Transcript CC Case Study Cervico-genic HA

CC Case Study
Cervico-genic HA
Patient Profile
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24 year old PT
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HA occipital lobe, insidious onset >2 yrs ago
- R temporal, parietal lobe 1 yr ago
- Sub-occipital tightness and pain 1 yr
- mid-lower cervical tightness 6-8 mos ago
Subjective
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Worst c/o: HA intermittent
Begins in occiput, travels to parietal & temporal
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Cx “tightness” constant
When tightness increases it leads to Cx pain which
leads to HA
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Sleeps through PM.
Rising in AM only Cx tightness
Aggravating-Ease
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Worst after mountain biking
requires 4 hours recumbent/ice to settle
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Sitting desk work >1/2 hr leads to Cx tight-pain-HA
standing 5” to settle
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Standing pt care: Cx tight-P-HA 4-6 hrs
Nights rest to settle
Sleeps through PM.
only
Rising in AM tightness
History
• Onset “insidious” 2 years ago
• MD: “migraine”, meds, minimal change
• PT (STM, traction, Jt Mob) : no change
• DC 1x, temporary relief only
• Past Hx 10 year gymnast; “no trauma”
Observation
• Upper Cx extension rest position
• Flattened cervical lordosis
• Flattened thoracic kyphosis
• Hypertrophied upper traps
Objective Exam
• Extension 0-15 slight increase Cx pain
• Flexion 0-10, no reversal of lordosis
“feels good”
• Rot R 45, tight U Cx
• Rot L 60, “clunk” sl U Cx
• SBR 0-20 painless
• SBL 0-30, “click” sl pain R U Cx
Objective Exam
• * Extension 0-15 slight increase Cx pain
• * Flexion 0-10, no reversal of lordosis “feels
good”
• ** Rot R 45, tight U Cx
• Rot L 60, “clunk” slight U Cx
• SBR 0-20 painless
• SBL 0-30, “click” sl pain R UCx
Objective Exam
• U Cx Extension increase U Cx P
• U Cx Flexion (minimal, from extensionneutral “feels good”
• U Cx Flex OP
0-5, stiff, elastic EF
“feels better”
• Mid Cx Flexion OP 10-20, “feels better”
• Rot R OP 45-55, stiff, elastic EF UCx
Palpation
• Hypertrophic MM: Sub-O, UT, LS
• Stiff & decreased SM with R UPA C-1 gr IV
• Stiff & painless with L UPA C-1 gr IV
• Stiff & pain with C-2 RPA gr IV
• Stiff & pain with C-2 LPA gr IV
Objective Exam
• Compression no change in Cx pain
• Distraction decreases Cx pain
Objective Exam
• Neuro: WNL:
• Special Tests:
DTR, Sens, Myotome
Transverse ligament: movement & ‘clunk’,
sustained decreased HA
Alar: laxity R (ie w LSB)
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Trial Rx
U Cx Extension increase U Cx P
U Cx Flexion (minimal, from extension-neutral
“feels good”
U Cx Flex OP 0-5, stiff, elastic EF
better”
“feels
Physiologic lengthening of sub O muscles in OA
flexion
Trial Rx
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Physiologic lengthening of sub O muscles in OA flexion
“tightness is gone”
U Cx Extension increase U Cx P
U Cx Flexion extension-flexion “feels good”
U Cx Flex OP 0- 10, elastic EF “feels better”
Trial Rx
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Posterior glide OA flexion
U Cx Extension: no U Cx P
U Cx Flexion extension-flexion “feels good”
U Cx Flex OP 0- 10, elastic EF “feels better”
HEP: Sub O lengthening stretch
antagonists deep Cx F
Rx 2
Re- Assess
No return of tightness
Increase Cx pain with HA prodrome after 1 hour at desk
Standing abated onset
After work Cx pain & HA
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U Cx Extension: no U Cx P ( retained )
U Cx Flex OP 0- 10, elastic EF “feels better”
Rx 2
Re- Assess
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U Cx Extension: no U Cx P ( retained )
U Cx Flex OP 0- 10, elastic EF “feels better”
RR 45, tight U Cx
C-1 UPA R Stiff & decreased Cx SM gr IV
C-1 UPA L Stiff & painless gr IV
C-1 R UPA grade IV
RR 55 “less tightness”
Rx 2
Re- Assess
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U Cx Extension: no U Cx P ( retained )
U Cx Flex OP 0- 10, elastic EF “feels better”
RR 55, tight U Cx
C-1 UPA R Stiff & decreased Cx SM gr IV
Stiff & pain with C-2 R UPA gr IV
Stiff & pain with C-2 L UPA gr IV
C-2 R UPA grade IVRR 60 “less tightness”
Rx 3
Re- Assess
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Desk 1 hour no HA ( stands at 1 hour )
Post work 80% decrease Cx pain, No HA
U Cx Extension: no U Cx P ( retained )
U Cx Flex OP 0- 10, elastic EF
RR 65, tight U Cx
Rx:
C1 L UPA grade IV
C-2 R UPA grade IV-
Rx 3
Rx:
C1 L UPA grade IV
C-2 R UPA grade IVno change
C1 R UPA grade IV
75 RR pain free tight w OP
PSFS
Day 1
Day 17
Mtn Biking: 2
Mtn Biking: ---
Work all day: 4
Work all day: 9
Desk x 30: 6
Desk x 30: 10
____________
_____________
12/3= 4
10/2 = 5
19/2= 9.5
Risky Circumstances
Cautious Assessment
You could jump in
Or, look for the safe way
The Sequel CG
Patient Profile
• 36 y/0 PT
• constant tight L TL jct post > ant
• int “diaphragm & rectus abdominus
spasm
• ant T pain over L UQ
• int paraesthesia B post thigh & leg
• int paraesthesia B post arm & fore-arm
History
• Sm began after epidural in childbirth 2
yrs ago
• Sm free prior, immediate onset post
• no change 1 mo
• PT 3 separate times : no change
• DC 1x 1 year ago 2 weeks relief
• recent MRI: “Normal L spine”
•Aggravating-Easing
Worst: lifting child into car seat
• requires 1 hour to settle
• All lifting provocative immediately
• Lumbar extension immediate
provocation
• relieved upon return to vert
• Not able to do sustained flexion
• Active abdominal contraction:
immediate
• Deep inspiration: anterior abdominal
pain
PSFS
• Lifting: child-car seat: 10
• Flexion exercise: 8
• Breathing deep: 6
• Standing BB: 8
• TOTAL =34 34/4 activities = 8.5
Observation
• lateral shift R @ TL jct
• flattened lower T & upper L curves
• apparent ant position of lower ribs on L
Objective Exam
• extension: minimal, TL provocation upon
reaching vertical
• flexion:
dev L, no mvmt in TL jct; B LE
paraesthesia
• sb R: 0, no T mvmt w TL provocation
• L: 20 painless
• Sacral-L extension 0, immediate
provocation TL pain
Palpation
• apparent anterior position of R6, 7, 8 on
L
• LT hypo into extension
• minimal RSB LT
• U PA R T6, 7, 8 hypo, reproduces her TL
SM
• C PA T10-11> T12, L1
• most tender @ interspace of T11-12
Special Testing
• Slump sit:
her LE SM -20 knee ext L , -
30 R
• SLR: 35 R, 45 L, her LE pain
• ULTT Base R elbow flexion 45, L 90
• NEURO: WNL
• Babinski Clonus WNL
Comparable SN
• Thoracic pain post: TL ext 0
• Thoracic pain ant: SB R 0
• LE SM: FB, SLR, Slump
Trial Treatment
• U PA R grade IV T6,7,8 :
• extension 10/ SB 10
• U PA R grade IV Ribs 6, 7,8:
• ext 20, SB 20
• TL manual traction in extension
• greatest relief of SM, full range ext
Treatment 2
• 80% decrease TL SM ant & post
• can’t do abdominal ex: her ant T pain
• worst: child - car seat
• BB & RSB WNL painless
• FB: her LE SM
• SLR B 60, limit her LE pain & R
• Slump -20 her LE pain & abd pain
Rx 2
• anterior STM into abdomen L UQ
• able to do oblique abdominal crunch
• TL GPM V into L rot in F
• SLR 90 B Slump 0
• L 4-5 GPM V L rot
• SLR 140!
Rx 3
April 3
• “no pain with car seat lift”
• HA 24 hours after last Rx
• “tight upper Cx spine R > L”
• “abdominal exercise: sl pain L
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Rx 3
• SLR B 140
• Slump full painfree
• BB full painfree
• ULTT R 30 L 90
Rx 3
April 3
• STM anterior abdomen UQ
• Resisted trunk rotation L through thorax
• STM into flexion Sub O
• painfree torso/ U Cx
• ULTT base L 30 elbow extension
• R 20
PSFS 2
• Lifting: child-car seat: 2
• Flexion exercise: 1
• Breathing deep: 2
• Standing BB: 0
• TOTAL =3 5/4 activities = 1.25