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Msc mt case presentation 3
- 1. Msc manipulative physiotherapyMsc manipulative physiotherapy Case Presentation IIICase Presentation III D Chan Physiotherapist
- 2. Background Information • Mr Chung M/36 • Occupation: Airport van driver and worker • Job nature: needed to drive small van, transfer and lift baggage • Reason of referral: LBP for physical rehabilitation
- 3. Subjective Examination Main complaint: • Immediate Pain over back when lying on bed at night • Left buttock pain when getting out of the airport van (P1 & P2 are not related subjectively)
- 4. Subjective Examination Body Chart P1: central low thoracic superficial dull ache, VAS 5/10 (he could pinpoint the pain site at spinuous process of T9) P2: Left buttock to lateral thigh down to 5th toe Buttock: deep, ‘locking’ ‘clicking’ discomfort, VAS 3/10. lower leg and toe: numbness
- 5. Subjective Examination • 24-Hour Pattern: – P1: No morning stiffness. Increase at work and changing diaper for his daughter at home. Lying on bed at night with immediate pain. – P2: no morning /night pain. Just activity related (getting out of the van)
- 6. P1: (1) lying supine on bed immediately at night. VAS 5/10, needed to put pillow underneath back (Lumbar region), VAS ↓to 2/10, can sleep afterwards (2) changing diaper for his daughter (functional demonstration: flexed trunk in standing), VAS 6/10, needed to straighten his back immediately afterwards, VAS to 2- 3/10 P2: after sitting in the airport van for 10-20 minutes, as he got out of the van and stepped on the ground, VAS 5/10. totally subsided after a few steps of walking Easing Factors: as above strategies. No use of medication Aggravating Factors:
- 7. Subjective Examination • Special Questions: – Good general health. Medication o Severe night pain o Surgery o Weight Loss o – No recent PT Rx – Bilateral hand/foot tinglingo Gait disturbanceo – Bowel and bladder disturbanceo Saddle anaesthesiao – X-ray (taken after IOD in 2002): no #. mild degree of convexity towards right side at T5-6. anterior osteophytes (lipping)
- 8. • Recent: sudden onset/recurrent of back pain one year ago after lifting baggage for 1/52, gradual increase in pain this year. Insidious onset of P2 2/12 ago, constant till now. • Past: 8-9 years ago, worked in basement/ under the plane for baggage delivery. He stepped on a roller and fell backwards and hit on the luggage and hurt his back (IOD). PT Rx that time: EPTs, Taping (with effect), no MT due to much pain. Almost complete recovery History
- 9. Sources of the symptoms (P1) Joints underlying the symptomatic area: Muscles & other structures underlying the symptomatic area: Structures referring to the symptomatic area: • IV joints (low Tx and upper Lx) • Facet joints • paraspinal muscles • IV disc •Mid Tx and Lx
- 10. Sources of the symptoms (P2) Joints underlying the symptomatic area: Muscles & other structures underlying the symptomatic area: Structures referring to the symptomatic area: (L) SI joint (L) Hip joint (L) Knee joint (L) Ankle joint (L) Gluteal muscles (L) Quadriceps mm (L) ITB and TFL Lx IV joints and (L) facet joints
- 11. S/E Hypothesis P1 1. Low thoracic IV joint pain • Supporting Statement 1. P1 increased on supine lying (direct force on the area) 2. P1 decreased by putting pillow on Lx (unloading the Low Tx) 3. Pain site is very localized and palpable 4. Same site as old injury • Neglecting Statement
- 12. S/E Hypothesis P2 1. Piriformis syndrome • Supporting Statement 1. prolonged sitting (on hard surface) then started WB increase pain 2. Compression of sciatic nerve can cause distal symptoms 3. Easy to subside due to decreased stretching in standing position • Neglecting Statement 1. No history of trauma (e.g. twisting the hip) 2. no exercise habit leading to overuse
- 13. S/E Hypothesis P2 2. Hip joint pain with referred symptoms (OA) • Supporting Statement 1. prolonged sitting then started WB increase pain 2. Relieved by several steps of walking 3. Hip problem can be presented as buttock pain 4. Hip pain can refer downwards • Neglecting Statement 1. Rather young age 2. No history of trauma 3. No c/o pain on walking stairs/SLS/ squatting (which are common in hip problem) 4. Distal numbness
- 14. Irritability • P1: moderate – quite easy to provoke – Moderate intensity: VAS 5/10 – quite easy to decrease • P2: low to moderate – Needed 10-20 minutes to provoke – Moderate intensity: VAS: 5/10 – Easy to subside: a few steps of walking
- 15. O/E Plan • standard tests – P1: move to P1 – P2: move to the limit of symptoms • Palpation, PAIVMs • Special tests: piriformis stretch test
- 16. Objective Examination • Posture: mild poking chin with rounded shoulder, increased mid Tx kyphosis • Low Tx: – F: to mid shin, VAS 2/10,usual P1, OP: same – E: – SF L: SF R: – Rot L: Rot R: – ＊ F/Rot L: VAS to 4/10 with OP (usual P1)
- 17. Objective Examination • Palpation: – Spasm o Sweating o Temperature o mm pain o – ＊ central PA to T8 and 9 with usual pain, VAS 4/10, stiffness++ – Other levels and unilateral PAs: no pain
- 18. Objective Examination • L gluteal muscles: usual P2, VAS 5/10 (especially dig into the site of piriformis muscle). R: no pain • L Hip: F/E, IR/ ER: Po • L Hip Q: usual P2(stretching) as Hip add with Hip F 90 • Observation: L hip kept ER in supine lying • ＊ Piriformis stretch test: +ve on L (with toes numbness if sustained), -ve R • SLR: Bil 40 degrees, no usual pain • Stairs : Po ,squatting : Po
- 19. O/E Hypothesis P1 Low thoracic IV joint pain with stiffness • Supporting Statement 1. P1 increased on supine lying (direct force on the area) 2. P1 decreased by putting pillow on Lx (unloading the Low Tx) 3. Pain site is very localized and palpable 4. Same site as old injury 5. Central PA caused usual pain 6. Other possible structures screened • Neglecting Statement
- 20. O/E Hypothesis P2 Piriformis syndrome • Supporting Statement 1. prolonged sitting (on hard surface) then started WB increase pain 2. Compression of sciatic nerve can cause distal symptoms 3. Easy to subside due to decreased stretching in standing position 4. Piriformis stretch test: +ve • Neglecting Statement 1. No history of trauma (e.g. twisting the hip)
- 21. 1st Rx session (1) Central PA T9, Gd III x 2lots C/O: VAS 3-4/10 O/E: Lx F+Rot: VAS 2/10 (improved) (2) L piriformis passive stretching x 3 C/O: VAS 4/10 O/E: piriformis stretch test: less tightness, same pain (improved)
- 22. Piriformis Syndrome (J.W. Thomas Byrd, MD; Oper Tech Sports Med 13:71-79 © 2005) • can result from overuse or repetitive trauma. • Overtraining and repetitive trauma, whether from exercise or sitting on hard surfaces (“wallet neuritis”) • Acute trauma • The sciatic nerve is susceptible to entrapment anywhere along its course from the lumbar spine through the posterior thigh
- 23. • Sitting for prolonged periods of time is typically uncomfortable and becomes increasingly intolerable. • The patient will characteristically describe posterior hip and buttock pain and a variable pattern of radicular symptoms. • These distal symptoms may be spotty and ill defined but will follow the pattern of the sciatic distribution. Piriformis syndrome:
- 24. • Palpation for the piriformis • Straight-leg raise findings are variable
- 26. 2nd Session • C/O: – P1: same that night. Increased mildly on Friday, with resting pain to today. Still painful when changing diaper for her daughter, VAS 5/10, but P1 became diffused. Same pain when lying supine on bed – P2: (Day off till today) no P2 emerged – No unaccustomed activities or Rx • O/E (asterisks reassessed): – Lx F: to shin, VAS 2/10, with OP: VAS 3/10; + L Rot: VAS 4/10 – Usual P1 with central PA to T9, VAS 4/10 with Gd III – Muscle soreness on palpation of R paraspinal muscles in mid Tx region
- 27. 2nd Session • O/E: – L piriformis stretch test: still tight and with usual P2, VAS 4/10 – Other screening tests done: Lx, SIJ, knee, ankle: -ve. Hip accessory movements: -ve – Neurological Exam: NAD
- 28. Post Rx Soreness Condition worse - P1 remained same range - Severity of P1 higher - O/E ＊ remains ISQ - Disappear in 1-2 days - P1 move far to left - O/E ＊ worsened - Unfavourable findings in O/E - Worse > 1-2 days S/E O/E P1 same same P2 better same Differentiate between: Post Rx soreness and Condition worse
- 29. 2nd Session (1) Central PA T9, Gd III x 2 lots C/O: VAS 4/10 O/E: Lx F+Rot: VAS 1-2/10 (2) L piriformis passive stretching x 3 C/O: VAS 4/10 O/E: piriformis stretch test: same pain (3) Self stretching ex to L piriformis mm
- 30. 3rd Session • C/O: – P1: still painful that night and next day. Decreased P1 on Wednesday, VAS 1-2/10 when lying on bed. Did not change diaper in aggravating position. Overall improvement: 40- 50%. Pain not diffuse now – P2: nil pain / numbness since last Rx during aggravating activities. Overall improvement: 80- 90% – No unaccustomed activities or Rx
- 31. 3rd Session • O/E (asterisks reassessed): – Lx F: to distal 2/3 shin, VAS 0/10, with OP: VAS 0/10; + L Rot: VAS 0/10, VAS 1/10 on return – Usual P1 with central PA to T9, VAS 3-4/10 with Gd III+ – No back muscle soreness – L piriformis stretch test: mild decreased tightness and with usual P2, VAS 4/10
- 32. 3rd Session (1) Central PA T9, Gd III+ x 2 lots C/O: VAS 3-4/10 O/E: Lx F+Rot: post Rx soreness throughout range, VAS 3/10, no usual pain (2) L piriformis passive stretching x 3 C/O: VAS 4-5/10 O/E: piriformis stretch test: same pain, decreased tightness (3) self stretching ex to L piriformis mm
- 33. Future Plan • Back stretching and strengthening exercises for correction of kyphotic convexity of spine • Reinforce piriformis mm stretching ex and self Rx • Self back care and ergonomic advice to prevent injury
- 34. Learning Issues • Clinical presentation of piriformis syndrome • Make Differential diagnosis between hip joint problem and piriformis syndrome
- 35. Discussion Time
Editor's Notes
- Background information for the case. Ms chan F/56, the date of admission is 6th September. She is a housewife and referral diagnosis is right CTS
- The main complaint by the patient is pain over right wrist, with vas 6-7/10; and also stretching pain over right lateral arm and forearm, with vas 4-5/10. Besides, there is P/N over right med 4 finger tips. And the patient claims that P1 and P2 are related.
- The aggravating factors are turning towel, here I put an asterisk for this functional activity, which will increase P1 to 7-8/10 and P2 to 6. Also carry handbag for about 2-3 mins will increase P1 and P2. Patient can ease the pain by rest and hold the arm by the other hand for about 1-2mins. For the 24 hours pattern, the patient has night pain and wake up by the pain 2-3 times per night but can re-sleep in a period of time. There is morning stiffness of the wrist and the pain seems will increase with effect of activities.
- The patient has good past health, except occ headache with panadol, and no dizziness. No bilateral hand/foot tingling and gait disturbance. No major surgery before except baby delivery. She has weight loss for ~ 20 lbs within ½ year and she think that the changes are because she change into a vegetarian. There are no x-ray taken for wrist or Cx. Ms Chan had her right wrist pain and P/N for about 3 wks with gradual stretching pain over right lateral upper arm and forearm. She claimed there is no trauma and previous episode She had seen GP with medication and slightly decrease pain. She had the history of nk and right shoulder pain 2-3 years ago and now recover.
- From the S/E, here are the possible sources of the symptoms. Joints underlying are right elbow joint include sup R-U j, H-R jt and H-U jt; right inf R-U jt and right wrist joint include intercarpel joints and cmc joints. Muscles and other structures underlying the symptomatic area may include right forearm extensor group mm, right brachioradialis mm and right wrist thenar and hypothenar mm and also flexor retinaculum. Possible structures that can refer to the symptomatic area include right C4-C8 nerve root, c4-t1 IVD, right C4-T1 facet joints and also right shoulder join.
- From the S/E, here are the possible sources of the symptoms. Joints underlying are right elbow joint include sup R-U j, H-R jt and H-U jt; right inf R-U jt and right wrist joint include intercarpel joints and cmc joints. Muscles and other structures underlying the symptomatic area may include right forearm extensor group mm, right brachioradialis mm and right wrist thenar and hypothenar mm and also flexor retinaculum. Possible structures that can refer to the symptomatic area include right C4-C8 nerve root, c4-t1 IVD, right C4-T1 facet joints and also right shoulder join.
- My first hypothesis from S/E is right C5-C8 nerve root irritation by right C4-T1 facet joints and / or C4-T1 IVD. It is because… Nerve root pain can only have distal pain and the pain edges are well-defined, also the body chart matched C5/6 dermatomes. However, there is no x-ray of Cx taken to prove whether there is any joint degenerative changes or decrease in intervertebral spaces.
- My first hypothesis from S/E is right C5-C8 nerve root irritation by right C4-T1 facet joints and / or C4-T1 IVD. It is because… Nerve root pain can only have distal pain and the pain edges are well-defined, also the body chart matched C5/6 dermatomes. However, there is no x-ray of Cx taken to prove whether there is any joint degenerative changes or decrease in intervertebral spaces.
- My first hypothesis from S/E is right C5-C8 nerve root irritation by right C4-T1 facet joints and / or C4-T1 IVD. It is because… Nerve root pain can only have distal pain and the pain edges are well-defined, also the body chart matched C5/6 dermatomes. However, there is no x-ray of Cx taken to prove whether there is any joint degenerative changes or decrease in intervertebral spaces.
- I will rate the irritability of Ms Chan as 4-5/10, low to moderate. Since the P1 & P2 are quite easily provoke, and the degree of pain provoked is moderate to high. But in turn, P1 & P2 are easy to reduce and return to the resting level within a short period of time.
- For objective examination, there is swelling around right wrist. Functional demonstration matched with S/E and increase P1 to 7-8 and P2 to 6. Neck standard movement is ok. By performing the sustained ext, rot, SF and lower Cx Q towards the pain, there are only local nk stretch feelings, but no change in either P1 or P2, and also P/N.
- Sustained right shoulder Q is also negative. In the ULTT 1, P1 increase to 6-7 and P2 to 5-6, P/N feelings are also increased. However, by adding left nk SF, no further changes in P1, P2 and P/N result. ULTT 2b also increase P1 and P2, but the test cannot change the P/N. Also, no further increase of P1 & P2 by adding left nk SF
- Elbow screening tests all are negative. Screening tests for right wrist only increase P1 but not the others. CTS special tests can provoke P/N but not P2. No positive findings in neurological examination.
- My first hypothesis from S/E is right C5-C8 nerve root irritation by right C4-T1 facet joints and / or C4-T1 IVD. It is because… Nerve root pain can only have distal pain and the pain edges are well-defined, also the body chart matched C5/6 dermatomes. However, there is no x-ray of Cx taken to prove whether there is any joint degenerative changes or decrease in intervertebral spaces.
- My first hypothesis from S/E is right C5-C8 nerve root irritation by right C4-T1 facet joints and / or C4-T1 IVD. It is because… Nerve root pain can only have distal pain and the pain edges are well-defined, also the body chart matched C5/6 dermatomes. However, there is no x-ray of Cx taken to prove whether there is any joint degenerative changes or decrease in intervertebral spaces.