In recent years, subluxation-based chiropractic care seems to have successfully moved away from the old “bone out of place pressing on a nerve” narrative that kept us locked into the realm of neck, back and musculoskeletal pain. This is truly a good thing, as research continues to explore the non-musculoskeletal presentations that may benefit from chiropractic care as well as the brain-based changes highlighted by other research. However, every now and then a case pops up that reminds us that nerve entrapment does happen and when it does, chiropractic care may be of benefit.
One such case is the topic of today’s blog. It is addressing a nerve entrapment case following a car accident, but truly it is championing the Manual Muscle Testing (MMT) and Professional Applied Kinesiology (PAK) administered by a chiropractor as part of a chiropractic care plan.
In 2018, an adult female was travelling in the passenger seat of a car and turned her head to the left just as the car was hit from behind. At the time of impact, her head was turned almost completely to the left.
Immediately following the accident the patient said she was dazed, and had a strange feeling of hitting her head even though she did not. She was taken to hospital and examined. However, no x-rays were taken and she was givenvalium and something for pain before she was released. Her early symptoms were soreness and stiffness in the neck and low back, and pain across the shoulders, particularly the inner left side of the scapula.
Following the event, the patient reported she didn’t miss any days at work, but after a few months she found she was only able to attend half-days of work. Primarily, she was struggling with her memory and it made filling out paperwork, an integral part of her job, difficult.
Over the next year or so, the patient underwent various therapies and tests to try and regain her previous quality of life. One of the first forms of care she sought was chiropractic. She presented for care in the month after the accident, and had a history of chiropractic care, but hadn’t presented for care two years previous to the accident. The patient described the care as ‘spinal manipulation’ and was prescribed an electric muscle-stimulation unit which she used at home. Additionally, she applied hot and cold packs at home, as directed by her chiropractor.
Treatment started with three sessions each week, but was reduced to ‘as needed’ and she hadn’t returned in two months. In those first few months, the chiropractor listed her main complaints as neck and lower back pain, numbness while sleeping, difficulty with tasks like reading and computer work, and pain that came and went. The patient noted there were improvements in her symptoms with adjustments, Biofreeze, and exercises.
X-rays and MRIs taken in September-October of 2018 (after the accident) revealed degenerative disc disease at multiple levels of the spine, aberrant posturing, early degenerative arthrosis of sacroiliac joints, chronic disc degeneration, disc space narrowing, and minor disc bulging. The moderate degenerative changes of the disc space with disc bulging was still noted on a follow-up MRI taken in August 2019. The more recent MRI also reported a straightening of the cervical curvatures ‘suggesting muscle spasm.’
The patient was seen by a psychologist and reported improvement with her memory and headaches. The psychologist observed there was lasting neurobehavioral dysfunction as a result of concussion. The patient also received cervical steroid injections by an orthopaedic medical doctor which she reported helped with her pain for 3-3.5 months, after which the pain would return. She often had to have 2 or 3 injections before benefit was noted. The predominant treatments were repeated left sacroiliac joint, left C7 transforaminal epidural steroid injections, and C6-C7 interlaminar epidural steroid injections. The orthopaedic doctor would suggest surgical options if she was not responding to the treatment.
Back under chiropractic care
Given the limited benefit of other therapies and modes of care, and given surgery was now on the table, the patients’ experience under a new chiropractor/course of chiropractic care took on significant importance. She began seeing the author of the paper for chiropractic care in October of 2019. She stated that her condition improved under the first chiropractor’s care, but eventually platured after the first few months.
A thorough examination was completed at this point and her overarching complaints included persistent arm numbness, daily headaches (for which she would take Tylenol and Alka-Seltzer for relief), neck and shoulder pain, weak shoulder muscles, increased eye strain, a general aching in the legs, and a declined ability to sleep. She also had some difficulty swallowing and found her lower back and knees hurt when walking. Previous to the accident the patient had a good health record albeit with a history of gallbladder surgery, a hysterectomy, and an appendectomy.
The patient also underwent extensive orthopaedic testing (MMT) completed by the chiropractor. Notably Wright’s tests were positive and costoclavicular tests were positive on both sides. The patient was rated in the ‘moderate’ bracket of neck disability and low back disability, using the Neck Disability Index and Oswestry Low Back Disability Questionnaire.
When considering this case, it is worth nothing that the author of the paper placed a large emphasis on the value of MMT in diagnosing and treating patients.
“The purpose of specific muscle tests in this examination is to determine if there is objective evidence to substantiate the continuing subjective complaints.”
Essentially, is muscle dysfunction driving the symptoms reported by the patient and can muscle function be improved? What comes next is narrowing the regions with abnormal function and delivering care to restore normal muscle strength and optimal function.
There were 3 areas identified by the Author through AK examination: subtle nerve entrapment of the Dorsal Scapular Nerve (DSN) on both sides, inhibited cervical extensors causing tension in the scalene muscles, and weak sternocleidomastoid muscles.
The DSN runs along the top and back of the shoulders and supplies levator scapulae and rhomboid muscles with motor control. It also passes through the scalene muscles before descending down the back. These muscles are common factors in whiplash associated disorders, which include long-term neck and arm pain that persist for years after an accident.
Pain, often like a dull ache, along the scapula and arms are common symptoms of DSN entrapment by the scalenus medius. If the condition is chronic, there may be atrophy of rhomboid muscles. Because of the origin of these muscles on the spinal column, their dysfunction may be the cause of recurrent subluxations in the cervical or thoracic spine. If these muscles are not tested and DSN entrapment not corrected, chiropractors may find the adjustments to vertebral subluxations may not hold well after the patient begins to move around. When DSN entrapment, and the associated muscle dysfunction, is addressed properly the vertebral subluxation corrections are no longer lost.
Coming back to the case at hand
Directed treatment was applied to scalene muscles, over the course of 2 visits, in the form of fascial release by massage and percussion. The corrections were found to strengthen her rhomboid muscles and retests after 2 and 4 days showed the change was long lasting.
- Cervical extensors were corrected with a category I and II pelvic adjustment
- The appropriate vector of correction was determined for the sternocleidomastoid muscles and a gentle left inspiration and right expiration was applied. There was an immediate restoration of strength to the sternocleidomastoid muscles and remained so at the third visit (corrected in the first)
After 2 weeks of Professional Applied Kinesiology treatment and chiropractic care, all cervical range of motion had improved, as wdid her visual analogue scales, neck disability and Oswestry low back disability scores with each going from ‘moderate disability’ to ‘no disability’ ratings.
This is a significant change for someone who had their quality of life severely and negatively impacted by nerve entrapment that traditional medical care had yielded only limited results. While this case is arguably a mixed-modality in that traditional chiropractic care was paired with manual muscle testing and professional applied kinesiology as part of the care plan, it is not worthy as the latter is not well-represented in chiropractic or chiropractic multimodal literature.
Either way, it is nice to see another person who has had their quality of life restored while under chiropractic care. We are about adding life to years after all.
- Cuthbert S. Dorsal Scapular Nerve Entrapments in Motor Vehicle Accidents: An Applied Kinesiology Chiropractic Case Report. Asia-Pac Chiropr J. 2022;2.6. URL apcj.net/papers-issue-2-6/#CuthbertDorsalScapular