Gathering place for osteopaths
Blurry vision
Hey all,
I've seen a patient this week who suffers from blurry vision. I'll fill you in on the history first of all:
58, female, first presented to me in july09, with right leg general weakness/heaviness, only noticed on walking (+500m) and standing (+10min).
At this time she did also report sole of the feet numbness and tightness feeling as well as cold.
An MRI done previously did reveal spinal cord compression at T6-7-8, following a local injury.
Right leg: muscle weakness found at all levels and hypereflexive L2-3-4. Inconclusive S1-2.
Anyway, this symptom got progressively better to 99% or so after 5 treatments, but she then started to suffer from vertigo, diagnosed as BPPV. This got 100% better within a couple of weeks of having performed the Apley's maneuver.
Now, she reports blurry vision
onset: 2 months
prog: worsening in the last 2 weeks
DP: worse as the day goes on
She only gets it when she walks or does any sort of neck movements.
She reports falling a couple of times in the last 2 weeks, tripping up.
Consulted a neurologist, NAD, who cracked her neck, so... whatever.
And consulted an ophthalmologist, NAD
VBI NAD
No cerebella ataxia
I actually tested keeping her neck immobile, and moving/rotating her trunk only, and this does bring on the blurriness.
There seems to be a connection with her spinal movements and eye symptoms. Perhaps a membranous connection...
Anyway, i treated her this week, i'll call her next week and check if there is any difference. She's also going to the hospital in the mean time...
Any ideas on what this unusual presentation may be?
Replies to This Discussion
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Permalink Reply by Lucy GArdner on -
Wondered what the outcome of your patient is? very intriguing. These could be completely out of the ball park but some thoughts come to mind....Benign intracranial hypertension, may present with apparently unrelated neuroligical symptoms, the other thought is MS due to eye symptoms, tripping up may be due to glove and stocking in her feet.
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Permalink Reply by Clement Rhein on -
Umm, i think i may have forgotten about her actually, as i don't recall calling her, but also i sometimes forget things i've done so. Nethertheless, i'll call her at the next opportunity and find out what's happening.
Thanks
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Permalink Reply by Hume O'Rous on -
Probably a cerebellar lesion. 'Red Flag'. Careful.
Why did the neurologist 'crack' her neck...?
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Permalink Reply by Hume O'Rous on
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It's true that the inferior cervical ganglion has direct and indirect efferent connections with the vertebral artery, ciliary ganglion (and pretty much every other tissue in the cranium for that matter), so how does that explain her ataxia....?
'No cerebella ataxia' says Clement... who came up with this claim, and on what basis was it made?
Also get a second ophthalmologist's opinion, to be safe.
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Permalink Reply by Clement Rhein on
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"Why did the neurologist 'crack' her neck...?"
I'm in Cyprus Donald, a little backwards here :-)
Anyways, interesting news:
I have a colleague I refer "difficult patients" to, the ones that don't clinically add up but more importantly do not respond to treatment. Within 2 treatments of that colleague, the patient is now 100% better. Meeting up with her later, she told me it was due to a psychoemotional issue with her dad...
She's a very spiritual therapist doing massage, hypnosis, NLP, EFT, reflexology, indian head and god knows what. All patients I've referred to her so far have got better, annnnyway...
However, I appreciate all the inputs. Thank you very much.
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Permalink Reply by Hume O'Rous on
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If it's true that....'Within 2 treatments of that colleague, the patient is now 100% better ' do you think you may have missed some indicators in her case history assessment that might have flagged up a possible psychosocial 'yellow flag' on another day?
Some of the 'failures' we have can teach us the most valuable rules, and reflective practice is a great way of learning not to overlook or undervalue the conscious and unconscious signals our patients offer us. Provided there is no sense of 'I failed to spot such and such a characteristic/clinical sign/ diagnostic clue/etc... hence I'm a poor clinician' behind the retrospective re-evaluation, I reckon nothing but benefit comes from this.
I still think she has a cerebellar lesion from the clinical picture you painted...!
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Permalink Reply by Theodore Jordan on -
I hate to sound like a broken record, but blurry vision & numbess of the feet - I would look for other signs of diabetes; polyuria, polydipsia, fatigue, and have a blood glucose checked. Sorry, but thats my medical training talking.
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Permalink Reply by Clement Rhein on
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Okay, I get your point Donald, but:
There was some clear link between cervical spine movements and vision blurriness, which makes me stir towards the fact that symptoms were clinically reproducible, so less space for yellow flag.
Secondly, I've personally been to this therapist and experienced her treatments. We achieved the biggest changes than any other therapist has achieved with me.
And thirdly, all patients that I've referred to her get better, when my osteopathy has failed.
I did all the basic ataxia tests Donald, all negative, apart from the walking one ofcourse. No disdidokenesis, no overshoot dysmetria, no problem slaping herself on the forearm... :-) But if she had, why would it be that only neck movements affect it?... Sorry I disagree Donald.
You love your diabetes Theodore don't you?! :-) I admittedly wrongly not include this in my DD. thanks.
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Permalink Reply by Hume O'Rous on
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With any early stage neuro condition there will be periods of normality. That's why an exam may produce NAD results. Same as viral upset... the timing of the testing is critical as the window of irregularity may alter. Sometimes a stress test will illicit the symptoms being complained of. Do the ataxia test after the patient has done some isometric exercises or light weight testing....
I wrote back Clement as I was thinking that your colleague's art of obtaining a clear picture of her patients subconscious state may be a real factor. Did the patient provide any info on their emotional bonds, family history, etc to you, hence generating the possibility of a yellow flag?
As I indicated some days your intuition will obtain an insight that reaches into the patient. Just as amazing as an MRI scan in its insight.
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Permalink Reply by Clement Rhein on
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Umm, didn't know that ataxia can be on/off like that, thanks.
She did not express problems in family, nor did I ask tho.
We perhaps need clarification on yellow flags:
"They are subjective and have a significant psychosocial predominance. Examples include negative coping strategies, poor self-efficacy beliefs, fear-avoidance behavior, and distress."
http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=15493
But I don't think she fitted into this category. She definitively did not come across as crazy or somewhat mentally deranged and looked as if she needed psychological help, but rather just a nice lady, who's on the ball, who is experiencing clinically reproducible symptoms.
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Permalink Reply by Hume O'Rous on
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Imagine this case is being considered at a third year out-patient clinic.
Lets assume this woman does indeed have deep emotional issues, and doesn't hopefully come back with more falling down episodes or other manifestations indicating serious cerebellar pathology.
With any student osteopath who seriously thinks someone needs to be perceived as 'crazy' or 'mentally deranged' (with all the unfortunate Loony Tunes connotations), then it's not surprising they missed any non-somatic indicators during the initial consult. You could perhaps excuse this gross insensitivity due to inexperience and immaturity.
I'd ask the student to detail what someone looks like if they need psychological 'help'....
"Yellow flags" are risk factors associated with chronic pain or disability. They are subjective and have a significant psychosocial predominance. Examples include negative coping strategies, poor self-efficacy beliefs, fear-avoidance behavior, and distress'.
'Subjective' can be used as a form of belittlement in the hierarchy of symptoms. In the same way that you see the term 'anecdotal' being similarly chosen.... "Oh!, you've only anecdotal evidence to support your opinion..."
Subjective beliefs in a real world context means 'relevant to the subject/patient', and can be anywhere on the emotional spectrum. If a subjective belief is missed during the consult, then whatever else the clinician does; however expert the clinical examination; however sensitive and dextrous the adjustments made to correct perceived dysfunction; All else will be irrelevant, and there will be no lasting positive outcome. The patient is also likely to fail to attend their follow-up tx!
That's the power of the subconscious mind.... so much more complex than the cognitive/cortical nervous system, and yet in the 1900's when the adventure of primitive neurology was just beginning, it was thought quite the opposite.
Perhaps we misunderstand nature and ourselves by allowing neocortex dominance.
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Permalink Reply by Clement Rhein on
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"Perhaps we misunderstand nature and ourselves by allowing neocortex dominance."
I agree, we do, especially as a society, but luckily we are all free thinkers, so some can diverge out of the box...
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