CAS CLINIQUE EN ANGLAIS

FRENCH VERSION

1. Present complaint
2. History
3. Past history
4. Family history
5. General health
6. Posture
7. Active movements
8. Passive movements
9. Diagnosis
10. Treatment

1) Present complaint

Pain in the neck and headache. In the cervical spine on the leftside the pain is like a dull toothache extending from the nape of the neck to the upper cervicals. On the right side the pain is very severe and slightly burning in quality associated with sharp twinges on attempt of movement and very localised mid-distance between the mastoid process and the cervico-dorsal junction.
This is associated with unilateral headache on the right in a patchy distribution sub-occipital and frontal over the right eyebrow. The quality of this headache is dull and constant.
There is no associated visual disturbances or pain spreading in the upper extremity.

1) History

The onset was acute. This morning at 7.30 am the patient washed her shoulder-length hair and, in order to dry her scalp with a towel, bent forwards to let her hair free in front of her face.
Then briskly rubbed her head. After a few seconds of so doing, she felt "something" go in her neck. As she kept rubbing, a sharp pain developed in the middle of the right side of the neck. Within a few minutes she found herself in agony and had to stop the process. She struggled to get dressed and within half an hour, her neck completely stiffened. Any attempted movements i.e. looking to either side, up or down and even reaching with the overstreched right arm was associated with sharp pain in the cervical spine. She could carry her handbag with the shoulder strap on the left side of her body. Was comfortable when still but supporting her head was not making any difference.

3) Past history

There was no previous history of spinal complaint. At eighteen years of age she sprained her left ankle stepping down from a kerb, recovered within three weeks and had no complaint since.
She enjoys a game of squash as a hobby. No history of fracture or traumatic accident.

4) Family history

Her mother is under osteopathic treatment for a recurrent interscapular pain. No history of rheumatoid or ankylosing arthritis.

5) General health

Her general health is very good, Wt. 56kg, Ht. 1.64m. Diet is mixed. She is not a vegetarian and is not under treatment with her family doctor. Has been taking the pill for the last four years, does not complain of any side effect and goes for regular check-ups at the family planning clinic.

6) Posture

The patient was acute and needed help to be undressed to her bra and underpant.
The head was held rigidly in a position of mid-flexion and sidebending to the left. The shoulders were braced and shrugged, the right one slightly higher than the left. The weight bearing was stable on both feet with a fair base of support. Intermittently she presented a mild postural nystagmus to the left. Her general morphological proportions were balanced and a good development of her muscular system was noticed.

7) Active movements

All active movements of the head and neck were limited and painful, the only possible movements were flexion and sidebending to the left, mainly taking place in the upper cervicals.
Any attempt of extension and sidebending-rotation to the right produced painful spasms and were not pursued. Elevation of the upper limbs were performed slowly. Full range of movements were obtained on the left but not on the right as discomfort was expressed by the patient. Active movements of the dorso-lumbar were normal.

8) Passive movements

The patient was asked to lie down but did so in a grotesque fashion in order to avoid too much pain. With the practitioner's help she sat on the left side of the treatment couch, lowered herself onto her left, taking great care all the time to keep her neck in a steady flexion and side-bending to the left, sunk her left cheek into the pillow and finally rolled into supine position. The head-flap of the table was raised to increase flexion for the patient's comfort.
The muscles were carefully palpated from the mid-dorsal to the forehead areas. On the left side they felt increased in tone associated with an overcrowded feel and on the right side a definite leathery and unyielding feel dominated from the cervicodorsal to the occiput. Particular attention was paid to the suboccipital area. The insertion of the trapezius, semi-spinalis capitis and all the small muscles of the sub-occipital triangle were found to be tender to palpation and presented a very solid feeling to pressure. Localised assessment of the upper cervical segments was possible and mobility was found to be within normal ranges.
From C4 to C6 on the right side the patient could just bear the contact of the practitioner's hand. This area felt very tense and solid with intermittent flickering of the deep, short postural muscles associated with the occasional more uncontrollable muscular spasms of the long muscles bringing the neck in further flexion. The apex of the side-bending was at the level of C4-C5 joint and the right transverse processes were more easily felt at this level. Very gentle traction-compression was performed with the head in the original protected position. If anything, compression gave marginal relief. All the passive movements confirmed the findings of the previous active assessment. Ho swelling was felt. There were no neurological signs or symptoms and reflexes were present and equal bilaterally in the upper and lower limbs.

9) Diagnosis

The patient is suffering from a capsulo-ligamentous condition affecting the C4-C5 rightt apophyseal joint due to a jarring trauma in flexion. The sudden overstretch of the capsuloligamentous system led to a massive muscular response (spasms associated with the dramatic reduction of mobility which was well illustrated by the patient's presentation.

10) Treatment

On the left side: cross fibre soft tissue from the cervico-dorsal junction to the upper cervicals. On the right side: longitudinal soft tissue to the Trapezius, Levator Scapulae and Spinalis Capitis etc... and gentle cross fibre technique to the small muscles of the suboccipital triangle combined with an element of traction and release. General soft tissue manoeuvres were also applied to the Occipitalis and Frontalis muscles. Very careful articulator"· techniques were performed to the midcervicals and a "momentum induced" HVT delivered to C 5 in flexion with minimal sidebending right and rotation left. This was accompanied by a low pitch, "non-metallic" noise. The treatment ended by checking the active movements as previously done, marginal improvement was noted but pain remained the principal restricting factor. The patient was advised to wear a loose scarf, silk or wool, round the neck not aiming at support (collar) but to keep the muscles at constant temperature (warmth}). Intermittent active and relaxing movements were encouraged: to walk with shoulders relaxed and arms loose (but to avoid the jerky soldier type of walk) and slow but steady movements of the head and neck, i.e. flexion, extension and rotation. No off-work certificate was delivered.

Two days later...

The night following the first treatment was not comfortable, the patient woke up three times turning in bed and resorted to taking.
two Neurofen tablets. Improvement was noticed at the end of the first day and thereafter. The headache was gone and the painful spasms were only elicited if a sudden and jerky right rotation was performed. All active movements were improved and the patient could overstretch freely her right arm. General soft tissue and articulatory techniques were given, similar to the first treatment. Ho HVT (high velocity and low amplitude technique) was judged necessary. This second visit was kept to a minimum; fifteen minutes was the approximate treatment time.

Five days later...

Sleep was back to normal. Extension and rotation to the right were near to normal. On passive assessment a "rubbery" sensation was felt at the extreme of these ranges. Deep and firm soft tissue was given to the cervical spine on the right side, more than on the left, to the deep and short postural muscles and the long more superficial prime movers. Particular attention was given to the right suboccipital muscles. Traction and release ended the treatment. Twenty to twenty five minutes was spent for' this third visit.

The patient was provisionally discharged.