Tami Brown 6/21/11 Treatment Plan Kim Woodcock Overview Kim Woodcock, a year old female, came to me today complaining of chronic pain in her right neck and shoulder region. She stated her pain was 7 out of 10 on pain scale. She damaged her rotator cuff 24 years ago while sewing covers on gymnastic mats with repetitive motion while holding her arm up and moving lateral to medial. Kim also has chronic pain in her right hip. Her pain is 6 out of 10 on pain scale. She hurt her right hip 29 years ago at work moving a gymnastics mat by herself, while wearing heels, she slipped and fell. She also had complaint in her bottom ribs, running from medial border to the spine on both sides. She said her pain was a 4 out of 10 on pain scale, but last night it was a 10 out of 10. She is diagnosed with fibromyalgia. She is currently taking: Savella 50mg 2xday, Medroxyprogesterone 10mg 1xday, Amitriptyline 5mg 1x at bedtime, Omeprazole 40 mg 1xday. Her neck and shoulders are aggravated by driving a 2 hour commute to work 5 days a week, standing, writing on chalk board, gardening, and she hit her head on the headboard today. To relieve it she applies heat, self massage, or self unwinding. Her hips are aggravated by improper shoe support, standing, driving a 2 hour commute 5x a week, sitting, and leaning on couch with left leg. To relieve the pain she does self- trigger points, tennis ball rolling, heat and self massage. Pre-treatment ROM Arm – Right flexion 145 degrees, extension 42 degrees, abduction 110 degrees, adduction 15 degrees. Left flexion 148 degrees, extension 40 degrees, abduction 142 degrees, adduction 20 degrees. Hip - Right flexion 50 degrees, with knee flexed 80, extension 12 Left flexion 25 degrees, with knee flexed 85, extension 24 Back – flexion 89 degrees, extension 11 Lateral flexion- right 15 degrees, left 12 Neck- Flexion 45 degrees, extension 16 Lateral flexion- right 28 degrees, left 28 degrees Primary focus My client is complaining of pain in her neck and right shoulder. The muscles that I addressed were the left levator scapula, entire cervical region and left upper trap fibers. I addressed the levator scapula muscles because they are what elevates the medial border of the scapula, also pulls the scapula up and medially, helps bend the neck laterally, and helps the trapezius and rhomboid muscles. When palpating this muscle I found that she had increased hypertonicity bilaterally, and trigger points in the right. I used petrissage and trigger point therapy, s curve, and then petrissage again to bring blood back. Working this area will decrease hypertonicity, and trigger points, therefore allowing for increased lateral flexion and extension. I also addressed the left upper fibers of the trapezius muscles. The upper trapezius fibers elevate and upwardly rotate scapula and extend neck. I found a tender point and increased hypertonicity. The technique I used started off by warming up the back with effleurage and petrissage. I also used friction. This will loosen up the muscles especially on the right side where her chief complaint is. My client had trigger points in her left medial soleus and hypertonicity in her left gastrocnemius. I applied effleurage and petrissage to warm up the muscle. Then I applied trigger point therapy to the left medial soleus, followed by petrissage and effleurage. Loosening up this muscle will allow for greater dorsiflexion. I found a tender point in the origin points of the left hamstrings and increased hypertonicity. This muscle provides extension at the hip. I applied some compression in this area. There were also trigger points in her left piriformis and origin point of her left glutes. This muscle laterally rotates thigh at hip and abducts hip when knee is flexed and I applied trigger point therapy to these areas to loosen up the muscle. I started with petrissage, then trigger points, and ended in petrissage. This will allow for greater abduction of the leg. I also used unwinding of her right arm. Because her right shoulder has been pulling and is tight this suggests that there are myofascial restrictions in that area. By unwinding the arm it will allow for the fascia to loosen allowing for greater ROM. Outcome After the massage my client stated she felt much looser and had less pain. Her pain scale went down in her right hip from a 6 to a 2 on pain scale of 10. Neck and shoulder pain from a 7 to a 4, and Ribs from a 4 to a 2 on pain scale of 10. ROM post treatment Neck- Flexion 30 (down 15), extension 15 (down 1), lateral flexion right 45 (up 15) and left 30 (up 2) Arm- Right flexion 160 degrees (up 15), extension 48 degrees (up 6), abduction 160 degrees (up 50), and adduction 15 degrees (stayed same) Left flexion 152 degrees (up 4), extension 55 degrees (up 15), abduction 155 (up 13), adduction 20 (up 1) Hip- Right flexion 98 degrees (up 48), with knee flexed 70 (down 10), extension 36 degrees (up 25) Left flexion 50 degrees (up 25), with knee flexed 75 (down 5), extension 36 (up 12) Back- Flexion 70 degrees (down 19), extension 20 (up 9) Lateral flexion Right 30 (up 15), Left 25 (up 13) Plan The reason for the ROM going down in some areas is because we loosend up her problem areas therefore decreasing in the antagonist. We will address those areas in subsequent sessions. I recommended to Kim that she come back for therapeutic massage for one hour 2x a week for 3 weeks, 1x a week for 3 weeks, then 2x a month working to once a month for maintenance massage. I will incorporate some myofascial techniques such as unwinding and more trigger point therapy. Stretching is too hard on her body because of her fibromyalgia. The homework that I recommended for Kim is to continue to do unwinding of the neck and slight stretches that her body can tolerate. She should also use a tennis ball to self massage her glutes to loosen up the muscles. Too lesson the strain on the lower back she should move around more often from one position to another, use a swivel seat to help get in and out of the care, continue with heat or ice to help with pain, hot baths and showers. Deep breathing and meditation will be very beneficial. It decreases the stress levels therefore looser muscles. She may need to take ibuprofen for pain. Client did not reschedule, she will call and let me know what is good for her.
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