then receive a message to decrease our appetite. However, people who are sleep deprived will have lower concentrations of Leptin. This lower concentration will spike our appetite and may slowly lead to obesity and eventually diabetes.

But I am young and healthy and don't need to worry.

A correlation between sleep deprivation and a high body mass index (BMI) has been found in children as young as 5 years old. Furthermore, a loss of one hour in sleep amongst adolescents has been deemed as an 80% increase in risk for developing diabetes later on in life. Those numbers are scary when considering adolescents to be highly sleep deprived and the prevalence today of obese children.

So the next time your reach over to shut the alarm off don't feel guilty. You're simply being health conscious. Dr. Wayne Button, BSc, D.C

For more info on this topic check out the following links and videos Health Column, The science of sleep 1The science of sleep 2

Spiegel, K. (2005). Sleep loss: a novel risk factor for insulin resistance and Type 2 diabetes Journal of Applied Physiology, 99 (5), 2008-2019 DOI: 10.1152/japplphysiol.00660.2005

Are your muscles dysfunctional? Treating neck pain: Part 3

Almost everyone you talk to claims to be an expert in mechanical neck pain (MNP). Hundreds of books, articles and now even a blog has been written on the topic. Prescribing any combination of exercises and techniques may be useful. However, when establishing a protocol for rehabilitation certain goals and objectives should be considered. This column will discuss the process of treating MNP in a continuation of Part 1 & Part 2 of our series on neck pain.

How do I guide my rehabilitation for MNP?

It is important to have a treatment plan in place. Without one we would be giving exercises with no real purpose. Consider the following:


When research is used to study the effectiveness of rehabilitation often protocols can be extensive. Patients in these studies will be diligent performing exercises everyday for long periods of time. Furthermore, such studies incorporate supervision of treatment with a protocol of progression and monitoring. After all this, results still may only produce 60-80% improvement. Such a study would be deemed a success. How much improvement do you think you will achieve with a housewife of three kids? How about if you give a patient 20 unsupervised exercises?

Guiding rehabilitation is never easy but the concept of applying it is. Simply ask yourself what am I trying to do? Rehabilitation for MNP should include the following two objectives:
1) Training individual muscle groups
2) Addressing problematic functional activity.

Addressing functional activity

Here a rehabilitation treatment plan should address those activities which are problematic. The list of activities may be extensive but posture is often the main culprit.

Do not underestimate your advice when educating a patient about posture. Studies have shown those patients which are given instruction achieve a more effective correct posture then those which are not given any instruction. Furthermore, these patients also achieve better activation of deep cervical flexor muscles (Importance discussed in  Part 2). [2]

Patients also usually need daily reminders to keep adjusting their posture. Every fifth phone call you receive talk while standing. Adjust your work chair every five minutes. Often patients can put little stickers on different areas of their workplace. These stickers should be placed in areas that will only be seen if they take on a problematic posture. The patient now remembers once seeing the sticker to change their posture.

Training individual muscle groups

This goal also works in synergy with addressing functional activity. This is because patients who display good muscle activation also favour a less problematic posture. These muscles now promote less of a forward head carriage or sloped shoulders. 

Exercise # 1

Training deep lower cervical extensor muscles

Patient should be in a four point kneeling position with their weight distributed on their elbows and knees. Starting in this position the patient should slowly lower their head into flexion and then slowly extend back to the starting position. Most of the movement should be coming from the lower cervical region. This isolation of movement can be facilitated with proprioceptive feedback and verbal cues by the therapist.

Exercise # 2

Training deep cervical flexor muscles

Patient should be in a supine position with their head rested on a small towel for support. With the forehead and chin lying parallel with the table the patients head is now in a neutral position. The patient should then be instructed to bring their chin towards their sternum slowly while slightly lifting their head off the towel. The patient should aim to not flex the head forward (as in the starting attempt of a sit up) but merely to sustain the neck in a slightly flexed posture. This position will best facilitate the deep cervical neck flexors.

In those patients who experience MNP with upper limb activity and scapular dysfunction a program of axioscapular exercises should be implemented. (Part 2).



What intensity of training should I use?

This is a good question and often can be confusing to physical therapist. The best way to guide your intensity level is again to ask yourself the question what is it exactly you're trying to do? These patients merely want a rehabilitation program that can help them in their everyday activities and reside some of their pain.

When considering rehabilitation for MNP low-level intensity exercises (approx 20% maximal voluntary contraction) is often the best choice. Consider the following:

Low level intensity training has been shown to
-Incorporate better coordination between both deep and superficial muscle groups [3]
-Assist activation of deep cervical flexor muscles [3]
-Produce hypoalgesic affects more so then higher-load exercises [4]
-Be more transitional to daily functional activities (20-50% MVC).
 

In summary, one should always remain critical yet open to different forms of treatment. However, a purpose should be appointed to everything you do. This point is emphasized all the time when patients, colleagues and lawyer will question your actions. So remember the next time you treat MNP, sometimes the best way to sink a golf ball is with a good putting game and not a long drive. Dr. Wayne Button, BSc, D.C 

O’Leary, S. (2009). Muscle Dysfunction in Cervical Spine Pain: Implications for Assessment and Management Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.2872

Schwarz, J. (2008). Recruitment of the Deep Cervical Flexor Muscles during a Postural-Correction Exercise Performed in Sitting manuelletherapie, 12 (2), 76-77 DOI: 10.1055/s-2008-1027472

Jull GA, & Stanton WR (2005). Predictors of responsiveness to physiotherapy management of cervicogenic headache. Cephalalgia : an international journal of headache, 25 (2), 101-8 PMID: 15658946

OLEARY, S., FALLA, D., HODGES, P., JULL, G., & VICENZINO, B. (2007). Specific Therapeutic Exercise of the Neck Induces Immediate Local Hypoalgesia The Journal of Pain, 8 (11), 832-839 DOI: 10.1016/j.jpain.2007.05.014

The infamies Gluteus Medius

Often when we work out we focus on the muscles which get us the most attention. Everyone wants to have the six pack abs, the toned legs and bulging biceps. However,training in this manner causes us to forget about some of the more important muscles. The muscles that our body uses for stability and preventing injury. 

The Gluteus Medius is a small muscle which is found along the outside of the hip joint.  Despite its size the Gluteus Medius plays an important role in exercise and injury prevention. This particular muscle is involved in stabilizing the hip joint.  Often when someone has a weak Gluteus Medius their hip will jut outwards while doing such activities as a single leg squat.

         

What most people don’t know is that having a weak Gluteus Medius has also been linked to injuries of the hip, knee and even the back. Some of the most elite athletes will get injuries because of this reason. Exercises like running and cycling involve mostly forward motion and can cause outside muscles such as the Gluteus Medius to be neglected.

Exercises for Gluteus Medius 

Side-Lying Hip Abduction: Start in a side-lying position on an exercise mat. Keep both knees fully extended and your hips in a neutral position.Slowly lift the top leg upwards towards the ceiling until reaching 30°. Then return the top leg slowly to the starting position. To challenge this exercise further place an elastic band around both ankles or use ankle weights. 

Lateral Band Walks Start with an elastic band tied around your ankles. Keep your knees and hips flexed 30° while keeping your toes pointed forward. Place your hands on the side of your hips. Starting with feet shoulder width apart begin side stepping approximately 130% of your shoulder distance repetitively. To progress tie the elastic band tighter or use one with more resistance.

Bridges Start by lying on your back and placing an elastic band around your knees. Lye on your back with your knees bent and your toes lifted. While attempting to squeeze your gluteal muscles together push outwards on the elastic band. Push your heels into the ground until your buttocks lift up 4-6 inches above the exercise mat. Now gradually lower your pelvic back down. Further challenge this exercise by doing a single leg bridge.

Are your muscles dysfunctional? Assessing neck pain: Part 2

     One should not assess mechanical neck pain (MNP) in an attempt to locate a specific structure which is flawed. Rather, MNP is often a contribution of different factors which lead to an end result of pathology. These contributing factors are dysfunctional muscles. This is a continuation of Part 1 and will discuss methods of examining MNP.  

     Manual therapist often will perform examinations with the goal of developing a diagnosis. Test will be performed and objective findings recorded. However, often performing examinations in this manner can produce a lot of black and white while forgetting to addressee the gray areas. With MNP the gray areas can be the most important areas. 

     So how do I assess cervical muscle function?

     Firstly, when assessing muscle function one must understand this is an observational skill. Such a skill will improve with the experience of the examiner.  There are no objective criteria which will produce a positive or negative result. Furthermore, this fact alone will create discrepancies between examiners. What one person deems as dysfunctional another may not.

     1. The Cranial Cervical Flexion Test (CFFT)

    This test is designed to examine and train deep cervical flexor muscles such as the longus capitis and longus colli [1]. These particular muscles play an important role in the stability of spinal segments. By using this test, examiners can indicate if these muscles are dysfunctional. In addition, we can also purpose a cause for patients MNP. Furthermore, this test can also help guide the rehabilitation process by indicating which muscles need to be targeted. 

     The test incorporates two important components of the deep cervical flexion muscles 1) upper cervical flexion and 2) flattening of the cervical spine. Studies have found those with both traumatic and non traumatic neck pain to lack the ability to perform the CCFT. Furthermore, while performing the CCFT these subjects displayed an increase in EMG activity of the superficial cervical muscles. This is hypothesised to be due to a compensation of weak and inhibited deep cervical flexion muscles. 

     To perform this test the patient must be lying supine with the forehead and chin parallel to the table. To achieve this position often the head must be placed in a small opened head rest (chiro table). The purpose of this position is to place the neck in a neutral position not favouring flexion or extension of any kind.

     Instead of using an inflatable pressure sensor (as described in studies) one may use a blood pressure cuff to gage the patient’s pressure. Place the blood pressure cuff below the occiput and behind the neck. Inflate the blood pressure cuff until the space between the neck and the table is filled but not to produce pressure upon the neck.

The patient is then instructed to nod the chin towards the sternum. The movement should be done without creating flexion of the head as if one is attempting to do a sit up. This position is then held for 10 seconds and should be performed at a level high enough to raise the blood pressure cuff by 10mmHg. If testing for endurance then repeat the same movement 10 times.

     Inability to do the test or to increase the pressure indicates weakness of the deep cervical flexors [2]. Observe the following Video.

  Keep in mind this test can be used to also train patients who present with muscle dysfunction. Patients can be progressed by increasing pressure (4mmHg to 5 mmHg) or by simply increasing the number or reps.     
      2) The Link to Posture

     How do I assess if there is a postural component to my patients pain?

    Patients will experience neck pain with prolonged sitting, repetitive upper limb activities or while maintaining a sustained position. 

     Patients will show poor cervicalthoracic postural habits when asked to mimic the aggravating postures which create their pain. Sitting for example has been shown in those with MNP to produce an increased cervical lordosis. This lordosis occurs due to compensating for a progressive thoracic kyposis over time from prolonged sitting.   
     
     Patients will report lessening of symptoms with postural correction strategies. 

3) The Link to the Scapula

     Patients with MNP have been linked to dysfunctional axioscapular muscle activity. These are patients who will experience their neck pain while performing repetitive task of the upper limb. Muscles such as the upper Trapizium and the Levator scapulae can be the source of this connection. These muscles have the ability to produce abnormal forces through spinal segments due to the scapula dysfunction.

     Scapular dysfunction can be assessed in multiple ways and would require an additional column. However, a good test is to first have a patient perform an aggravating activity which involves upper limb movement. Often I will try to reproduce the patient’s pain by having them bounce a ball repetitively against a wall with their arms elevated overhead. A connection can be made to their neck pain if pain is reproduced.

     Now have the patient perform the same task as before but with their scapula repositioned in the proper manner. This repositioning can be performed manually with either the scapular retraction test or scapular assistance test. Both test are often used to test shoulder pathology and purposed by Kibler. Another method to help reposition the scapula is the use of tape. If the patient now can perform the same task but with symptoms lessened or resolved this indicates they may benefit from scapular setting exercises in their treatment plan.

     In summary, one should be aware of multiple observational strategies to assessing MNP.  These three valuable points will be overlooked if a practitioner simply focuses on objective findings and questionnaires. Pain may be resolved but could reoccur if these factors are not addressed. So remember don’t just examiner but assess and observe.

Falla, D., Jull, G., & Hodges, P. (2004). Patients With Neck Pain Demonstrate Reduced Electromyographic Activity of the Deep Cervical Flexor Muscles During Performance of the Craniocervical Flexion Test Spine, 2108-2114 DOI: 10.1097/01.brs.0000141170.89317.0e   FITZGERALD, K. (2008). D.J. Magee, Orthopedic Physical Assessment (fifth ed.), Saunders Elsevier (2008) ISBN 978-0-7216-0571-5 1138 pp., Hardback, illus, CD-ROM, AUD 124.00 GBP 48.99. International Journal of Osteopathic Medicine, 11 (2), 69-69 DOI: 10.1016/j.ijosm.2008.02.002   O’Leary, S. (2009). Muscle Dysfunction in Cervical Spine Pain: Implications for Assessment and Management Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.2872