Coat Hanger Phenomenon & The Pretzel Leg Sign

Now we get to the Coat-Hanger Phenomenon.  One example of the power of obtaining the autonomic history is the Coat-Hanger Phenomenon.   In people who have neurogenic orthostatic hypotension or orthostatic intolerance, they can complain of pain, or like a charley horse kind of sensation, in the back of the neck and shoulder areas in the distribution that’s like a coat hanger.  And it goes away when the person is lying down.  That’s an important symptom.  And the way I explain it is that the muscles that control your head are tonically active, otherwise your head be falling down all the time.  Tonically active.  That means they’re using up oxygenated blood all the time.  Well suppose you’re in a critical situation where there’s a drop in blood flow at the delivery of oxygenated blood to the head.  In that situation these muscles are not getting enough oxygenated blood.  They’re tonically active, so they’re producing lactic acid and you get a charley horse, just like you’d have a cramp anywhere else.  It’s a skeletal muscle thing.  So, I think when somebody complains of Coat Hanger Phenomenon, that’s a very important sign or symptom.  And that is not invented.  That’s a real phenomenon.  It points to ischemia to the skeletal muscle holding your head up.

Another example of the importance of the autonomic history is what I call Pretzel Legs Phenomenon.  This is a strong sign of orthostatic intolerance or orthostatic hypotension.  When you see somebody with that kind of a posture as you walk in the room, you think, well I don’t know what this person has, but whatever it is, it’s real.  The person is trying to use muscle pumping to get blood up towards the chest.