Msc mt case presentation 2
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This case presentation describes a 32-year-old man referred for physiotherapy for neck pain. He reported neck pain for 2-3 years that was exacerbated by morning stiffness and computer use. Examination found restricted cervical range of motion, tenderness over the cervical spine and right trapezius muscle, and positive neural tension tests. Treatment included sustained cervical extensions that reproduced his proximal pain, and manipulations to the right first rib and cervical spine that provided short-term relief but increased soreness. Further treatment directly addressing tender points over C3 provided relief of his usual morning neck pain.
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Msc mt case presentation 2
- 1. Msc manipulative physiotherapyMsc manipulative physiotherapy Case Presentation IICase Presentation II D Chan Physiotherapist
- 2. Patient Information: Mr K, 32/M, property manager Reason of referral: neck physio
- 3. 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.
- 4. 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
- 5. Behaviour of symptoms: P1: 鐚 every morning, VAS 6-7/10, with morning stiffness with self neck active exercises and self massage for 10-15 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
- 6. Behaviour of symptoms: P2: For 1-2 years after using computer for 30 minutes, VAS 2/10, subsided completely if change of position IRRITABILITY
- 7. 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 .
- 8. O/E Posture: Poking chin with rounded shoulder Cx: F: . P1 4-5/10 at EOR 鐚 E: 2/3 ROM. P1: 6/10 (most usual) SF L: 種with OP SF R: 種with OP Rot L: . P1: 2/10 Rot R: . P1: 4/10 Inter-segmental movements mainly occurred in upper and mid Cervical
- 9. 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
- 10. O/E MMT: NAD Sensation: NAD Jerk: NAD Shoulder and Elbow : NAD
- 11. 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?
- 12. Beauty of SUSTAIN Cx Extension: local P1 + sustain for 7-8 seconds: P2 reproducible How to explain?
- 13. Neurodynamics (Michael Shacklock, Physiotherapy, January 1995) Intraneural Blood Flow Neurogenic symptoms (pins and needles) appear 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
- 14. Neural Tension tests ULTT (median nerve bias): R +ve ULTT (ulnar nerve bias): R +ve
- 15. 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+++
- 16. Movement Diagram of R1 A B DC R1 R2 (IV++) L P1 (VAS3-4/10) P (VAS 8/10)
- 17. 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
- 18. Learning Issue: treating soreness The 3rd lot: Use the same technique at III- Longer resting periods given in between lots
- 19. 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
- 20. 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
- 21. 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
- 22. 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
- 23. PLAN: Pillow use Neck exercises postural correction Poking chin Upper crossed syndrome
- 25. Discussion Time