Osteopathic Medicine REV 7
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DATE @ “dddd, MMMM dd, yyyy” Sunday, August 14, 2016
Appraisal of a Case Study: Osteopathic Medicine
The present case study represented the ailment and possible mitigating strategies for a 59-year old school teacher. In a nutshell, the concerned individual suffered from bilateral neck pain. She complained of pain and heaviness in her right shoulder and over the right arm. Her medical history revealed long working hours on the computer and asthma. Moreover, she also suffered from whiplash injury ten years ago. She had constrained relationship with her husband and was under stress. Her possible diagnoses included cervical spine spondylosis, thoracic outlet syndrome and polymyalgia rheumatic. The present article reviewed the etiology of these conditions and the possible mitigation strategies.
Differential Diagnosis of the Proposed Ailments
Differential diagnosis is essential for diagnosing a specific disease and ruling out the probabilities of other diseases. For undertaking, a differential diagnosis the presenting signs and symptoms are correlated with the clinical history of a patient for arriving at the appropriate diagnosis. Differential diagnosis is essential for designing appropriate management/therapeutic strategies. The pathophysiology and differential diagnosis of the predicted conditions are described below:
Cervical Spine Spondylosis
Cervical Spine Spondylosis is a degenerative disease of the cervical spine. It is also referred as neck arthritis or cervical osteoarthritis and is an age-related condition. The disease affects the intervertebral disks of the neck and the cervical region of the spine. It results from the wear and tear of the cartilage and bones that are found in the cervical spine in the neck (Garfin, 2000, p 335-338). While age is the common causative factor for Cervical Spine Spondylosis, it could also be caused due to traumatic injuries and postural stress (Garfin, 2000, p 335-338). The intervertebral disks are located between the vertebras and help to absorb the shock of various physical activities like twisting and lifting. These discs consist of a jelly-like substance called nucleus pulposus. In Cervical Spine Spondylosis, dehydration occurs in the nucleus pulposus. This situation leads to dehydration of the intervertebral disks. This situation causes the vertebras to rub against each other and leads to degenerative changes (Morishita et al., 2009, p2642-2645). Whiplash injuries and traumatic injuries could accelerate and increase the risk of degenerative changes. The degenerative changes are pronounced with advanced age.
With age, the intervertebral disk loses their elasticity due to dehydration. Such dehydration increases the risk of cracks and fractures. The elasticity of the adjacent ligaments is also lost. This results in the development of traction spurs. When the vertebras rub against each other, the disk is likely to collapse. The outer portions of the vertebra are surrounded by bony coverings and the nucleus pulposus bulges inward on the spinal cord. On the other hand, the annulus fibrosis collapse and bulge outward. The bulging of the nucleus pulposus compresses the nerves and spinal cord which results in sciatica and numbness (McCormick, 2003, p 899-904).
The common symptoms of this condition are pain around the shoulder and stiffness around the neck. Usually, patients often complain of pain along the arms and fingers. Since the never roots and spinal cords are impacted, the concerned individuals suffer from lack of coordination, difficulties in movement, weakness, and numbness in arms, legs, hands or feet. Moreover, it leads to the genesis of neuropathic pain due to the resultant radiculopathy. Some of the conditions that increase the risk of cervical spondylosis include smoking, depression, anxiety, postural stress, occupation, genetics, and traumatic injuries to the neck (Panjabi et al., 1988, p838-842).
The present case study indicated that cervical spondylosis originated from postural stress. Postural stress could have developed from the prolonged working hours on the computers. The neck leans forward and impacts the normal lordosis of the cervical spine. As a result, the intervertebral discs are stressed and are predisposed to degenerative changes. The use of steroid inhalers and menopausal age are the additional risk factors for the patient described in the case study. Menopause leads to reduced estrogen levels in the body. Reduction in estrogen levels leads to osteoporosis and demineralization of the bones. Therefore, menopause could be a predisposing risk factor for degenerative changes in the vertebra (Kelly et al., 2012). The postural stress due o prolonged sitting tasks could be the major risk factor for the genesis of cervical spondylosis in the concerned patient.
2) Thoracic Outlet Syndrome (TOS)
This condition describes a group of disorders that result from injury, compression or irritation of the nerves or blood vessels (like arteries and veins), in the upper chest area (thorax) and the lower neck. The brachial plexus is situated in the neck region. It is situated between the anterior and middle scalene muscles and the first rib. The scalene muscles combine the 5th, 6th, and 7th cervical vertebra with the 1st rib. The shortening and increased tension in the scalene muscles impose pressure on the brachial plexus. On the other hand, the nerve roots of the C-8 and T-1 forms the lower trunk of the brachial plexus. As the scalene muscles are tightened, it pulls up the 1st rib. As a result, the lower trunk of the brachial plexus is compressed. This area is referred as the thoracic outlet. Anatomically, the thoracic outlet refers to the costoclavicular space that is found just behind and below the collarbone. This space accommodates the blood vessels and nerves that innervate the arms. Thoracic Outlet Syndrome is caused due to compression of the brachial plexus, subclavian artery and subclavian vein (Hooper, 2010).
Thoracic Outlet Syndrome is categorized into three types, depending on the structure that is affected. The first type is referred as neurological TOS, which occurs due to compression of the nerves to the arms. The second type is referred as Venous TOS, which occurs due to the obstruction of the nerves to the arms. The third type is referred as Arterial TOS, which is commonly associated with an abnormal first rib or an extra rib.
Hypertension and stress injuries of the neck lead to acute hemorrhage and swelling of the scalene muscles. As a result, the interscalene triangle is narrowed. The resultant compression leads to fibrosis and tightening of the scalene muscles. The narrowing and compression result in angulations of the neurovascular bundle.
It is caused by the venous obstruction due to the costoclavicular ligament and relative muscle hypertrophy. The vascular compression results from increased usage of the neck and maintenance of inappropriate postures.
Arterial TOS results from congenital abnormalities. However, the prevalence of arterial TOS is low.
The common symptom of TOS depends on affected structures. The symptoms of neurological TOS include numbness, pain, tingling sensation and weakness in the hands and the arms. Fatigue is another common symptom of neurological TOS. The symptoms worsen with prolonged usage of the hands and the neck. The other symptoms include a headache and pain. The pain is localized at the back of the head, in the neck, fingertips, arms and shoulders of the affected individual. However, the pain of TOS does not radiate to different body segments. TOS is more prevalent among women and is manifested between the age 20 and 60 years. The risk of developing TOS is increased by factors like pregnancy, repetitive movements of the shoulder and arms. Other factors like whiplash injury, poor posture, congenital defects, stress, and depression predispose the risk of TOS.
The present case study reflected that the concerned individual was exposed to repetitive movements of the shoulder and arms. On the other hand, repetitive flexion of both the arms could have predisposed her to TOS. Since she was asthmatic, there is a high probability that her neck muscles were hypertonic. Hypertonic neck muscles might have resulted from increased work of breathing and stressful life. Working on computers is itself a predisposing risk factor for TOS. Moreover, the concerned individual had postural stress on the neck and shoulders. Finally, whiplash injury, stress, and age of the concerned individual predisposed her to the risk of TOS. The compression or irritation of the nerves or blood vessels occurred due to repetitive movements of arms and shoulders while working on the computer (Evans, 2006).
3) Polymyalgia Rheumatica
It is a chronic inflammatory condition, which is featured by muscle stiffness widespread pain of bilateral shoulders. The condition occurs due to inflammation in the muscles around the neck, hips, and shoulders. Polymyalgia Rheumatica is an autoimmune disorder that affects the neuromuscular system. The common symptom of Polymyalgia Rheumatica is muscle stiffness during the morning, which lasts for at least 45 minutes. Other symptoms like depression, loss of appetite, weight loss and extreme tiredness are strongly associated with the disease (Hernández-Rodríguez, 2009, p1839-1850).
Polymyalgia rheumatic is caused by a combination of environmental and genetic factors. It is an age-related condition that commonly affects people over the age of 50. Polymyalgia rheumatic is more common in women compared to their male counterparts. The accepted hypothesis is that Polymyalgia rheumatic is an autoimmune disease. The autoimmunity develops as a result of an interaction between viruses and monocytes. This leads to the production of cytokines which leads to arthritis and resultant inflammation. Studies have indicated that the disease stems from the use of inhaled or systemic corticosteroids. Age, smoking and excessive consumption of alcohol increase the risk of Polymyalgia rheumatic (Hernández-Rodríguez, 2009, 1839-1850).
The present case study indicated that the concerned individual was on inhaled corticosteroids for her asthmatic condition. Moreover, the age of the individual and the history of smoking could have predisposed her to such conditions. The other predisposing causes include stress and fatigue. Stiffness in muscles resulted from repetitive motions of the hand and wrist. A blood test and MRI should be conducted to confirm Polymyalgia rheumatic.
Application of osteopathic principles for the management of the Concerned Individual
1) Cervical Spine Spondylosis
Osteopathic principles embrace the idea of structure- function relationships. It considers that human body is a combination of mind, physique, and spirit. It further contends that the body is capable enough for self-regulation and self-healing through homeostatic mechanisms. Treatment and management of cervical spondylosis involve physical therapy. The therapeutic interventions are related to the increase of stability of the cervical spine. This is achieved through immobilization of the cervical spine. Such interventions restrict neck movements and reduce the irritation on the spinal nerves. Cervical collars and rigid orthosis are used to restrict the movement of the cervical spine. Isometric exercises of the cervical spine are also useful in preventing the loss of muscle tone (Harrop et al., 2007, p 14-20).
Various options regarding pharmacological treatment can be helpful to victims of cervical spondylosis. Use of epidural steroid injections may reduce the inflammation and irritation of the spinal nerves. Reduction of inflammation and irritation of the spinal nerves help to reduce the prevalence of neuropathic pain. Tricyclic antidepressants (TCAs) are also used for managing the symptoms of chronic pain. However, TCAs are associated with different side effects like urinary retention, dry mouth, sedation, cardiac conduction blockage and constipation (Uher, 2009, p 202-210). NSAIDs can also be applied in pharmacological treatment. NSAIDs are used to reduce the pain and inflammation (Higuchi et al., 2009, p879-888). However, NSAIDs would not be helpful in case of neuropathic pain. If the condition becomes very severe and fails to respond to other treatment, surgery may be advised (Emery, 2001, p 376-388). Surgical interventions include removal of bone spurs, herniated disks and some parts of the neck bones so as provide enough space for the spinal cord and nerves. (Payne, 1959, p. 178-196).
The present case study necessitates the use of a cervical support and use of isometric exercises in the concerned individual. Epidural Steroidal injections could be administered for reducing the prevalence of neck and shoulder pain (Gross et al., 1999, p 162-176, Norman, 2003, p449-453). As a preventive measure, the concerned individual should be asked to change postures frequently and would be advised to take breaks after every 2 hours.
2) Thoracic Outlet Syndrome (TOS)
Osteopathic management of TOS pivots around sinus drainage. Various techniques can be utilized to achieve drainage (Rochkind et al., 2014, p 145-47). For instance, the opening of the thoracic inlet and reducing the symptomatic tone helps to reduce the sensitivity of the nerves (Povlsen, Hansson & Povlsen, 2007). The reduction in compression of the underlying structures could be achieved through inhibitory pressure over the branches of the trigeminal nerve (Futgate et al., 2009, p 176-188). Malfunction of the upper thoracic region and the neck could also be addressed. Such interventions would help in lymphatic drainage from the sinuses, as well as drainage via the diaphragmatic motion and thoracic outlet. Physical therapy can also be used for treatment and management of Thoracic Outlet Syndrome (TOS) For example; use of therapeutic ultrasound significantly alleviates the symptoms of TOS (Thompson, 2013, p. 256-260)
3) Polymyalgia Rheumatica
Since Polymyalgia Rheumatica is an acute inflammation, it can be managed by the use of steroid drugs. However, excess use of these drugs may result in various side effects. These side effects include diabetes, weight gain, glaucoma, and osteoporosis. Non-steroid anti-inflammatory drugs (NSAIDs) can also be used to control the resulting pain however they too can lead to digestive problems, nausea as well as stomach bleeding. The most appropriate method of managing this condition is by ensuring that the body produces an adequate amount of steroids (Dejaco, C; Singh, 2015, p1799-1807). This can be achieved through reduced intake of sugar and caffeine. Reduction of stressor would reduce the secretion of steroid hormones. Food and herbal remedies are also useful in managing this condition. For instance, the use of essential fatty acids like Omega-3 could reduce inflammation decrease pain and increase the mobility of affected of the affected individual. Bromelain (an enzyme that is obtained from pineapple plant) helps to reduce the inflammation, associated with this condition (Dasgupta, 2010, p.270-274). The case study indicated that the concerned individual should be advised lifestyle and dietary interventions for reducing the risk of Polymyalgia Rheumatic.
The appraisal of the given case study indicated that osteopathic medicine could be useful in managing the symptoms of the concerned individual. The therapeutic approach should pivot around lifestyle interventions and administration of minimal intervention measures for maintaining the patency of nerves and blood vessels. Such interventions would reduce the risk of compression radiculopathy and reduce the prevalence of pain. The condition of the patient implicated the principle of osteopathic medicine. The specialty assesses the clinical issues on a holistic ground. It contends that the physical and psychological domains are interrelated for the manifestation of the disease. The specialty also contends that any organic disease is manifested due to underlying structural abnormality. The cervical spondylosis was partially responsible for the thoracic outlet syndrome and suspected polymyalgia rheumatic. All the three conditions could be considered as work-related musculoskeletal disorders (WMSDs) and primarily originated due to poor posture. The risk factors either predisposed or alleviated the prevalence of WMSDs. On the other hand, stress and depression are predisposing risk factors for these WMSDs. The conditions originated due to structure-function correlation of the different tissues that were impacted. The management of the patient should be holistic from the perspective of osteopathic medicine. The focus of management should pivot around alleviation of neuropathy, myopathy, and psychopathy.
Benzel EC (1993) Cervical Spondylotic Myelopathy: Posterior Surgical Approaches in Cooper PR (ed): Degenerative Disease of the Cervical Spine. Park Ridge, AANS Publications, , pp91-104
Dasgupta, B. (2010). Concise guidance: diagnosis and management of the polymyalgia rheumatica.Clinical Medicine, 10(3), pp.270-274.
Dejaco, C; Singh, YP (October 2015). “2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative.”. Annals of the rheumatic diseases. 74 (10): 1799–1807
Emery SE (2001) Cervical Spondylotic Myelopathy: Diagnosis and Treatment. J Am Acad Orthop Surg 9:376-388
Evans R. W. (2006) Neurology and Trauma. 2nd Ed. USA: Oxford University Press.
Garfin SR(2000) Cervical Degenerative Disorders: Etiology, Presentation, and imaging Studies. Instr Course Lect 49:335-338
Gross JD, Benzel EC (1999) Dorsal Surgical Approach for Cervical Spondylotic Myelopathy. Tech Neurosurg 5:162-176
Harrop J, Hanna A, Silva M, Sharan A (2007). Neurological Manifestations of Cervical Spondylosis: An Overview of Signs, Symptoms, and Pathophysiology. Neurosurgery 60: 14–20
Fugate, Mark W.; Rotellini-Coltvet, Lisa; Freischlag, Julie A. (2009). “Current management of thoracic outlet syndrome”. Current Treatment Options in Cardiovascular Medicine. 11 (2): 176–83
Higuchi K, Umegaki E, Watanabe T, Yoda Y, Morita E, Murano M, Tokioka S, Arakawa T (2009). “Present status and strategy of NSAIDs-induced small bowel injury”. Journal of Gastroenterology. 44 (9): 879–888
Hernández-Rodríguez J, Cid MC, López-Soto A, Espigol-Frigolé G, Bosch X (2009).
“Treatment of polymyalgia rheumatica: a systematic review”. Archives of Internal
Medicine. 169 (20): 1839–1850
Kelly J.C., Groarke P.J., Butler J.S., Poynton A.R., and O’Byrne J.M., (2012) The Natural History and Clinical Syndromes of Degenerative Cervical Spondylosis. Advances in Orthopedics. ID: 393642
Laulan J, Fouquet B, Rodaix C, Jauffret P, Roquelaure Y, Descatha A (September 2011). “Thoracic outlet syndrome: definition, aetiological factors, diagnosis, management and occupational impact” J Occup Rehabil. 21 (3): 366–73
McCormick WE, Steinmetz MP, Benzel EC (2003): Cervical Spondylotic
Myelopathy: Make the Difficult Diagnosis, then Refer for Surgery.
Cleve Clin J Med 70:899-904
Morishita Y, Falakassa J, Naito M, Hymanson HJ, Taghavi C, Wang
JC (2009). The Kinematic Relationships of the Upper Cervical Spine Spine
Norman D (2003). “Epidural analgesia using loss of resistance with air versus saline: does it make a difference? Should we reevaluate our practice?”. AANA Journal. 71 (6): 449–453.
Panjabi M, White A (1988) Biomechanics of Nonacute Cervical Spinal Cord Trauma. Spine 13:838-842
Povlsen, B; Hansson, T; Povlsen, SD (2014). “Treatment for thoracic outlet syndrome.”. The Cochrane database of systematic reviews. 11: CD007218
Payne, E. (1959). The Cervical Spine and Spondylosis. min – Minimally Invasive Neurosurgery, 1(02), pp.178-196.
Rochkind, S; Shemesh, M; Patish, H; Graif, M; Segev, Y; Salame, K; Shifrin, E; Alon, M (2007). “Thoracic outlet syndrome: a multidisciplinary problem with a perspective for microsurgical management without rib resection”. Acta neurochirurgica. Supplement.100: 145–147
Thompson, J. (2013). Thoracic outlet syndrome. Surgery (Oxford), 31(5), pp.256-260.
Uher R.; Farmer A.; Henigsberg N.; Rietschel M.; Mors O.; Maier W.; Aitchison K. J. (2009). “Adverse reactions to antidepressants”. The British Journal of Psychiatry. 195(3), 202–210