A 67-year-old female presented to neurology with a history of essential tremor since she had been a teenager. Since her last neurology appointment, she had several near falls when walking. She recently experienced cramping in her forefingers. She felt the tremor most when lying in bed with her head turned to the left. The patient denied any upper extremity tremor.
The patient's medical history was also positive for lumbar degenerative disc disease leading to chronic back pain, resolved L3-5 herniated nucleus pulposus, prolapsed uterus, and esophageal reflux. The chronic low back pain had been managed with OMT for more than 10 years. She denied any past surgeries or hospitalizations. She had a family history of essential tremor from her father. She was taking the following medications: dexlansoprazole daily, multivitamin daily, vitamin D3 1,000 IU daily, probiotics one capsule three times daily, calcium 1,000 IU daily, vitamin C 500 mg daily, B complex 50 as directed, and ibuprofen as needed. The patient last smoked over 10 years ago. She did not drink alcohol, and her tremor did not improve with alcohol. The patient was a retired physical education teacher. The review of systems was otherwise negative.
Physical examination revealed normal vital signs. Neurological examination revealed prominent head tremor (yes-yes and no-no). There was an increase in head tremor while independently ambulating. She exhibited a normal-based gait with good arm swing bilaterally. There was also an increase in tremor when her head was turned to the right, and a decrease in tremor when turned to the left, both upright and lying down. Mental status was normal and there were no cranial neuropathies. Motor strength, bulk, and tone were normal, and the sensory examination was unremarkable. Reflexes were 2/4 bilaterally, except 1/4 at the Achilles tendon bilaterally. Cerebellar signs were positive for a slight postural tremor on finger-to-nose action bilaterally. The results of general, head and face, eyes, neck, pulmonary, and cardiovascular examination were unremarkable. The diagnosis was changed to cervical dystonia with dystonic tremor. She refused medications or BTX at the time. Reducing caffeine intake and a trial of OMT for cervical dystonia was recommended.
On consultation for osteopathic manipulative medicine, the musculoskeletal examination revealed a forward head carriage posture with increased cervical lordosis and thoracic kyphosis. There was no evidence of scoliosis. Somatic dysfunctions in the head included suboccipital muscle spasm, left mastooccipital suture restriction with overlying myofascial hypertonicity, superior vertical strain of the sphenobasilar synchondrosis, and left temporal bone exhalation dysfunction with temporalis muscle hypertonicity. The motion of the head on C1 (OA (occipito-atlanto) joint) was limited to a flexed-side-bentleft-rotatedright position. C1 was rotatedright. C2 was flexed-rotated-side-bentright. C5 was extended-side-bent-rotatedleft. There was marked hypertonicity of the sternocleidomastoid muscles and the cervical myofascia. In the thorax, T1 was flexed-side-bent-rotatedright, T2 and 3 were flexed-rotated-side-bentright, and T4-6 and T10-12 were side-bentleft. There were bilateral rhomboid muscle spasms. The right ribs 10-12 were posteriorly positioned and tender to palpation. There was rib 12 inhalation dysfunction. In the lumbar area, L1 was flexed-side-bent-rotatedright, L5 was extended-side-bent-rotatedleft, and the right psoas muscle was in spasm. In the pelvic girdle, there was an anterior sacral base, a left posteriorly rotated innominate with superior shear/displacement of the left pubic symphysis, a right iliotibial band spasm, and right piriformis muscle spasm. She had bilateral shoulder internal rotation. In addition, there was paravertebral muscle spasm or hypertonicity in all regions.
The somatic dysfunctions were treated with BLT, myofascial release, muscle energy, fascial unwinding, facilitated positional release, cranial OMT, sacroilio gapping, inhibition, counterstrain, and lumbosacral decompression. The patient was instructed to perform at-home pelvic tilt exercises and use heat as needed for treatment of back muscle spasms.
Directly after OMT, the patient reported a decrease in pain. On the 1-week follow-up, she reported that her family noticed a decrease in her head tremor while playing softball, and she noticed less tremor when laying down to rest.