Clinical Reasoning Exercise

Last Updated on Monday, 13 June 2011 00:01 Written by Administrator Thursday, 17 February 2011 12:04

I: Body Chart

From the body chart what is your 'working hypothesis'?

Do you think there is more than one structure involved? Why?

Are there symptoms suggesting referred somatic or radicular pain? What are they?

 

II : Past History

nil history of Pain A prior to 6/12 ago

past history of Pain B over past 5 years

- onset after lifting a heavy load (~body weight) in a bent over position

- initial injury took 2-3 weeks to subside

- gradually worsening

increased frequency of Pain B (~ 2-3 times per year)

increased intensity of Pain B

takes longer to get better again ( ~ 4-6 weeks vs a few days)

takes less effort/strain for pain B to come on again

quality of pain B has changed from a 'dull ache' to a 'deep ache & throbbing'

past history of Pain C similiar to Pain B

- onset 5 years ago during the incidence of Pain B

- also gradually worsening , however the recurrences are not as frequent as Pain B

 

Pain D started at a similar time to pain A but is more frequent (almost constant tightness)

Pain E started some 2 years ago - insidious onset / little changed

history of recurrent sprained ankle on left.

unsure of onset of Pins and Needles / Numbness

previous physiotherapy treatment consisted of electrotherapy and massage and some exercises that helped

What information does the past history reveal w.r.t

- the relationships of the pain?
- your 'working hypothesis'?

III : Current History

Pain A commenced 6/12 ago

• insidious onset that gradually worsened over the past few months
• started in the bottom of the heel and became greater in area and intensity.
• mostly constant pain since 2 months
• had been working a lot in the cold open air at the time of onset
• 3 week rest from running made little change
• 12 treatments from a Physiotherapist consisted of massage, ice and a stretching regime - has helped a little but did not last. Recommenced back exercises as Pain B had also been getting worse. Exercises consisted of 'modified' pushups and bring knee to chest whilst lying on back

What information does the current history reveal to help your 'working hypothesis'?

- central pain generating mechanisms? (neurophysiology)

-peripheral pain generating mechanisms? (neurophysiology and anatomical)

History of abuse, overuse, misuse?

Aggravating factors

• standing on a ladder for 30 minutes -> Pain A 3/10; Pain B 3/10
• can continue standing on ladder (risk of Pain C and D)
• standing and moving on ladder for 60 minutes -> Pain A 5/10; Pain B 2/10
• running 10km, the first few km?s are quite painful (~3/10) then it settles down to ~1/10, unless on uneven ground.

Easing factors

• After standing on the ladder for 60 minutes must stop activity, whereby Pain A decreases after approx. 30 minutes to 2-3/10. Pain B remains at 2-3/10.
• Stretching the 'Hamstring muscles' relieves Pain E somewhat.
• Extension exercises help Pain B, little effect on Pain A during day but good a.m.
• Brief (~ 5 minutes) icing of the heel helps Pain A when severe
• NSAIDS help Pain A a little with morning pain and stiffness
• Repeated or heavy (~10kg overhead) lifting may cause pain B

V : 24 hour behaviour

Morning

• the morning after running 10 km, when getting out of bed-> Pain A 7/10 ; stiff in region of pain B. Occasional Pain E.
• takes Pain A some 30 - 45 minutes to loosen up using a hot shower and stretches.

Evening

• both Pain A and Pain B can be worse if having spent a lot of the day climbing ladders;
• frequently Pain D is worse at the end of the day, as are the pins & needles
• running on even ground in the evening helps Pain B and Pain A after a period of time

Note

• pain A constant dull ache but better than during the day
• pain B wakes him occasionally. Unsure whether he wakes due to movement or due to positioning. Takes some 10-15 minutes to sleep again. Prefers to sleep on right side with the left knee up towards chest
• occasional calf cramps at night
• no pins and needles at night

What is the "irritability"? why?

What is the "Severity" ? Why?

What is the "Stage" of the disorder ? Why?

What is the "stability" of the disorder? Why?

Is there evidence for inflammation?

• neurogenic?
• non neurogenic?
• adverse neural tension?

How will you measure technique and treatment success?

Special Questions
Weight loss OK; Steroids OK; Corda Equina OK; Cord OK; Xrays NAD; Operations OK; Other jnts; OK Diabeties OK

VI: Physical Examination

Achilles : very tender to palpation, some rubifaction, some swelling, medial and lateral calf tightness

• : heel raise -> pain A 2/10, dev.inv.

Ankle : lateral instability

• : small big toe

Detailed information regarding the neuromodulation of pain as it relates to musculoskeletal physiotherapy

more clinical reasoning for the cervical spine-upper quadrant