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Cervical Dystonia

Exit forum ID Forum Discussion Cervical Dystonia

This topic contains 9 replies, has 2 voices, and was last updated by   Christopher Stepien December 18, 2018 at 5:03 am.

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    Brian Vranes DC

      Ive been treating a 48 yr old woman who’s been diagnosed with cervical dystonia. Deals with significant tension and discomfort in her neck that comes and goes. Her initial measurements were:

      UCF: 12 hard pulling in the neck, worse on the right

      CF: 22 increased generalized pulling through the neck

      CTF: 40 same symptom

      Her measurements have improved to UCF: 21, CF: 32, CTF: 44. After 10 treatments.  It will seem like we are making good steady progress and then she’ll wake up with a flare up of significant tightness again.

      I’d like to know if any of you have had patients with this diagnosis. I was skeptical about it at first but working with her has made me respect that she must have some other underlying stuff going on.  Researching cervical dystonia left me dissatisfied.  It seems to be a condition no one really has much of an answer for.

      I’d value any input on this


      Christopher Stepien

        Hey Brian,

        What are the 7 first order Hx points and from there, what’s your initial diagnostic tissue-pathology list?

        I’ve learned that when I get caught up in diagnoses like “cervical dystonia”, it’s often because I’m skipping steps.


        Carl Nottoli, DC

          I agree with Chris. Let’s get the full picture of the case first. Cervical dystonia is like a “syndrome” type of diagnosis. Sometimes its from a neurological disorder so we need to find out how much of this case is MSK vs. neurological and out of our scope.


          Brian Vranes DC

            48 yr old Female

            Sx location right sided upper back pain for the last 8 weeks. Before that it was left sided for about 1 year 9 months

            Quality: hard tension, pulling right side

            Intensity: current- 8/10, average 7/10, worst is 10/10 (8 weeks ago when she woke up with pain

            Provocative: looking down repeatedly (cleaning) tipping her head to hold phone between head and shoulder. Laying on her bed on her back with head flat hurts

            Palliative: laying down with head propped up. Sitting and letting it lean back

            Onset: woke up with it suddenly one day

            Course: see above

            Occupation: pharm tech

            Recreation: read, golf (both hurt her)

            Meds: zanoflex, Botox injections, ibuprofen

            MRI- demonstrates facet hypertrophy at C3/C4 that mild/moderately narrows the left neuroforamen and uncovertebral joint hypertrophy that moderately narrows the C6/C7 neuroforamen. Moderate degenerative Spondylolysis at C6/C7 with grade 1-2 asymmetric disc bulging and marginal end plate spurring

            Diagnosis Tissue List

            1)RCP major and minor adhesion

            2)accessory nerve entrapment at rhomboid/trap on the right

            3)degeneratve Spondylolysis with reflexive guarding

            (sorry about the font weirdness, I’m copying and pasting from my phone)


            Carl Nottoli, DC

              This case looks to be disc related based on her symptom location (lower cervical sclerotome referral, episodic, acute onset, and provocative with load. So degenerative disc with active derangement would be first on my list.

              My guess is that the dystonia part of the diagnosis is a doctor not respecting disc pathology and protective tension.

              If she is still flaring up she needs to decrease her load during the day. If that’s close to ideal, you could probe about diet, stress, etc but don’t get distracted. Most people don’t think they are doing anything to flare their neck, but you will watch them in the waiting room staring down at their phones.


              Brian Vranes DC

                Great, thank you for your input! I’ll really focus on load sparing strategies with her and see if we can calm the disc down enough so that we can continue to progress through the tests. I’ll keep you posted on progress.


                Logan Reading

                  Any idea what her sleep position is like (too many pillows, stomach sleeper, etc.)? I often find that patients that wake up with neck symptoms may have sleeping pattern/habit that loads/irritates the neck. First rib/post scalene are other structures I consider as well. Anyone find these same correlations?


                  Adam Holen D.C.

                    What would you say the % distribution is for degeneration vs. adhesion in this case? In other words, if you could use the ‘magic wand’ and get rid of all of her adhesion or all of her degeneration, which would make a bigger impact on function and symptoms? It may be worth moving on to rotation if you’ve plateaued with CF and CTF to continually unload the degeneration.

                    Also, have you assessed/treated nerve roots? She already has compromised area for the nerves to pass through, so if she has nerve entrapments at the scalenes, treating those may help reduce her consistency for flare-ups.


                    Brian Vranes DC

                      Excellent stuff to consider! I know that when she lays down, she props her head up because it doesn’t feel good to lay neutral. Her sleeping posture may very well be loading the already present degeneration.

                      That’s a great question about adhesion vs degeneration. At this point I’d have to say that removing all degeneration would have the biggest impact on her since I feel like I have reduced relevant adhesion in her suboccipitals and paraspinals and no longer feel like the accessory nerve is entrapped. I think both suggestions for moving on to rotation and checking the scalenes for nerve entrapment with nerve roots are excellent suggestions with her.

                      Thanks again guys!


                      Christopher Stepien

                        You need healthy discs to maintain Cervical neutral. If the discs are degenerated enough, people won’t be able to maintain it (hence problems or pain with the quadruped chin retraction exercise).

                        As my own discs get weaker, I can feel when I’m inflamed because it literally feels like I have a 40 year old kid on my C7 area and I feel “weak”.

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