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Patient:
63 year-old female hairdresser
Diagnosis: Bilateral elbow tendonitis (epicondylitis),
bilateral shoulder pain, neck pain, and chronic low back pain.
Patient history Patient owns a hair salon,
and reports chronic low back pain (10 years) and severe bilateral
elbow, shoulder, and neck pain (for several months) when working.
Significant findings: Patient presented with
painfully limited cervical rotation and side bending to the right.
Bilateral elbow flexion and right shoulder abduction were also
limited moderately and painful at the end ROM. Backward bending
of the lumbar spine was also painfully limited. Muscular hypertonicity
and tender points were present in the right posterior cervical
spine, right shoulder and ribcage, both elbows, and right hip
flexors.
Intervention: Patient was treated twice weekly
for seven visits total. Treatment consisted of a neuromuscular
treatment approach (Strain/Counterstrain)
to eliminate the muscular hypertonicity and ROM limitations, followed
by instruction in spinal stabilization exercises for the cervical
and lumbar spine, and strengthening exercise for both upper extremities.
Outcome: Patient was discharged after seven
visits with no complaint of pain in elbows, shoulders, neck, or
low back, and she reported no difficulty with working. Patient
did return for one follow up visit four weeks after discharge
for minor low back stiffness, and correction of her technique
with her lumbar stabilization home exercise. Patient reported
four months later that she was still pain-free and working without
restrictions.
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Patient: 33 year-old female administrative assistant
Diagnosis: Headache, neck pain
Patient history: The patient reported that she
turned her head and felt a "pop" in her neck which resulted
in significant left sided neck and shoulder pain. Two days later,
she went to an urgent care center and her X-Ray reported was negative
for any cervical abnormality; she was seen for her initial evaluation
at ARC. At the time, she was c/o 5 out of 10 constant pain, and
she described pain as "a ton of bricks on my shoulder:. She
reported sharp neck pain and shoulder pain when she turned her head.
She was also c/o frequent sub-occipital headaches.
Significant findings: The patient presented with
significantly limited and painful cervical active movement in all
directions, but especially while rotating her head to either right
or left. With palpation, she presented with marked tenderness and
increased tone at the sub-occipital region and left cervical musculature,
including elevator scapula.
Intervention: The patient was seen for five total
sessions over the course of two weeks. Treatment consisted of Strain/Counterstrain,
myofasial release, manual cervical traction at her first two sessions,
then mechanical cervical traction, PROM, scapula stabilization,
and cervical isometric exercises, at her last three sessions.
Outcome: Patient contacted us two weeks later
after her last session to report she has no complaint of pain.
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Patient: 58 year-old, female, social worker
Diagnosis: Low back pain, piriformis spasms
Patient history: Patient began experiencing low
back and left posterior thigh pain during her recovery period from
bladder surgery. She reported severe pain after walking about 20
feet. She also reported pain with sitting, especially in a recliner
chair. She had been prescribed an anti-inflammatory, but had no
significant relief.
Significant findings: Patient presented with
severely limited lumbar flexion which caused low back pain and extreme
cramping in hamstrings. Left hip ER was also moderately restricted
and SLR was positive on the left. Severe hypertonicity and tenderness
were noted in the left medial hamstrings and buttocks.
Intervention: Patient was treated three times
a week for two weeks then weaned to two times a week for two more
weeks. Treatment consisted of a neuromuscular treatment approach
(Strain/Counterstrain) to hyper tonic areas of left hamstrings and
buttocks, joint mobilizations to the sacrum, muscle energy techniques
to improve spinal alignment, and a home exercise program of gentle
stretching an isometric abdominal exercise.
Outcome: Patient was able to do some light gardening
after four sessions and returned to work full-time after four weeks
of treatment. Patient discharged after four weeks of treatment with
no complaint of pain or loss of function.
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Patient: 17 year-old female gymnast
Diagnosis: Status post left knee ACL reconstruction
Patient history: Patient was referred to clinic
by her orthopedic surgeon, at 8 weeks post-op, after having received
8 weeks of physical therapy treatment at another provider. The surgeon
reported displeasure with the lack of full knee extension.
Significant findings: The patient presented with
a 13º flexion contracture of her surgical knee. Passive knee extension
was painfully restricted, with the patient reporting severe anterior
joint line pain at the end of range. Palpation of the popliteal
space revealed a 2cm diameter zone of dense, tender soft tissue,
directly adjacent and medial to the posterior border of the lateral
femoral condyle.
Intervention: A neuromuscular treatment approach
was applied to the painful area, one visit only.
Outcome: After one visit, patient achieved an
80% reduction of the pain at end range extension, gaining 10º of
knee extension (3º short of full extension). With the surgeon's
permission, the patient was referred back to the original physical
therapy clinic she had been treated at.
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Patient: 67 year-old retired but active Grandmother
Diagnosis: Scoliosis and LBP
Patient history: Patient with chronic history of
recurrent LBP which she relates to her scoliosis persented to ARC
physical therapy after a sudden increase in the low back pain over
the last three weeks which limited her ability to perform any sustained
weight brearing activities especially while standing and walking.
Significant findings: She was found to have significant
limitation in her lumbar flexion and left sidebending ROM. Her left
hip and right lumbar musculature were hypertonic and tender to palpation.
Intervention: Patient was treated predominantly
with (Strain/Counsterstrain) for her
first six sessions and reported the resolution of the majority of
her pain complaints after the first four sessions. She was seen for
a total of ten sessions and was instructed in a follow-up exercise
program with emphasis on core strengthening and lower extremity felxibility.
Outcome: Patient reported the resolution of her
acute LBP as well as most of her chronic low back discomfort and had
resumed all of her normal ADLs without limitations.
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Patient: 52 year-old female
Diagnosis: Right hip trochanteric bursitis
Patient history: This patient reports falling on
two separate occasions in December of 2008 and January of 2009 in
which she landed directly on her right hip. Her X-rays were normal
and she was diagnosed with a contusion and trochanteric bursitis. After
receiving an injection to the trochanteric bursa and taking anti-inflammatories
for several months, she was referred to ARC physical therapy.
Significant findings: Patient presented with
limited and painful lumbar and right hip ROM in all planes of motion.
She was unable to tolerance sustained periods of standing or sitting
secondary to pain and had stopped many of her normal ADLs such as lifting
her grandchildren and gardening secondary to the pain. The pain was
also disrupting her sleep and made it impossible to climb stairs reciprocally.
Upon clinical exam, she was found to have a right sided pelvic obliquity
which was most likely a result of her fall with significant muscle quarding
in her right lower quadrant muscles.
Intervention: Patient was treated two to three times a week,
receiving (Strain/Counsterstrain) and
muscle energy and was demonstrating a resolution of her pelvic obliquity
as well as 70% reduction in her pain complaints after only four sessions.
She was seen for a total of twenty sessions over the next two months to help
restore her normal core strength as well as restore her normal lower extremity flexibility.
Outcome: Patient recovered fully while reporting the
total resolution of her pain and had returned to all her normal activities,
including gardening.
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Patient: 50 year-old male electrician
Diagnosis: Left shoulder pain status post left shoulder
arthroscopy and subacromial decompression.
Patient history: The patient was involved in a motorcycle
accident nearly two years prior to surgery from which he suffered a fractured
left clavicle and scapula as well as a collapsed left lung. He was treated for
the collapsed lung and the fractures were left to heal. Over the following two
years the patient continued to complain of left shoulder and scapular pain as
well as pain and tingling in the left forearm. All symptoms were worsened with
overhead activity. Throughout this time the patient continued to work full duty
as an electrician. He received ultrasound treatments and cortisone injections prior
to undergoing surgery on 3/26/09. Following surgery he was referred to therapy
for ongoing left shoulder pain with movement. At the time the patient began therapy
at Advanced Rehabilitation Clinics on 4/9/09, he was off work due to his recent
surgery and continued complaints of signs and symptoms.
Significant findings: Patient presented with moderately limited
left shoulder range of motion that was moderately uncomfortable at the end ranges.
Forearm symptoms (numbness and tingling) could be reproduced with left shoulder
flexion and left scapular retraction. The arthroscopic portals were healing well
and there was minimal swelling present. The patient exhibited hypertonicity and
tenderness to palpation in the left pectoralis minor muscle as well as the
intercostal muscles of ribs 3-5.
Intervention: Patient was treated three times per week for
eight weeks at which time he returned to work full duty. He was seen two times
per week for an additional three weeks after his return to work. In total the patient
completed thirty-one sessions of therapy over a four month period. Treatment consisted
of (Strain/Counsterstrain) to address hypertonicity
in the left upper quadrant, patient education regarding posture and body mechanics
and strengthening for the left rotator cuff and scapular musculature. At the end of
eight weeks, the patient no longer complained of distal symptoms with overhead activity
or scapular retraction, had regained full active range of motion and strength of the
left shoulder and scapular region, and was independent in a home exercise/stretching program.
Upon return to work (at full duty), the patient experienced a mild increase in left
upper quadrant signs and symptoms as well as a minor decrease in left shoulder
range of motion. His remaining two weeks of therapy focused on the resolution of
neuromuscular dysfunction in the upper quadrant using (Strain/Counsterstrain)
and range of motion was restored to within normal limits (despite working eight or
more hours per day that included a significant amount of overhead activity).
Pain upon discharge was minimal and patient was able to self manage symptoms.
Outcome: Patient was returned to work full duty and without restrictions.
He was discharged from therapy (to self management of symptoms) reporting 80% reduction in his original symptoms.
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Patient: 75 year-old retired female
Diagnosis: Chronic low back pain
Patient history: Patient reported history of chronic
low back pain (LBP) over the last five years which had progressively
worsened to a 5-7 out of 10 (on a 0-10 scale) over the last four months.
Patient complained of severe difficulty with rising in the morning
and could not tolerate any prolonged standing or walking for more than
5-10 minutes. This was particularly frustrating for the patient as she
just moved into a retirement community a couple of years ago and could
no longer go on many of the planned day trips that she used to enjoy.
She also reported pain in both knees which hindered her ability to climb
stairs or get in or out of the bus, and required her to use a walker
when walking outside her apartment.
Significant findings: Upon evaluation the patient
exhibited painful restrictions in both lumbar flexion and extension
as well as restricted right knee extension and flexion which caused
her to ambulate with a limp. Patient also exhibited significant hypertonicity
in the left lower quadrant musculature with tenderness to palpation of
the left hip flexors, and lumbar paraspinals as well as tenderness over
the posterior knee musculature. The core musculature was significantly
weak with limited function fo the deep stabilizers (transverse abdominals and multifidus).
Intervention: A neuromuscular technique
(Strain/Counsterstrain) was applied to
the hypertonic left lower quadrant and right posterior knee
musculature and the patient reported significant reduction in the
severity of her low back pain after 2-3 visits. The techniques were
continued to the right posterior knee and the patient was able to
wean from her walker after four weeks of physical therapy. The patient
continued physical therapy for an additional four weeks, emphasizing
core strengthening and flexibility and strength of the lower extremities.
Outcome: The patient was discharged to an independent
home program after two months of physical therapy, reporting only an
occasional aching in her low back with prolonged standing. Functionally,
she was very excited because she has resumed taking the many day trips
offered by her retirement community, without any significant side affects.
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Patient: 49 year-old male stock broker
Diagnosis: C7 Radiculopathy
Patient history: Radiculopathy noted in fourth and
fifth digits after serving a tennis ball approximately one year ago.
Patient continued to have symptoms after undergoing ulnar nerve release
surgery and C7 epidural injection seven months ago.
Significant findings: Patient presented with a
10 degree elbow flexion contraction and 15 degree wrist supination
contracture as well as fourth and fifth digit numbness when performing
the combinaiton movement of end range elbow flexion and wrist pronation.
Dense fibrous tender tissue noted in cubital fossa as well as moderate
fascial restrictions in proximal wrist felxors and surgical incision
scar tissue. Strength was within normal limits. No change in symptoms
was noted when patient returned to spot.
Intervention: Augmented soft tissue mobilization of wrist
flexors and biceps, myofascial release of the distal biceps and ulnar
nerve stretches.
Outcome: After two visits patient reported only rare
occurances of finger numbness and was able to achieve normal supination,
active range of motion and improved elbow extension. Physical therapist
recommends ergonomic workstation set up consultation, tennis serving lessons
as well as continued neural stretching to maintain current reduction in nerve tension.
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Patient: 35 year-old male businessman
Diagnosis: Hallux Limitus RIght Foot S/P Total Joint Implant
Patient history: The patient is a marathon runner who
injured his right foot three years prior. He began experiencing dull, ahcy
pain with occasional shooting pain in his right big toe during long runs.
The severity and frequency of his symptoms increased significantly,
limiting his runs to no more than 3 to 4 miles. Surgical correction
was recommended. The patient was referred to Advanced Rehabilitation
Clinics post-op Total Joint Implant of the first toe.
Significant findings: The patient presented with
moderate edema right foot and toes. Passive toe extension was painfully
restricted. The patient was not weight bearing through the first toe
during level walking and he was unable to run.
Intervention: A musculskeletal treatment approach
was initiated including joint mobilization, massage, range of motion
and strengthening exercises, and gait training. A progressive running
program was designed to return the patient to his marathon training regimen.
Outcome: The patient successfully returned to pain
free running three months post-op. He was discharged with a self directed
training program to allow for completion of a marathon five months post-op.
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Patient: 47 year-old female
Diagnosis: Cervical Degenerative Joint Disorder and Chronic Headaches
Patient history: Patient with chronic history of
recurrent headaches since being in a motor vehicle accident in 1979.
Reported several trials of physical therapy over the last fifteen years
with no substantial change in symptoms, and in one trial of physical therapy,
the symptoms had actually worsened. Patient is diagnosed with cervical
degenerative joint disorder and cervicogenic headaches and referred
to physical therapy with complaints of daily headaches and pain
throughout her neck and upper back.
Significant findings: Patient exhibits grossly normal
ROM with end range pain in all directions of movement. There were multiple
tender points throughout the left upper quadrant musculature with asymmetrical
posturing of the left scapula and upper rib cage, with an elevated and
protracted prosture (forward and depressed shoulder).
Intervention: The patient was treated with
(Strain/Counsterstrain) two sessions for
eight weeks after which she reported a reduction of the frequency of her
headaches to once a week. Patient also reports no pain with end range
crevical motion. The intensity of her headaches had been reduced by 50%.
She was weaned to one session a week for two months during which postural
exercises were introduced. At the end of the two months, the patient was
experiencing infrequent headaches whose intensity were only 20% of her original symptoms.
Outcome: The patient stopped by our office two months after
her last visit and reported that she has been headache free for the prior month.
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