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CASE STUDY III
PATIENT HISTORY:
Heather B. – 33 year old female with Lymes Disease and due to her condition has suffered for 10 months with neuromuscular pain and spasms. The patient is under medication by her primary care doctor for the condition however still experiences discomfort in her neck and low back at 10 of 10 on the pain scale. The patient indicates the pain as a constant throbbing aching sensation that when exacerbated will radiate to her hands and feet. Patient is limited in her activities of daily living and unable to participate in her routine yoga classes. Patient is also under medication for her facial acne condition and hyperthyroidism.
EXAMINATION FINDINGS:
Positive Orthopedic Tests indicating Cervical&Lumbar localized spasms. (+Cervical Compression, +Cervical Distraction, +Shoulder Depression, +Maximum Cervical Compression, +5/5 Muscle Strength on Upper Extremity Bilaterally, Sensory Deficit in Both Arms; +Kemps, +Straight/Well Leg Raise, +3/5 Muscle Strength on Iliopsoas and Piriformis, Sensory Deficit in Both Feet, +Milgrams, All Reflexes within Normal Limits)X-rays indicate change of curvature in both cervical and lumbar spine with malposition of vertebrae at multiple levels with associated subluxation rotations.
DIAGNOSIS:
Migratory Musculoskeletal Pain due to Lymes Disease, Brachial Radiculitis, Sciatica, and Associated Hypertonicity in Paraspinal Musculature.
TREATMENT PLAN:
1Month
1st Week– treated patient a total of 2 times. Each visit consisted of ice therapy to reduce the inflammation in the soft tissue and pre-modulated interferential therapy to provide pain relief. Ancillary therapy was followed by a gentle manipulation to the cervical and lumbar spine. Once the patient’s pain reduced to lower than 5 out of 10 on pain scale, therapy was changed from ice therapy to heat therapy to address low grade soreness and tightness.
2nd Week – treated patient a total of 2 times.Each visit consisted of heat therapy to reduce the tightness in the soft tissue and pre-modulated interferential therapy to provide pain relief. Ancillary therapy was followed by a gentle manipulation to the cervical and lumbar spine.
3rd – 4th Week – treated patient a total of 2 times. Each visit consisted of heat therapy to reduce the tightness in the soft tissue and pre-modulated interferential therapy to provide pain relief. Ancillary therapy was followed by a gentle manipulation to the cervical and lumbar spine. Patient was given a protocol of cervical and lumbar stretches/exercises to address residual tightness. Patient was also explained the importance of a diet high in anti-inflammatories to prevent exacerbations of the Lymes Disease.
OUTCOME:
Patient’s pain level gradually dropped from a 10 to 2 out of 10 on the pain scale and the patient was released on an as needed basis. Patient was instructed to continue a normal routine of physical activity and appropriate diet, and if ever in an inflammatory or exacerbated state to report to clinic for updated treatment.
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