Client Presentation
Client presented complaining of chronic pain in his neck, shoulder,
and shoulder blade area on the left side at a level 8 on a pain scale of
1 to 10 where 1 is minimal and 10 is severe. He also complained of
pain and parathesia in his left arm. He indicated movement made his
pain worse and lying down, being still, decreased the pain. He reported
having considerable pain
for nearly two years.
The
pain was significantly affecting his life in that he couldn't move as
quickly so all tasks took longer and he said he was “always behind on
assigned tasks.” It was difficult to lift and carry things, turn his
neck left and right as well as it is difficult to “push things forward”
away from himself.
History of the Problem
He
had been experiencing pain for nearly 2 years. It began when
approximately 22 months ago he was on foot and was hit by a motor
vehicle reversing out of a parking lot space. Prior to impact the
client considerably torqued and twisted his body in an attempt to avoid
being run over. As a result of the impact the client incurred a number
of symptoms including:
• Headaches
• Tinnitus in his left ear
• Left jaw pain
• Neck pain;
• Left shoulder pain
• Low back pain
• Bilateral buttock pain
• Insomnia
His
initial examination right after impact documented multiple contusions
with pain. Cervical and lumbar spine x-rays showed disc space narrowing
at C 5-6 and C 6-7. He was given a Toradol injection and an analgesic
prescription to fill. He was then referred to and completed physical
therapy for recovery. He also had a series of acupuncture for the pain.
Seven
months post the initial injury the client had a follow up exam. While
he had some improvements from the severity of the initial symptoms he
still had pain complaints on the left side of his neck and left
posterior shoulder. The exam notes demonstrate that palpation produced
tenderness along his left cervical paraspinous and left trapezial
musculature. Nonetheless, the medical evaluator noted the client had
achieved
permanent and stationary status. For his symptomatic
complaints, the evaluator opined that it would take 12-18 months for
full resolution of his myofascial and musculoskeletal symptoms. The
evaluator indicated that future physical therapy, acupuncture, or
referral to an orthopedist were possible future treatments. The client
engaged a personal injury attorney.
Current Findings
The
client presented for examination 22 months post the original incident
symptomatic as above. The examination as well as the diagnostic mode of
the SCENAR pinpointed the muscle-skeletal damage at the C 5, 6, 7
level, as well as T1 along with the left arm peripheral neuropathy.
As
this was a chronic condition without any new components and previously
diagnosed specifically as muscular skeletal trauma to the lower C spine
to T 1 resulting in chronic pain in that area as well as left arm
neuropathy, further diagnostics didn’t appear necessary and weren’t
being sought by the client.
Course of Treatment
The
findings were explained the findings to the client along with
information on a recommended course of therapy. Upon his consent he
began regenerative electrotherapy treatments with the SCENAR three times
per week in-office. The SCENAR therapy was applied to the asymmetries
in the affected area.
Outcomes
Over the
course of treatment the client reported decreasing pain with increasing
range of motion (ROM). As he continued to progress he was able to move
more and more freely without pain. The paresthesia in his left arm
resolved.
He was discharged after a total of nineteen
(19) treatments in a six week period. He was fully satisfied that his
goal was reached with good range of motion without pain and an overall
pain free-state.
