Physiotherapy Of Neck Stiffness Pain And Headaches - Fictitious Case Study - Nursing Assignment Help

Assignment Task -

Fictitious scenario -

Physiotherapy consultation :

Patient: Susie Smith, 28 year old primary school teacher. 

Therapist: John Jones

This is Susie’s second consultation with John Jones, a physiotherapist in private practice. She first attended 4 days ago, reporting neck stiffness, pain and headaches.
Today you are here to observe, but prior to the observation John told you a brief summary of the initial assessment: 

“Susie reported pain over her neck and upper traps, right greater than left. Her headaches were in the occipital region, and clearly linked to her neck. No red flags like dizziness or anything. Aggravating factors included marking students book work and computer work at home. She didn’t have a specific thing that caused it, reckons it came on gradually over the past 6 months or more. Her movements were all generally restricted, especially rotation and lateral flexion to the right, cervical joints were all stiff, especially her right C3-6 facet joints, and I found some pretty significant trigger points in her traps too. Her posture’s pretty shocking as you’ll see. I loosened up her neck with some mobilisations, stuck some acupuncture needles in the trigger points and gave her some chin tuck exercises to do – some immediate improvement on the day, hope it’s been maintained!”

John asks Susie in from the waiting room and confirms her consent to your observation. After exchanging pleasantries John enquires about her neck. Susie replies:

“It’s better, but not great, still taking paracetamol after work and I’m dreading report writing next week! I think the treatment helped, and I generally feel a bit better after I’ve done the chin tucks which is good.”

John asks to assess her neck movement. You observe she does have a somewhat kyphotic thoracic posture, with forward head position. Her cervical spine movements are approximately 40°flexion, 60°extension, 15°lateral flexion to the right, 20°lateral flexion to the left, 45°rotation to the right, 60°rotation to the left. Susie grimaces at the end of range of rotation and lateral flexion to the right and reports it is painful. John seems happy with this, telling Susie that her movements were better than last time.  He asks her to show him her chin tuck, and she performs the movement in standing. You notice she has a reasonable concept of the action, completing upper cervical flexion on lower cervical extension to flatten her excessively lordotic cervical spine, but she only holds it for a second before returning to her starting position. John confirms with her that she’s doing this “a few times a day”. He then asks her to lie prone and palpates her spine, telling you that she’s “tight” over both sides and centrally. He indicates to you that she still has marked trigger points in her upper traps bilaterally also. 

He outlines his treatment plan to Susie:

“I’ll just do what I did last time, yeah? I’ll free up these joints for you and then needle those trigger points again?”

Susie implies consent. You observe him mobilise her cervical spine bilaterally from C3-6 (Maitland A-P, grade III, approximately 1 min for each joint), then watch as he places 6 acupuncture needles in her trigger points. He leaves these in for about 3 minutes while he writes her an exercise program. When he removes the needles, he reassesses her movements. These have all improved by about 10 degrees, and Susie reports there is less pain. 

They run through the exercise program together. John has given her two new exercises: chin tucks in prone to “strengthen her deep cervical muscles” (3 sets of 10 per day), nose to armpit stretch “for her upper traps” (hold 20 seconds, 3 times a day) and given her a handout sheet on office ergonomics. Susie makes an appointment to return to see John again in a week and you thank her for allowing you to observe the appointment.

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