CASE STUDY VI

PATIENT HISTORY:

Julia B. – 38 year old female with seven year history of neck pain with radiating signs and symptoms going down left arm and hand. Patient states that when pain is flared up it can be as high as 7 out of 10 on pain scale and will travel to both hands. Patient states that work forces her to be in a seated position with a flexed posture at a computer. This prolonged period of bad ergonomics has recently aggravated her complaint and limited her from her normal activities of daily living and work. Patient has taken Aleve for pain relief and done Brueggers stretches, but this only provided slight relief. Movements in and about the neck are painful and excessive motion can induce a tension type throbbing headache. No other history of trauma is reported. All other patient history is unremarkable.

EXAMINATION FINDINGS:

Positive Orthopedic Tests indicating disc inflammation and swelling in associated soft tissue structures. (+Cervical Compression, +Cervical Distraction, +Shoulder Depression, +Maximum Cervical Compression, +4/5 Left Muscle Strength on Bicep-Tricep-Deltoid, Sensory Deficit on Left Arm) X-rays indicate disc degeneration and osteoarthritis at multiple levels with associated changes in curvature.

DIAGNOSIS:

Moderate Cervical Disc Bulge with Radiculopathy and Associated Hypertonicity in Paraspinal Musculature.

TREATMENT PLAN:

1 Month

1^st – 2^nd Week– treated patient a total of 5 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 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. A protocol of cervical traction decompression was prescribed after 2^nd visit.

3^rd – 4^th Week – treated patient a total of 3 times. The last three visits consisted of heat therapy to address the tight musculature in the cervical spine and pre-modulated interferential therapy to provide pain relief. Ancillary therapy was followed by a gentle manipulation to the lumbar spine. Patient completed last three treatments with cervical traction decompression.

OUTCOME:

100% resolution of neck pain and radiating symptoms after 5^th visit. Patient had a latent response to cervical traction decompression and therefore was released on an as needed basis. To address residual pain and soreness patient was prescribed a strict regiment of cervical exercises and instructions on proper ergonomic positioning at home and in the work setting for preventative health benefits.