The following individual case is intended to illustrate that there are many people who are advised to undergo surgery from a medical point of view, even though the problems that have arisen can be solved through differentiated functional diagnostics (I will explain the term later) and specific training. Of course, not every case is the same and surgery may be the last resort. However, I would like to give hope, because it can be well worth investing at least 8-12 weeks in targeted training, as the body has an incredible potential for self-regulation. The crucial point for success is that it needs the right things.
The case study – Susanne
Diagnosis and symptoms
Susanne came to me with a diagnosis of “slipped disc and spinal canal stenosis in the cervical spine”. Her symptoms were increasing stiffness in her neck during various movements, occasional headaches and sometimes tingling sensations in her left arm. The thing that bothered her most, however, was that her left arm only had a subjective strength level of approx. 50-60%. The simplest tasks, such as pushing open a heavy door, were only possible with compensation. Her fine motor movements were also affected; for example, she was unable to pour water from a bottle into a glass without experiencing uncontrollable tremors in her left hand.
The first scare – the MRI and doctors’ opinions
If you now look at the MRI findings, you read “herniated disc” and “spinal canal stenosis”, i.e. both a leakage of the disc nucleus into the posterior intervertebral space and a narrowing of the spinal canal itself. Of the doctors Susanne consulted, some recommended surgery, while others said she could try physiotherapy for a while and see if she could live with the restrictions in her cervical spine and arm.
First of all, a few words about the findings: when you hear words such as “spinal canal stenosis” and you see the MRI image and are told where the nerves are constricted and which structures are all damaged, isn’t it completely natural that you see yourself as vulnerable and fragile at that moment and are initially afraid? It is also easy to conclude that the visible damage in the picture is the direct cause of the painful symptoms. This is where the doctor’s verbal and non-verbal communication is the decisive tool in dealing with patients.
Imaging findings must ALWAYS be compared with other information; in the vast majority of cases, they are not a sufficient explanation for people’s symptoms. This is because “abnormal” findings in MRI images are not really abnormal at all: there are now several scientific studies that have shown that almost everyone has signs of wear and tear, injuries and misalignments in the musculoskeletal system, but most of them are not symptomatic. For example, the chance of having a slipped disc at the age of 30 is already over 40%, and over 60% from the age of 50.
This means that the changes we see on the MRI image were in most cases already present before the symptoms, regardless of the current symptoms. Pain and limitations usually have no causal connection with changes that can be seen on the MRI.
In the following info box you will find a selection of studies on this topic:
Here you can see studies on the topic "Asymptomatic MRI findings"
If the doctor, primarily based on the MRI image, directly considers surgery, your alarm bells should go off. Fortunately, Susanne was in a position to consult several doctors, including neurosurgeons and sports orthopaedists, and not everyone wanted to get the scalpel out straight away.
Two key facts about our movement system have long been the subject of clear scientific research and have been successfully tested in many areas of practice:
1. The human body is an enormously adaptable organism that becomes stronger from almost any position if it is stimulated (trained) accordingly. This applies to the musculoskeletal system, but also to organs, the respiratory system, the circulatory system, the lymphatic system, etc.
2. the human brain is highly plastic, it adapts daily to the given stimuli and can learn EVERYTHING, from pain perception to complex movements, new thought patterns, regulation of emotions, strategic action, simply everything. (you can find an interesting book on the subject HERE).
Against this backdrop, it is a great pity that it is now not standard practice for patients to receive professional recommendations from their doctor on training for their individual needs. One of the reasons for this is that doctors are not trained in this area. In order not to go too far into this topic, here is a link to the classic way of dealing with musculoskeletal complaints: click HERE.
Susanne fortunately had a physiotherapist who also treated her complaints holistically and incorporated active training into her therapy process. Unfortunately, this is not a matter of course.
Extended medical history and differentiated functional diagnostics
Medical history
So what did we do? First of all, we made a comprehensive record of the injury and health history, because every event in the past can influence the body up to the present day. The history should be written down over time, preferably also in a timeline as an overview, then you can recognize any connections more quickly. What falls have you had in the past? How did you fall? Have you ever had a car accident? Scars? Operations? All these questions are very important. What is your mental status? How stressed do you feel? How do you eat? If there are any significant factors in your lifestyle or injury history that may, for example, increase general muscle tension or promote the development of a functional disorder, it is absolutely crucial to know these in advance.
In the following, I will describe the contents that, in my view, constitute differentiated functional diagnostics. These are essential examination methods that together can provide a clear picture of which functions are not optimal on a neuronal, mechanical and structural level.
With targeted functional diagnostics, tailored to the situation and the goal, an enormous field of potential can be achieved: the detection of so-called sub-clinical deficits. More on this at the end of the article.
Screening of functional movements
We then looked at basic movements such as raising the arm overhead or shaking hands to gather information about any abnormalities. Several simple movements showed a slight
Palpation of muscle and fascia tissue
Palpation, i.e. the systematic feeling of soft tissue, is another essential component for making the right decisions in training and therapy. Dysfunctions can be present anywhere, but the structures that cause the most problems are 95% hypertonic (have a high basic tension), and some are also hypersensitive (overactive reaction to pressure or touch). Furthermore, the gliding properties of the fascia layers must be recorded, as they also provide valuable information about which parts of the movement may be impaired. In Susanne’s case, we found several areas that were conspicuous, including the left cervical spine, the brachial plexus (large nerve plexus in the upper body, see picture) and the forearm, which was disturbed by older burn scars.
The targeted examination of soft tissue and fiber-specific muscle testing is the core element of my work.
Sensory testing of the receptors on the skin
As the largest organ in contact with the outside world, the skin can be particularly altered in areas that were once injured. On Susanne’s left forearm, for example, we found that the perception of specific stimuli (in this case sharp, blunt) was reduced. More on this topic in my article on scars, click HERE.
Fiber-specific muscle function tests
Then we tested the simple response of the neuromuscular system to trigger muscle fibers at different angles to counteract my manual resistance (fiber-specific muscle function tests, more on this topic in my article HERE). A clear picture emerged: multiple forms of movement were inhibited from head to toe. Not only was the left arm (incl. hand, elbow, shoulder, shoulder blade) unable to respond to a slight increase in resistance in several directions of movement, but the entire left side of the body was also unable to stabilize when I pushed my body to the side. This indicates a global disorder, i.e. a disorder that can affect the entire body (in this example, the entire left side). Almost every muscle test was as soft as butter in my hands, but only on the left side. Why was the left side inhibited? There were several reasons for this: on the one hand, compression of the cervical spine and several constrictions of the nerves in the course (see next point) and the sensory disturbance of the burn scars on the forearm (see last point).
Test for nerve entrapment points (nerve compression points)
Problems such as loss of strength, lack of coordination or sensory symptoms in the limbs such as stinging, tingling, heat and cold or loss of perception can be triggered by various disorders. In addition to the typical radicular, i.e. nerve root-related symptoms, nerves can also be constricted or irritated in the extremities. This occurs primarily due to inhibited, i.e. restrained, muscles, as these have poorer gliding properties to the surrounding myofasciae – this increases the likelihood of irritation or constriction (compression) of the pathways there.
When loss of strength or sensory disturbances occur in the arms, it is not only the vertebral bodies that are important. There is often an additional nerve constriction later on. The image shows the small pectoral muscle, which can constrict the largest nerve plexus for the arms directly below it.
We found several points where the nerve course was compressed: the joints of the upper cervical spine, the posterior muscles of the left cervical spine, the small pectoral muscle, the posterior shoulder capsule and a point in the forearm .
Tests of activity in the cerebellum (small brain)
Functional tests from neurology can be used to draw immediate conclusions about how certain regions of the brain control the trunk or extremities, i.e. how active they are at the moment. Cerebellar tests are extremely important because the body needs well-coordinated coordination for every movement, as well as good error correction when movements do not go well. This is exactly what the cerebellum is responsible for, a small part of our brain with powerful significance. The cerebellum has only 10% of the brain volume, but 50% of ALL nerve cells of the entire brain! (see picture)
Although the cerebellum only accounts for 10% of the brain volume, it contains half of all nerve cells. This underlines the essential importance of complex forms of movement for health, as the cerebellum only becomes active under complex forms of movement and constant error correction.
Cerebellar tests usually involve rapidly changing movements or precision movements according to standardized specifications. In several cerebellar tests, it was noticed that the coordination of the left hand and fingers is limited, they could be moved less rhythmically, less persistently, less precisely and only with more errors than on the right side.
In the following video we see the so-called ABC test. This is a test for all parts of the cerebellum. The aim is always to touch the tip of your nose with your fingertips as quickly and accurately as possible. When I’m not filming, I touch the fingertips briefly beforehand so that the person doesn’t know which finger will come next. Then I observe how well the movements can be carried out and whether there are any noticeable differences in lateral movements, especially in terms of speed and precision, but also whether evasive movements occur and how “difficult” the subjective sensation is.
What can you see? First of all, it is noticeable that the movements of the left hand are somewhat slower than those of the right. Furthermore, the precision is not quite optimal, the fingers do not reach the tip of the nose accurately enough. The body tries to compensate for the reduced perception and control of the left limb by moving the neck to the left, which should actually be still. A crucial point is also noticeable at the end of the movement: a so-called terminal tremor. The hand begins to tremble when the fingertips are just before the tip of the nose. This can also be seen on the right side, but to a greater extent on the left. These are all signs of an underactive cerebellum on the (primarily) left side.
What did we do? What did the training look like?
In summary, the functional status is as follows:
- Uncertain / hesitant movements
- Compression of the upper cervical spine with effects on nerve conduction
- Constriction / irritation of several nerve branches in the peripheral course (especially radial nerve, median nerve, ulnar nerve, axillary nerve)
- Sensory disturbances of sensation on the left forearm due to the old burn scar
- Underactivity in the left cerebellum
This results in muscle inhibition and changes in the tone of the soft tissue (muscles, fascia), which in turn changes the sensory system, as fewer ascending signals are transmitted to the brain. However, the upper cervical spine is compressed even more due to the loss of stability (protective pattern of the nervous system, it always wants to create stability). The poorer sensory system on the left side and the resulting reduced use (less movement, less sensation, less force stimulation, less joint stimulation, etc.) only fuels this cascade even more. The loss of strength leads to further compensation: the front shoulder is overused (classic compensation pattern in the shoulder girdle), resulting in more tension on the brachial plexus, which in turn worsens the sensory system, and so on.
We have taken the following measures to solve the dysfunctions:
- Decompression of the cervical spine
- Release / loosening of the hyperactive structures (left cervical spine extensors, short chest muscles, posterior shoulder capsule) with subsequent activation of the most inhibited muscles (shoulder blade stabilizers and intrinsic grip muscles)
- Stimulation of the receptors on the burn scar of the left forearm
- Activation of the left cerebellum through complex movements, here we practiced figure-eight circles with individual fingers, as well as wrist movements that require a lot of precision and attention. Before that, we used vibration to increase the general perception of the carpal bones and fingers.
- All the above-mentioned tests and the first training measures are completed in one unit (duration 2h)
In the next video, we can see the results of the first intervention. As a re-test, we used the ABC test to see how the nervous system reacts to the new stimuli. If the quality of movement improves, regardless of the level, this indicates that the body needs more of it.
As can be seen in the video, the quality of movement improved immediately after the first training measures.
- Faster initiation of movements –> Faster processing
- Significantly faster movement execution –> more safety, better perception
- No compensatory movements of the cervical spine, the head remains still
- Significantly better precision
- Lower tremor
In this case, the nervous system has reacted with a positive output, which means that the corresponding stimuli have a biopositive effect and their threshold is just right. In this state, the brain can learn and store the “new” forms of movement better, and no protective patterns are formed.
This was also reflected in the fact that the mobility in the whole body was better directly after the exercises, the overactive muscles showed much less tension and the stability in the left side of the body, as measured by the muscle tests, was significantly greater. The head also felt lighter and the cervical spine was much freer.
What happened next?
Susanne did her homework for about 3 weeks, with about 10-15 minutes of training a day. The content was exactly what we had tested in the first session: Decompressing the cervical spine, releasing the overactive muscles, activating the underactive muscles, then stimulating the left forearm and activating the left cerebellum through hand and finger exercises.
Within just a few days, she noticed noticeable improvements in her everyday life, her strength returned and her body was no longer in protective mode.
In a second session, we then took care of the next steps: the compensation patterns were gone, the neck was free, and 90% of the strength was restored. Perception on the left forearm was almost equal on both sides. Now it was back to the cerebellum: in order for the brain to further develop the improved state, it needed even more new movement stimuli. We therefore integrated new variations into the training that challenge the movement coordination of the left upper limb. With good results: even in the weeks following the second session, there were further improvements, Susanne was able to do all her everyday tasks as usual and, with targeted strength training, was able to get her arm back on its feet again, even under heavier loads. The tingling in her arm is no longer present and her hand no longer trembles when she pours water. The neck can move freely and is pain-free.
Conclusion
Susanne’s case study illustrates very well why a differentiated functional diagnosis is of great importance: all the abnormalities in movement quality that were seen in the case would not come into focus from a doctor’s point of view. Why is this the case? Traditional conventional medical training is not initially designed to identify functional problems for which the musculoskeletal system needs to be considered in combination. It is primarily concerned with the identification or diagnosis of larger, pathological conditions (such as a herniated disc) and their treatment using either technology or medication, possibly supplemented by physiotherapeutic measures.
So if you look at which protagonist in the healthcare system does which things – it is quite clear that many of the cases, including Susanne’s, do not end successfully enough. The doctor primarily looks for disorders that are already so severe that they are pathological, based on medical guidelines and definitions of illnesses and injuries. In addition, they usually do not have the time to deal with more complex, functional contexts, either for themselves or with the patient. At best, physiotherapists have undergone extra training and are more familiar with functional correlations, but then they are usually not familiar with movement control and practically applied neuroanatomy. Even if they could, they would have an average of 20 minutes per patient.
Ultimately, the patient is at the center of this structure with all their feelings and thoughts (which we have only touched on sparingly so far, but which also have an immense influence). This makes it all the more important to carry out this kind of educational work and inform people about how their bodies function.
Inhibited muscles, a slight tremor in the hand or fingers, a feeling of tension in various parts of the body, reduced mobility, limited perception. Are these things that concern YOU as an individual? I hope so, because your body should be worth that much to you, it is the only home you have. However, from a medical point of view, all these things are just subclinical deficits.
In this case, it was precisely the resources that Susanne’s body needed to reactivate in order to get into a better state, and the symptoms are no longer necessary to remind the body of this.
