Anne Carlson was the first patient ever to show up in my examining room with instrument in hand. When I saw her, she was dressed in a pale blue patient’s gown and was carrying a trumpet case.
As I would soon learn, Anne was a 35-year-old musician who had recorded professionally and performed around the world, playing classical works with well-known orchestras. Her health had been perfect until two years ago. That’s when, she told me, she began developing a painful burning and stiffness in her neck and upper back. This constant pain had been joined by another bizarre malady: her head and neck trembled, but only when she played her trumpet.
With such an impediment, Anne said, she could not perform. She had tried resting for two months, avoiding her trumpet in the hope that the burning pain and trembling would go away. They did not. The problem stumped her internist. He couldn’t identify it, so he referred her to a neurologist. The neurologist said she was suffering from stage fright and essential tremor--a term applied to movement for which there is no known cause--and prescribed one of the beta-blocker drugs that keep the brain from registering anxiety-producing chemical signals. When that treatment failed, Anne tried an acupuncturist. The acupuncturist recognized that the problem was beyond her expertise, so she referred Anne to me, an osteopath. An osteopathic perspective, she thought, might allow some new insight into Anne’s symptoms.
Osteopaths are trained to understand how muscles interact with joints, nerves, and organs, and more than our classically trained medical colleagues, we apply that understanding of biomechanics to our treatment of illness and injury. The difference is chiefly one of emphasis. We receive the same medical education as m.d.’s, and we are licensed to perform surgery and prescribe medications. Yet unlike m.d.’s, we are educated to perceive how structural problems--such as an injury in one part of the body--can have a ripple effect, causing pain or discomfort in other parts of the body. The osteopathic goal is to prevent disease by identifying structural problems before they become chronically disabling. Thus, again unlike m.d.’s, we frequently use techniques of manipulation and stretching to help retrain muscles, joints, and connective tissue that have been stressed or damaged. For some painful conditions I have treated, these techniques can provide more relief than drugs.
By the time I saw Anne, she was desperate. Music, she said, provided her with more than just a livelihood--it gave her her very identity. Now her years of devotion were in jeopardy, and the passion that burned within her was being extinguished, all without apparent reason. Her eyes quickly filled with tears as she described how frustrated and helpless she felt.
Have you had anything similar to this before? I asked.
No.
What makes it better or worse?
Acupuncture helps the pain, but it doesn’t stop my head from shaking. And I’ve noticed that the problem gets worse if I’m tired or stressed.
Her medical history was unrevealing. A left shoulder dislocation at age two. Coronary artery disease in both parents. No drug or alcohol abuse.
Anne offered to demonstrate her problem. She opened the case and raised the trumpet to her lips. Her head began wobbling left and right, as if it were gesturing no, no, no. . . . When she lowered her arms, her head became still.
Please do that again, I asked politely, trying to maintain a professional demeanor. In reality, Anne had just blown me out of my seat, without playing a single note. But doctors learn to remain poker-faced; we can deliver a neutral Hmm when in fact we want to yell, What the hell was that?
Anne obliged. When she lifted her trumpet, her head wobbled. When she lowered it, the wobbling stopped.
Would you do it one more time, but this time without your trumpet?
Again the tremor appeared, just as if she had the trumpet in hand.
Now just raise your left hand as if you’re holding your trumpet. Anne’s head wobbled as before.
Now with only your right hand.
This time the movement was still present, though less pronounced. Just lifting either arm was enough to produce the tremor.
I went on with the examination. Anne’s gait was normal, as were her speech patterns, eye movements, and facial expressions. Then I tested her sensory system: her pupils’ sensitivity to light, her gag reflex, her sense of smell, her hearing. All responses were normal. The cranial nerves, which control the muscles of the face and head, were working properly.
Next, I checked the strength of Anne’s major muscle groups, as well as her sensitivity to a pinprick, touch, temperature, and vibration. I also checked her deep tendon reflexes and finger positions. I was looking for signs of problems in the cerebellum and basal ganglia, the brain regions that control movement. So far, all was normal.
I did notice, however, that Anne tilted her head ever so slightly to the left and that she carried her left shoulder higher than her right. To check the muscles that control this part of the body, I stood behind her and placed my hands over the tops of her shoulders. My fingertips rested just above her collarbone, which is where the uppermost ribs are located. As Anne breathed in and out, my hands were gently lifted and lowered by the ribs’ movement. The motion of Anne’s left shoulder felt tight and locked. I probed the muscle groups in the shoulder and neck area. The scalene muscles and the sternocleidomastoid muscle were shortened on the left side.
The scalene muscles are a group of three muscles on each side of the neck that help bend and twist it. The lower ends of the scalene muscles attach to the uppermost ribs; the other ends attach to the highest vertebrae in the neck. The sternocleidomastoid muscles--the thick, ropelike muscles that run along each side of the neck--help turn the head from side to side. These muscles attach at both the sternum (the breastbone) and collarbone, then extend up and attach to the mastoid process, the knobby bump of bone behind each ear.
It took no great insight to understand why Anne’s head was slightly tilted. The muscles that controlled the left side of her neck and shoulder were involuntarily contracting and tugging at their attachments. The smaller muscle groups surrounding the delicate vertebrae in Anne’s neck were also taut on the left side. Osteopaths call this alteration in how muscle attaches to bone somatic dysfunction. What I still didn’t have, however, even after this diagnosis, was an explanation for Anne’s peculiar tremor.
I needed more data. I drew blood and obtained a urine sample. I also requested tests to measure the amount of copper and copper-carrying protein in Anne’s blood. There is a rare metabolic disorder called Wilson’s disease that is caused by copper accumulation in the liver. When the copper migrates to the brain, it can trigger strange, tremorlike movements. Finally, I wanted a magnetic resonance image of Anne’s head, to determine whether a brain tumor or a bulging or broken blood vessel could be the cause.
Meanwhile, I suggested to Anne that some osteopathic manipulation might help restore symmetry and normal function to her tightened muscles. I did not expect to make the tremor go away, but I thought I could alleviate the burning pain and the persistent muscle spasm.
After I had Anne lie facedown on the examining table, I started massaging and stretching all the muscles that lie parallel to the vertebrae in the neck. Then I put my hands on her neck and gently rotated it to the side as far as it could move comfortably. While I held her in this position, I asked her to resist my gentle movements. We repeated this several times. Her muscles began to soften.
Satisfied that her muscles were loosened, I teased her head with a slight twisting movement. This technique often helps restore the alignment of the affected joint and improve its function. After doing this, I checked to make sure that Anne’s neck was moving from side to side more easily. I then began working on the muscles attached to her left uppermost ribs to restore normal movement.
When I finished, we made an appointment for the following week. I asked her to take a warm shower when she got home and to call me if she had any problems.
When I got Anne’s lab work back, all the results were normal. The mri showed no signs of abnormalities. I called Anne to tell her that the results were normal and that she need not fear the worst.
I had a strong hunch that Anne was suffering from some form of dystonia, a family of neurological conditions that affect muscle movement. In idiopathic torsion dystonia, for example, the patient’s large muscle groups are affected, causing the body to bunch up in uncomfortable positions. Other forms, called focal dystonias, affect isolated muscle regions. Among them are writer’s cramp, which causes spasms of the hand muscles, and blepharospasm, which causes blinding contractions in the muscles that shut the eye.
Anne was probably suffering from cervical dystonia, the most common of all dystonias. Cervical dystonia affects muscles that attach to the vertebrae in the neck, and its most striking characteristic is a strange twisting of the head. The condition usually crops up among adults, and its cause is unknown, although sometimes trauma or drugs are involved. In Anne’s case, I could only speculate that hours of practicing the trumpet may have taxed the nerves and muscles controlling her upper arm and neck region. The first sign of the disorder is a subtle and intermittent muscle spasm. With time, the spasm becomes more pronounced and constant. A tremor often accompanies the spasm, but it is unusual for the tremor to be more prominent than the spasm. And Anne’s tremor seemed to be the most prominent symptom.
To confirm that I was on the right track, I called a neurologist friend who specializes in movement disorders. I was pleased when he agreed with my diagnosis (always a supreme compliment coming from a colleague, and particularly from a friend). Then he added something I was eager to tell Anne. You know, he said, some of these patients go for years without the correct diagnosis. Some are told it’s in their head, and they start believing it. It could be enough to drive one crazy.
As it turned out, though, my reassurance wasn’t necessary. When Anne arrived for her next appointment, she appeared different. Her head wasn’t tilting to the left as much, and she was smiling.
Just watch! she said.
She raised the trumpet to her lips. To my astonishment, the tremor had changed from the coarse wobble to a faintly perceptible side-to- side shaking.
We repeated the neurological exam. Then we went over the results of the tests I had ordered. I explained that since the normal results had ruled out many troubling possibilities, the most likely remaining cause was cervical dystonia. Then I told her about the various treatments to control the condition. A relatively new therapy involves injecting botulinum toxin into the spasming muscle. The toxin binds to receptors on nerve endings, which reduces the nerve’s ability to release the chemical signal-- acetylcholine--that causes muscles to contract. The resulting paralysis of the muscle fibers can provide relief from the spasm for many months. Oral medications are also often effective. Some are muscle relaxants; others block acetylcholine receptors at the nerve-muscle junction.
But I’m putting the cart before the horse, I added. I want to get a second opinion from a specialist, and I want to check out the work we did last time.
When I reexamined Anne, her muscles were more relaxed and symmetrical.
I don’t mean to sound in the least disrespectful, said Anne, but do you know why I’m doing better?
It was an excellent question. Was it a coincidental spontaneous remission, or had the osteopathic treatment fixed the problem in the nerves that communicated with the muscles in her left upper arm and neck? Unfortunately, I didn’t know the answer. No one does. There are some theoretical arguments for how osteopathic manipulations might affect the transmission of chemical signals along nerve pathways, but in truth there is precious little hard evidence to go by. And the thought that I might have helped her without knowing why was rather humbling.
After treating Anne, I suggested that she contact one of several neurologists my friend had suggested for further evaluation. During the weeks before her appointment with the specialist, I treated her a few more times. Although the pain and stiffness had virtually vanished, a slight tremor remained.
The neurologist started Anne on two oral medications to treat the tremor. One of them blocks acetylcholine receptors on nerve endings in muscles and in the brain; the other is an anticonvulsive drug. After a while we discovered that the first drug alone worked well enough to eliminate Anne’s faint tremor.
Over the next month, Anne returned to me a few more times. When I last met with her, she was free of the tremor, and music had returned to center stage. Before she left, she placed her hands together and bowed graciously to me, in gratitude. I bowed in return, in humility.
