Neck Pain: A Case Study

890 Words 4 Pages
This is a 32-year-old male with a 7/3/2014 date of injury, due to a MVA.

DIAGNOSIS; Cervical spin e S/S, Lumbar spine S/S, Left shoulder S/S

12/08/15 progress note describes that the patient complains of neck pain at a 6/10-scale level; low back pain at a 6-7/10-scale level, which radiates to the right leg; left shoulder pain at a 4/10-scale level, which radiates to the left arm; and sleep problems. PE revealed slight to moderate spasticity and tenderness over the para-cervical muscles. ROM of the cervcal spine is decreased by 15 %. The foraminal Compression Test and Distraction Test were positive. There were discrepancies in sensory and reflex. There was pain on flexion and extension. There were also discrepancies noted in the girth measurements
…show more content…
The request is for PT for 1hr Lumbar & cervical spine, Physiotherapy 2 x 4 Lumbar & cervical spine, Acupuncture 2 x 4 Lumbar & cervical spine, Chiro 2 x 4 Lumbar & cervical spine, EMG/NCV/SSSEP of the cervical spine and left upper extremities, Work conditioning x 6 Lumbar & cervical spine, Work hardening x 6 for Lumbar & cervical spine
Treatment: cane,OVs, mod activity, meds, MRI LS & CS,PT x 6 Lowback & neck, Acupuncture x 6 Lowback & neck.
…show more content…
In addition, a request to initiate treatment would make it reasonable to require documentation of objective functional deficits, and functional goals for an initial trial of 6 chiropractic/manipulation treatment. CA MTUS states using cervical manipulation may be an option for patients with neck pain or cervicogenic headache, but there is insufficient evidence to support manipulation of patients with cervical radiculopathy. The progress report denotes that the patient has radiculopathy. Guidelines do not support neck and low back chiropractic treatment in patients with radiculopathy. Recommend non-certification.

EMG/NCV/SSSEP of the cervical spine and left upper extremities, CA MTUS criteria for EMG/NCV of the upper extremity include documentation of subjective/objective findings consistent with radiculopathy/nerve entrapment that has not responded to conservative treatment. The patient has neck pain; low back pain, which radiates to the right leg; left shoulder pain, which radiates to the left arm; and sleep problems. There were discrepancies in sensory and reflex of LE. There was pain on flexion and extension of LE. EMG/NCS/sSSEP seem medically appropriate and necessary. Recommend

Related Documents