Application brief #9403-BH-2
submitted by Jill Speer LPT, based on case history.
Physical symptoms: Patient's chief complaint was of constant achy pain originating in the central occiput and radiating to the spinous process of C7, also complained of cervical stiffness and muscle spasm in her bilateral cervical paraspinals and levators. Symptoms have been present daily for greater than five years. Patient presented with a severe forward head, thoracic kyphosis and bilateral protracted scapulae. She reported tenderness to palpation in her bilateral cervical paraspinals, upper traps and over the spinous process of C7. Cervical range of motion was 75% of normal for all motion. Patient was working as an RN in a gynecologist's office and stated her pain was disrupting her work schedule. She frequently rested (1-2 times a day at work) for 20 minutes and applied cryotherapy to her C spine which diminished her symptoms for several hours. Previous treatment had consisted of chiropractic adjustment which significantly decreased her discomfort. Immediately prior to seeking treatment at our facility, the patient had been receiving physical therapy for five weeks, initially three times a week for three weeks, then two times a week for two weeks. Her treatment consisted of cryotherapy, electrical stimulation, ultrasound, moist heat, iontophoresis and exercise. She reported decreased discomfort for 1-2 hours post treatment, but states that her ability to function during the work day was not improved. Past medical history was significant for partial L5/S1 discetomy, repair of umbilical hernia, right TMJ dysfunction and Addison's disease.
Method: The following acupuncture points were treated starting distally and treating towards the spine: LI 4, SI 3, SJ 5, GB 21, and GV 14 or 30 seconds each, then UB 10 and GB 20 for 15 seconds each. One probe was used with the patient completing the circuit by holding the wand in her hand.
Settings used: Acutron Mentor preset Probe #4. or specific settings:
Intensity 25 µa
Timer: 30 seconds
Other therapies: Pharmaceuticals (aspirin), cryotherapy and exercise. Cryotherapy was used to the cervical spine either pre or post microcurrent treatment. Patient performed cervical and thoracic flexibility exercises, postural exercises post cryotherapy and microcurrent and at home at least two times daily. Patient was also performing cardiovascular exercise 1-1 1/2 minutes daily, 3-4 times weekly.
Average results: Excellent Good Fair Poor
Response to TX:
Carryover of results: