康復(fù)診療思路病例總結(jié)

1、康復(fù)診療思路病例總結(jié)我們分析的病例是一個(gè)以疼痛為主要表現(xiàn)的病人， 從這篇病例中我們學(xué)習(xí)的 作為一個(gè)治療師如何對病人進(jìn)行問診、查體、分析的一個(gè)思路。問診，病人來找到治療師是， 我們首先應(yīng)該細(xì)致的觀察病人剛進(jìn)來的一個(gè)體 態(tài)、面部表情、步行姿勢等， L 先生進(jìn)來時(shí)是彎腰駝背的體態(tài)進(jìn)來的，再進(jìn)行問 診部分，問診的內(nèi)容主要包括癥狀、性狀（加重、減輕、 24 小時(shí)等）、病史。在 L 先生的問診過程是這樣的， 18 個(gè)月前他從沒有過這些癥狀 , 也沒有這樣的家族 史。他經(jīng)歷了各種各樣的治療 （傳統(tǒng)的和非傳統(tǒng)的 ）超過 6個(gè)月,但沒有取得效果。 有一段時(shí)間的癥狀緩解了 ,但癥狀并沒有消失。 接下來的前三周 ,

2、 他的疾病加劇了 他進(jìn)行了腰椎穿刺 （為陰性）并在醫(yī)院做了一星期的牽引 . 在這之后 ,他的腰痛加 劇。當(dāng)他第一次去做物理治療時(shí)他的體征如下他早上醒來時(shí)伴隨著腰痛和背部僵 硬, 并會持續(xù)幾個(gè)小時(shí)?？人詴r(shí)會引起背部疼痛和左小腿疼痛。他每晚使用消炎 鎮(zhèn)痛栓劑 （吲哚美辛 ）, 他覺得這些都是減輕他的疼痛的重要部分 （ 這意味著很有 可能有炎癥成分 ） 。彎腰會引起他背部和腿部的劇烈疼痛 , 站直之后便立刻放松下 來。 （這一事實(shí)表明 ,治療技術(shù)可能不是引起腿部疼痛的禁忌癥 ;技術(shù),是有效的, 只是在實(shí)際上可能需要激發(fā)腿部疼痛。 ）這些是 L 先生自己訴說的情況，我們應(yīng) 該詳細(xì)的記錄下來，以便后面的

3、分析。查體及分析，通常查體和分析往往是同時(shí)進(jìn)行，肌節(jié)、皮節(jié)、反射、疼痛的 方式，在查體分析過程中是很關(guān)鍵的，下面就來看看病例里面的查體和分析1. 通過進(jìn)一步詢問來確定他的疼痛情況 ,有趣的是 ,盡管他主要是小腿后部疼痛， 但他主訴為小腿上、下、外側(cè)不同的疼痛，這幾個(gè)疼痛P1、 P2、 P3、 P4 有時(shí)同時(shí)存在但更多時(shí)候是分開的 （ 這往往表明它們可能來源于幾個(gè)不同的部分 ） 。2. 站（他不能直立，事實(shí)上他有點(diǎn)彎腰駝背）激起了他的左腿疼痛 P3,并且他無法 向后彎腰 （軀干后伸 ）, 因?yàn)檫@樣會增加他腿部的疼痛 P3。3. 頸前屈身體持續(xù)向左地旋轉(zhuǎn)使腿部腿疼痛 P3達(dá)到100%然后向右旋轉(zhuǎn)減

4、少腿 部癥狀, 很輕微但是很明顯。 （這是非常有用的治療觀點(diǎn)， 從不同的角度旋轉(zhuǎn)會有不同的反應(yīng)。注重手法操作的體位和方向 ） 在這個(gè)病人的情況中，它是明智的要考慮到技術(shù)的選擇和進(jìn)行方向旋轉(zhuǎn)時(shí)要選取緩解的部位） 。4. 在直立位置 , 軀干側(cè)移到左（ lateral shift to left ）來緩解他的疼痛 P3; 側(cè)移到右邊時(shí)則稍微增加了癥狀。 （因?yàn)檫@個(gè)疼痛反應(yīng) , 直接關(guān)系到他的活動障 礙。）5. 直腿抬高試驗(yàn)左邊是35度,導(dǎo)致腿后部疼痛P3o右邊是70度,他說,這造成了 一個(gè)不舒服的緊張感覺 , 再加上左腳的外側(cè)的刺痛感 P4。6. 測試他的小腿站立能力， 出現(xiàn)了一些弱點(diǎn) ,（這可能

5、是有神經(jīng)性的衰弱但也可 能是存在疼痛抑制反應(yīng)。）7. 試圖站起來，只能堅(jiān)持很短的時(shí)間（半分鐘），此時(shí)他腰部P1和腿P3疼痛和駝 背加劇，歷時(shí)約15秒或更多（長時(shí)間）才能消散。（因?yàn)轳劚臣觿∪绱酥欤@意味 著障礙引起的背部疼痛很容易變遷。）8. 他的腿部疼痛P3在剛剛站起來那一刻是最小，然后疼痛越來越劇烈。（這意味 著疾病引起他的腿痛有一個(gè)潛在的因素 ）o9. 他的腿部疼痛P3和背部疼痛P1可能是分離的。（這意味著至少有兩個(gè)組成部 分的障礙。隨著信息數(shù)量增加。綜上，他至少有2個(gè)病理因數(shù)。）10. 治療性診斷，治療師以軀干旋轉(zhuǎn)為主的治療方法：患者左側(cè)臥位，在其左髂 嵴上墊毛巾卷，軀干稍屈曲，先使

6、患者骨盆向左運(yùn)動，接著使胸段向右運(yùn)動，持 續(xù)一段時(shí)間。患者的疼痛得到了一個(gè)很好的緩解。診斷， L 先生有壓迫神經(jīng)根的麻木和無力感，同時(shí)又有側(cè)彎加重的一個(gè)椎管異常的現(xiàn)象，綜合以上問診查體及分析，病人是神經(jīng)根壓迫合并椎管病變項(xiàng)目結(jié)果疼痛位置P1、P2、P3、P4站立P3軀干后伸P3身體向左持續(xù)旋轉(zhuǎn)P3 +頸屈位然后身體再向右旋轉(zhuǎn)P3 -軀干向左側(cè)移P3 -身體直立軀干向右側(cè)移P3 +左35 P3直腿抬高右75 P3小腿站立能力減弱獨(dú)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