Top 5 Fridays! 5 Interesting/Odd Cases from this Month | Modern Manual Therapy Blog

Top 5 Fridays! 5 Interesting/Odd Cases from this Month


Here are 5 recent cases that I either found interesting, frustrating, or just plain odd.


1) Something is "Off"
  • my current intern saw an older male patient two days ago, who returned after DC 6 weeks ago
  • I filled him in on what I had found previously, and what treatments and HEP he was doing
  • should have been a simple re-eval, but my student's gut told him something was "off" about the presentation
    • he was previously coming in for LBP, and had new severe onset of TL junction area pain
    • it was bilateral with severe tenderness to touch
    • it turns out after more questioning, the patient had been feeling feverish that morning, and his urine was "very dark, and it's never like that"
  • we immediately referred him to his PCP, who diagnosed him with a kidney infection and put him on antibiotics, which directly leads to the following case
2) Life's Necessities
  • I inherited a patient previously treated by my last intern for HA, cervical pain and TMD
  • she stopped coming for about 6-8 weeks, then ended up on my schedule
  • notoriously non-compliant including
    • not doing her exercises regularly
    • refusing not to sit in a recliner that made her worse
    • would "forget" to work on her posture, breathing.... etc...
  • I spent several weeks with her, with transient relief after each session, enough to get her through several dentists appointments, but her HA always returned
  • the first patient was her husband, and she told me that he does not drink enough water
  • knowing she was always complaining about HA, plus has severe dry skin on her hands (always wears gloves), I asked her how much water she drinks
  • the reply, "I don't drink water, it tastes bad."
  • she drinks 1 coffee a day, 1 pop (soda for the rest of you), and a small glass of water at the end of the day
  • what followed was all kinds of arguments about dehydration, how it could lead to HA, etc.... and how water was pretty much a necessity of life
  • she kept saying, it was impossible, or she couldn't do it
  • I explained it just her choice not to do it, and of her HEP, posture, breathing, etc... the EASIEST thing we have ever asked her to do
  • she asked if she could "ramp up" to 5-6 glasses a day, and by now if in a week she could just go with 2 small glasses
  • after several more useless minutes of education and failed persuasion, I treated her, then she said she would try
  • I wanted to go all Yoda on her but ended up telling trying is not enough and tells me she is not going to do it
  • I also told her not to schedule again until she tries hydrating regularly
  • to top all this off, she is a nurse
3) You're Not Going to Want to See Me After Today

  • Recent eval was a OOW (25+ years) mid 40s male who had an odd presentation of brachial plexus/right shoulder injury made worse after surgery
  • his right chest wall, scapula, GH were denervated as was his upper arm, but he had full use of his hand
  • chronic right sided cervical pain
  • he started off with, "You're not going to want to see me after today..."
  • I like a challenge, but this is how it went down
  • I spent about 35-40 minutes using pain science explanations about his arm, cervical MRIs etc as a neurosurgeon wants to perform surgery for his neck pain
  • most of this was met with eye rolls, so I attempted to find a directional preference 
  • as I expected his cervical retraction and SB was limited to the right, but mild postural correction was painful
  • I attempted light cervical retraction into a pillow in supine and gave that for HEP
  • when instructing him on how to use a lumbar roll for HEP, he said, I don't own a chair
    • my reply, "What? Seriously?" 
    • Patient: "Yes, and I can't do the previous exercise in bed either, I haven't slept in my bed for 20+ years."
  • apparently he spends all day and night on the same couch
  • I told him to do his best
  • on the second follow up, he said he was worse, so I shook his hand, wished him good luck and for 25 minutes tried to convince him not to get surgery
  • his friend apparently even had the same fusion and was worse, yet he was still considering it... sigh....
  • he was right on the first visit though, I absolutely do not want to see anyone who can't be bothered to own a chair

4) Lifting "Patients"

  • 30 yo female, saw at least 5-6 other practitioners and had everything from KT, to manipulation, stabilization, but not MDT
  • this case was part 2 of what got me in a clinical funk, similar case to my COTW posted two days ago
  • both of these cases were young females, who had similar HA presentations, and did not respond rapidly (seeing them both on the same days)
  • on the first visit, this patient told me she was a lab researcher, doing cardiac research
  • she said her job involved prolonged sitting, using microscopes
  • after the first visit of postural correction, IASTM to cervical spine and occiput contours plus subcranial shear distraction she reported 98% improvement in cervical spine pain, and 75% improvement in her HA
  • the third visit she was worse, and could not attribute it to anything
  • tried the above, plus some balloon breathing with only mild relief
  • no change for 2 more visits, and working more on breathing, changing up ther ex, adding thoracic manipulation and RockTape for postural awareness
  • on her most recent visit, she came hobbling in to the clinic, literally looking like she had been hit by a car
  • she worked out so hard in a boot camp class that she had to take off of work the day before, which was 48 hours after
  • upon further questioning, her current non class workouts involve squats and lunges holding dumbbells in shoulder flexion at 90, and scaption at 90, with straight arms held statically
  • she does this 3-4 times/weekly as this is how she transfers patients at work 1-2 days/week
  • my intern and I had suggestions on how to transfer patients, using a gait belt, but they had no belts
  • I said try their pants, she then said the "patients" were anesthetized sheep, each one weighing 120 pounds, that she is transferring from one table to another straight armed 
    • keep in mind this was after 10 minutes of calling them patients and teaching her transfer techniques!
  • no line of initial evaluation questioning could have brought that out, especially when the patient insists they are not doing anything to aggravate their condition
  • bottom line: if someone has 75-98% improvement after 1 visit, with having no improvement for years from other clinicians, then immediately regresses, it's always something that is causing it, or 120# somethings combined with squatting and lunging with the same lifting patterns
  • previously, her HA went away for 1 year after going gluten free, but came back after working 1 year on her current job
  • current solution may be gluten, MDT, and proper transfer mechanics, plus strength training 

5) 75 yo Lucky Guy

  • a current favorite patient of mine, 75 yo, very cheery gentleman who fell skiing 3 years ago and had right hip pain ever since
  • he saw a chiro for 2 years until a recent flare up
    • he was backing up his car with the door open
    • he slipped on his wet driveway, fell out of his car, landed on his right hip again, and watched in slow motion movie style as the car door went over his head
    • he then got back into the car, and prevented it from smashing into his house
  • he's a lucky guy because at his age, either one of these falls could  have lead to a rapid decline in health as shown by fall research
  • naturally, as a pattern I blog about often, he had limited SGIS to the right
  • some prolonged rotation in flexion, with pressure on/pressure off oscillations to load the right side completely abolished his right hip pain
  • right hip was still limited in all planes - most likely a slow responder, but he felt the best he had in 3 years
  • gave this as a HEP
  • he followed up the next day, COMPLETELY non-compliant but still felt nearly 100% better
  • I tried to tell him he had to be compliant for prevention sake
  • I realized I had no rational argument since he was better despite being non compliant
  • the plan is to follow up 3-4 more times to work on his slow responding hip and monitor his rapidly responding lumbar spine

It's been a few weeks of interesting and sometimes frustrating cases, but mostly fun, and in the end always satisfying to help those who can actually help themselves.

Keeping it Eclectic...


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4 comments:

  1. "to top all this off, she is a nurse"-good heavens ha!

    ReplyDelete
  2. Prolonged rotation in flexiom? Is that r side lying?

    ReplyDelete
  3. Yes, for ipsilateral loading/closing the involved side

    ReplyDelete