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(duì)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(shì)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,他的疾病加劇了,他進(jìn)行了腰椎穿刺(為陰性)并在

2、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(huì)持續(xù)幾個(gè)小時(shí)?？人詴r(shí)會(huì)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(huì)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

3、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(huì)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(huì)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，

4、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(dòng)障礙。)5.直腿抬高試驗(yàn)左邊是35度,導(dǎo)致腿后部疼痛P3。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(cè)試他的小腿站立能力，出現(xiàn)了一些弱點(diǎn),（這可能是有神經(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)?/p>

5、駝背加劇如此之快,這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)。9.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，先使患者骨盆向左運(yùn)動(dòng)，接著使胸段向右運(yùn)動(dòng)，持續(xù)一段時(shí)間?；颊叩奶弁吹玫搅艘粋€(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

6、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)頸屈位然后身體再向右旋轉(zhuǎn)P3 +P3 - 軀干向左側(cè)移身體直立 軀干向右側(cè)移 P3 -P3 + 左 35直腿抬高 右 75P3P3小腿站立能力減弱獨(dú)立站立P1 P3原文：It is useful to include here an example of how the manipulative physiotherapist thinks her way through a patients difficulty and atypical spinal problem. This particu

7、lar example demonstrates how to link the theory with the clinical presentationit also demonstrates the different components a patients problem may have, and how one components may improve and another not.this patient disorder demonstrates how the therapist must adapt her techniques to the expected a

8、nd unexpected changes in the symptoms and signs.The example also demonstrates how open-minded she must be, and how detailed and inquiring her mind must be in making assessment of changes and interpreting them.Mr LEighteen months ago ,a 34-year-old fit,well-built man (Mr L)with no history of previous

9、 back problem,wakened with pain in his left buttock area over the previous 2 days he had suffered very bad low lumbar backache ,which his doctor had diagnosed as being viral because he also had general aching in other parts of his body Mr L did say that ,although he had flu-like aches all over,his l

10、ower back was the worst area he had been on holiday during the previous week and had done a lot of lifting and been wind -surfing(a new experience for him). Twodaysaftertheonsetofhisbuttockpainitspread,ovenight,downtheleftlegwithtinglingintothebigtoeareaofhisleftfoot(?L5radicularsymptom). Some days

11、later, the big toe tingling alternated with tingling along the lateral border of his foot and into the lateral two toes (? S1 radicular symptom).Atnotimepriorto18monthsagohadheeverhadanyback symptoms, andtherewasnofamilialcomponentsHehadundergonenumerousformsoftreatment(orthodoxandunorthodox)over6mo

12、nths,butwithoutsuccess.overaperiodoftimethesymptomseased, buthedidnotbecomesymptomfree. Followingafall3weeksago, whichexacerbatedhisdisorder, hehad alumbarpuncture(whichprovednegative)andhospitaltractionforaweek.followingthis,hislowbackpainincreased.whenhefirstwentforphysiotherapyhissymptomswereasfo

13、llows1.Hewouldwakeninthemoringwithbackpainandbackstiffness,andthestiffnesswouldlastforafewhours.(Unusualforanon-inflammatorymusculoskeletaldisorder.)2.Coughingcausedbothbackpainandleftcalfpain3.Hewasusingindomethacin(Indocid)suppositorieseverynight,andhefeltthatthesewereessentialtolessentolevelofhis

14、pain(Perhapsthismeanstheremustbeaninflammatorycomponent)4.Bendingcausedhimseverebackandlegpain,bothofwhicheasedimmediatelyonstandingupright.(thislatterfactindicatesthatatretmenttechniquethatprovokeslegpainmaynotbeavontraindicationtoitsuse;thetechnique,tobeeffective,mayinfactneedtoprovokelegpain.)5.o

15、nstandingfor1minute,thepainwouldincreaseinhisbackandwouldspreaddownhisleg.(thisindicatesthatasustainedtechniquemayberequired)6.theonlyneurologicalchangepresentwascalfweakness.theinitialphysiotherapytreatment,whichhehadundergoneelsewhere,hadimprovedallofhisdymptomsmarginally,thisfirstthreeofthesetrra

16、tmentsconsistedofPAsonL5andunilateralPAstotheleftofL4.thelatter,hesaid,provokedcalfpaininrhythmwiththetechnique.onthethirdtreatmentintermentintermittenttractionhadbeenintroduced, butthisdidnothelphim Assessment Isawhimforfirsttime5dayslater1.Onmorepositivequestioningtodeterminehisareaofpain,itwasint

17、erestingtonotethat,althoughhismainlowerlegpainwasposteriorhehadwhathedescribedasadifferentpainintheupperposterolateralcalf.thesetowpainsweresometimespresentatthesametime,butweremorefrequentlyfeltseparately.(thistendstoindicatethattheymayarisefromtowdifferentsources-twocomponents.)2.standing(andhecou

18、ldnotstanderect,infacthehadalumbarkyphosis)provokedpaininhisleftleg,andhewasunabletobendbackwardsbecauseofincreasedlegpain3.Hehadanipsilaterallistonflexion.(Items(2)and(3)seemtoindicatethathehasadiscdisorder,whichisprovokingpossibleradicularpain.theoffendingpartofthediscisprobabymedialtothenerveroot

19、anditssleeve,andwillthereforebehardertohelpbypassivemovementtechniques.)Neekflexionwhilehewaslimitedbyincreasedlegpain.(Theremustbeacanalcomponentinhisdisorder.)Itdidnotincreasehisbackpain.(Thecauseofhisbackpainisprobablynotcausinghislegpain.Towaspectsoftheonestructureperhaps?Thedisc?)4.Whilestillin

20、theflexedposition,rotationtotheleftincreasedhislegpainbyabout100%.Rotationtotherightinflexiondecreasedthelegsymptoms,slightlybutdefinitely.(itisveryhelpfulfromatreamentpointofviewtohavedifferentresponseswiththedifferentdirectionsofrotation.)Inthismanscircumstancesitiswise,whenconsideringtheselection

21、oftechniquetochoosetherelievingpositionwhileperformingtherelievingdirectionfortherotation.5.Intheuprightposition,performingalateralshiftofhistrunktowardstheleftdecreasedhispain;shifttotherightslightlyincreasedthesymptoms.(Becauseofthispainresponse,thelistmustbedirectlyrelatedtohisdisorder.)6.Straigh

22、t leg raise on the left was 35du, causing posterior leg pain. On the right it was 70du, and he said it caused an uncomfortable tight feeling, plus tingling, in the left foot laterally.(Crossed SLR response-treatment may need to include mobilizing the right SLR.)7.Testing the power of his calf in sta

23、nding demonstrated some weakness, which may have been a neurological weakness but may also have been a pain inhibition reaction.8.Attempting to stand, from sitting only a short time (half a minute), he had back pain and a severe lumbar kyphosis, which took some 15 seconds or more (a long time) to di

24、ssipate.(Because the kyphosis developed so quickly, this meant that the disorder causing his back pain was very mobile.)9.His 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 the disorder causing his leg pain

25、 had a latent component.)10.His 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 four components.)11.Tingling was felt

26、either in the big toe or the lateral border of his foot.(This indicated the possibility of two nerve roots being involved. This could mean that two intervertebral discs may be involved, or the patient may have an anatomically abnormal formation of the nerve roots.)12.Healsohadcanalmovementabnormalit

27、iesaswellasintervertebraljointmovementabnormalities.MrLsdisorderwasobviouslyatypical.Thedisccomponentseemedtobecausinghimmoredisabilitythantheradicularaspectbutobviouslytheradicularaspecttookhigherpriority.Beingatypicalmeansthatonehastobeveryquicktonoticethechangesintheexaminationsignsoftheseparatec

28、omponents,andraectwithappropriatetechniquechanges.TreatmentBecauseitseemedtobediscogennic(gettingupfromsitting)withanerve-rootirritation:1.Thechoiceoftechniquewouldberoation,asthesymptomsandsignsareclearlyunilateral2.Theroationwouldbeperformedinthesymptom-relievingpositionanddirectiontoavoidprovokin

29、gpain3.Thinkingaheadtofurthertreamenttechnique,itseemedpossiblethatcanalsignswouldnotimproveinparallelwiththejointsigns,andthatthereforeSLRstretchingmayberequiredlaterMrLwspositionedlyingonhisleftsidewithasupport(foldedtowel)underhisiliaccresttogainalateralshifttotheleftposition(himcomfortableshiftp

30、osition,seeitem(5)above).Hewasalsopositionedinadegreeofflexiontokeephislumbarspineawayfromthepainfulandmarkedlylimitedextensionposition.Arotationofthisthoraxtotherightinrelationtothepelviswasalsoadopted,andhisrightlegwaskeptuponcouchtoavoidanycanaltensioning(whichwouldoccurifhisrightlegwereallowedto

31、hangovertheedge).Thetechniquewastorotatehispelvistotheleft(thatis,thesamedirectionasthoravicrotationtotheright, but performedfrom below upwards) as a sustained (sustained because of the latent component) grade IV.During the performing of the technique he felt an easing of his leg symptoms, which was

32、 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 longer sustained period. During the performing of this technique all tingling in his foot disappeared. Following t

33、he 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 greatly improved, but SLR , although improved, was nowhere near as much improved as were the joint movements. Sitt

34、ing 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 ligament both the L4/5 and L5/S1 levels.Because the, discogenic, component was improved, and also the radicular symp

35、toms 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 still felt tight and did provoke minimal left leg symptoms. It was decided to do right SLR as the treatment technique .The tightness cleared and remained clear for 4 hours.The next treatment session consisted of performing SLR on each leg and ending the session with a repeat of the previous positioning and rotation technique. It was decided to stop treatme