Transcript Patient Profile - Fearon Physical Therapy

Patient Profile
• 27-year-old female Ortho Nurse (nights). Single, lives independently.
• Chief complaint: In PT for R LBP w/ radicular sx, awoke w/ severe B HA,
acute upper L neck pain w/ inability to look up or rotate – 24 hrs duration
• Self Report inventories
– Numeric pain scale
• Best in the last week: 0/10
• Worst in the last week: 8/10
– Neck Disability Index: 56%
– Fear Avoidance Belief Scale: 38/66
• Physical Activity Subscale: 21 / 24
• Work Subscale : 17/42
– Depression Screen - Negative
Patient Specific Functional Scale
Functional Impairment:
Where 0 = unable and 10 = able to perform at pre-injury level
Total
Score
**
1) Turn head L
2
2) Look up
1
3) Turn head R
4
Total
2.3
Body Chart
P1: L C2-3 (yellow)
P2: headache (blue)
P3: R low back (red)
Relationship of Areas – HA
consistent, neck pain related
to motion
x
X
History of Current Episode
• Duration of symptoms:
– 24 hours
• Mechanism of onset:
– Sleeping in sidelying. (Patient typically sleeps on her stomach – changed to
sidelying due to low back pain.)
• Progression of symptoms since onset:
– Worsened pain intensity, decreased range of motion, decreased sleep
• Current status (improving, static, worsening): Worsening
• Treatment and response: None
Previous History
• Previous Episodes: No previous episodes
• Contributing Factors: *LBP (10/8 ED), change in
sleep positions (from prone to sidelying), posture
• Previous Treatment: None @ neck.
• Medical History/Co-morbidities: LBP (current), R LE
radic** (resolved), obesity (53.4 BMI), pre-op gastric
bypass
**subsided w/ off work and PT
Aggravating/Easing Factors
Area
Aggravating Activity
Time required /Pain Level reached
Eases with/
Time to ease back to baseline
P1
L cervical rotation – immediate**
Retraction - immediate
Cervical extension - immediate
Return to neutral – minutes
P2
Being upright, head unsupported
Supine, head supported – minutes
P3
Standing/walking – 5 minutes
Sit/supine – minutes
Worst area: L upper cervical
Preferred Position of Rest: Supine or seated w/ neck supported, bolster under knees
24 hour behavior: Increased w/ neck activity, rotation. Poor sleep from neck pain.
Red & Yellow Flag Screen
•
•
•
•
•
•
•
•
•
General Health – weight gain
Age 50 with history of cancer – N/A
Cord: N/A
Clumsy hands, gait disturbance suggestive of spasticity: N/A
Cauda Equina: N/A
Steroids or anticoagulants: N/A
Numbness and tingling in the hands and feet: N/A
5 D’s (dizziness, diploplia, dysphagia, dysarthria): N/A
Yellow flags? N/A
Working Hypotheses
• Hypothesis:
P1 – L C2-3 facet irritation*, diskogenic, nerve entrapment
P2 (HA) – upper cervical (related to P1)*, mm. tension, posture
• Evidence supporting: Leaning toward C2/3 due to
localized symptoms, aggravated by recent change in head
position. No upper extremity or scapular symptoms.
• Evidence against: B HA vs. L side, posture may indicate
lower cervical component/limitations, C1/2 vs. C2/3 due to
significant rotation deficit.
Presentation
Area
P1 – Upper C/S
P2 – HA
Severity
High
High
Irritability
Low
Moderate
Nature
Facet
Muscle
Stage
Acute
Acute
Stability
Worse
Worse
Objective Examination
• Observation
– Affect: guarded, calm
– Fitness: nurse, 12-hour shifts, obese
– Gait: N/A
• Posture
– Habitual: computer/patient care – forward postures
– Spinal contours: dec. C/S lordosis, inc. T/S kyphosis, inc. L/S lordosis
– Signs of muscle imbalance: N/A
• Functional Screens
– Unable to turn head in waiting area & during subjective assessment
– Pain limiting basic function
Neurological Examination
•
•
•
•
•
Reflex: N/A
Dermatome: negative
Myotome: negative
Cranial Nerve examination : intact
Upper cervical ligamentous stability: negative
Additional Testing……
• Traction: Decreased HA symptoms in supine, increased soft tissue
irritation
Active Range of Motion Cervical
Range
Deviation
Symptoms
Limit of
Range
Flexion
WFL
Stiff
Extension
O
+
PAIN L
Rotation left
10
++
PAIN L
Rotation right
20
+
PAIN L
Lateral flexion left
WFL
Stiff
Lateral flexion right
WFL
Stiff
Retraction (dorsal
glide)
-0
Sig. head
forward position
++
PAIN
Active Range of Motion Thoracic
Range
Flexion
WNL
Extension
0
Rotation left
WNL
Rotation right
WNL
Lateral flexion left
WNL
Lateral flexion right
WNL
Deviation
Symptoms
Limit of
Range
Palpation Findings: PPIVMS
Palpation Findings: B OA tenderness, L C1-3 w/ gentle palpation unilaterally,
difficult to assess due to guarding
Range
End Feel
Symptoms
Reason for stop
Occiput C1
Hypo
Dec flex/ext
Tender, HA
HA
C1C2
Hypo
Dec flex, SB, rot- early
+
Pain
C2C3
Hypo
Dec flex, SB, rot - early
++
Pain
C3C4
Hypo
C5C6
C6C7
Hypo
C7T1
Hypo
Rib 1
Palpation Findings: PAIVMS
Range
End Feel
Symptoms
Reason for stop
Occiput C1
HYPO
Early resistance
++
HA symptoms
C1C2
HYPO
Early resistance
+
Pain
C2C3
HYPO
Pre-resistance
++
Pain
C3C4
HYPO
Early resistance
+
Pain
C5C6
NORM/HYPER
End range
C6C7
HYPO
Resistance
C7T1
HYPO
Resistance
Rib 1
Assessment Following the Objective:
Review and re-rank your hypotheses
• Hypothesis:
L C2-3 facet irritation + upper cervical
headache
• Evidence supporting: Prone unilateral PA at C2 +
rotation = relief; localized symptoms; dec HA w/ traction in
supine
• Evidence against: Posture may indicate lower cervical
component/limitations
Select Subjective and Objective Asterisks
Subjective /Functional Asterisks
Objective Asterisks
Driving, L>R rotation
C2-3 limitation, L PA & unilateral glide
10 degrees L rot, 20 degrees R rot
HA, Upper cervical retraction
OA B tenderness, guarding
Relief w/ supine traction
Treatment Day 1
Technique/Intervention: grade 2 to 3+ L
C2/3 PA unilateral  + L rotation
Intention of Technique : Establish
mobility
Patient /tissue response during
performance of technique: Improved,
worked into resistance w/o pain
Reassess Subjective /Functional Asterisks
Reassess Objective Asterisks
Driving, L>R rotation
30 degrees B rotation
HA, Upper cervical retraction
Able to retract
Exercise to support intervention: Seated self-assisted rotation at C3
Trial of exercise: x5
Result: Improved soft tissue soreness during active range of motion.
Patient Education/Instruction: Perform every hour, 3-5 reps to comfortable range.
Sleep positions, increased thoracic mobility.
Assessment Following Treatment
• Working hypothesis: C2-3 L facet irritation
• Was your initial hypothesis CONFIRMED & CLARIFIED, modified or
rejected?
• Can the disorder be classified or is a clinical syndrome apparent?
– Cervical Pain/Mobility and Cervical Pain/HA
• Did your assessment of Presentation change?
– Severity: Low
– Irritability: Low
– Nature : Facet
– Stage: Acute
– Stability: Improving
• PROGNOSIS?? & PLAN?? (Talk here. )
Visit # 2 Assessment
Subjective: Significant improvement,
minimal pain w/ rotation
Effect of the last treatment: 24 hrs of
soreness  relief w/ HEP
Time from start of care: 11 days
Time from last visit: 5 days
Reassess Subjective /Functional Asterisks
Reassess Objective Asterisks
Driving, L>R rotation
C2-3 tender, L PA & unilateral glide – 3/10
50 degrees B cervical rotation
HA, Upper cervical retraction
Relief of HA, extension/retraction limited
by stiffness
Treatment Visit 2
Technique/Intervention: PA GIII glides to
C@2-4, L uni C2/3  L rotation
Intention of Technique : Resolve
remaining joint restriction
Patient /tissue response during
performance of technique: Further
improvement in comfort w/ B rotation
Reassess Subjective /Functional Asterisks
Reassess Objective Asterisks
Driving, L>R rotation
WFL B rotation, painfree
HA, Upper cervical retraction
Extension limited by stiffness
Exercise to support intervention: upper thoracic towel stretch, abdominal bracing +
UE/LE resistance (rows, shld extension, leg lowering)
Trial of exercise: x5-10 ea. Emphasis on neutral spine, dec. muscle guarding
Result: Lessened lumbar and cervical compensation
Patient Education/Instruction: Cont. w/ rotation stretch, abdominal program.
Encourage body awareness w/ return to light duty nursing.
Reassessment
Total
Score
Outset
Current
Score
1) Turn head L
2
8
2) Extend neck
1
5
3) Turn head R
4
9
Total
2
7
Numeric Pain Rating Scale : Average
8
3
56%
10%
Patient Specific Functional Scale
Impairment:
Where 0 = unable and 10 = able to perform at pre-injury level
Neck Disability Index
Assessment Functional Asterisks and Impairments
At initial evaluation
Current Status.
8/10 L neck pain
3/10 neck pain
Unable to rotate head
Full cervical range of motion
Unable to sleep
Not limited by neck pain