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