Examination Date: 06/12/2018
Initial Exam
Chief Complaints
- Bilateral Posterior Neck
She has a complaint of bilateral posterior neck pain. Patient reports insidious onset of the complaint for the past two weeks ago. She attend ER yesterday. Radiographs were obtained and she was given Naproxen. She feels a bit less pain with medication. She 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 is reported as aching and dull and is radiating into the right shoulder. The pain is made better by resting while neck movement and prolonged sitting exacerbates the condition.
History
Patient reports of having IBS.
Social History
Her occupation is that of a PSW.
Neck Disability Index
The patient was asked to complete the Neck Disability questionnaire. The disability score calculated was 29 out of 50. Their responses are as follows.
The pain is moderate and does not vary much. I can look after myself without causing extra pain. I can lift very light weights. I cannot read as much as I want because of moderate pain in my neck. I have headaches almost all the time. I can concentrate fully when I want to with slight difficulty. I cannot do my usual work. I cannot drive my car as long as I want because of moderate pain in my neck. My sleep is greatly disturbed (3-5 hours sleepless). I am able engage in a few of my usual recreational activities because of pain in my neck.
Physical Examination
Physical examination revealed an individual who was alert, cooperative and orientated.
The patient’s gait appeared normal. Minor’s sign was negative.
Sex: Female
Age: 49
Height: 165 cm
Weight: 71 kg
BMI: 26.1
Complexion: Normal
Size: Normal
Grip strength: Normal bilaterally.
Posture
There is no indication of a head tilt in the patient’s posture. Her shoulder level appeared even bilaterally. She had a forward head carriage. The patient has rounded shoulders.
Ranges of Motion
Cervical Spine
Motion Degree Normal Pain Level
Flexion: 45 50 Moderate
Extension: 55 60 Significant
Lateral Flexion Right: 39 45 Significant
Lateral Flexion Left: 29 45 Significant
Rotation Right: 45 80 Moderate
Rotation Left: 44 80 Moderate
Neurological Testing
Reflexes Wexler’s Grading System
L R
Biceps (C5-6) 2+ 2+
Brachioradialis (C6-7) 2+ 2+
Triceps (C7-8) 2+ 2+
Dermatomes
Upper Extremities:
Left Right
C-6 Equal
C-7 Equal
C-8 Decrease
Cervical Spine Evaluation
Cervical spine evaluation provided the following results:
Tenderness is observed in the cervical region bilaterally (grade 2). Cervical spine tenderness was noted in the spinous process region at: C4, C5 and C6 (grade 2). Myofascial trigger points are present in the trapezius on both sides (moderate) and levator scapulae muscles on both sides (moderate). The following cervical orthopedic tests were negative: Compression and Foraminal Compression bilaterally. There was no change with pain intensity performing the distraction test. The following cervical orthopedic tests were positive: Shoulder depression was positive on the right. Kemps test caused pain positive for possible facet and meniscoid entrapment. Lateral Shear, Transverse ligament stress and VBI tests revealed no soft end feel, dizziness, nystagmus or nausea.
Muscle Testing – Kendall’s Grading System
Manual muscle testing of the upper extremities received the following grades:
Upper Extremities Muscle Testing
Left Right
Deltoids 5/5 5/5
Biceps 5/5 5/5
Wrists Extensors 5/5 5/5
Wrists Flexors 5/5 5/5
Fingers Flexors 5/5 5/5
Diagnosis
S1348 Other sprain and strain of cervical spine
Acute, moderate to severe traumatic joint and muscle dysfunction in the above region with associated symptoms of pain, ROM reduction and functional difficulties.
Management Plan
Short Term Goals would be for patient to report 50% pain reduction and 50% increase in ROM within 2 weeks. Functionally patient should also be able to perform half of his ADL’s within these 2 weeks easier. Long Term Goals would be for patient to report over 80% pain reduction and demonstrate over 80% increase in ROM within 4 to 6 weeks. Functionally patient should also be able to perform most of his ADL’s within this period. Patient 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.
Myofascial Release 2x per week/duration of 1 month (to release muscular lesions)
Spinal Manipulation 2x per week/duration of 1 month (to reduce pain, inflammation and spasm as well as increase range of motion)
Therapeutic Exercises 2x per week/duration of 1 month (to improve strength, flexibility, balance, range of motion, or endurance to one or more areas of the body)
Home Exercise Program 1x (for the patient to follow a sound home exercise program to increase flexibility, strength and endurance)
Physical modalities 2x per week/duration of 1 month (Modalities such as heat, cold, electrotherapy, ultrasound, laser, acupuncture and myofascial release are used to reduce pain and inflammation and increase range of motion. )
Today’s Treatments
Today’s treatment consisted Simply Align Technique. Proper use of heat or ice, sitting, standing, transferring, lifting, pushing and sleeping was explained to Ms. Ramlackhan today.
Prognosis
The prognosis for improvement of the patient’s condition is considered good.
Examination Date: 27/12/2018 (Four sessions of treatment)
Intermediate Exam
Chief Complaint
- Bilateral Posterior Neck
She has a complaint of bilateral posterior neck pain. Patient reports significant improvements sine the start of treatments. She rated this pain as a 2 on a scale of 0 to 10 with 10 being the worst and considers this condition to be mild. The pain is intermittent according to the patient. The pain is reported as aching and dull and is radiating into the right shoulder. The pain is made better by resting while neck movement and prolonged sitting exacerbates the condition.
Neck Disability Index
The patient was asked to complete the Neck Disability questionnaire. The disability score calculated was 3 out of 50. Their responses are as follows.
The pain is mild at the moment. I can look after myself without causing extra pain. I can lift heavy weights without extra pain I can read as much as I want to with no pain in my neck. I have no headaches at all. I can concentrate fully when I want to with no difficulty. I can only do my usual work, but no more. I can drive my car as long as I want with slight pain in my neck. I have no trouble sleeping. I am able engage in all recreational activities with some pain in my neck.
Physical Examination
Posture
There is no indication of a head tilt in the patient’s posture. Her shoulder level appeared even bilaterally. She had a forward head carriage. The patient has rounded shoulders.
Ranges of Motion
Cervical Spine
Motion Degree Normal Pain Level
Flexion: 55 50 No
Extension: 60 60 No
Lateral Flexion Right: 38 45 No
Lateral Flexion Left: 45 45 No
Rotation Right: 63 80 No
Rotation Left: 68 80 No
Neurological Testing
Dermatomes
Upper Extremities:
Left Right
C-6 Equal
C-7 Equal
C-8 Equal
Cervical Spine Evaluation
Cervical spine evaluation provided the following results:
Tenderness is observed in the cervical region bilaterally (grade 1). Cervical spine tenderness was noted in the spinous process region at: C4, C5 and C6 (grade 1). The following cervical orthopedic tests were negative: Compression and Foraminal Compression bilaterally. There was no change with pain intensity performing the distraction test.
Diagnosis
S1348 Other sprain and strain of cervical spine
Management Plan
Patient is being discharged at this time. She has achieved 80% improvement both subjectively and objectively since the start of the treatments. Continuation with home exercise program and return to therapies should the impairments return is recommended.
Home Exercise Program 1x (for the patient to follow a sound home exercise program to increase flexibility, strength and endurance)
Today’s Treatments
Today’s treatment consisted of Simply Align Technique.
Patient has been discharged with a home exercise program and will return if pain or impairments return.
Prognosis
The prognosis for improvement of the patient’s condition is considered good.