康复诊疗思路病例总结

1、康复诊疗思路病例总结我们分析的病例是一个以疼痛为主要表现的病人， 从这篇病例中我们学习的 作为一个治疗师如何对病人进行问诊、查体、分析的一个思路。问诊，病人来找到治疗师是， 我们首先应该细致的观察病人刚进来的一个体 态、面部表情、步行姿势等， L 先生进来时是弯腰驼背的体态进来的，再进行问 诊部分，问诊的内容主要包括症状、性状（加重、减轻、 24 小时等）、病史。在 L 先生的问诊过程是这样的， 18 个月前他从没有过这些症状 , 也没有这样的家族 史。他经历了各种各样的治疗 （传统的和非传统的 ）超过 6个月,但没有取得效果。 有一段时间的症状缓解了 ,但症状并没有消失。 接下来的前三周 ,

2、 他的疾病加剧了 他进行了腰椎穿刺 （为阴性）并在医院做了一星期的牵引 . 在这之后 ,他的腰痛加 剧。当他第一次去做物理治疗时他的体征如下他早上醒来时伴随着腰痛和背部僵 硬, 并会持续几个小时。咳嗽时会引起背部疼痛和左小腿疼痛。他每晚使用消炎 镇痛栓剂 （吲哚美辛 ）, 他觉得这些都是减轻他的疼痛的重要部分 （ 这意味着很有 可能有炎症成分 ） 。弯腰会引起他背部和腿部的剧烈疼痛 , 站直之后便立刻放松下 来。 （这一事实表明 ,治疗技术可能不是引起腿部疼痛的禁忌症 ;技术,是有效的, 只是在实际上可能需要激发腿部疼痛。 ）这些是 L 先生自己诉说的情况，我们应 该详细的记录下来，以便后面的

3、分析。查体及分析，通常查体和分析往往是同时进行，肌节、皮节、反射、疼痛的 方式，在查体分析过程中是很关键的，下面就来看看病例里面的查体和分析1. 通过进一步询问来确定他的疼痛情况 ,有趣的是 ,尽管他主要是小腿后部疼痛， 但他主诉为小腿上、下、外侧不同的疼痛，这几个疼痛P1、 P2、 P3、 P4 有时同时存在但更多时候是分开的 （ 这往往表明它们可能来源于几个不同的部分 ） 。2. 站（他不能直立，事实上他有点弯腰驼背）激起了他的左腿疼痛 P3,并且他无法 向后弯腰 （躯干后伸 ）, 因为这样会增加他腿部的疼痛 P3。3. 颈前屈身体持续向左地旋转使腿部腿疼痛 P3达到100%然后向右旋转减

4、少腿 部症状, 很轻微但是很明显。 （这是非常有用的治疗观点， 从不同的角度旋转会有不同的反应。注重手法操作的体位和方向 ） 在这个病人的情况中，它是明智的要考虑到技术的选择和进行方向旋转时要选取缓解的部位） 。4. 在直立位置 , 躯干侧移到左（ lateral shift to left ）来缓解他的疼痛 P3; 侧移到右边时则稍微增加了症状。 （因为这个疼痛反应 , 直接关系到他的活动障 碍。）5. 直腿抬高试验左边是35度,导致腿后部疼痛P3o右边是70度,他说,这造成了 一个不舒服的紧张感觉 , 再加上左脚的外侧的刺痛感 P4。6. 测试他的小腿站立能力， 出现了一些弱点 ,（这可能

5、是有神经性的衰弱但也可 能是存在疼痛抑制反应。）7. 试图站起来，只能坚持很短的时间（半分钟），此时他腰部P1和腿P3疼痛和驼 背加剧，历时约15秒或更多（长时间）才能消散。（因为驼背加剧如此之快，这意味 着障碍引起的背部疼痛很容易变迁。）8. 他的腿部疼痛P3在刚刚站起来那一刻是最小，然后疼痛越来越剧烈。（这意味 着疾病引起他的腿痛有一个潜在的因素 ）o9. 他的腿部疼痛P3和背部疼痛P1可能是分离的。（这意味着至少有两个组成部 分的障碍。随着信息数量增加。综上，他至少有2个病理因数。）10. 治疗性诊断，治疗师以躯干旋转为主的治疗方法：患者左侧卧位，在其左髂 嵴上垫毛巾卷，躯干稍屈曲，先使

6、患者骨盆向左运动，接着使胸段向右运动，持 续一段时间。患者的疼痛得到了一个很好的缓解。诊断， L 先生有压迫神经根的麻木和无力感，同时又有侧弯加重的一个椎管异常的现象，综合以上问诊查体及分析，病人是神经根压迫合并椎管病变项目结果疼痛位置P1、P2、P3、P4站立P3躯干后伸P3身体向左持续旋转P3 +颈屈位然后身体再向右旋转P3 -躯干向左侧移P3 -身体直立躯干向右侧移P3 +左35 P3直腿抬高右75 P3小腿站立能力减弱独立站立P1 P3原文：It is useful to in elude here an example of how the ma nipulative physiot

7、herapist thinks her way through a patie ntsdifficulty and atypicalspinal problem. This particular example dem on strates how to li nk the theory with the cli nical prese ntati onit also dem on strates the differe nt comp onents apatie nts problem may have, and how one comp onents may improve and ano

8、 ther not.this patie nt disorder dem on strates how the therapist must adapt hertech niq ues to the expected and un expected cha nges in the symptoms and sig ns. The example also dem on strates how ope n-min ded she must be, and how detailed andinq uiri ng hermind must be in making assessme nt ofcha

9、 nges and in terpreti ng them.Mr LEightee n mon ths ago ,a 34-year-old fit,well-built man (Mr L)with no historyof previous back problem,wake ned with pain in his left buttock areaover theprevious 2 days he had suffered very bad low lumbar backache ,which his doctorhad diag no sed as being viral beca

10、use he also had gen eral ach ing in other partsof his body Mr L did say that ,although he had flu-like aches all over,his lower back was the worst areahe had bee n on holiday duri ng the previousweek and had done a lot of lift ing and bee n wind -surfi ng(a new experie nee for him).Twodaysaftertheon

11、setofhisbuttockpai nitspread,ove ni ght,downtheleftlegwithtin gli ngintothebig toearea of his leftfoot(L5radicularsymptom).Some dayslater,the big toe tin gli ngalternatedwith tinglingalong the lateral border of his foot and into the lateraltwotoes ( S1 radicular symptom).Atno time priorto 18 monthsa

12、go had heever hadanybacksymptoms, and therewasno familialcomponentsHehad undergonenumerous formsof treatment(orthodoxandunorthodox)over 6 months ,butwithoutsuccess.overa period oftimethe symptoms eased,buthe did notbecomesymptomfree. Followinga fall3 weeksago,which exacerbatedhisdisorder,hehada lumb

13、ar puncture(whichproved negative )andhospitaltractionfora week .following this ,his low back pain increased .when he f irst went for physiotherapy his symptoms were as followswouldwaken inthe moringwithback pain and backstiffness ,and thestiffnesswould lastfora few hours.(Unusualfor anon-inflammator

14、y musculoskeletal disorder.)caused bothback painand leftcalf painwasusingindomethacin(Indocid)suppositorieseverynight,andhefeltthatthese wereessentialto lessento levelofhispain(Perhaps this means there must be an inflammatory component)caused him severe back and leg pain ,both of which eased immed i

15、ately on standingupright.(this latterfact indicates that a tretment technique that provokes leg pain may not bea vontraindication to its use;the technique ,to be effective ,may in fact needto provokeleg pain.)standing for1 minute,the painwouldincreasein his back andwould spreaddown hisleg.(thisindic

16、atesthata sustained technique may be required)only neurological changepresent was calfinitialphysiotherapytreatment ,which he hadundergoneelsewhere ,had improved allofhis dymptoms marginally,this firstthreeof thesetrratmentsconsisted of PAs on L5 and unilateral PAs to the left of latt er ,he said ,p

17、rovoked calfpain inrhythmwith thetechnique.onthe third treatment interment intermittent traction had been intr oduced, but this did not help himAssessment I saw him for first time 5 days latermore positive questioning to determine his area of pain ,it wasinteresting tonotethat,althoughhismain lower

18、leg painwasposterior he hadwhathe describedasadifferent painintheupperposterolateralcalf.these tow painswere sometimespresentatthesame time,butwere morefrequentlyfelt separately.(thistendsto indicatethatthey mayarisefrom tow differentsources-two components.)(and he could not stand erect,in fact he h

19、ad a lumbar kyphosis )p rovoked pain in his left leg,and he was unable to bend backwards be cause of increased leg painhad an ipsilateral list on flexion .(Items(2)and(3)seem to indicate that he has a disc disorder ,which is provoking possible radicularoffendingpartof thediscis probabymedialtothener

20、ve rootand itssleeve,andwillthereforebehardertohelpbypassivemovement techniques.)Neekflexionwhilehewaslimitedby increasedlegpain.(Theremustbea canalcomponentinhisdisorder .)Itdidnotincrease hisbackpain.(The causeofhisback pain isprobablynotcausinghislegaspects oftheonestructure perhaps The disc)stil

21、lin the flexed position ,rotationto the left increased his leg pain by about 100%.Rotation to the right in flexion decreased the leg symptoms ,slightly but definitely .(it is very helpful from atreament pointof view tohave differentresponseswiththe differentdirectionsof rotation.)Inthis manscircumst

22、ancesitis wise ,whenconsideringthe selectionof techniqueto choosetherelieving position whileperforming therelievingdirection fortherotation.the upright position,performing alateral shiftofhis trunk towards the left decreased his pain ;shift to the right slightly increased the symptoms.(Because of th

23、is pain response ,the list mu st be directly related to his disorder.)leg raise on the left was 35du, causing posterior leg pain. On the right itwas 70du, and he said it caused an uncomfortable tight feeling, plus tingling,in the leftfoot laterally.(Crossed SLRresponse-treatment may need to includem

24、obilizing the right SLR.)the power of his calf in standing demonstrated some weakness, which may havebeen a neurological weakness but may also have been a pain inhibition reaction.to stand, from sittingonly a short time (half a minute), he had back pain anda severe lumbar kyphosis, which took some 1

25、5 seconds or more (a long time) to dissipate.(Because the kyphosis developed so quickly, this meant that the disorder causing his back pain was very mobile.)leg pain was minimal on first standing but then gradually increased in intensity and also in the pain referral down his leg.(This meant that th

26、e disorder causing his leg pain had a latent component.)leg pain and his back pain could be provoked separately.(This meant that there were at least two components to his disorder. With the added information in number (1)above, he has at least three components. Number(4)above makes it fourcomponents

27、.)was felt either in the big toe or the lateral border of his foot.(This indicatedthe possibility of two nerve roots being involved. This could mean that twointervertebral discs may be involved, or the patient may have an anatomicallyabnormal formation of the nerve roots.)alsohad canal movement abno

28、rmalitiesas well as intervertebraljointmovement abnormalities.Mr Lsdisorder was obviously atypical.The disccomponent seemed to becausinghim more disabilitythanthe radicularaspect but obviouslytheradicularaspect tookhigherpriority.Being atypicalmeans thatone hasto be veryquickto noticethechangesinthe

29、 examination signsof the separatecomponents,andraectwithappropriatetechniquechanges.TreatmentBecause itseemed tobe discogennic(getting up fromsitting)wita nerve-root irritation:choice oftechnique would beroation,as the symptoms andsignsare clearlyunilateralroation would be performed inthesymptom-rel

30、ievingpositionanpaincandirection to avoid provokingalsigns wouldnotimprove inparallelwith thejoint signs,andthat therefore SLR stretchingmayberequired laterMrL ws positionedlying onhisleftside witha support(foldedtowel)under hisiliac cresttogaina lateralshift tothe leftposition (himcomfortableshiftp

31、osition ,seeitem(5)above).He wahead to further treament technique,it seemed possible thatas also positioned in a degree of flexion to keep his lumbar spine away from the painful and markedly limited extension position.Arotationof this thoraxto therightin relationto the pelviswas alsoadopted ,andhis

32、rightlegwas kept upon couchtoavoid anycanal tensioning(whichwouldoccur if his right leg were allowedto hang overthe edge ).The techniquewas to rotatehis pelvistothe left (that is,thesame directionas thoravicrotation tothe right, but performedfrom below upwards)as a sustained(sustained because of the

33、 latent component) grade IV.During the performing of the technique he felt an easing of his leg symptoms, which was a favourable indication.On reassessing his movemengts after the technique, the joint movements were improved but SLR was unchanged.The technique was repeated, but more firmly and for a

34、 longer sustained period.During the performing of this technique all tingling in his foot disappeared.Following the technique movements had further improved, but SLR was still unchanged Symptomatically, he felt more comfortable and felt he could stand straighter.After four such treatments Mr L was g

35、reatly improved, but SLR, although improved, was nowhere near as much improved as were the joint movements. Sitting was also improved. His calf power was normal. During this stage of treatment, a scan revealed posterior disc protrusions slightly lateral to the left of the posterior longitudinal liga

36、ment both the L4/5 and L5/S1 levels.Because the, discogenic, component was improved, and also the radicular symptoms were less(plus calf power improvement), left SLR was used as a technique and after four treatment sessions of this his left SLR became full range and pain free. However,the right SLR

37、still felt tight and did provoke minimal left leg symptoms. It was decided to do right SLRas the treatment technique .The tightness cleared and remained clear for 4 hours.The next treatment session consisted of performing SLRon each leg and ending the session with a repeat of the previous positioning and rotatio