A 68 year old female who was referred to Melanie Massey Physical Therapy with a diagnosis of neck pain. She was initially evaluated on 9/28/11, and was seen for a total of 5 treatment sessions.
The patient had complaints of chronic neck pain for 17 years, which effected her sleep patterns and quality of life, and she had a cervical fusion surgery @ C5-6 & C6-7 over 10 years ago. At the time of the evaluation, Mrs. T also had complaints of headaches and radiating pain into her head, back, and bilateral upper extremities. She had complaints of severe neck pain and pain into her arm with washing clothes, house cleaning, and lying on her back. She presented in the clinic with decreased strength, decreased cervical motion,and muscle tightness leading to poor posture. Her score on the Neck Disability Index at the time of the evaluation was 56%, which is classified as severe disability.
Treatment: Manual therapy (including segmental cervical mobilization), stretching, strengthening, HEP, pt. education, modalities
Progress: This patient met all of her goals with physical therapy by 10/10/11, including increased arm strength, increased range, and independence with home program. Her score on the Neck Disability Index at discharge was 8%, which is classified as WFL.
At the time of discharge, she was able to complete a full day of regular activity with no pain, including personal care, reading, work, driving, sleeping, and recreational activities.
Please feel free to contact us if you should have any questions.