Adventures in the Psychosomatic
During my travels over the course of the last weekend I had the opportunity to visit a dear friend's new yoga and personal training studio. As we discussed the development and growth of her business and trends in her clientele, the topics of pain, movement, trauma, and the relationship between experience and sensory information as input and pain as output evolved into a question of biceps tendon pain in her own right shoulder. It is important to note that my friend has a significant history of traumatic violence, fear, and PTSD as a result of the events of her past.
Upon evaluation, her shoulder exhibited no signs of structural damage, no positive special tests, pain with palpation rated at a 5/10 at the right bicipital grove with some fullness of the tissue in the area directly adjacent to the biceps tendon. 5/5 MMTs with AROM and PROM WNL and equal compared bilaterally. Specific provoking patterns were reported during rock climbing including cross body pulls, regardless of hand position, and bent arm hanging positions. The onset of the shoulder pain was insidious with no specific MOI and began roughly 2 years prior. This was roughly around the time she had made a cross country move. She reported having sought medical attention for her shoulder pain near the time of the initial injury reporting that another health care provider, a physical therapist, had suggested to her that she had a labral tear. This clinical diagnosis proved to be inaccurate with imaging.
With some inquiry, it became apparent that this misdiagnosis had been upsetting and had made her distrust the physical therapist and feel less empowerment surrounding her own autonomy as much of the outlet for her feelings of anxiety and trauma revolve around activities such as hiking, camping, paddleboarding, and rock climbing. We muscle tested these words and found them to be weak, but not dramatically. Her response to a 'first thought question' surrounding these words produced an exciting and emphatic "I trust myself!" I suggested that while this is an excellent thing, it does little to inform her about her relationship to trusting others, particularly in the direct context of her shoulder.
It was at this point in our conversation that I decided to abstain for a time from my normal patterns of treatment to continue to demonstrate some of the... energetic... techniques we had been discussing with regard to her clientele as we sought some relief from her shoulder pain. Again using the standard single finger adduction resistance muscle testing we discovered that she was not weak to physical contact with her right shoulder but was quite weak to physical presence in her... field... roughly four inches away from her right shoulder. This was an outstanding revelation for her and she asked me to repeat the test with her eyes closed. I repeated the test with my off hand on/at her hip, low back, abdomen, and shoulder. All responded strong with the exception of the shoulder. She then suggested that we make the stimulus more challenging for her, testing her with me standing behind her. This was done at random with my off hand on/at her scapula, low back, and again near the front of her shoulder. When I reached the previously weak position both her left arm and left leg gave way. She then broke into a visible sweat and laughed off what she described as the beginning of a stress response. The position I was in during this test had my right arm nearly wrapped around her from behind creating an understandably more threatening environment. Given the level of trust my friend and I have this was not difficult for her to shake off but the response was physiological and dramatic. We performed one more series of tests without using muscle testing at her request. Again in a standing position I moved one hand round her with her eyes closed until she felt any altered sensation. I attempted to do this moving only my arm without making any sound in order to not give away my position. When I got to her R shoulder she said OK, opened her eyes and was again shocked at the position my hand was in, roughly 4-6 inches away from her right anterior shoulder. However, we had yet to find the root of the issue. At this point she mentioned ipsilateral jaw pain with an onset roughly around the same time as her shoulder pain wondering if they might be related. I again inquired as to the nature and onset. She reported that this was also non-traumatic in nature. She then asked me to perform the same tests I had done before but with my hand on her jaw. She responded strong with contact and dramatically weak without.
Here it may be important to note that the patient is right handed and has congenital Marcus Gunn Jaw-winking Ptosis (MGP) affecting her right eye. MGP is synkinetic disorder wherein there is an aberrant connection of the motor branches of the trigeminal nerve and oculomotor nerve. Essentially during movements of the jaw, the upper eyelid opens wider causing a reverse wink in one (generally) or both eyes.(1)
I proceeded to investigate eye and motor pattern weakness asking her to read a sentence forward (strong), backward (well read and strong), to walk forward (strong), and backward (strong). Direct eye movement however produced more interesting results with left (strong), up (strong), down (strong), and right (weak). I suggested that she 'TMR' her eye movements looking to her left roughly 30 times with rest intervals when she felt necessary. After treatment of eye movement with TMR we retested eye movement to the right (strong), the shoulder without contact from the front, and behind with her eyes both open and closed (strong), and I once again asked a 'first thought question' regarding trust, empowerment, and autonomy. Her response to the 'first thought question' was quite literally... "ummmm..." I then suggested that the patient retest some previously pain provoking range of motion which produced no adverse sensation. Results of palpation of the area were a bit more interesting. The tissue remained more rigid and full when compared bilaterally but much to her surprise her pain rating was 0/10. I then asked the patient to check cervical AROM. All were WNL with the exception of right rotation which stopped at roughly 45 degrees. I asked the patient to check right rotation AROM again. This second test stopped well over 70 degrees of rotation again causing a rather shocked response from the patient. She had thought she was at full AROM the first time and couldn't remember having greater AROM in right cervical rotation.
Post-treatment, over coffee, the patient suddenly became quite animated mentioning that in years past she had always carried self protection implements (e.g. pepper spray) in her right hand whenever in public alone. We agreed that this may be correlated with her hyper awareness, dysfunction, and pain. Approximately 24 hours later I received a message from the patient reporting that she had gone rock climbing later that evening without any pain or dysfunction and that the treatment had held through to the time of the message.
It is here that must challenge the notion of 'energy' medicine or work. If pain, sensation, and even emotion are subjective outputs from the brain to external and internal stimuli, it would appear that each of these tests and interactions, while very real, have little to do with 'energy' and are largely, if not entirely, based in the human nervous system. "Any sufficiently advanced technology is indistinguishable from magic"- Arthur C. Clarke -"Magic is just science we don't understand yet"- Jane Foster from Marvel's Thor attempting to quote Arthur C. Clarke. When we evaluate the mechanisms of our treatments, as well as the bewilderment that our patients and we ourselves might sometimes express at their efficacy, it may be wise to keep the notions expressed by Arthur C. Clarke and, perhaps more easily understood, Jane, in mind.
References
1. Marcus Gunn Jaw-winking Syndrome - http://eyewiki.aao.org/Marcus-Gunn_jaw_winking_ptosis - accessed November 19, 2018.