Cervical Spondylosis 'Delayed' Symptoms. How C/S Symptoms manifest themselves.

[gerry the neck]

HI Geoff

Thanks for your encouraging comments, and yes, you are correct, I have no formal training in spinal conditions. All I go on is my own C/S experience, and, although there may be many technical errors, to the trained eye, I'm only claiming that I use an intuitive approach. I totally understand that a trained P/T must be critical of these types of speculation, because, having to deal with many varying conditions, they must maintain a balanced judgement. Perhaps, some of the answers to the puzzles we all seek to resolve lie somewhere in the middle. I dream to think that some of my speculations may have relevance on a wider scale, but even in this I may be overstepping the mark.

It was the lack of identifiable descriptions of C/S which kick started my investigations, which, besides my proposed sleep therapies and avoidance of aggravation therapies, are only conducted on a private thinking level, and not on the levels which a P/T would encounter. I am always open to opinions on this, critical or not, and am prepared to adjust my overview as necessary. As you can probably detect, currently I believe strongly in what I have posted previously, but even those ideas evolved through changes. So, any comments are welcome, within reason.

PS. Any easy way to access your earlier writings on 'protective reactions' ?

Regards
Gerry Daly

[ginger]

Hi Gerry, some points to begin, as mentioned there is an essentially correct central paradigm which you have alluded to numerous times in your posts, that being spinal protective behaviour.(SPB)
This behaviour is the link to the brain ultimately providing pain, as well as a series of altered sensations and products of nerve irritation at the spine. These include numbness, tingling, reduced power, altered autonomic events etc.
It is not necessary ( or even common) for there to have been either trauma or disease for these protective behaviours and conseqent symptoms to be present.
The state of affairs when SPB occurs may be diagnosed as spondylosis or spondylitis, when it is assumed the major inflammatory involvement is to the spondyl. ( an anotomical term that can be googled for detail, but includes the facet joint, space through which the nerve root exits the spine, aspects of the spinal segment and the nerve tissues themselves). SPB will commonly induce inflammatory events in and of the spondyl as a result of limits to facet joint movements resulting from increased paravertebral tone of muscles near to the joints.
All pain is a product of the brain, in the case of spinal pain, as a feature of a successful protective response. This output from the living brain is highly variable under a range of internal and external circumstances.
Sleep is that state where movements are reduced normaly. not entirely to nil , but significantly reduced. Thus any pain associated with poverty of spinal joint movements will be likely to be felt more strongly in the morning. Movements commonly reduce this am pain for those whose internal driver for the SPB is NOT disease.
Sleep is also that time when a series of internal palliative effects reduce their effects, attention, altered higher frontal lobular inhibitions, emotional cues, as well as the effects of chemistry associated with wakefullness and activity ( opiate like substances ).
While improved sleep will doubtless rejuvenate and refresh the mind and body, it's effects and those of improved sleep related postures, are of little significance compared, for instance, to active and passive movement therapies in general.
It's been a big day on the water today, I'll get to the nitty gritty of what makes SPB go away tomorrow.
Cheers

[gerry the neck]

Hi Geoff

I might be able to save you some work here. I've been able to access your CM theory under 'frozen shoulder' posts. Also got to see your vid on youtube. Much food for thought, indeed.......keeps the old grey matter bubbling over ! So far, I think we are on the same page regarding cause and effect, especially regarding cyclical protective behaviour being the cause of many 'associated' symptoms. Also, we both seek user friendly ways to deal with unpredictable on/off symptoms, rather than lumping them all together as some complex insurmountable whole. Although my approach is 'home based', and yours is 'clinic based' , so far I see no reason why they shouldn't compliment each other. I was wondering if your CM manipulations could be self applied (neck only obviously), or even applied by someone who has watched your vid, so I could assess for myself any benefits ? A 24,000 mile round trip would cause its own problems ! There are some issues I'd like to go into further, and will do, when I'm sure I can contribute intelligently....just working them over first.

Regards
Gerry

[ginger]

Hello Gerry, glad you have been able to see the CM method. When applied to the cervical spine I find this is a means to reliably reduce protective tone and most often the means to restore normal pain free movements for long periods. There will always be a subset of neck pain sufferers that do so when SPB is driven by structural losses to normal integrity and/or trauma/disease processes. Many of those however who I have treated successfully are victims of the cyclical tightness , mentioned by you, that is more likely the "natural"product of internal drivers of protective behaviour , where the threshold of inflammatory irritants induce a repeat of and incremental additions of SPB.
Most of the longer posts I have written on this subject can be found on the Rehabedge.com website, further more recent posts on Somasimple.com.
Self treatment is possible with CM to the neck. Results depend to a large degree on the quality of and duration of these passive movements. Try sitting in the littlest room ( on the throne) where you can position your elbows at head level on the adjoining walls. This is of course possible where your throne is indeed in a little room, alternatively sit in the corner so that your elbows can be set and movements by the neck INTO the treating thumb can offer reasonable approximations of CM type movements.
What beneifits you may get however I warrant will be limited and short term this way. Best without doubt would be to offer the CM info to a friend with strong hands or enlist a willing physio who may already have skills of a similar kind. You appeal to me as a relentlessly curious kind of guy Gerry, I have little doubt you will find value. Good luck and keep posting.
Cheers

[gerry the neck]

Hi Geoff

Thanks for advice re CM. What I like about your methods is the non-aggravational aspect. Although you do manipulate the facet joint somewhat, it is relatively gentle, and it doesn’t involve traction, twisting exercises, collars, or even medications. All big plusses in my book….I’ve had all these to no avail. I think we both understand that the principal goal is relief rather than the prospect of even further aggro….a principle which all too often escapes the attention of the practitioner ! Probably best that your methods are applied by a willing helper, rather than self applied, and I will try it out in the fullness of time and report anon.

However, I don’t want to let you off the ‘sleeping postures’ so easily, without knowing that you’ve had a good think about it. There may be some misunderstanding in the way that I describe why the whole ‘sleep / C/S thing is so important, and seemingly always casually overlooked. Usual response ‘ Of course, a good sleep is important to general well-being’ . This misses the point that something strange happens when we sleep which instigates all sorts of protective reactions. This may well be only apparent to an actual C/S sufferer, who experiences these on/off unpredictable changes. The sleeping posture alterations I speculate upon, do actually have an effect on these processes, usually beneficial, and, as a means to lessening the intensity of symptoms and instilling a sense of self control and self management, they are a quick, home-based, and self applied method for achieving these ends…even if only temporarily.

In my particular case its about getting rid of cyclical headaches and muggy head sensations as quickly and as effectively as poss. No medications, except when absolutely needed, and no waiting for appointments either. The first goal is to restore clear headed thinking, thus allowing a better environment for considering further self management techniques. This might all sound a bit wishy washy to someone who constantly deals with the mechanics of the spinal structure, but, from my point of view, after years of these types of disorientating symptoms, and after years of distracting ineffective therapies, it looks like a very worthy goal to me.

I understand that sleeping postures are difficult to monitor, in a clinical sense, and as such may have been overlooked in favour of more clinic-based techniques. However, I would feel guilty about myself if I didn’t make a big noise about this, in the same way you might feel aggrieved if your CM methods were being overlooked by fellow P/Ts with their heads buried in the sands of textbooks !

Enough ‘soap-box’ for now, and thanks again.

Gerry

[ginger]

Dear Gerry, I ought to have said that your approach viz sleeping postures is entirely fitting and valuable. Your idea about inadvertant postural complicity in the natural inclination spines have where already present irritations and protective behaviours , may become worse with even vague extra loads . I do actualy agree with you. That point may have escaped proper spelling out as it were in my post earlier. I see no reason why your ideas and methods could and should not be further explored, for your own as well as the potential for benefit broadly.
The point I attempted clumsily was that movement trumps rest everytime as the means to 'unlock' protective spinal behaviour leading to pain etc. By unlock here I mean to resolve and eliminate both the behaviour and the symptoms with long term effect.
Happy Ioster, good egg hunting and hope you get amongst the fertility rituals wherever you may over the coming festive period.
Cheers

[gerry the neck]

Of course, I nearly forgot……Happy Easter. Note to self…” must remember not to forget the niceties when I’m stuck in the bunker scratching my theories onto two constantly crumbling stone tablets !”. As ever, some more speculations below.

I’m going to try and explain how the nervous system might behave when it recognises a threat to itself, as might happen when a nerve, exiting the spine, is threatened with compression of any nature. The nervous system, as a highly refined protective system, and besides its other duties, must have an inherent ability to protect itself, perhaps using means which are a bit beyond our comprehension. Otherwise, its function as our primary defence would be vulnerable to malfunction….and this simply must not happen. It would defeat its own purpose.

In the case of a threatened, but not yet compressed, nerve in the neck, that nerve most likely sends a signal, through the brain, to instruct local muscles, close to the vulnerable point, to stiffen up and protect. However, those same muscles are also receiving signals, by means of our default operating processes (again, nerve signals), to do their normal duty of maintaining normal flexibility and functionality of the neck. The neck is a conduit for other vital organs, and their best functioning must be ensured.

So, it seems that the local muscles must be receiving contradictory instructions from the nervous system, and without the ability to determine which might be its primary role, the muscle can enter a phase of repetitive internal conflicts with itself, causing varying symptoms in the surrounding area, or even as referred spasm as in frozen shoulder or cyclical headaches etc. Assuming that the nervous system must be ‘ pre-aware’ of any possible outcome resulting from its protective signalling, we have to assume that it allows this muscle conflict to continue, without either signal taking priority, for a good reason. Perhaps the nervous system has already ‘decided’ that this is better than allowing the stiffening signals to dominate, and thus threaten further other functions of the neck.

So, in summary, perhaps the nervous system allows this muscle conflict and cyclical protective reactions as a less risky alternative to shutting down any specific neck functionality, although such shutting down can occur in more critical circumstances. Although speculative, this might help to explain the variety of symptoms experienced by a C/S patient who doesn’t also display any direct symptoms of actual nerve compression, as occurs with long term C/S with no underlying disease apparent.

How to deal with this possible scenario is the big question here. If it were possible to intervene in such a way that one set of nerve signals could relax their intentions, then, without the confusion of conflicting signals, the other set of signals could also resolve quickly (i.e. achieve their purpose ), and thus the reacting muscles could return to their normal duty of maintaining unstressed functionality. I’m inclined to believe that something of this nature happens when each rough phase of C/S relaxes back to its default status, which is within a range of allowable flexibility.
How to intervene is another question, which I and others here have already gone into before in these postings. What I’ve tried to do here is simply is to try to reduce the nerve behaviour to a less confused description, and hopefully render options for suitable therapies less confusing also.
Gerry

---------- Post added at 12:52 PM ---------- Previous post was at 12:47 PM ----------

ps...forgot to mention that the only fertility rites I engage in these days are cerebral. I know that's unfortunate for anyone who happens upon my postings !
Have a good one !

[gerry the neck]

I know. It seems I contradict myself. However, there must be some way, besides instigating referred pain to an area where no problem exists, that the nervous system recognises its own vulnerabilities and reacts to protect. Otherwise the whole system becomes vulnerable and I can't visualise that this could ever happen. The weird thing is that pain doesn't register at point of nerve compression, so we have to assume the nerve has other means of warning / reacting in order to preserve its integrity and to instigate muscular reactions to this end. Thus the speculations on confused priorities of signals and their possible effect on the muscles.
Gerry

[ginger]

"The only exceptions to this are the brain, which isn't served by the nervous system, and the nerves themselves, which don't have other nerves dedicated to warning of any threats to the nervous system."

Our homo sapiens brain has a huge prefrontal cortex to assimilate and understand our environment, guage, relate to and percieve all manner of potential threat to self as well as an equal ability to confuse, become disoriented, and just plain stuff it up. We've all heard of the operations going ahead on living human's brains with the patient responding, without pain to various probings into the cortex. The surrounding soft tissues are however, endowed with the common elements of local sensitivity to pressure, inflammation and disease. While the central processor , so to speak, has very limited capacity to relate to direct threat when occuring deeply, the balance is made up for , for the most part, by periphery.
Nerves, as mentioned further up the chain of these posts, have the nervo nervorum as well as blood vessels. Nerves are indeed capable of having sensations of pain ( created in the brain like all other pain ), such pain is apparent at sites local to trauma, compression etc.
The far more common experience however is that caused by protective spinal behaviour, where irritations to spinal nerves give rise to nociceptive input such that the brain will interpret the threat ( and therefore provide the pain ) as if required at the presumed site of threat, the structure served by the nerve, rather than the nerve body itself. This gives rise to the experiences grouped together known as referred events. These include, altered sensations, altered patterns of muscle recruitment, altered autonomic functions and pain.
The chronic sufferer of spinal pain ( with or without it's attendant three other states) is suffering from the disposoition that this successfull feedback loop has to reinvigorate and redispose itself to continued action, untill turned off.
Movement does this, provided that any historical or present threat is minimised or not present.

[gerry the neck]

This all makes good sense, particularly with the final proviso…..”Movement does this, provided that any historical or present threat is minimised or not present.”. However, there is one issue with pain experience which keeps bouncing around my head unresolved. The nervous system, like all protective systems, must be an integral incorruptible system. It exchanges information with the brain by means of coded signals, and the brain hopefully decodes properly and instigates local reactions. This end seems to be accomplished quite comfortably when we are not conscious, i.e. when asleep, offering us a fairly pain free environment for healing to proceed. I’m not so sure about this decoding ability of the brain when we are conscious, perhaps due to possible distractions, and I’m playing with the idea that pain sensations might result from an obstruction in the decoding processes, i.e. due to a failure to decode when we are conscious. Otherwise, there doesn’t seem to be much sense in the nervous system allowing the distress of pain to occur when really whats needed is a good environment for healing….like when we’re asleep. I’m inclined to think that the nerve signal contains all the information needed to instruct the brain to react efficiently, and where the need for a sensation of pain fits in is a mystery. All purely speculative……but why not ? Don’t know if you’ve visted my “Re: Pain Explored” page yet, where I’m trying to get my head around these types of issues, just to see if any new insights appear out of the blue. Save yourself a headache and avoid at all costs !

Gerry

[gerry the neck]

Hello again


Having just re-read all the previous posts here, after a short break, I feel a need to clarify, to present a more rounded, easily understood, picture of the C/S problem, and thus hopefully highlight the pertinent issues which might affect the options for appropriate treatments being applied.
The most important issue, as I see it, is to be able to make the distinction between actual compressed nerve referred symptoms ( ‘ARS’….I know…that’s very close ! ) and associated protective symptoms ( ‘APS’ ). Just my little acronyms to ease the effort of typing the whole phrase out later. In my case, with my C/S condition, I had nearly 30 years of the latter, without any real manifestation of the former, and I believe this caused certain confusions when it came to applying appropriate treatments. So, here’s the picture……


Actual referred symptoms (ARS) are usually easily definable. Any sensations of clumsiness / numbness / tingling / pins and needles / pain / burning in the hands / legs / arms / bowel or bladder ( although I’m not really familiar with these last two ) usually signify an actual compressed nerve in the neck area, whether it be in the root canal ( stenosis ) or where the nerve exits the cervical spine. I don’t think there is any argument about the source of these referred symptoms, and the options for treatment , although debatable, are well documented. The reason why the nervous system should choose to manifest it’s own distress in this manner may not yet be fully understood, but at least the symptoms will hopefully direct us to the source of the problem and we can make our own choices for relevant treatments. It’s not a perfect science yet, but we can clearly see cause and effect and we can try and rationalise it from there.


With associated symptoms ( APS ) , i.e. any symptoms or discomforts between and including head and chest (including shoulders) , the picture gets more confusing. Both types of symptoms ( ARS and APS ) can act independently, or together, in various combinations. I would argue that APS are more predominant long before any ARS symptoms might manifest themselves, and, by their nature, are difficult to define and present their own problems in determining cause and effect. Consequently, the recommended treatments for APS are confused, and sometimes inappropriate. Mostly, these APS symptoms are caused by protective reactions to a perceived threat of nerve compression ( not actual compression ), and so, any treatments should be focussed on alleviating that threat. Where ARS symptoms tend to be more permanent, even more stable although degenerating slowly, the APS symptoms will vary and fluctuate depending on the required reactions which the neck instigates in order to negate any other perceived threat to the nerves, especially any nerves which have not yet been compressed but are in danger of being so. Thus the ever varying re-occurrence of headaches / muggy sore head / stiff neck / frozen shoulder / chest pains etc. etc. The key to treating these APS symptoms is simply to understand how best to remove the threat of nerve compression, whether by external manipulation, or by developing means of allowing the neck to quickly find its own best solution, for instance with sleeping posture therapies. All debatable, of course. Where it can’t be proved that the outcome will not be further aggravation, then an option for Benign Neglect will become apparent. I fully realise that both patients and professionals have a desperate need to engage actively in aggressive therapies to try and improve the patient’s condition, but we shouldn’t allow that to override our instincts when assessing the options as thoroughly as we can……. “ Where angels fear to thread “ .


I hope this presents a more recognisable picture of the issue of distinguishing between the 2 sets of symptoms, ARS and APS ( do feel free to criticise my acronymising ) , which, in my opinion, is critical to any consideration before trying to rationalise any appropriate treatments.

Gerry

[gerry the neck]

And again…..


I started these postings describing the ‘delayed’ nature of ‘associated’ C/S symptoms, and the confusion such reactions can cause when assessing the benefits of manipulative therapies. Added to that, there also exists the possibility of shock / numbing effects, resulting from aggressive therapies, which also confuse assessments. I’m not suggesting that all manipulative therapies don’t work, but assuming that any do work, without consideration of the above proviso, is, in my opinion, an assumption too far. Any therapy which wilfully overlooks or ignores the reactions which the neck is already engaged in, as it tries to protect from even greater distress, is inherently heading in the wrong direction.


Put simply, if I were to say that a particular treatment, whether it be massage, traction, exercises, or even medications, were to result in unnecessary worsening of symptoms, and without any long term benefits, wouldn’t it be wise to put a question mark before that treatment. And, accepting such treatments as standard, when results so often expose their ineffectiveness, is really a practice which belongs more to a less enlightened era. I accept there is a need to engage in positive action, whatever form that may take, both for the patient and the professional, if only to try and re-assure a difficult situation. However, that, in itself, shouldn’t become a stumbling block to exploring other less well documented ways of tackling the problerm.#


Perhaps the best way to re-assess treatments would be to choose a starting point which assumes that the neck, itself, is already applying the most appropriate therapy, and any external manipulations which may not complement this process, or may even counteract it, must be questioned. Understanding how the neck chooses to react to any given threat is complicated, for sure, but not impossible, especially when it is assumed that the neck is always trying to maintain a certain flexibility and functionality. The two main protective purposes of the neck reactions, with C/S, are to protect from threatening nerve compression, and to not allow any nerve threat to hinder other vital functions e.g blood flow, breathing, etc. So, rather than just stiffening up until healing has been achieved, the neck engages in various complicated reactions which, although distressing, allow a limited functionality.

It seems that most of these ‘associated’ neck reactions are instigated during sleep, thus the typical C/S patient’s common experience of worst ‘associated’ symptoms on waking. Therefore, the most useful and safe therapies might well be applied during the sleeping process, when the neck can best read its own vulnerabilities and can instigate its best possible reactions. Treatments applied during waking hours can be easily resisted, in fact such resistance can cause further problems. Alternating sleeping postures, as discussed before, can have a remarkable effect on how the neck chooses to react to any given threat. The obvious difficulties in monitoring sleeping postures, on a clinical basis, is probably the only reason why such methods have never been explored with any intent. But that, in itself, is not a justifiable reason for ignoring the possibilities.

I also accept that there will be differences in how a C/S patient will experience the dynamics of their condition ( i.e what seems to work and what doesn’t ), and the technical understandings of the professional. As patients, we have no inclination to enter the world of technical disagreements. We see that as an obstruction to our instinctive understanding of what we experience. So, we place ourselves in the trust of professionals who are in dispute with each other ! Double trouble ! I’m reminded of Ambrose Bierce’s definition of a Dentist in the ‘Devil’s Dictionary’……..” A highly trained professional who, whilst implanting metal in your mouth, extracts metal from your pocket”. No offence.


Gerry

[gerry the neck]

Why must I be both Einstein and Oppenheimer embodied as one ?



There are many ways to tackle any problem, but basically there are only two methods of approach. One is to take the actual or envisioned end result and work the thing backwards, to reveal where things may have gone wrong that may have produced that particular result, and hopefully, try and reconfigure those elements to produce a better result next time. The other is to approach the problem from a ‘before the problem arose’ perspective i.e. to assume that everything should work normally, and then to try and spot, and limit, the errors as it progresses, with a view to returning to some kind of normality. I see these two approaches as highlighting the differences between intuitive assessment and textbook assessment.

My feet are firmly planted in the intuitive approach for the simple reason that, as a method, it allows an option to assume a required result which looks beneficial, and any deviations on the route to that result can be highlighted and avoided next time. Thus a continuous self repairing method. So, where an assumed required result might merely be, as in the case of C/S, to achieve minimal discomfort from a chronic health condition, the elements which disrupt such a requirement make themselves obvious. For instance…I can easily assess that my discomfort has increased because I lifted something heavy two days ago, etc, etc. Must remember etc.


With the textbook approach, the entire problem tends to be overviewed with the assumption that all efforts should be geared towards regaining normal functioning. This may well be an impossible required result which has, over time, become the standard upon which most recommended C/S therapies are based. To me, it seems the required result of this method doesn’t fit the problem. Also, to try and tackle a progressively degenerative ( or regenerative ?) condition with knee jerk reactions each time a new phase kicks in, seems to lack a reasonable ‘assumed required result’ in the first place. The overall plan is continually thwarted by unpredictable events and any reactions are usually after the event. In fact, there seems to be no plan for learning from past events, or for applying lessons learned to possible cyclical repetitive events in the future….a glaring omission in any learning process. With no plan, except to react to events as they arise, and with no reasonable assumed required result to guide a path to progress, how can such a method ever hope to achieve progress, or even to acquire an ability to recognise its own failings.

Basically, what I’m saying, without wanting to appear to be too cynical about textbook approaches, is this…..if we lower our expectations and just focus on achieving an assumed required result of ‘less discomfort’ , then other methods of approaching the problem will make themselves apparent. Setting the post too high, as in requiring an assumed ‘ back to normal’ result, may well be over-influencing decision making when devising C/S therapies. It seems its just too easy to overlook the little things which might really matter.

Hope this makes sense.

Ps…Perhaps I should have titled this post “ Welcome to the lecture. Today we’ll be discussing my complete disregard for the obvious lack of responses to my recent posts” !

[gerry the neck]

A Little Rant…..

Anyone, on first being diagnosed with Cervical Spondylosis ( C/S ), will initially want to fight the problem aggressively. For the first few years there may just be a sense of continual discomfort at rear of head / neck, and maybe some referred aches / pains in shoulders etc., and the natural response will be to try and shake off these symptoms with aggressive exercises, traction, medications etc. Unfortunately, this desire to be rid of the symptoms by any means lends itself to the entire culture of C/S treatments.
The professionals also have a need to respond with suggested treatments that look convincing. Thus the cycle of patient’s expectations being met by treatments which simply ignore the on-going behavioural patterns which the neck adopts to protect its delicate disposition. Whether the neck is ‘degenerating’, as might be the case where an underlying disease is evident, or whether it is ‘regenerating’, as with an injury based condition, is critical to being able to adopt treatments which are fit for purpose. Perhaps ‘slow degeneration’ is really ‘regeneration’ with normal wear and tear, as would occur with any injury based structural problem. Rapid degeneration obviously indicates an underlying problem. They are different processes, and they require different approaches. One is acute, and needs responsive damage / distress limitation. The other simply needs guidance to accommodate the behavioural processes which the neck is already engaged in.
Non-aggravation is essential to the success of any treatment, for either condition. Think of it this way….there are unlikely to be any changes to the faulty structure simply by mobilising the surrounding area, so why bother ? Why take a risk which could backfire ? The only flexible element in the equation is the manner in which the local muscles are instructed, by the nervous system, to respond. Believing that we can interfere beneficially in that process with aggressive therapies, without really understanding these complex muscular reactions, is perhaps an arrogance too far. However, simply accommodating the process, by allowing it to inform us of how it wants us to engage with it, can reap benefits. The aches and pains are indications of where we have not responded properly to signals, which we may not have recognised in the first place, and thus must endure a rectifying process. The neck knows what it is doing. Trust it, and, importantly, allow it to reveal its methods in its own language, and the management of C/S will get easier.

Most C/S patients experience confusion and distress when trying to understand their predicament, leading to bad decision making and possible acceptance of inappropriate treatments. A proper analysis of why the neck behaves as it does helps to clear up this confusion / distress, and opens the door to assessing the benefits of approaching the whole condition with a more open mind. Paticularly important, in my opinion, is the role that sleeping arrangements play in generating cyclical symptoms, and which can be controlled with intelligent sleeping posture therapies, as described previously.

Gerry

[gerry the neck]

Here’s a story……..

A long time ago, about 1990 in fact, I was referred to a certain London general hospital for Xrays, physio and neurologist assessment for my C/S. Had the xrays…..no problem. Attended physio (traction and exercises) which left me with a muggy sore head. I felt like I’d been physically mugged ( I often describe early morning C/S symptoms as being like having been mugged whilst asleep ). A few weeks later I got to see the Neurologist. Although she said that the xrays showed my neck to be stiff and tensed, with restricted curvature, she couldn’t actually see anything causing it (I’d been diagnosed 10 years previously with C/S by means of xray) and I was more or less dismissed as not requiring further investigation or treatment. I was more than aware of the symptoms I’d had for those 10 years, and I left that hospital feeling like I’d been cast adrift by those I most relied on. I felt both physically and psychologically mugged, having placed myself willingly in their hands. It was a bad experience which seriously affected the frustration and confusion I was experiencing with my condition. And, I should add, not a single word of advice on how to manage it on a daily basis. Needless to say, my attitude to these unfit for purpose systemised processes has been coloured ever since. In fact, I felt inclined to avoid having to endure such a disappointment ever again, and , on second thoughts, I’m going to name and blame. They deserve it. It was Chase Farm Hospital. Done.

About 3 years ago I developed the numb hand / painful arm symptoms, which needed attention. GP referred me to Physio, who referred me to a hospital based Physio, who referred me for MRI scan, then back to hospital Physio, who referred me to a Neurologist. She offered me 2 choices of Neuro, one being at the previous hospital I had attended in 1990. No thanks, I said, I’ll have the other, which was a lot further away. Rather strangely she said “ Good choice. You chose the best in London”. Hmmmm! I got a copy of DVD with MRI scan (which I cleverly made a copy of myself, and which I still have) to take to the Neuro. A few weeks later I attended for assessment. I was seen by a trainee Neuro (I assumed) who did all reflex testing and talked me through the MRI. I had some stenosis and multilevel degen. from C3 to C7, much as expected really. At the end I asked if it was possible for current symptoms ( not condition ) to self resolve in any way, and was told no, only with surgery. I was booked for further tests, EMG and another MRI, and eventually returned after 3 months to see the actual Neuro consultant. I briefly explained my 30 years of symptoms and how I like to try and manage it my own way, and she agreed that was a good idea, unless it suddenly got worse. So, any intervention was put on hold. Suited me. From GP to this point all took about 6 months, and 9 separate appointments at varying venues. True. In all that time, not once did I get any advice on how to manage my condition daily ( Perhaps I should exclude the Neuros from that criticism, because they’re busy enough with surgical matters ).

Anyway, I returned a year later for an appointed review. This time, as all seemed to be going well, although still with semi numb hand, I was offered the option of physiotherapy. I declined, explaining my new belief in benign neglect and sleeping posture therapies. At this the Neuro laughed, in a way I can only describe as ‘knowingly’, and when I left I thought to myself “ At last, a little common understanding”. Still no advice on self managing, but, after 30 years, I was getting used to that.

I really hope I haven’t blown my precious anonymity here. Don’t really want my Neuro inviting me in for an early retirement…for being too mouthy !

Moral of the story is this…..each time, and there have been many, I seek treatment, I go through the motions, and then I am very politely shunted back to square one, with no guidance, to start the whole process over again. Is it really any wonder that I choose to put my faith in home based therapies, which I’ve had to devise myself, and which seem to work better than what I’ve been offered. And, is it really any wonder that I should explore the theory of the C/S condition and try to rationalise how it really works. I have accumulated a lot of information on how a C/S patient might change their overview of their condition, and on how they can self manage it, to some degree, without endless clinical appointments, medications, or bad advice, and without conflicting with current practices. Controlling the intensity and unpredictability of symptoms is the way forward. My intention is to combine all into a comprehensive guidance booklet and make it available. Unfortunately, I don’t have independent means, I must work to survive, and therefore it may take some time. In the meantime, I hope that the arguments I have put forward in these postings are convincing enough to attract any C/S patients seeking a better way, and perhaps they might also encourage any concerned professionals to rethink systems which may look workable to them but are, in fact, mostly a repeating disappointment to C/S sufferers.


Gerry

[gerry the neck]

ps.......Of course, its not my intention to push my arguments onto professionals who may be otherwise busily occupied with matters of delusional denial. Hope I haven't uncovered a new condition there, endemic amongst medical professionals who can't see the wood for the trees ! Systemised failure, rebranded as some kind of second class success, is not really an option here. I'm the one being served with this weird dish, and I'm sending it back. Surely you can do better !

[gerry the neck]

Misconceptions.


Just to move on before the last posting is spotted !

The best therapist available to us is our own body. Indisputable. The body is a highly refined organism, genetically designed to conduct its own repairs where necessary. Like everything else, there are limitations, but mostly it does an excellent job. There are no fees, no appointments, no waiting, its available 24/7, and it seldom makes mistakes. It hasn’t had to study for many years how to deal with a crisis, it inherently knows its own best reactions. It could teach us a lot. All these services are available to us unconsciously, and our conscious appreciation of its methods is still someway behind the advanced systems it applies.

The first law of any applied therapy should be ‘ Try and understand what the body is already trying to do’. Of course there are situations where the body’s defences are overwhelmed, and we can intervene by, for example, removing the main threat, and then allowing the body to resume its self recovery role. There is no doubt than in many areas of medical crisis we have learned how to intervene beneficially. But not in all.

Where we fail, we must keep an open mind. There is no point in insisting that an applied therapy, which has been proven to work for one condition, should be applied to another where outcome is unknown. The history of medical practices is one of many failures, and some great successes. The arrogance of those successes must be contained if we wish to always be improving. There also isn’t much point to us entering self congratulatory mode whilst the job remains unfinished.

Where C/S is concerned, I can see where differences occur between my 30 years experience and the efforts of an interested professional, who doesn’t have the condition, to try and understand how the condition works. It might take such an interested party 300 years to achieve the same levels of intuitive understanding that I’ve had no choice but to learn. Its never going to be top of their ‘to do’ list, and results can only be monitored by evaluating trial and error over a wide demographic. It’s a slow process. Not so with me. I’ve been privileged to monitor the condition 24/7…..not a single moment lost. So, my 30years v 300years comparison probably doesn’t look so outrageous in that context.

However, its not a contest. We all want the same end result, and the best way to do that is to share our accumulated knowledge. That is why I chose to share on this site rather than challenging the views of a Physio in a clinic somewhere. I would just be reducing the options to that same old slow process. I believe that most professionals who deal with C/S have a particular ‘accepted’ overview of the condition which I have difficulty relating to, and that overview is determining treatments which don’t necessarily meet their purpose in ways which I consider beneficial.

The purpose of these postings is to try and encourage trained professionals and patients to revisit their basic understanding of the C/S condition, and to not ignore how the nervous system uses the sleeping process to instigate the varied ‘associated’ symptoms, which in turn can then be controlled somewhat by adjusting sleeping postures. I understand that there might be a certain loss of income associated with this suggested therapy, but I can also assure that there will be greater rewards in feedback feelgood factors !

[gerry the neck]

The Neck’s Hierarchy of Priorities.


The neck is probably the most used organ of the body. Its worth saying because mostly we forget its there, which is also a good indication of its refinement. It has the responsibility of ensuring we can breathe, we can swallow, and that blood flow to and from the brain is uninterrupted. All vital functions. It is also designed to protect the routes which the nervous system uses to both gather and disperse vital information about threats to the body general. All these functions must be protected so that they operate successfully, otherwise, in theory, we die. On top of all this, the neck also has the responsibility to allow movement of the head, and thus the senses of seeing, smelling, hearing, tasting etc are fully utilised to aid our survival in a threatening world.

When an actual structural problem occurs in the neck, as with cervical spondylosis, the neck must then refer to its default protective system to decide which functions take priority, and which functions must be maintained, even if its at the expense of applying a direct reaction to that structural problem. These are pre-set inherent instructions which must be enacted regardless of any external interference. If this is true, then its not too difficult to see that how the neck deals with its own structural problem is demoted down the list of absolute priorities, simply because how it reacts cannot be allowed to endanger the other vital functions. In this way, its reactions differ from reactions to similar structural problems in other parts of the body ( perhaps with the exception of sciatica ). And it also helps to explain why the nervous system should choose to use referred pain, rather than direct pain, as a warning method. The use of direct pain in the neck area could easily cause a conscious reaction by us, which might endanger other functions. The nervous system inherently doesn’t trust these possible conscious reactions by us, and so, its methods are designed to counteract them, before they might occur. This is how refined the nervous system actually is.

So, we’ve established that how the neck reacts to structural problems might be well down the list of its priorities. Also, within those ‘delayed’ reactions there exists yet another sub-list of reactive priorities. Without these reactive priorities the neck would probably just stiffen up, painfully, until some sort of natural healing was achieved. It can’t do this because of the possible resulting dangers. And so, what it does instead, is to employ a whole range of ‘safe’ alternative muscular adjustments, which don’t threaten other functions, but which cause all sorts of ‘associated’ symptoms which we are familiar with as C/S ‘associated’ symptoms. It should be stressed here that these are not ‘actual’ trapped nerve symptoms, which in themselves don’t have such an effect on the neck. The ‘associated’ symptoms occur mostly because of threats to a nerve, rather than actual compression.

Basically, what I’m saying is this. The way in which the neck prioritises it reactions is always one step ahead of any possible conscious reaction on our part, and as such, any external manipulations should take this into account before being applied. If it doesn’t suit what’s already happening, its wrong. We might like to believe that we can outwit the nervous system, when in fact, we are always, by default, one step behind. Its inherent in the design !

G

[gerry the neck]

What is ‘Referred Pain’ trying to tell us ?

Again, I’ll reiterate that I’m exploring these issues purely on an intuitive basis. Sometimes, too much knowledge is an obstruction. Just trying to focus rationally on why ‘referred pain’ exists at all, I believe, can reveal certain secrets about how the nervous system chooses to operate as it does.

I’m going to assume here that all referred pain originates with some actual threat to the nerve system itself. I don’t know if this is strictly true, but in my experience, it is. Its probably reasonable for anyone to assume that, where a nerve is compressed, it might cause pain further along its extremity, and only in that part of the body to which that nerve is dedicated. However, as I see it, it should cause numbness, not pain. Pain would only be relevant if there was an injury at that extremity. Where there is an occurrence of pain (referred pain) at an extremity, and there is no obvious injury there, then we must reverse our thinking on normal nerve system signalling processes so we can locate the actual problem.

To me, this is a clever tactic which the nerve system employs to slow down our responses, because it doesn’t trust how we might consciously react if it simply signalled pain at the actual source…i.e. a threat to itself. I know that sounds like I’m giving the nervous system a separate identity of its own, capable of making decisions and enacting processes, and capable of outwitting our conscious reactions. And I am, but only in the same way that we understand our conscious and subconscious beings tend to interact. One or the other must dominate according to the circumstances. But, with the nervous system, it must always dominate by default, otherwise its protective systems become vulnerable to corruption, and that just wouldn’t make sense. ‘Referred Pain’, in itself, causes this puzzle, and we must re-learn the process backwards to find the logic in it.

Where the neck is concerned, I can easily see why the nervous system resorts to such ‘referred pain’ to achieve its protective aims. The neck must carry on functioning regardless of its own distress, and any actual neck pain is reserved by the nervous system as a last resort. Considering the human race has gone through many thousands of years unaware that referred pain in the hand might signify a threat to a nerve in the neck, I think that the nervous system has been very patient, waiting for us to gain the knowledge to interpret its signals correctly. And now that we know, what do we do ? It seems that we resort to interfering aggressively with external manipulations, which seem to me to go against the very reason why the nervous system adopted ‘referred pain’ signalling processes in the first place. Maybe the whole ‘referred pain’ system worked better when we knew less !

And, the nervous system hasn’t yet adjusted itself to our new methods. If its original intention was to somehow distract us from the source of the problem, what must it do now that we are no longer distracted ? Should it evolve an electric shock for anyone who dares to touch the damaged area ? Of one thing we can be sure. Now that the secrets of referred pain are being unravelled, we must assume that the nervous system is likely to resort to other, as yet unknown, methods, to maintain its position in the hierarchy of control over threats to itself.


Gerry

[gerry the neck]

Pre-emptive Protective Nerve Behaviour


I think most would agree that nerve reactions are generally seen as post incident events. An injury or malfunction occurs, and the dedicated nerve reacts with whatever warning signals it deems necessary to alert us to the danger, and possibly to also kick start the immune system into instigating local reactions. I don’t think that we ever accept that the nerve could have predicted such an event in any way, and somehow managed to warn us before the injury / malfunction actually occurred. However, where there might occur an incident of a possible threat to the nerve system itself, I suggest that the nerve system can adopt a more pre-emptive protective warning and reaction role. It just makes sense that it would have the ability to protect itself and thus maintain it’s integrity for dealing with other problems in the usual way.

We train ourselves to rationalise events with a ‘cause and effect’ overview, which most of the time proves itself to be adequate. Where that ‘cause’ has not yet happened, but the nervous system has predicted that it might, we have to change our overview for assessing the problem, and try and see that it’s the nerve’s predictive ability which is the real ‘cause’. Obviously, because of the nerve system’s ability to instigate reactions, before the threat to itself becomes a reality, that reality can be avoided, and all we are left to deal with are the after effects of the nerve system’s pre-emptive protective measures.

The key to all this would be whether we accept that the nerve system can enter this pre-emptive mode, and if so, how we should react to it, because we may be dealing with muscular reactions which have been instigated for good reasons. Perhaps for better reasons than any external interference could claim. If we accept that this can happen, then what we really ought to be looking at, in terms of interfering, is how to remove the threat which the nervous system has recognised. Just dealing with the after effects does seem a bit pointless when we consider that the nervous system is always one step ahead of our reactions, and can pre-emptively instigate its own reactions to whatever manipulations we might attempt. So, recognising, and somehow relieving, the threat to the nerve is really the only way forward, and all therapies should be contained within the spectrum of limitations which such an overview allows.

My interest in all this mostly concerns the neck area, and particularly the Cervical Spondylosis condition, where the ‘associated’ symptoms familiar to all who have the condition are brought into sharp contrast. But, maybe the same theory can be applied to all spinal conditions where a nerve is threatened. Where a threatened nerve has evolved into a compressed nerve, there will be different symptoms and a different theory applies. How to read the symptoms correctly, and whether they are ‘associated’ to a possible threat, or whether they are ‘direct’ as a result of actual nerve compression, is all important when choosing an external treatment. I’ve experienced both types and have become familiar with their differing behaviours, and I’m on a little mission to help clarify the dynamics involved and, at the same time, to suggest exploring appropriate treatments, particularly concerning the remedial effects of adjusting sleeping postures.

I’m interested in hearing about any reports or investigations into sleeping posture therapies for these types of nerve threatened conditions, mostly because I’ve come to realise through my own experiences that the sleeping process seems to be where the nerve reactions are first instigated.

[gerry the neck]

Frozen Shoulder.

Because there seems to be many contradictory opinions on what causes ‘Frozen Shoulder’, I’m going to add my opinion to further confuse, or resolve, our understandings. Firstly, I believe the terms ‘Frozen Shoulder’ and ‘Adhesive Capulitis’ are misleading, and only help to add to the confusion by directing attention to the fallacy that it is solely a shoulder problem. In my opinion, it’s not, and here’s why…….


The most common vulnerability to the nervous system, and how it distributes itself throughout the body, occurs where the nerves exit the cervical spine, between the C1 and C7 vertebrae. Because of possible degeneration or regeneration, whether due to an underlying arthritic condition (such as Osteoarthritis) or an injury based condition (such as whiplash), and because of the full range of flexibility allowed to the neck structure, the risk of a compressed nerve, or even the ‘threat’ of such a risk, becomes a greater possibility than would normally be the case.

Where an actual compression has occurred, there would be obvious indicating symptoms manifested in the hand, at the extremity of that particular nerve’s field of influence. These symptoms are usually self explanatory and point to a direct cause i.e. trapped nerve in neck area. Where there is just a ‘threat’ of nerve compression, the nervous system is capable of reading this vulnerability, and, in order to protect from such an event, it can instigate certain muscular reactions to help protect itself. So, the shoulder (which is the next flexible joint along the nerve route) muscles are instructed to restrict the arm’s movement. This is achieved simply by introducing pain for any arm movements which might refer their effects back to the neck, and thus increase the threat to the nerve.

Unfortunately, this process can enter a cycle, perhaps due to ‘muscle memory’ issues, and can take many months to resolve itself. The actual initial threat to the nerve may have already resolved itself, but the shoulder effects carry on regardless. If that initial threat didn’t resolve for any reason, then the frozen shoulder would keep repeating itself endlessly. This doesn’t happen normally…it does resolve with no obvious lingering damage. In fact, there was never any tissue or structural damage in the shoulder, and it returns to normal painfree flexibility in time, usually about 10 to 12 months. It can be very painfull for first 3 to 4 months, and then gradually reduces in pain intensity until eventually it disappears.

So, to summarise, the painful shoulder is just the nervous system’s way of restricting arm movement so that it can better protect a vulnerability to itself as it exits the cervical spine. Any manipulations of the shoulder, especially painful manipulations, are likely to increase that vulnerability in the neck, and thus lengthen any recovery timespan. Any surgical intervention in the shoulder, where no obvious damage is apparent, is even more questionable. Frozen Shoulder is caused by protective nerve behaviour, and it only resolves itself when the threat to the nerve eases off by itself..

I believe that a lot of confusion, particularly regarding a patient’s understanding, is caused by the use of the terms ‘Frozen Shoulder’ and ‘Adhesive Capulitis’. Perhaps it should just be renamed ‘Referred Shoulder Spasm’ to ease patient anxiety.

[Dr Damien]

Dear gerry the neck

I hope im not joining this band wagon a little too late, i just want to give my own two cents worth based on my own experience of patients with cervical spondylosis. you are definitely right in that sleeping positions play a great role in providing relief. Im not going to go into all the explanations already given by my colleagues as to management techniques etc. i personally believe that cervical spondylosis is an age related problem, by age related i mean the older you get the more likely you would have this problem. You dont have to be elderly to start showing signs, lifestyle postures in a daily activities makes us susceptible to this. in my experience postural problems are often the predisposing factors, trauma only adds to speed up the process.
i had a patient once who would suffer the whole day with neck pain but felt the most comfort when she was lying down on her side needless to say she always looked forward to going to bed at night. the pain most c/s patients feel usually are muscular pains, this can gravitate to nervous pains in time etc but 90 percent of the time the issue is muscular, once you take some of the load of the tensed muscles they feel relief almost immediately. All the treatments we provide from a physiotherapy point of view is to maintain range/improve range and strength, improve posture and reeducate on how to unload tensed muscles either through postural work, positioning, modification of daily activities. We only try to prevent the worsening of the problem. This lady in quesstion would get pain on neck rotations and extension, sometimes causing her a headache. now being the age she was and the medications/pmh , it was too risky to trial any manual therapy but with just some basic exercises and advice her neck pains on rotation improved dramatically. now there was no way she was going to get any significantly better because she was extremely kyphoscolitic. so in all fairness, you are right with regards sleeping positions which many of the sufferers automatically know anyway, what they often need help with is improving neck rom/and strength, they are often good at adjusting their own daily activities sometimes to their own detriment because in avoiding some movements they automatically make things worse.
I had another patient with a similar problem, her pain was from bothersome triggerpoints , she was a c/s patient as you would describe but had gotten in the habit of maintaining some awful sustained postures just to avoid pain. now again, she had rheumatoid arthritis and was on long term steroids so manual mobilizations for me was a no no!...a lot of soft tissue work was needed to help her regain some range , offload the overworked muscles and reduce her pain. will the pains come back, almost certainly but with the right advice and maintenance strategy (exercises) she was able to control it more. my take home message to you...yes, there is a neck problem, yes it is cervical spondylosis, but the it doesnt have to be as bad as some people suffer from it once we look at posture and the overwork some neck muscles are having to do

[gerry the neck]

Hi Dr Damien

Again a great description of C/S. Will respond soon.

Thanks

[gerry the neck]

Sorry, a bit of a delay in responding properly. Briefly I can say that such a sympathetic and constructive overview of C/S is more than welcome. Such an approach can only lead to improvements in treatments. I might have some reservations about usefulness of exercises / manipulations in the waking hours, but if some relief is achieved, and as long as there are no new symptoms appearing, that's ok. Inevitably, I keep returning to the fact that I don't necessarilly see an inclination towards further exploration of how the sleeping process, which in my opinion, is the catalyst by which all associated symptoms (as distinct from actual trapped nerve symptoms ) are instigated. Or, for that matter, why the sleeping process is not therapeutically investigated to reveal the benefits it can offer. Best I usually get is the default assumption that, of course, sleeping posture can affect the C/S experience. But where's the therapeutic plan in that ? Over 30 years, I've never had sleeping postures advised or explained to me, and my worry is that it might take the average C/S patient many years of unnecessary discomfort before arriving at such a conclusion themselves about how to somehow control what they are experiencing. I have to be frank and say, it seems to me to be an area of obvious benefit, certainly to someone who experiences those benefits, which has been ignored in terms of proper assessment, for whatever reason. Currently I'm trying to put together a good case for explaining why, in terms of assessing good therapies for C/S, it is all important to focus on what occurs during the sleeping process, and perhaps, that all external therapies should compliment the reactions instigated whilst asleep. Will post anon.

Gerry

[Dr Damien]

Dear gerry the neck

I understand your frustrations and your idea with regards the influence of sleep on c/s, however in practice this is very hard to control. people do not develope c/s because of sleeping or sleeping positions, their everyday lifestyles and posture creates a cascade that starts the process which gets worsened by some unhealthy positions some of which you can get from sleeping. This is why the focus of treatment is on everything else that you do during the day, for sleeping there is very little you can do to control problems. I can advise you as a therapist to sleep in a certain way but because you move about in your sleep you find yourself in another position. I can say put x amount of pillows on certain areas of your bed and by morning all the pillows are on the floor. This is why inherently the onus is on the sufferer to find what works, unless of course you are a neurological patient that needs help moving generally. Its not as simple as you describe it, what position works for you may not work for someone else. There are so many factors to consider, comorbidities ie postural hypotension, breathing issues, postural issues ie.kyphosis, now when you are awake, the therapist can give good advice as to how you should sit, stand or walk because you are "awake" and can make necessary adjustments whenever alignment issues arise. To try and research problems with sleep and the cervical spine is a long shot.. im sure there are companies out there claiming to have the best sleeping equipment to protect your spine and what not however these equipment mean nothing for the restless sleeper, for the person with orthostatic bp issues, for the COPD patient, or for people with recent surgeries, im sure my colleagues will have even more factors that need to be considered to investigate this. I dont think you can get the best advice on how to sleep to protect your neck from a therapist, you may be better off discussing with an occupational therapist who can give the necessary equipment to mitigate these problems but it will always be a long shot for as long as you have the capacity to move independently.