Student name / Jason Paterson
School / LSSM
Course code / 28D
Submission date / 12/01/18
Case study number - 1,
Category - from list of 6 - each case study must be from a different category
· Medical condition
General information - first name only, age, gender - do NOT include any personal identity information
Tony 64
Occupation - describe the physical aspects of their job and also their level of occupational stress or other relevant factors
Retired police officer. Worked at a senior level as a detective, was involved in high profile cases and managed a lot of people
Sport - in detail if this is in the Athlete category
Not applicable
Medical history - in detail if this is in the medical condition, physical disability or over 70 category
Parkinson’s disease and Lewy Body Dementia. I started treating Tony for a very tight back and shoulders post L4 and 5 spinal surgery to fuse them after a lon standing injury sustained in the line of duty as a police officer. He was already exhibiting sympotms of parkinsons This progressed through the following months like this : Signs include:-
Shaking or tremorsin limbs starting usually in one hand. I worked with a client recently who has developed parkinsons over time and this is how it first manifested itself with a light tremor in his right hand.
Slowed movement. Taking longer to activate the brain into performing the task you want it to do. With Tony (see case study) He found it particularly difficult to change direction. He was fine coming down stairs but as he reached the bottom and needed to transition from stairs to floor and to turn a corner, he would freeze. He also struggled with changes in floor surface such as going from carpet to wood.
Stiff or rigid musclesThis is how I met Tony. He had been operated on and had two vertebrae fused. He was experiencing very stiff muscles in his neck and shoulders to the point that he could not lift his head up to drink from the bottom of a cup. This also can be another symptom in terms ofStooped posture and Balance.Balance became a big issue with Tony walking on his tip toes and almost falling forward in a slight run rather than walking. He also found that his balance was greatly affected at night and he would often fall out of bed.
Loss of autonomonic movementssuch as blinking etc. With Tony his all came together in his walking, he stopped swinging his arms and had to be given verbal prompts to do so in order to try to help his balance.
Speech and writingIn some Parkinsons patients speech may become slurred. In Tony's case his speech slowed down as if he was struggling to process what he was trying to say. He would also speak very quietly sometimes dropping to an inaudible level, he would then catch himself and speak a bit louder. He would start stories or anecdotes but his tone would lose inflection
Tony also developedLewy Body Dementiawhich is closely linked to Parkinsons disease. He had changes in alertness sometimes appearing completely fine and lucid other times losing attention and becoming confused. Often in the same time frame he could go from one to the other appearing lucid one minute and confused the next. He also had visual hallucinations, especially at night time and often described it as if there were two versions of himself and his wife in the house. His self being the imposter and the real one being just out of sight somewhere. He also halucinated snakes, ripples on solid surfaces, miniaturised items such as bags of tiny cutlery on the bed etc.
Sleep disturbances. Tonys wife excplained that during the day he was mostly lucid with physical signs being the main problem. At night time Tony would act out dreams and be shouting out while sleeping, at one point she had to call the police as he was so aggressive and confused. He would often fall out of bed. Putting ear plugs into the ears seemed to help a lot.
Injury history - in detail if this is in one of the injury categories
Tony had spinal surgery after an injury sustained at work. He had begun to rehabilitate and was actually up and walking but then lost his balanace when walking and ended up falling making the muscles lock and spasm. He was in great discomfort and could not sit up straight in a chair fully raise his head or move particularly well when I met him.
Lifestyle - family, hobbies, activities, lack of activity, diet, smoking, social life, etc
Good diet and non smoker. Previous heavy drinker due to pressures of job and inherent culture within the job. However now at this stage of his life Tony rarely drinks. Tony used to be active as a squash player but for a few years pre op and post op he has done very little.
Treatment goals
Client - what the client hopes to achieve· Primary (eg treat the main injury)
· Secondary (eg treat another problem, get back to playing sport, lose weight and get fitter
Intially more movement and relief form pain. Being able to sit upright and feel able to walk more decisively.
Therapist
· Are client’s goals achievable?
· How many sessions may be needed and over what timescale?
· If/when you would consider referring the client to a medical practitioner
· If/when you would consider referring client to another discipline such as Pilates, sports coach, podiatrist
It became apparent that due to the symptoms of parkinson’s that once diagnosed it was unlikely that we would achieve the intial goals set. However Tony found the treatment to be of benefit and we did get some movement back into the neck and shoulders and back. The client was already speaking with a doctor and whislt he and his wife were hoping for the best they made me aware of the possible diagnosis of parkinson’s I researched this accordingly and also wrote to his doctor to ensure it was ok to continue treating him.
Assessment
Current symptoms - client’s account of their symptoms - pain, restricted movement etcSevere stiffness in the neck and shoulders restricted ability to move and pain at certain points at the end of the range of movement.
Posture - neutral, lordotic/kyphotic, flat-back, sway-back or other noticeable features
Highly Kyphotic. The lordotic part of the spine having been fused was quite straight. However Tony could barely lift his head beyond looking down at a 45 degree angle. He was slightly rotated to the right as if favouring this arm. Head movement was severely restricted too.
Spine - either normal or describe the degree of excessive lordotic/kyphotic curvature (cervical, thoracic, lumbar, sacral)
L4 L5 vertebrae surgically fused. Kyphotic curvature to the spine . This was post operative and since the fall. I have seen photos of Tony pre op and he has good posture for a man of his age and looked good.
Pelvis - either normal or describe the degree of excessive anterior/posterior alignment (left and right sides) and lateral alignment (one side higher than the other)
Pelic alignment was ok but very rigid movement with very little ability to tilt.
Shoulders - either normal or describe the degree of protraction/retraction, elevation/depression (right and left sides)
Very protracted more so on right hand side but noticeably on both .
Leg/arm alignment - either normal or describe any features such as hyper-extended knees, over-pronation or other foot issues
Legs and arms aligned ok but Tony shuffled when he walked walking on tip toes almost as if falling forwards. His Right arm would shake at times and he would carry this arm in front of him and slightly bent.
Mobility - which joints or spinal sections appear to have a restricted range of movement or are hyper-mobile
L4 and 5 due to fusion. Cervical spine is very stiff as is thoracic . Illio sacrial joint is also very atiff
Range of movement (ROM) tests
The joints or spinal sections you apply active, passive and/or resistive ROM tests (or any other tests) to / Conclusions
Due to the severity of the condition I could not conduct Thomas tests etc. I worked with Tony sitting on the side of the couch and we used markers around the room to assess his range of movment . Example keep your shoulders traight and move your head to look at the clock, now look out of the window etc. We used the same position each time I treted him so we could use these as a benchmark to any progress. I tested shoulder rotation, arm movement, head and neck movement, hip rotation and leg movement / Everything was severely restricted with the Neck shoulders and back having the least movement. Hips were also severely restricted but as Tony was in pain from the upper body it was difficult to isolate hips specifically.
Palpation and observation - which muscle areas look and/or feel hyper/hypo-tonic
Neck infraspinatus, levator scapula, Shoulders deltoids back upper and lower trapezius and rhomboids, chest pec minor
Assessment summary - describe what you think the problem is, based on the above assessments
Intially I though the muscles were all in spasm due to the fall and had locked up as defence to portect the spinal surgery.
Treatment plan
What measurable improvements are you hoping to make to the symptoms?More range of motion acorss all area’s Being able to get Tony sitting up right would be a great achievement.
SESSION 1
General massage - where did you apply general massage (effleurage, petrissage, friction) techniques and where did you focus more specifically, and why?Effluerage and petrissage to whole of back neck and shoulders to get Tony used to being touched and to start to feel and understand what was going on. Gentle work to see if by just massaging in this way I could get any relaxation in the muscles. Due to the surgery and being the first time I had treated anyone like this I was very cautious in my approach.
Soft tissue techniques
Where did you apply other soft tissue techniques - STR, MET (PIR/RI), myofascial, positional release or other?
Why did you pick each of these particular techniques and what were you aiming to achieve?
I applied PIR tachniques to neck, shoulders and back. I wanted to be able to ‘reset’ the muscles thinking they were locked up due to the fall. The fall had caused a dramatic change in Tony’s posture and movement but there did not appear to be any muscular damage through touch and assessment.
Reassessment - describe any changes that have resulted from the treatment
The progress was very slow. We did gain some increased range of motion but there was no eureka moment where muscles released. He was noticeably able to move better afterwards and felt more relaxed
Advice - what advice or exercises did you give to the client
I gave Tony movement exercises to do. Simple stretches. Using a chair (these are called Otago principle stretches and are used with older people to prevent falls. Due to the nature of Tony’s surgery and how severe his symptoms I hoped these gentle exercises would encourage movement and be a slow but gentle start.
SESSION 2
How long after Session 1?Two weeks after session 1
Client feedback - what client says about their condition since the last treatment
Improvments lasted a day or two but as Tony is spending most of his time sitting in a chair there is little improvement.
Reassessment - describe any changes that have occurred since last treatment
Tony seemed no better than the first time I saw him and has some shaking to his hands. I have been informed he has an assessment for Parkinson’s
General massage - where did you apply general massage (effleurage, petrissage, friction) techniques and where did you focus more specifically, and why?
As before I relaxed Tony to his back and shoulders. He found laying down difficult to get into but we persevered.
Soft tissue techniques
Where did you apply other soft tissue techniques - STR, MET (PIR/RI), myofascial, positional release or other?
Why did you pick each of these particular techniques and what were you aiming to achieve?
Same as previously I still felt I could release some of the muscles in this way and as we had had some success decided to continue trying.
Reassessment - describe any changes that have resulted from the treatment
Same increase in mobility as last time, some ROM improvement and better balance after the session.
Advice - what advice or exercises did you give to the client
Tony has not been doing the exercises. I advised to do them at set times. His wife was going to encourage him.
SESSION 3
How long after Session 2?8 weeks
Client feedback - what client says about their condition since the last treatment
Felt better again for a few days, however Tonys health has deteriorated somewhat and he now has a diagnosis of Parkinson’s with a further diagnosis of Lewy Body Dementia. His medication has changed
Reassessment - describe any changes that have occurred since last treatment
Tony is significantly different. His medication has changed and the pain killers he was previously on have been masking his symptoms, he shakes a lot in both arms, his balance when walking is more of a falling run. He struggles to change direction .
General massage - where did you apply general massage (effleurage, petrissage, friction) techniques and where did you focus more specifically, and why?
As Tony was unable to get on the couch I tried to massage him sitting in a chair. He found that the sensation of being touched was strange.
Soft tissue techniques