Paul H. Goodley, MD

Disclosures

May 14, 2007

" We command nature only by obeying her."
                           I wish I knew who said that.

The moderator of the cervical pain symposium at a large orthopaedic surgical meeting opened the session with the frustrated lament, "People with neck pain are a pain in the neck."

My predictable reaction was tempered by the fact that it was, in fact, an honest general statement, the self-inflicted price of ignorance about tissue-familiar biomechanics, the anguish of bearing professional responsibility for a common area of pain whose rational approach has been denied to its most influential practitioners.

This third contribution of Goodley Intentions focuses on offering some understanding of examination approaches to pain in the neck.

Some of the prerequisites have already been addressed. Succinctly:

  • The spine must be seen honestly as it is: a neurologically mediated, integrated series of interdependent, complexly articulated, distinct joints -- each of which contributes to the overall function of an exquisitely orchestrated continuum of motion and stabilization that is achieved through countless proprioceptors that normally, reflexively coordinate the actions of the tiny, small, and large muscles that extend from the head as far to the lumbar region.

  • All are part of one mechanism and ignoring that is the third step to failure: The first is insisting on treating the neck as if it were a spring (its movements a unitary motion); the second is thinking in terms of "neck pain" instead of "pain experienced in the neck." In fact, it is far safer to initially consider the site of neck pain as a "liar" concerning its source until it is confirmed than to focus on it too soon. The neck's mechanisms are bewilderingly complex, but their practical management only requires managing some principles, the same as being able to drive a car without the need to be competent under the hood.

To illustrate the problems implicit in precipitously fixating on the site of pain (one of my histories in Release From Pain): Randy was one of the physical therapists I trained when I was Consultant to the Veterans Administration for Orthopaedic Medicine. For a few years, its chief PTs from around the United States were periodically flown to Los Angeles. It was during the tragicomic days when physiatry perceived itself in a life-and-death battle with Physical Therapy. When they arrived for their first session, they were (understandably, euphemistically) skeptical about they were in for. The apathy passed fast, and we had fun, and during subsequent training the injured would first line up for care before we started.

Randy was in the group of about 8 who, one splendid morning, I was fortunate to successfully treat in less than half an hour. When it was over and they sat down satisfied, I sucked the air out of them by spontaneously commenting, "And just think: I was able to do all that without a single hot pack."

Randy's problem was unique in my experience. He complained of intense, unremitting cervical pain precisely localized at the right posterior C2 area. It began immediately after he collided with another player face-to-face at the net during a volleyball game several weeks before. He'd already had the gamut of physical therapies, all unsuccessful.

I will describe the cervical examination I performed later, but it was completely negative. That is an extraordinarily powerful statement! Please reflect on it. The examination of the structures of his neck was completely normal! Why is that statement so important? Because I comfortably knew that the cervical spine was innocent. And since Randy was obviously in pain, and I was confident that his cervical structures were normal, I knew without any confusion that I had to look elsewhere.

The impact had been directly face-to-face. Subtleties in facial features can easily be missed in already familiar features. I asked Randy to lie down and observed him "upside down" from behind. There was a slight flattening of his left maxillary area. It was paler than the surrounding skin, and the diameter of his left orbital fissure was wider than the right.

There have been a few times when my hands seemingly became independent, as if I were witness to what they were doing. I asked Randy to sit up. (Obviously after washing my hands) my right index finger entered his mouth and ascended the left cheek in front of the teeth. As it approached the zygomatic arch, Randy stiffened, his eyes suddenly red with pain. I urged him to forebear as my left hand crossed the right and my fingers touched his cheek a little laterally from where my right finger was -- each on a side of the zygomaticomaxillary suture. As I gently moved medially with my right and laterally with the left, after just a few seconds there was the softest of sounds, like a thin toothpick cracking.

Almost instantly, the area of pallor became intensely red and hot; the flattening filled; the orbital widening became symmetric, and the intense pain at the opposite backside of his neck was instantly relieved! Amazing, the vast spectrum of the body's mechanisms that we are totally ignorant about!

I obviously could not have predicted such a result. How the stresses in Randy's left anterior cranium transferred across virtually 180º I can't imagine. But the procedure was curative and all of it totally consistent to the circumstance, although certainly unique in its clinical presentation! The dream of a teacher for his students to witness such as that.

The face-to-face impact had subluxed the joint, the smallest I think I have ever manipulated. (The skull obviously has many bones, all with functioning joints, which I will eventually discuss.) What is critically important is that Randy presented with pain in his right posterior neck, and he was cured with a unique manipulation in the left side of his face. Again, the confidence of a normal cervical examination was crucial to the hunt. Please appreciate that.

Concerning his general examination, Randy's cervical gross motion was normal. I might have tested muscle strength with isometric contractions in 6 directions. (When you do that, be sure to secure the forehead, not the jaw. The TMJs can be very unforgiving.) As with all muscle testing, weakness, pain elicited by tissue stress -- and volition -- are all elicited for correlation: testing, sifting and comparing, testing, sifting and comparing.

Some preliminary considerations for the examination I will describe (I literally spent hours writing this section attempting the near impossible, to successfully convey what truly requires dedicated hands-on tutoring. If you are serious about this, and this is new to you, please read this meditatively):

  • Palpation requires relaxed concentration. Palpation is the respectful, purposeful, inoffensive, sensitive handling of living tissues.

  • Ordinarily, relaxation comes after the learning of a new task. But it is essential to be able to begin to palpate.

  • The catch-22 has to be confronted.

  • Very frequently, learning how to relax the hands is most expeditiously accomplished with what may seem a humiliating procedure. I assure you, it is not. It can be your most valuable assistant. But if it were an ego blow, it would still be worth it.

  • It is so often desirable because, almost universally -- especially in experienced physician new learners -- there is a near overwhelming tendency to tighten the hands as the tissues are approached. Somehow the compulsion/anxiety has to be terminated.

  • The affliction is directly proportional to how authoritative the owner of the hands demands to be.

  • Somebody observing the tensing needs to sequentially take each of the wrists firmly and shake -- and shake -- until the hands are finally forced to go slack. Every time they retighten as they approach, the shaking has to be repeated until finally the individual's incredulity is surpassed by the realization that the rigidity is a fact. So, finally, it can be replaced with a genuine softness in the hands. The successful shaking, which incontrovertibly proves the stiffness that most often the "shakee" had little awareness of, may be considered a rite of passage, or a curse that has been broken. Once it happens, it is not usual to have to repeat it. At times I have even had to do it half a dozen times to someone who had gazed at me numbly, unaware that their hands had "rigor mortised" until, finally... the thaw.

  • If this is new to you, I urge you to never presume palpatory skill. It will bite you.

  • Remember! Tightness paralyzes sensation.

  • Again, every tendency that attempts to insinuate authority (false authority, by the way) grossly interferes with the "listening" or "seeing" with the hands -- whichever term better impresses you.

  • Before the hands are laid on, the eyes should visualize the part to be palpated as much as possible.

  • The hands should largely be placed and moved by the proximal, fatigue-resistant muscles of the upper arms.

  • The hands need to be essentially passive. Never twiddle. Twiddling is ignorant nervousness. Don't twiddle!

  • The hands need to be soft receivers -- receptors -- antennas -- mops that absorb what is there.

  • Try to surround the part to be palpated with the soft parts of the hands. Never "lobster claws." Don't pinch tender tissues.

  • Bring the part as close to your body as possible -- or approach it.

  • Often the movement that needs to be imparted to the testing emanates through a relaxed swaying of the balanced body while the concentration is focused for what is ascending through the hands to a developing consciousness as the engrams are forming so the sensations will be appreciated. However long it takes, when that happens, a seeming miracle eventually occurs when the perceived greatly amplifies. (What might have taken me 20 minutes to try to comprehend 25 or so years ago, I now appreciate almost instantly in an amazingly magnified reality.)

  • So -- the hunter sees what is, whether with the eyes or the hands.

Now back to Randy's examination:

As he lay on the examining table, and I stood behind him, I might have gently placed my hands on the sides of his head and slowly, gently approached his neck. Touching another's tissues is a privilege. The careful clinician should seek to get "permission" from the patient. If they are irritable and you blunder and incite spasm, they may not forgive you. So approaching the area from a distance allows time to "prepare" for you. Gentleness from the first invokes trust.

The need to examine the cervical anterior tissues is mandatory and possibly the most forgotten (ignored) aspect of the examination. The tissues are (obviously) most often injured during a flexion/extension type injury. Failure to treat them is a primary cause of failure. To avoid my committing that sin, I routinely perform it first.

In my experience, if the sternocleidomastoid (SCM) muscles are of normal tone and nontender, it is likely that the anterior area is not injured. It is critically important to palpate the SCM insertions -- onto and just behind the clavicle proximal to the sternoclavicular joints. For this, it seems natural to place the radial side of a thumb onto the site and gently press dorsally. Normally the pressure reveals a "normal," nontender sense of give on the tendon of a relaxed muscle. If it is tender and tense, it must be specifically treated. In my experience, CounterStrain Technique is often sweetly effective. (I will describe the technique in an upcoming column, but my best advice is to learn it hands-on ASAP.)

When I first learned CounterStrain in the 80's, I truly was too embarrassed to use it for over a year. It seemed so simple. I finally got my nose rubbed in it when I unnecessarily hospitalized a patient on whom all my other therapeutic attempts had failed, and I had insisted on the hospitalization. Failing there with a special traction, I finally tried CounterStrain. It worked dramatically. A 90-second procedure terminated a month of disabling low back pain. I haven't made that mistake again. It is one of my favorite approaches.

Examining the dorsal cervical spine by applying transverse glide to each vertebra is an excellent test, and to me, essential to the examination. If you wish, you can count the vertebra by finding the spinous process of C2, usually easily palpable as the first bony landmark encountered in the midline as your fingers leave the midline occiput. The ring-like C1 is directly above it, its transverse processes palpable immediately inferior to the ear (mastoid processes) just dorsal to the superior mandibular rami. I'll discuss that more later.

I usually sequentially do transverse glide beginning inferior to superior, starting at the angle of the neck. It is performed by keeping both wrists softly dorsiflexed and resilient, the radial side of the soft proximal index fingers placed on the lateral sides of the vertebrae. I am bent over the patient. My forearms are close to perpendicular to the neck, my elbows far out to the sides, the force delivered directly along the line of my forearms. My hips move my torso, my right arm nudges to the left as I assess what is normally a gentle "give," like a moderately stretchable rubber, and then I compare it with the movement to the right, pushing with my left arm. All is slow and perceptive. I need to be aware of the first provocation of pain. The neck must not laterally flex. At all times, the position of the head is neutral. Is the musculature tone normal? Is there immediate restriction -- "hardness?" Is it tender to the gently delivered force? (Later -- much later -- similar information may be obtained by contact through the fingertips.)

I must digress here. I am striving to be comprehensively descriptive. Do not allow yourself to be deluded that by reading this you will be competent... You must practice. Hopefully, this little story will encourage you: I was originally taught testing of passive cervical motion (in 1972) with the patient sitting. It is another technique. As I repeatedly extended the subject's neck over my examining finger, I felt nothing. As that first week passed, and I practiced 20, 30, 40 times, I felt nothing. Finally, I began to question what on earth I was doing and what I was supposed to feel. Then I palpated my first abnormal! It was a startling, almost "eureka" experience. I had established my engrams for what normal felt like. "Nothing." The accommodation of flexible joints about my finger. My finger didn't move. But when the joint was restricted, passively extending the neck pushed my finger back with it. It was a revelatory experience.

Now, again returning to Randy's neck -- translational glide all the way up to C1 revealed normalcy: no abnormal resistance, full symmetry, bilaterally equal translational glide. Then, with fingers close together and gently cupped, I placed them on the dorsum of the neck, the fingertips adjacent to the spinous processes as I moved my hands anteriorly, gently, slowly, to progressively palpate into the tone of the tissues while seeking tenderness with a slow deeper probe with my fingertips.

A technique I may have developed, and certainly have a special affection for, has very significant potential value. It is a variant of passive extension of the joints against the palpating finger, as I alluded to. I may use it when my initial examination is normal but inconsistent with a convincing history.

It is a challenge test. Again the patient lies supine and relaxed. I sequentially place the radial side of my index fingers on the dorsum of the patient's neck, at the facets, where I perform a gentle series of "upward" ballottements, maybe 5 or 6 times at each site, one side then the other (as if I were bouncing something rhythmically in my hands to estimate its weight). The force comes down from my shoulders. It does not originate in my hands. Slowly. Gently. At each site, I may slightly rotate the head towards my active hand so the facet is flush against my finger. Normally, each time I lift, the joint should extend a little around my fingers. A normal joint will relax around the fingers "indefinitely." But if there is an intermittent, borderline dysfunction lurking, this technique is, in my experience, likely to flush it, converting a flirt to a frank exposition. Feeling it happening over the fingers is, in a way, a very satisfying diagnostic experience. If it is singular, it likely isolates the/a site of trouble.

C1 passive motion can be assessed by gently palpating its transverse processes moving laterally. The tips are close to the skin, again, just dorsal to the superior aspect of each mandible. With one finger palpating, the other hand tilts only the head towards the same side, just inferior to the ear. The cervical spine remains in the midline. Normally, the TP glides towards the palpating finger, like anything "slippery" reacting to beveled opposite forces, like a pit being spit out from between the teeth. It's a small motion.

When I first learned this technique, or tried to, my palpatory skill wasn't well developed, and I couldn't appreciate the motion for weeks. (But it was always there.) It was long before I began to study Craniosacral Technique. But when you learn how, it is a good technique to assure that C1 is free to glide -- or not.

Truly, the entire examination I just discussed is accomplished in considerably less than a minute, maybe two.

In contrast to "hard signs" -- such as atrophy, weakness, gross joint restriction, reflex and sensory alterations -- which occur far down the road of the pathologic process -- long after a professional should have been able to appreciate the early cascade as happens in many common painful conditions, I am discussing some of the "soft signs" -- the hallmark of the competent professional -- the successful hunter, who would never utter, "People with neck pain are a pain in the neck," who know how to examine the neck.

There is no overemphasizing the essential of hands-on knowing before one can move far from the frustration expressed by that symposium moderator. And it can sometimes take some humility to observe one's hands and realize that, however much one's office wall may be strewn with professional certificates, this fundamental skill did not come conferred with them.

With all of that expressed, please read this for what it is and accept what it cannot be. Strive to appreciate sufficiently that you accept that you are professionally deprived if you do not at least appreciate the basics of palpatory sensitivity. Commitment to advance your knowledge under appropriate circumstances will be a practical contribution to ending the Pain Pandemic.

Abnormal tissues frequently feel different. Their tone alters; passive movements become restricted in particular patterns; there is a change in the ease of passive motion and in the relative position of joints; patterns of tenderness develop; relative temperatures often change. While the variations may be small, they are objective and commensurate. "Observing only one broken twig may decide the hunt."

A succinct review: The acquisition of palpatory skill requires acknowledging the sensitivity of the sensory system and how it must be accessed by "listening" quietly and patiently. In contrast to the hands extending authority, the fingers busily twiddling the tissue, they must be considered antennae that have been laid on the part to be examined by the proximal musculature of the arms. The mind must quietly concentrate on the sensations that enter the hands. The mind must wait until appreciation begins. The hands must be perceivers. Ego disturbs all of it. Preconception destroys it. Authoritarianism insults it. Dogma denies it.

Literally, the hands are given permission to feel whatever is. In the beginning, the hands must be intentionally relaxed (which often requires someone to vigorously shake your hands until they are "forced" to relax [take this very, very seriously]). They must be soft, so as not to lose the sense of the available signs because they are exerting too heavy pressure. (That is very easy to unintentionally do!) Before "knowing hands" go onto a part, they "see" it and gently conform to it before contact. When possible, the involved structure is enclosed within the whole mass of the soft parts of the hands to spread the pressure. They must be capable of patience, waiting quietly. The fingers must not twiddle. They cannot be used as pincers, like lobster claws, to grope, which can flare pain that fires protective reflexes resulting in increased irritation -- which incites spasm, then pain. Any effort to impose one's will through the hands deafens their alleged purpose. They must be left alone to listen. They must be the alert extensions of the awaiting undisturbed, focused mind. What may be originally undetectable to the mind remarkably enlarges in consciousness once the "engram" forms for what the hands are transmitting.

Palpatory skill is a wondrous tool, but like a musical instrument, it must be learned. It is not conferred with the professional diploma. It is task-specific and needs time to develop.

Palpatory skill is the first essential for manipulative competence, whose first priority is to restore biomechanical efficiency to a moving part.

The musculoskeletal clinician's obligation is to restore appropriate motion. All the rest is commentary.

Postscript:

In this discipline, Dr. Moti Taler is the most brilliant, innovative clinician I have ever encountered. I learn something new every time we meet. He obtained his medical training and PhD in exercise physiology at the University of Texas and then chiropractic training at Los Angeles College of Chiropractic. For almost 10 years, he dedicated himself to developing a special clinic at Tel Hashomer Rehabilitation Hospital, near Tel Aviv, where we met when I was consulting. He has catalogued in his head reflexes that I don't think exist on paper.

As I completed this, I took 2 of my patients for consultations with him. One is a young woman who was experiencing intractable upper cervical pain. To further expand on my Randy example about the need to look elsewhere, in this young woman I hadn't gone far enough. She was hurting, and it was my turn to consult with him.

The woman had been in a play in Telz Stone, where we live. She told me that she began to experience neck pain as she walked off the stage. I unquestioningly accepted that part of her story and considered her pain likely a dysfunction occurring from the excitement of performing. I treated her several times but provided only temporary relief.

In the first minutes of the examination, Moti asked her if she had come down steps onstage and if their vertical distances were irregular. The immediacy of the direct, in fact, accurate question stunned me. (Later he told me he had seen the same occurrence in dancers who had been similarly injured.) Indeed she had and been jarred but had immediately forgotten it.

Moti's examination revealed how her left shoulder moved anteriorly when she shrugged instead of superiorly as the right shoulder did. He predicted tenderness, that she hadn't been aware of, just inferior to her left clavicle and at the left inferior rhomboids and the edge of the right mid trapezius. After manipulatively balancing her thoracic structures, her cervical pain began to diminish. Then he focused on her neck. When he finished, for the first time she experienced low back pain that had been reflexively suppressed by the upper dysfunctions, and he promptly relieved that. She left his office happy. It was a virtuoso performance from a remarkable, intensely dedicated and flowing fountain of accumulated unique competence. I would be impudent if I allowed the implication that she was totally relieved. I am now working with the residuals, but most of the abnormalities Moti illuminated were not present when I examined her 2 days later.

Be well,

Paul H. Goodley, MD
Telz Stone, Israel
https://www.drgoodley.com

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