1. Left Posterior Neck
The patient is complaining of left posterior neck pain. Patient has had surgery in the right shoulder. He now feel pain in his neck that radiated down the left UE. The pain is described as sharp and stabbing. He rated this pain as a 7 on a scale of 0 to 10 with 10 being the worst and considers this condition to be moderate. The pain is frequent according to the patient. The pain occurs most often during the night. The pain radiates into the left arm, left fingers, left hand and left shoulder. The pain is reduced by resting while prolonged standing aggravates the condition. Side effects of this condition are numbness and tightness.
Mr. XXXXX has recorded that his family doctor is Dr. SSSS. The name of the patient’s chiropractor is Dr. Pardisnia. The patient reports that he had surgery on 2010-11-26. Right Shoulder Rotator Cuff surgery. Mr. XXXXX states that he currently has high blood pressure and mental/emotional difficulty. Mr. XXXXX does not report any problems with vision, speech, balance, nausea, dizziness, or numbness. He reports a family history of high blood pressure.
He has never smoked and is a non drinker of alcohol. XXXXconsumes about 1 drink containing caffeine per day. He is currently doing 3 hours of light exercise per week.
Capabilities of Daily Living
The patient states that capabilities of daily living have been affected in the following areas:
I experience MODERATE pain, which causes a significant limitation on my physical performance of activities. Pain is FREQUENT, and occurs between 50% and 75% of my awake time.
Physical examination revealed an individual who was alert, cooperative and orientated.
The patient’s gait appeared normal. Minor’s sign was negative.
Height: 167 cm
Weight: 69 kg
Grip strength: Reduced
Mr. XXXXX shoulder level appeared high on the left. He had a forward head carriage. The patient has rounded shoulders. Observation and inspection of the thoracic spine revealed a normal spine. Profile view of the lumbar spine revealed normal curvature. Romberg’s test was negative. Adam’s sign was negative. Left heel walk: WNL. Right heel walk: WNL. Left toe walk: WNL. Right toe walk: WNL.
Ranges of Motion
Motion Degree Normal Pain Level
Flexion: 53 50 Mild
Extension: 66 60 Mild
Lateral Flexion Right: 55 45 Mild
Lateral Flexion Left: 45 45 Moderate
Rotation Right: 80 80 Mild
Rotation Left: 69 80 Mild
Reflexes Wexler’s Grading System
Biceps (C5-6) 2+ 2+
Brachioradialis (C6-7) 2+ 2+
Triceps (C7-8) 2+ 2+
Cervical Spine Evaluation
Cervical spine evaluation provided the following results:
Cervical spine tenderness was noted in the spinous process region at: C2 (grade 2). Myofascial trigger points are present in the left scalenus (moderate) and left suboccipital muscle (moderate). The following cervical orthopedic tests were positive: Valsalva’s. Valsalva’s produced pain at C7. Shoulder depressor was positive on the left.
Thoracic Outlet Orthopedic Tests
Examination of the Thoracic Outlet produced the following results:
Roos (elevated arm stress test) test caused pain and/or symptoms in 10 seconds.
Muscle Testing – Kendall’s Grading System
Manual muscle testing of the upper extremities received the following grades:
Upper Extremities Muscle Testing
Deltoids 5/5 5/5
Biceps 5/5 5/5
Wrists Extensors 5/5 5/5
Triceps 5/5 5/5
Wrists Flexors 5/5 5/5
Fingers Flexors 4/5 5/5
Mr. XXXXX demonstrated right handgrip with 60 lbs, and left handgrip of 50 lbs.
M5412 Radiculopathy, cervical region
Acute, moderate to severe traumatic joint and muscle dysfunction in the above region with associated symptoms of pain, ROM reduction and functional difficulties.
Short Term Goals would be for Mr. XXXXX to report 50% pain reduction and 50% increase in ROM within 2 weeks. Functionally Mr. XXXXX should also be able to perform half of his ADL’s within these 2 weeks easier. Long Term Goals would be for Mr. XXXXX to report over 80% pain reduction and demonstrate over 80% increase in ROM within 4 to 6 weeks. Functionally Mr. XXXXX should also be able to perform most of his ADL’s within this period. Mr. XXXXX is also to be discharged with a home exercise program when the above goals have been achieved and he is over 80-90% impairment free.
Spinal Decompression 3x per week/duration of 3 weeks (Mr. XXXXX treatments are consistent with spinal traction group where there are signs and symptoms of nerve root compression and no movement centralizes symptoms.)
Today’s treatment consisted of Spinal Decompression (Supine,6,18 lbs,-7deg and18min NP) in the cervical region. XXXX endured these treatments with no pain.
The prognosis for improvement of the patient’s condition is considered good.
This patient has had right shoulder sugary. He also has rotator cuff issues on the left shoulder. But that should not cause numbness and pain down the left UE. Therefore I decided from today that he is going to be on our DOC table cervical spine program for the next 3 weeks.
Supine: That is the only way for cervical spine.
Protocol 6: This is good starting point with may pulls and rests.
Force: 18 lbs. This patient is 69 Kg or 152 lbs, therefore 18 lbs is good start.
Angle: I had his cervical angle more flexed to address C8 numbness he has in the fifth finger in the left hand. That caused more pain so I reduced the angle to -7 and he was feeling pain-free.
Time/Cycle: I chose 18 min or 21 cycles at protocol 6. I think this is easy to remember and built on, 18 lbs for 18 min.
Right after the treatment there was no report of radiculopathy by the patient. This is a very common and a great finding specially during DOC cervical decompression.
Again Patient is scheduled for the next 3 weeks. He should have a good excuse if he misses an appointment. He has insurance and had coverage for our treatments. He understands how serious we are with our DOC treatments.