SCM Syndrome Case Report

Title
Neuromuscular Dysphagia as a variant of sternocleidomastoid syndrome

A Case Report

Running Header
Dysphagia from SCM Dysfunction

Author
Randall C. McLeod DC, FCCRS(c), DACRB
Private practice, IHCrehab, 52401 Range Rd 13, Stony Plain, AB T7Z 1Y4

Keywords
MeSH -Chiropractic, manipulation, dysphagia. Non MeSH – sternocleidomastoid, trigger point

ABSTRACT

Introduction
This patient was a 10 year old female who was suffering from a progressive dysphagia. Her condition was highly responsive to chiropractic spinal manipulative therapy coupled with trigger point therapy and proprioceptive neuromuscular facilitation.

Case Presentation
This patient presented complaining of a progressive dysphagia of 11 months duration and apparently insidious onset, which, by this point, was causing severe difficulty in swallowing. Her condition further resulted in a mounting anxiety regarding her ability to ingest food and provoked a severe weight loss. My examinations revealed mechanical cervical dysfunctions, autonomic and postural functional anomalies as well as mediation of her symptoms through trigger point and articular stimulation.

Outcome
This patient responded exceptionally well to chiropractic spinal manipulative therapy coupled with neuromuscular rehabilitative techniques. She showed a very good early response and ultimately complete resolution of her signs and symptoms.

Conclusion
Dysphagia can be the primary presenting symptom of a cervical neuromusculoskeletal dysfunction such as sternocleidomastoid syndrome.

FULL TEXT

Introduction
Dysphagia (difficulty swallowing) is a relatively uncommon primary symptom in a chiropractic office. When experienced however, it can be extremely disconcerting for the patient in that the process of ingesting foods and fluids is a biological necessity for sustaining life. As well it can create a concern for the practitioner regarding differential diagnosis.

According to the online Merck Manual (1) the majority of cases of dysphagia are the result of some type of severe central nervous system pathology. Of particular interest to the chiropractor would be the possibility that a presentation of dysphagia could be a symptom of an evolving stroke, as outlined in the diagnostic protocol represented by the “5D’s And 3 N’s” (table 1). There are a small but intriguing number of papers which refer to a multitude of symptoms, including dysphagia, arising from “sternocleidomastoid syndrome” (That being the result of a functional disturbance of the sternocleidomastoid (SCM) muscle(s) and it’s attendant innervations). Missaghi (2) gives an excellent overview of this syndrome as well as a detailed description of the anatomy and usual symptoms associated with SCM syndrome. Dr Donald Murphy DC, DACAN (clinical faculty at Brown Medical Univ), in his summary notes the potential for swallowing disorders associated with this syndrome. His position is supported by Dr Burl Pettibon DC, FABCS, FRCCM, PhD.(Hon) in his text on chiropractic rehabilitation (3) and Travell and Simons (4) note the shared neurology of these tissues. Further, Braune et al (5) cites a case where dysphagia was apparently caused by a fasciculation of the SCM muscle.

My particular interest in this case was piqued by having seen two prior occasions of dysphagia which responded to chiropractic care. The first was in me. I had spent an entire day renovating a ceiling with my head and neck in extension. Late in the afternoon I suddenly found I had great difficulty swallowing, my throat simply would not work. A prompt visit to my chiropractor relieved the problem; however I can clearly recall the sense of near panic that I felt when I realized that I was unable to swallow. The second incidence was in an adolescent female who was suffering from a diffuse juvenile myositis and hospitalized for the same. Her mother advised me she was having difficulty swallowing and her physicians were proposing surgery in an attempt to alleviate her symptoms. A trial of spinal manipulative therapy (SMT) resulted in her also responding very rapidly and subsequently demonstrating a complete resolution. With these cases in mind, when I was presented with a third case, I felt it should be documented somewhat more carefully for further consideration or study.

Case Presentation
In this case a 10 year old female presented with an11 month history of progressive dysphagia of apparently insidious onset. For the first 9.5 months her condition progressed slowly (Sept to mid June). Approximately mid June her symptoms began to progress much more rapidly resulting in such difficulty swallowing that she suffered a weight loss of 26 lbs during the next 6 weeks. This was not only a red flag denoting the advancing severity of her condition, but also resulted in a substantial amount of anxiety on the part of the patient due to her inability to ingest food or drink normally. The patient had been examined by her physicians including a referral for endoscopic evaluation, all of which were unremarkable.

Closer inquiry revealed that she was able to recall that she had experienced 3 memorable traumas the previous summer, including an injury from rough play with her siblings, a trampoline injury and a boat/tubing injury. (In general, it is my experience that when a patient remembers an injury 12 months later it was usually significant.)

My evaluation revealed:

  • Mechanical dysfunction of the cervical spine;
    • Rt lat bend 33deg, Lt lat Bend 50deg,(norm 49)
    • Flexion 58deg (norm 67) , Extension 70deg, (norm 86)
    • Rt Rot 70deg, Lt Rot 80deg, (norm 76)

      (norms are age weighted and from CROM charts)
  • Specific site fixation was noted at C5 on Rt. lat. Bending (motion palpation)
  • She had notable weakness of the deep cervical neck flexors (poor resistance to forced extension)
  • Her symptoms were aggravated by;
    • Lateral pressure on C5
    • C5-6 facet pressure on the right
    • Full Cervical extension
    • Trigger point pressure at Rt. Medial sub occipital area, Rt SCMs and Rt Levator scapulae musc. (figure 1)
  • Her symptoms were diminished by;
    • Cervical flexion
    • Trigger points at Lt. SCMs and Lt. Levator scapulae.musc.
  • An ad hoc “Borg”(6) type of severity scale was created where 0 meant no difficulty or normal swallowing and 10 meant complete inability to swallow. She reported a difficulty of 8
  • Her thermography showed a strong unilateral bias as well a severe asymmetries in her cervical spine
  • A postural sEMG study showed only mild to moderated increases, predominately in the lower thoracic spine and a moderate spike at C1.

    I arrived at a working diagnosis of dysphagia of somato-visceral origin as a result of referred symptoms from post traumatic subluxation of the mid cervical spine, co-morbid with symptom referral from the cervical musculature, ie. an atypical sternocleidomastoid syndrome.

    Management and Outcomes
    Due to the severity of her symptoms and the relatively short chronicity of her condition, I advised an intensive but declining treatment schedule beginning at 5X the first week, 3X the second week, 2X the third week followed by 1X weekly support until she was satisfactorily resolved.. This would parallel a program I would use for acute pain levels of 8 or more. Her treatment would involve chiropractic spinal manipulative therapy (SMT), proprioceptive neuromuscular facilitative (PNF) techniques (predominately post isometric relaxation/stretching) and active home care as required.

    More specifically she was treated with SMT at C6 (right posterior), C5 (left posterior) occasionally C7 (inferior or extended) with mild 5 + 6 rib on the left and some lumbar adjustments at L2 and L3 which were not likely directly related. Her PNF care consisted of post isometric relaxation (contract-relax-stretch) at both heads of the SCMs, sub occipital musculature and the pectoralis muscles (roughly the same PNF care as would be used for an upper crossed syndrome of Janda). Her home care was predominately for strengthening the deep cervical neck flexors and involved neck retractions against resistance (supine with mid cervical pressure into a cervical roll under C5) as well as seated neck retractions with no resistance.

    Her progress was excellent. By the end of her first week of care she still demonstrated some apprehension regarding food but her difficulty in swallowing was down to a 2 of 10 (a 75% reduction). Most soft foods had been re-introduced. By the end of the second week hard foods were being introduced and her swallowing difficulty was down to a 1. By the end of her third week of care her swallowing difficulty was at 0.

    At re-evaluation (after ten visits) she showed:

    • Mild tendency to recurrence
    • Aggravation at full cervical extension
    • Mild mechanical dysfunction of the cervical spine;
      • Rt lat bend 50deg, Lt lat Bend 52deg, (norm 49)
      • Flexion 60deg (norm 67), Extension 92deg, (norm 86)
      • Rt Rot 80deg, Lt Rot 80deg, (norm 76)
        (norms are age weighted and from CROM charts)

    Her care continued at 1X per week for 4 more weeks and at that time she self discharged as satisfied. At 2.5 years she has had no recurrence of her condition

    head-neck-pain
    From: Myofascial Pain and Dysfunction, The Trigger Point Manual, Vol. 1, Upper Half of the Body, Simons DG, Travell JG, Simons LS, Lippencott Williams and Wilkins © 1999, used with permission

    Discussion
    It appears that this case could well represent an atypical presentation of a sternocleidomastoid syndrome.

    With this case, I felt a high degree of confidence regarding a probable positive outcome due to the combination of the negative outcomes of her conventional diagnostic studies, the presence of a probable mechanism(s) of injury, relatively short duration of chronicity and the combined positive and negative responses of her symptoms during provocative testing. With neuromusculoskeletal conditions, we tend to find that if we can provoke the symptom, we can effectively treat it. This was clearly the case with this patient. We had a body of data which was encouraging, positive physical findings and negative histopathological findings.

    As we continue to progress and expand our body of knowledge, we are finding that not only pain conditions, but also a great many other disorders are, or can be, facilitated by abnormal neurological / neuromusculoskeletal function. Anatomical advances teach us that there are many delicate tissues and fibers supplying (or attaching to) sites which used to be seen to be unrelated but which we now find are, in fact, related or connected (such as T4 syndrome where fibers from the upper thoracics have now been found to contribute to the brachial plexus). It seems quite possible that these relationships may account for many of the uncommon results we see in practice.

    It is important to remember that our evidence base begins with clinical experience, which then leads to the studies that eventually provide “good” evidence. But it all begins with sharing our clinical experiences. If we all wait until there is good evidence before we move ahead, we never move ahead. Hippocrates told us to; “Look well to the spine, for it is the requisite of many diseases”. My hope is that sharing this clinical experience may stimulate other practitioners to pursue, or at the very least, consider the possibility of, neuromusculoskeletal involvement in more that just pain cases. I refer not only to dysphagia, but also the many other atypical presentations we see as well. In particular we should be mindful of those patients who seem to have no clear etiology and/or who demonstrate those perplexingly normative histopathological diagnostics. These patients may well be, and indeed often seem to be, suffering from a functional disturbance of the neuromusculoskeletal system which is cascading out to other areas.

    Post Script
    Since I began this article I have seen 4 more similar cases. One, a juvenile female whose condition showed a duration of approx 1 month, responded with 100% resolution with only one or two visits and currently remains symptom free several months later. The others, all adults, (one male two female) have responded positively and are all progressing well.

    Acknowledgements
    I would like to thank Dr. Brain Budgell for his encouragement and assistance in getting me to step outside my comfort zone.

    References
    1. Merk Manuals, online Medical Library- www.merck.com
    2. Missaghi B. Journal of the Canadian Chiropractic Association, 2004: Sept:48(3):201-205
    3. Dr Burl Pettibon DC, FABCS, FRCCM, Phd (Hon), The Pettibon System, Chiropractic and Rehabilitation Procedures Re-Invented to Correct the Spine and Posture, © 2006, Ch – Initiating Event Displacement Complex pp4
    4. Travell, Simons, Thoraco Fascial Pain and Dysfunction, the trigger Point manual, Vol 1 2nd edition
    5. Braun et al Involvement of the Esophagus in the Cramp Fasiculation Syndrome, Muscle and Nerve, 1998 June:21(6): 802-4
    6. Borg Pain Scale; Leibenson C, Rehabilitation of the Spine, pp 61

    TABLE 1
    Explanation of the 5D’s And 3N’s

    Diplopia Double vision or other vision problems
    Dizziness Vertigo, light-headedness
    Drop Attacks Sudden numbness/weakness of face/arm/leg
    Disarthria Difficulty speaking
    Dysphagia Difficulty swallowing
    Ataxia of Gait Difficulty walking
    Nausea Vomiting or queasiness
    Numbness Loss of sensation on one side
    Nystagmus Involuntary rapid eye movements