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Assume you did not see the patient described in Case Study 1 until 4 weeks after the accident. He no longer has constant pain and has returned to work. His complaints are an inability to sit at the computer for more than 30 minutes before his hand starts to tingle. Numbness occurs after 1 hour of work. Headaches begin within 2 hours of work. Neck and shoulder pain is 6/10 by midday at which time he takes NSAIDs so he can continue working. Positive tests include forward-head posture with forward shoulders; decreased flexibility in the suboccipital muscles, anterior thorax, and internal rotators of the shoulder. Cervical flexion is 75%, extension 50%, and side bending and rotation 75% bilaterally. Sustained extension of the cervical spine causes tingling in the thumb, index, and middle finger of the right hand. Strength of scapular adductors and lateral rotators of the shoulder is 4/5; myotome testing is normal bilaterally.

â–  What are your goals and interventions for this patient at this stage?

â–  After studying the techniques described in Chapter 16, describe the techniques you would use with this patient and practice them on a laboratory partner.

â–  For each therapeutic exercise technique, practice progressions and determine how you would progress this patient so he could work without exacerbation of symptoms

Case Study 1

A 45-year-old man sustained injuries in a rear-end collision 4 days ago (car hit him going approximately 45 mph while he was stopped at a stop light). He was in an older car without an air bag or properly positioned headrest, although he was wearing a seatbelt. Initially, he hit the headrest at the midcervical spine as his neck extended, and then his head flexed forward but did not hit anything. He has been cleared of cervical fractures or instability. Medical history is unremarkable; he is a social drinker and gave up smoking 5 years ago. He is an accountant and usually works long hours at a computer but has been unable to work since the accident. He presents wearing a cervical collar and has a facial expression of distress. He states he has had difficulty sleeping because the pain wakes him whenever he moves.

Pain: constant posterior cervical pain, headaches, and pain radiating into the shoulder region bilaterally; intermittent tingling in the right thumb, index, and middle finger. Pain rated at 8/10 when at rest, 10/10 when attempting to move.

Positive findings: guarded forward-head posture. He is unwilling to move more than 10° into flexion or extension, 25° into side bending bilaterally; minimal rotation.

Gentle traction to the head relieves the neurological symptoms. Palpation tenderness in upper trapezius and posterior cervical and anterior throat muscles bilaterally. Increased tenderness along facet margins of C4–5, 5–6 and 6–7, right > left.

â–  Based on the above impairments and functional limitations, identify goals and interventions for this patient. Describe the techniques you would use and practice them on a laboratory partner.

â–  How long do you anticipate the patient will have these symptoms? At what point will you change your goals?


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