Thursday, May 10, 2012

Mrs. R Case Study Pt. 2 Initial Assessment

For Mrs. R's second day of the plan, I went through some assessment techniques from Erik Dalton's Myoskeletal Alignment Level 1 course and some Myofascial soft tissue assessment I've learned from several sources, which included a bit of stretching to find range of motion limitations.

Mrs. R reported that her left hip is usually the more problematic. The lumbopelvic firing order was off when extending the left leg while prone. The contralateral erector fired first and the glute fired very quickly second. The hamstrings and ipsilateral erector fired virtually at the same time- the hams seemed to stay just ahead after 5 repetitions of extension. According to Dalton's book, "The ideal firing order sequence is hamstrings, gluteus maximus, contralateral erector spinae, and ipsilateral erector spinae."

Extension of the right leg presented the "ideal firing order sequence" but was weak and shaky- 3 repetitions were difficult for her to complete.

Both hamstrings had good muscle mass but had very dense, cable like segments in the medial, ischial attachment area. Neither presented any pain with firm fist compressions.

After having Mrs. R turn supine, I discovered that both quadriceps, especially the rectus femoris, were visibly tight and were very tender with light direct pressure with my fingertips. The right quad was more tender and tight- presumably from the many hours of driving each week.

Very little difference in leg length- If I had to pick, the left was maybe a millimeter shorter.ASIS comparison did not reveal any dramatic difference either, but I have very little practice on either test, so far. 

The piriformis test/stretch showed fine movement from the piriformis and IT band- normal range without pain to the midline, but I stopped the crossover stretch due to shooting pain in the adductor/groin area. As the text cautions, "...femoral nerve entrapment is possible..." but could also be due to "...adhesions in the anterior joint capsule."

I moved directly into the adductor assess and stretch and found very limited range of motion before painful results. Then I had Mrs. R do a bilateral adduction squeeze with her knees bent while I resisted, to test the pubic synthesis. The squeeze was very weak- barely perceptible each of the 3 repetitions. There were no noticeable audible cracks or adjustments.

Next I performed a straight leg traction for the low back, but pulling the ankles. Then I moved laterally while maintaining the traction. Each direction got about 40 degrees from midline before any discomfort. No noticeable problematic side. Both can be improved by further stretching.

Because I already know the right is tighter, and it's clearly visible when standing, I skipped the levator and trapezius assessments.

The only therapeutic technique I performed was Walt Fritz's "Lumbar Myofascial Release Lift." The only modification was that Mrs. R was wearing sweatpants and a baggy t-shirt that I could easily work under.

She reported that it "felt good" and did not cause any pain. Her tissue warmed and loosened within 3 drags from sacrum to mid-back- less than 3 minutes altogether.

In his blog entry, Curiosity and the Magic Wand, Walt Fritz, PT  explains an interview technique where the therapist asks the client to describe one thing that could magically be fixed, what would it be. To answer this question, Mrs. R. stated she would get a new neck, because her current neck is "ruined and damaged." Strong, meaningful words to say the least! Later we came back around to the "Magic Wand" question and she changed her answer; it would be more important to "Take out the balls in my shoulders." She was pointing to her neck at the levator scapula attachments on the scapula. She has referred to those "balls" before where there is dense adhesion and possibly scar tissue. The reasoning is that they "connect the neck pain to the shoulders." I would paraphrase that to mean she wants to disconnect and mobilize the neck from the head from the shoulder, so that they can all work as fluid, separate, healthy structures. I'm excited to explore this line of questioning with further clients, because it created an intriguing dialogue that allowed my client to explain her needs without relying on medical jargon.

It was an interesting appointment for several reasons. Mrs. R. abruptly changed jobs two days earlier due to a timing conflict with an internship. She was mentally stressed by the task of finding a new job to pay for school which would be flexible enough to continue her internship and full time school schedule. She also had a keen eye on her phone because she was expecting several calls about jobs. Thankfully, during this assessment session, she was fully clothed in comfortable work out clothes, giving her security and ability to jump off the table and answer the phone the couple of times it did ring.

Despite the underlying stress, Mrs. R. was cheerful, very accommodating with my requests for random movements, and was excited to continue treatment based on my findings. As she walked out towards the door to leave, she said she felt some relief in the back and that walking was a little looser feeling, even with the minimal movement and stretching we did.

This treatment was Tuesday the 8th and she is due back Thursday the 10th.

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