Student name / Jason Paterson
School / LSSM
Course code / 28D
Submission date / 12/01/18
Case study number - 2
Category - from list of 6 - each case study must be from a different category
- OVER 70
General information - first name only, age, gender - do NOT include any personal identity information
Rita 84 Female
Occupation - describe the physical aspects of their job and also their level of occupational stress or other relevant factors
Retired lady, lives on her own having been widowed many years before. Highly active for her age. Is affluent and has a nice lifestyle so appears to have limited stress.
Sport - in detail if this is in the Athlete category
Not Applicable
Medical history - in detail if this is in the medical condition, physical disability or over 70 category
Rita has had a very active life and is in amazingly good health for her age. Has three children all from natural births and all are now over the age of 40. Rita has never had surgery and has mild arthritis in her hands. By her own admission her life has been quite affluent and therefore she has had minimal stress and been able to live a good standard.
Injury history - in detail if this is in one of the injury categories
Rita came to me with a stiff right shoulder, she was unable to move it very far to look over to the right hand side. It would get very painful and was stopping her sleeping at night. Normally she would sleep fine.
Lifestyle - family, hobbies, activities, lack of activity, diet, smoking, social life, etc
Good diet and non smoker. Very active. Walks long distances 6 or 7 miles at a time twice a week as part of a walking group. Is in fine physical condition for someone 20 years younger! She is a great character and has a fantastically positive outlook on life and lives it to the fullest.
Treatment goals
Client - what the client hopes to achieve- Primary (eg treat the main injury)
- Secondary (eg treat another problem, get back to playing sport, lose weight and get fitter
Intially more movement and relief form pain. Return head movement back to original position and be able to sleep pain free.
Therapist
- Are client’s goals achievable? yes
- How many sessions may be needed and over what timescale? 3 or 4
- If/when you would consider referring the client to a medical practitioner if there are any contraindications
- If/when you would consider referring client to another discipline such as Pilates, sports coach, podiatrist. If I am unable to solve the problem in the agreed number of sessions.
Assessment
Current symptoms - client’s account of their symptoms - pain, restricted movement etcSevere stiffness in the right shoulder restricted ability to move head and pain at certain points at the end of the range of movement. Arm movement is fine through all ROM
Posture - neutral, lordotic/kyphotic, flat-back, sway-back or other noticeable features
SlighltyKyphotic but for her age is surprisingly good.
Spine - either normal or describe the degree of excessive lordotic/kyphotic curvature (cervical, thoracic, lumbar, sacral)
All good
Pelvis - either normal or describe the degree of excessive anterior/posterior alignment (left and right sides) and lateral alignment (one side higher than the other)
Also fine
Shoulders - either normal or describe the degree of protraction/retraction, elevation/depression (right and left sides)
Right shoulder slightly protracted and appears to be protecting this shoulder.
Leg/arm alignment - either normal or describe any features such as hyper-extended knees, over-pronation or other foot issues
Legs and arms aligned ok some pain down the right arm but think this is coming from the shoulder.
Mobility - which joints or spinal sections appear to have a restricted range of movement or are hyper-mobile
Mobility is not only fine but great for her age. Head rotation to the right is restricted as is shoulder elevation.
Range of movement (ROM) tests
Conclusions
Head back / Some difficulty pulling hesd back to look upards
Head movement to right shoulder / Restricted
Head to left shoulder / Fine but pulls a little on the right
Chin to chest / All good
Arm movements ib all planes / Both arms good. Slight impingement when ligfting right arm above shoulder height.
Palpation and observation - which muscle areas look and/or feel hyper/hypo-tonic
Neck infraspinatus, levator scapula, Shoulders deltoids back upper and lower trapezius and rhomboids, chest pec minor. Feeling for any issue and to relax client. Prone lying on couch.
Assessment summary - describe what you think the problem is, based on the above assessments
Tight muscles in the neck possibly Sternocleinomastoid muscle.
Treatment plan
What measurable improvements are you hoping to make to the symptoms?To be enable Rita to move her head again and sleep well.
SESSION 1
General massage - where did you apply general massage (effleurage, petrissage, friction) techniques and where did you focus more specifically, and why?Effluerage and petrissage to whole of back neck and shoulders to get Rita used to being touched and to start to feel and understand what was going on. Gentle work to see if by just massaging in this way I could get any relaxation in the muscles. Tightness felt in neck and along infrapinatus and upper trapezius
Soft tissue techniques
Where did you apply other soft tissue techniques - STR, MET (PIR/RI), myofascial, positional release or other?
Why did you pick each of these particular techniques and what were you aiming to achieve?
At this point I had not learned any PIR or RI techniques so was limited to MET and NMT. I tried NMT on points I thought were tight to see if the muscle would relax under applied pressure.
Reassessment - describe any changes that have resulted from the treatment
Significant movement improvement and felt much more relaxed. Not 100% but better.
Advice - what advice or exercises did you give to the client
Gentle head movement exercises to end of ROM and then to try to relax into that point and go further. To do each night when brushing teeth.
SESSION 2
How long after Session 1?4 weeks after session 1
Client feedback - what client says about their condition since the last treatment
Improvments lasted a week and sleep was good. Came back slowly over the next few days. Definitely sees the value in treatment and wants to continue.
Reassessment - describe any changes that have occurred since last treatment
ROM was not as good as at end of treatment last time but better than at the beginning.
General massage - where did you apply general massage (effleurage, petrissage, friction) techniques and where did you focus more specifically, and why?
As before I relaxed Rita to her back and shoulders. I wanted to try releasing the pecminor muscle but lying supine coaused Rita to feel dizzy and she was a little distressed so we sat her up again and tried to work sitting on the side of the couch.
Soft tissue techniques
Where did you apply other soft tissue techniques - STR, MET (PIR/RI), myofascial, positional release or other?
Why did you pick each of these particular techniques and what were you aiming to achieve?
Same as previously At this point I did not have any other skills in my tool box. I had released some of the muscles in this way and as we had had some success decided to continue trying.
Reassessment - describe any changes that have resulted from the treatment
Better increase in mobility than last time and ROM i
Advice - what advice or exercises did you give to the client
Rita has been doing the exercises and feels they help. Gve her some different ones in addition to those she has been doing. Suggested she moves her armchair or television as she is sitting at a side angle to it
SESSION 3
How long after Session 2?4 weeks
Client feedback - what client says about their condition since the last treatment
Felt better again for a longer period and the results lasted a bit more time few days. Rita thinks it is improving each time and wants to see me every two weeks.
Reassessment - describe any changes that have occurred since last treatment
Rita seems to be able ot move more freely although some limitations have returned.
General massage - where did you apply general massage (effleurage, petrissage, friction) techniques and where did you focus more specifically, and why?
I had learned PIR since seeing Rita last. I wanted to try this technique straight away as I felt it would help her but used effleurage and petrissage to warm the muscles up first. I worked her neck and shoulders but felt it was mostly the neck that was the issue.
Soft tissue techniques
Where did you apply other soft tissue techniques - STR, MET (PIR/RI), myofascial, positional release or other?
Why did you pick each of these particular techniques and what were you aiming to achieve?
I would have prefered to od PIR with Rita lying supine but due to her not liking being on the couch in this way I worked sitting. I was able to get her to push her head into my hand to activate the muscles and we seemed to get a much greater ROM in the muscles. She felt it moving and it was really impressive!!
Reassessment - describe any changes that have resulted from the treatment
Full ROM appears to be back. Certainly for now.
Advice - what advice or exercises did you give to the client
Keep moving and keep using it as well as keep doing the exercises. Warm up in the morning and no sudden movements.
Conclusion - summarise results and future plans (if any) with the client
PIR worked great. Think if I had known about it earlier on I could have applied it sooner and had better results. Rita is coming back again in two weeks anyway just in case and I think she likes the chat and relaxation of it all! I think initially I thought it was the shoulder and need to assess all areas and think about victim and villain principle. Also trying to adapt to different positions because of the clients need was interesting and valuable.
ISRM use only
Marker / initials / % mark for this case study
Comments
Average % for three Case Studies