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Msc manipulative physiotherapy CasMsc manipulative physiotherapy Case Presentation IIe Presentation II
D Chan
Physiotherapist
Patient Information:
• Mr K, 32/M, property manager
• Reason of referral: neck physio
S/E:
C/O: Loss of consciousness then slipped and fell from stairs last week, ?trauma to neck ?head injury. Neck and headache subsided afterwards. Gradual onset of neck pain for 2 days.
PHx
• History of neck pain for 3-4 years
• ? History of injury after falling from a bicycle
• The ‘kind’ of neck pain was same as his chronic pain
Behaviour of symptoms:
• P1: – *↑ every morning, VAS 6-7/10, with morning stiffne
ss– ↓ with self neck active exercises and self massage for 1
0-15 minutes, VAS to 4/10; intake of painkillers; bed rest
– 24-hour pattern: afternoon: pain and stiffness persisted (VAS 4/10). Mild increase after work. night pain0/sleep disturbance0
IRRITABILITY
Behaviour of symptoms:
• P2: – For 1-2 years– ↑ after using computer for 30 minutes, VAS 2/1
0, subsided completely if change of position
IRRITABILITY
Special Qs
• GH: good except regular headache once per week, needed panadol for relief. dizziness0
• Medication: panadol for headache• X-ray: • No previous PT Rx. Infrequent visit to massagers
with temporary effect• Bowel / bladder disturbance0
• saddle anaesthesia0 / gait disturbance0
• hobbies0 weight loss0 surgery0.
O/E
• Posture: Poking chin with rounded shoulder• Cx:
– F: . P1 4-5/10 at EOR– * E: 2/3 ROM. P1: 6/10 (most usual) – SF L: with OP– SF R: with OP– Rot L: . P1: 2/10– Rot R: . P1: 4/10
• Inter-segmental movements mainly occurred in upper and mid Cervical
O/E
• Tender spots over R trapezius mm (usual shoulder pain)
• Multiple Cx levels with pain VAS 2-4/10, not quite usual (no headache)
• T1-T4: local tenderness, VAS 6/10, not usual
• Generalized stiffness in Cx and Tx
O/E
• MMT: NAD
• Sensation: NAD
• Jerk: NAD
• Shoulder and Elbow : NAD
• Patient self reported NOT related
• Low irritability = negligible?
• In previous assessment failed to find out P2
Learning Issue: were the distal and proximal symptoms related?
Beauty of SUSTAIN
• Cx Extension: local P1
• + sustain for 7-8 seconds: P2 reproducible
How to explain?
Neurodynamics (Michael Shacklock, Physiotherapy, January 1995)
• Intraneural Blood Flow– Neurogenic symptoms (pins and needles) appea
r with time because the neural elongation strangles the intra-neural blood vessels.
– The time dependent nature of the symptoms suggest that, with ongoing vascular compromise, the axons become hypoxic and produce symptoms
Neural Tension tests
• ULTT (median nerve bias): R +ve
• ULTT (ulnar nerve bias): R +ve
Learning Issue: Trapezius syndrome
• What kinds of structures involved?– Not only the trapezius mm– Scalenes, levator scapulae– 1st rib
R1 P1: VAS 6/10 and P2:VAS 2/10
Stiff+++
Movement Diagram of R1
A B
DC
R1
R2 (IV++)
L
P1 (VAS3-4/10)
P’ (VAS 8/10)
Tier 4 situation
• If the P line and R line are almost parallel throughout the range, treat vigorously, despite severity and irritability
• Need to seek consent and give full explanation
• Watch for latency
RX: R1 IV++, 2 lots
Learning Issue: treating soreness
• The 3rd lot: Use the same technique at III-
• Longer resting periods given in between lots
Responses to Rx
• Provoking technique: produce much post Rx soreness next 1-2 days
• However, S/E and O/E gradually improved
• No emergence of P2 all along
• Add R C6-7, III++, 2 lots to treat the shoulder pain
Retrospective Assessment
• 18/10/10
• No shoulder pain since treatment
• Reported 50% improvement
• c/o: central neck pain, VAS 6-7/10 in the morning, afternoon 3-4/10
Retrospective Assessment
• Patient could clearly distinguish between shoulder and neck pain
• We are treating the shoulder right, but not the neck
• AIM: to find out the neck pain
Aim to find anything in the treatment that
helped or not helped the patient
Retrospective Assessment
• Palpation: central PA to C3 reproduce usual morning pain
• C4-C7: local tender not as comparable as C3
• Add Rx: central PA C3, III++, 2 lots
PLAN:
• Pillow use
• Neck exercises
• postural correction – Poking chin– Upper crossed syndrome
Discussion Time