1、康復(fù)診療思路病例總結(jié)我們分析的病例是一個以疼痛為主要表現(xiàn)的病人，從這篇病例中我們學(xué)習(xí)的作為一個治療師如何對病人進行問診、查體、分析的一個思路。問診，病人來找到治療師是，我們首先應(yīng)該細致的觀察病人剛進來的一個體態(tài)、面部表情、步行姿勢等，L先生進來時是彎腰駝背的體態(tài)進來的，再進行問診部分，問診的內(nèi)容主要包括癥狀、性狀（加重、減輕、24小時等）、病史。在L先生的問診過程是這樣的，18個月前他從沒有過這些癥狀，也沒有這樣的家族史。他經(jīng)歷了各種各樣的治療（傳統(tǒng)的和非傳統(tǒng)的）超過6個月，但沒有取得效果。有一段時間的癥狀緩解了，但癥狀并沒有消失。接下來的前三周，他的疾病加劇了他進行了腰椎穿刺（為陰性）并在醫(yī)

2、院做了一星期的牽引.在這之后，他的腰痛加居限當他第一次去做物理治療時他的體征如下他早上醒來時伴隨著腰痛和背部僵硬,并會持續(xù)幾個小時?？人詴r會引起背部疼痛和左小腿疼痛。他每晚使用消炎鎮(zhèn)痛栓劑（呷深美辛）,他覺得這些都是減輕他的疼痛的重要部分（這意味著很有可能有炎癥成分）。彎腰會引起他背部和腿部的劇烈疼痛，站直之后便立刻放松下來。（這一事實表明，治療技術(shù)可能不是引起腿部疼痛的禁忌癥；技術(shù)，是有效的，只是在實際上可能需要激發(fā)腿部疼痛。）這些是L先生自己訴說的情況，我們應(yīng)該詳細的記錄下來，以便后面的分析。查體及分析，通常查體和分析往往是同時進行，肌節(jié)、皮節(jié)、反射、疼痛的方式，在查體分析過程中是很關(guān)鍵的

3、，下面就來看看病例里面的查體和分析1.通過進一步詢問來確定他的疼痛情況，有趣的是，盡管他主要是小腿后部疼痛，但他主訴為小腿上、下、外側(cè)不同的疼痛，這幾個疼痛P1、P2、P3、P4有時同時存在但更多時候是分開的（這往往表明它們可能來源于幾個不同的部分）。2.站（他不能直立，事實上他有點彎腰駝背）激起了他的左腿疼痛P3,并且他無法向后彎腰（軀干后伸）,因為這樣會增加他腿部的疼痛P3o3 .頸前屈身體持續(xù)向左地旋轉(zhuǎn)使腿部腿疼痛P3達到100%然后向右旋轉(zhuǎn)減少腿部癥狀，很輕微但是很明顯。（這是非常有用的治療觀點，從不同的角度旋轉(zhuǎn)會有不同的反應(yīng)。注重手法操作的體位和方向）在這個病人的情況中，它是明智的，

4、要考慮到技術(shù)的選擇和進行方向旋轉(zhuǎn)時要選取緩解的部位）。4 .在直立位置，軀干側(cè)移到左（lateralshifttoleft）來緩解他的疼痛P3;側(cè)移到右邊時則稍微增加了癥狀。（因為這個疼痛反應(yīng)，直接關(guān)系到他的活動障礙。）5 .直腿抬高試驗左邊是35度，導(dǎo)致腿后部疼痛P3o右邊是70度,他說，這造成了一個不舒服的緊張感覺，再加上左腳的外側(cè)的刺痛感P4o6 .測試他的小腿站立能力，出現(xiàn)了一些弱點，（這可能是有神經(jīng)性的衰弱但也可能是存在疼痛抑制反應(yīng)。）7 .試圖站起來，只能堅持很短的時間（半分鐘），此時他腰部P1和腿P3疼痛和駝背加劇，歷時約15秒或更多（長時間）才能消散。（因為駝背加劇如此之快，這

5、意味著障礙引起的背部疼痛很容易變遷。）8 .他的腿部疼痛P3在剛剛站起來那一刻是最小，然后疼痛越來越劇烈。（這意味著疾病引起他的腿痛有一個潛在的因素）。9 .他的腿部疼痛P3和背部疼痛P1可能是分離的。（這意味著至少有兩個組成部分的障礙。隨著信息數(shù)量增加。綜上，他至少有2個病理因數(shù)。）10 .治療性診斷，治療師以軀干旋轉(zhuǎn)為主的治療方法：患者左側(cè)臥位，在其左骼崎上墊毛巾卷，軀干稍屈曲，先使患者骨盆向左運動，接著使胸段向右運動，持續(xù)一段時間?；颊叩奶弁吹玫搅艘粋€很好的緩解。診斷，L先生有壓迫神經(jīng)根的麻木和無力感，同時又有側(cè)彎加重的一個椎管異常的現(xiàn)象，綜合以上問診查體及分析，病人是神經(jīng)根壓迫合并椎管

6、病變。項目結(jié)果疼痛位置P1、P2、P3、P4站立P3軀干后伸P3頸屈位身體向左持續(xù)旋轉(zhuǎn)然后身體冉向右旋轉(zhuǎn)P3+P3-軀干向左側(cè)移身體直立軀干向右側(cè)移P3-P3+左35°直腿抬高右75°P3P3小腿站立能力減弱獨立站立P1P3原文：Itisusefultoincludehereanexampleofhowthemanipulativephysiotherapistthinksherwaythroughapatient'sdifficultyandatypicalspinalproblem.Thisparticularexampledemonstrateshowtoli

7、nkthetheorywiththeclinicalpresentationitalsodemonstratesthedifferentcomponentsapatient'sproblemmayhave,andhowonecomponentsmayimproveandanothernot.thispatient'disorderdemonstrateshowthetherapistmustadapthertechniquestotheexpectedandunexpectedchangesinthesymptomsandsigns.Theexamplealsodemonstr

8、ateshowopen-mindedshemustbe,andhowdetailedandinquiringhermindmustbeinmakingassessmentofchangesandinterpretingthem.MrLEighteenmonthsago,a34-year-oldfit,well-builtman(MrL)withnohistoryofpreviousbackproblem,wakenedwithpaininhisleftbuttockareaovertheprevious2dayshehadsufferedverybadlowlumbarbackache,whi

9、chhisdoctorhaddiagnosedasbeingviralbecausehealsohadgeneralachinginotherpartsofhisbodyMrLdidsaythat,althoughhehad'flu-likeachesallover',hislowerbackwastheworstareahehadbeenonholidayduringthepreviousweekandhaddonealotofliftingandbeenwind-surfing(anewexperienceforhim).Twodaysaftertheonsetofhisb

10、uttockpainitspread,ovenight,downtheleftlegwithtinglingintothebigtoeareaofhisleftfoot(?L5radicularsymptom).Somedayslater,thebigtoetinglingalternatedwithtinglingalongthelateralborderofhisfootandintothelateraltwotoes(?S1radicularsymptom).Atnotimepriorto18monthsagohadheeverhadanybacksymptoms,andtherewas

11、nofamilialcomponentsHehadundergonenumerousformsoftreatment(orthodoxandunorthodox)over6months,butwithoutsuccess.overaperiodoftimethesymptomseased,buthedidnotbecomesymptomfree.Followingafall3weeksago,whichexacerbatedhisdisorder,hehadalumbarpuncture(whichprovednegative)andhospitaltractionforaweek.follo

12、wingthis,hislowbackpainincreased.whenhefirstwentforphysiotherapyhissymptomswereasfollows1 .Hewouldwakeninthemoringwithbackpainandbackstiffness,andthestiffnesswouldlastforafewhours.(Unusualforanon-inflammatorymusculoskeletaldisorder.)2 .Coughingcausedbothbackpainandleftcalfpain3 .Hewasusingindomethac

13、in(Indocid)suppositorieseverynight,andhefeltthatthesewereessentialtolessentolevelofhispain(Perhapsthismeanstheremustbeaninflammatorycomponent)4 .Bendingcausedhimseverebackandlegpain,bothofwhicheasedimmediatelyonstandingupright.(thislatterfactindicatesthatatretmenttechniquethatprovokeslegpainmaynotbe

14、avontraindicationtoitsuse;thetechnique,tobeeffective,mayinfactneedtoprovokelegpain.)5 .onstandingfor1minute,thepainwouldincreaseinhisbackandwouldspreaddownhisleg.(thisindicatesthatasustainedtechniquemayberequired)6 .theonlyneurologicalchangepresentwascalfweakness.theinitialphysiotherapytreatment,whi

15、chhehadundergoneelsewhere,hadimprovedallofhisdymptomsmarginally,thisfirstthreeofthesetrratmentsconsistedofPAsonL5andunilateralPAstotheleftofL4.thelatter,hesaid,provokedcalfpaininrhythmwiththetechnique.onthethirdtreatmentintermentintermittenttractionhadbeenintroduced,butthisdidnothelphimAssessmentIsa

16、whimforfirsttime5dayslater1.Onmorepositivequestioningtodeterminehisareaofpain,itwasinterestingtonotethat,althoughhismainlowerlegpainwasposteriorhehadwhathedescribedas'adifferentpain'intheupperposterolateralcalf.thesetowpainsweresometimespresentatthesametime,butweremorefrequentlyfeltseparatel

17、y.(thistendstoindicatethattheymayarisefromtowdifferentsources-twocomponents.)2.standing(andhecouldnotstanderect,infacthehadalumbarkyphosis)provokedpaininhisleftleg,andhewasunabletobendbackwardsbecauseofincreasedlegpain3 .Hehadanipsilaterallistonflexion.(Items(2)and(3)seemtoindicatethathehasadiscdiso

18、rder,whichisprovokingpossibleradicularpain.theoffendingpartofthediscisprobabymedialtothenerverootanditssleeve,andwillthereforebehardertohelpbypassivemovementtechniques.)Neekflexionwhilehewaslimitedbyincreasedlegpain.(Theremustbeacanalcomponentinhisdisorder.)Itdidnotincreasehisbackpain.(Thecauseofhis

19、backpainisprobablynotcausinghislegpain.Towaspectsoftheonestructureperhaps?Thedisc?)4 .Whilestillintheflexedposition,rotationtotheleftincreasedhislegpainbyabout100%.Rotationtotherightinflexiondecreasedthelegsymptoms,slightlybutdefinitely.(itisveryhelpfulfromatreamentpointofviewtohavedifferentresponse

20、swiththedifferentdirectionsofrotation.)Inthisman'scircumstancesitiswise,whenconsideringtheselectionoftechniquetochoosetherelievingpositionwhileperformingtherelievingdirectionfortherotation.1 .Intheuprightposition,performingalateralshiftofhistrunktowardstheleftdecreasedhispain;shifttotherightslig

21、htlyincreasedthesymptoms.(Becauseofthispainresponse,thelistmustbedirectlyrelatedtohisdisorder.)2 .Straightlegraiseontheleftwas35du,causingposteriorlegpain.Ontherightitwas70du,andhesaiditcausedanuncomfortabletightfeeling,plustingling,intheleftfootlaterally.(CrossedSLRresponse-treatmentmayneedtoinclud

22、emobilizingtherightSLR.)7.Testingthepowerofhiscalfinstandingdemonstratedsomeweakness,whichmayhavebeenaneurologicalweaknessbutmayalsohavebeenapaininhibitionreaction.8 .Attemptingtostand,fromsittingonlyashorttime(halfaminute),hehadbackpainandaseverelumbarkyphosis,whichtooksome15secondsormore(alongtime

23、)todissipate.(Becausethekyphosisdevelopedsoquickly,thismeantthatthedisordercausinghisbackpainwasverymobile.)9 .Hislegpainwasminimalonfirststandingbutthengraduallyincreasedinintensityandalsointhepainreferraldownhisleg.(Thismeantthatthedisordercausinghislegpainhadalatentcomponent.)10 .Hislegpainandhis

24、backpaincouldbeprovokedseparately.(Thismeantthattherewereatleasttwocomponentstohisdisorder.Withtheaddedinformationinnumber(1)above,hehasatleastthreecomponents.Number(4)abovemakesitfourcomponents.)11 .Tinglingwasfelteitherinthebigtoeorthelateralborderofhisfoot.(Thisindicatedthepossibilityoftwonervero

25、otsbeinginvolved.Thiscouldmeanthattwointervertebraldiscsmaybeinvolved,orthepatientmayhaveananatomicallyabnormalformationofthenerveroots.)12 .Healsohadcanalmovementabnormalitiesaswellasintervertebraljointmovementabnormalities.MrL'sdisorderwasobviouslyatypical.Thedisccomponentseemedtobecausinghimm

26、oredisabilitythantheradicularaspectbutobviouslytheradicularaspecttookhigherpriority.Beingatypicalmeansthatonehastobeveryquicktonoticethechangesintheexaminationsignsoftheseparatecomponents,andraectwithappropriatetechniquechanges.TreatmentBecauseitseemedtobediscogennic(gettingupfromsitting)withanerve-

27、rootirritation:1.Thechoiceoftechniquewouldberoation,asthesymptomsandsignsareclearlyunilateral2.Theroationwouldbeperformedinthe'symptom-relieving'positionanddirectiontoavoidprovokingpain13 Thinkingaheadtofurthertreamenttechnique,itseemedpossiblethatcanalsignswouldnotimproveinparallelwiththejo

28、intsigns,andthatthereforeSLRstretchingmayberequiredlaterMrLwspositionedlyingonhisleftsidewithasupport(foldedtowel)underhisiliaccresttogainalateralshifttotheleftposition(himcomfortableshiftposition,seeitem(5)above).Hewasalsopositionedinadegreeofflexiontokeephislumbarspineawayfromthepainfulandmarkedly

29、limitedextensionposition.Arotationofthisthoraxtotherightinrelationtothepelviswasalsoadopted,andhisrightlegwaskeptuponcouchtoavoidanycanaltensioning(whichwouldoccurifhisrightlegwereallowedtohangovertheedge).Thetechniquewastorotatehispelvistotheleft(thatis,thesamedirectionasthoravicrotationtotheright,

30、butperformedfrombelowupwards)asasustained(sustainedbecauseofthelatentcomponent)gradeIV.Duringtheperformingofthetechniquehefeltaneasingofhislegsymptoms,whichwasafavourableindication.Onreassessinghismovemengtsafterthetechnique,thejointmovementswereimprovedbutSLRwasunchanged.Thetechniquewasrepeated,but

31、morefirmlyandforalongersustainedperiod.Duringtheperformingofthistechniquealltinglinginhisfootdisappeared.Followingthetechniquemovementshadfurtherimproved,butSLRwasstillunchangedSymptomatically,hefeltmorecomfortableandfelthecouldstandstraighter.AfterfoursuchtreatmentsMrLwasgreatlyimproved,butSLR,alth

32、oughimproved,wasnowherenearasmuchimprovedaswerethejointmovements.Sittingwasalsoimproved.Hiscalfpowerwasnormal.Duringthisstageoftreatment,ascanrevealedposteriordiscprotrusionsslightlylateraltotheleftoftheposteriorlongitudinalligamentboththeL4/5andL5/S1levels.Becausethe,discogenic,componentwasimproved

33、,andalsotheradicularsymptomswereless(pluscalfpowerimprovement),leftSLRwasusedasatechniqueandafterfourtreatmentsessionsofthishisleftSLRbecamefullrangeandpainfree.However,therightSLRstillfelttightanddidprovokeminimalleftlegsymptoms.ItwasdecidedtodorightSLRasthetreatmenttechnique.Thetightnessclearedandremainedclearfor4hours.ThenexttreatmentsessionconsistedofperformingSLRoneachlegandendin