康复诊疗思路病例总结我们分析的病例是一个以疼痛为主要表现的病人，从这篇病例中我们学习的作为一个治疗师如何对病人进行问诊、查体、分析的一个思路。

问诊，病人来找到治疗师是，我们首先应该细致的观察病人刚进来的一个体态、面部表情、步行姿势等，L先生进来时是弯腰驼背的体态进来的，再进行问诊部分，问诊的内容主要包括症状、性状（加重、减轻、24小时等）、病史。

在L先生的问诊过程是这样的，18个月前他从没有过这些症状,也没有这样的家族史。

他经历了各种各样的治疗(传统的和非传统的)超过6个月,但没有取得效果。

有一段时间的症状缓解了,但症状并没有消失。

接下来的前三周,他的疾病加剧了,他进行了腰椎穿刺(为阴性)并在医院做了一星期的牵引.在这之后,他的腰痛加剧。

当他第一次去做物理治疗时他的体征如下他早上醒来时伴随着腰痛和背部僵硬,并会持续几个小时。

咳嗽时会引起背部疼痛和左小腿疼痛。

他每晚使用消炎镇痛栓剂(吲哚美辛),他觉得这些都是减轻他的疼痛的重要部分(这意味着很有可能有炎症成分)。

弯腰会引起他背部和腿部的剧烈疼痛,站直之后便立刻放松下来。

(这一事实表明,治疗技术可能不是引起腿部疼痛的禁忌症;技术,是有效的,只是在实际上可能需要激发腿部疼痛。

)这些是L先生自己诉说的情况，我们应该详细的记录下来，以便后面的分析。

查体及分析，通常查体和分析往往是同时进行，肌节、皮节、反射、疼痛的方式，在查体分析过程中是很关键的，下面就来看看病例里面的查体和分析1.通过进一步询问来确定他的疼痛情况,有趣的是,尽管他主要是小腿后部疼痛，但他主诉为小腿上、下、外侧不同的疼痛，这几个疼痛P1、 P2、 P3、 P4有时同时存在但更多时候是分开的 (这往往表明它们可能来源于几个不同的部分)。

2.站(他不能直立,事实上他有点弯腰驼背)激起了他的左腿疼痛P3,并且他无法向后弯腰(躯干后伸),因为这样会增加他腿部的疼痛P3。

3.颈前屈身体持续向左地旋转使腿部腿疼痛P3达到100%，然后向右旋转减少腿部症状,很轻微但是很明显。

(这是非常有用的治疗观点，从不同的角度旋转会有不同的反应。

注重手法操作的体位和方向)在这个病人的情况中，它是明智的,要考虑到技术的选择和进行方向旋转时要选取缓解的部位）。

4.在直立位置,躯干侧移到左（ lateral shift to left ）来缓解他的疼痛P3;侧移到右边时则稍微增加了症状。

(因为这个疼痛反应,直接关系到他的活动障碍。

)5.直腿抬高试验左边是35度,导致腿后部疼痛P3。

右边是70度,他说,这造成了一个不舒服的紧张感觉,再加上左脚的外侧的刺痛感P4。

6.测试他的小腿站立能力，出现了一些弱点,（这可能是有神经性的衰弱但也可能是存在疼痛抑制反应。

）7.试图站起来，只能坚持很短的时间 (半分钟),此时他腰部P1和腿P3疼痛和驼背加剧,历时约15秒或更多(长时间)才能消散。

(因为驼背加剧如此之快,这意味着障碍引起的背部疼痛很容易变迁。

)8.他的腿部疼痛P3在刚刚站起来那一刻是最小，然后疼痛越来越剧烈。

(这意味着疾病引起他的腿痛有一个潜在的因素)。

9.他的腿部疼痛P3和背部疼痛P1可能是分离的。

(这意味着至少有两个组成部分的障碍。

随着信息数量增加。

综上,他至少有2个病理因数。

)10.治疗性诊断，治疗师以躯干旋转为主的治疗方法：患者左侧卧位，在其左髂嵴上垫毛巾卷，躯干稍屈曲，先使患者骨盆向左运动，接着使胸段向右运动，持续一段时间。

患者的疼痛得到了一个很好的缓解。

诊断，L 先生有压迫神经根的麻木和无力感，同时又有侧弯加重的一个椎管异常的现象，综合以上问诊查体及分析，病人是神经根压迫合并椎管病变。

原文：It is useful to include here an example of how the manipulative physiotherapist thinks her way through a patient's difficulty and atypical spinal problem. This particular example demonstrates how to link the theory with the clinical presentation it also demonstrates the different components a patient's problem may have, and how one components may improve and another not. this patient' disorder demonstrates how the therapist must adapt her techniques to the expected and unexpected changes in the symptoms and signs. The example also demonstrates how open-minded she must be, and how detailed and inquiring hermind must be in making assessment ofchanges and interpreting them.Mr LEighteen months ago ,a 34-year-old fit,well-built man (Mr L)with no history of previous back problem,wakened with pain in his left buttock area over the previous 2 days he had suffered very bad low lumbar backache ,which his doctor had diagnosed as being viral because he also had general aching in other parts of his body Mr L did say that ,although he had 'flu-like aches all over',his lower back was the worst area he had been on holiday during the previous week and had done a lot of lifting and been wind -surfing(a new experience for him).Two days after the onset of his buttock pain it spread,ovenight,down theleft leg with tingling into the big toe area of his left foot(? L5 radicular symptom). Some days later, the big toe tingling alternated with tingling along the lateral border of his foot and into the lateral two toes (? S1 radicular symptom).At no time prior to 18 months ago had he ever had any back symptoms, and there was no familial componentsHe had undergone numerous forms of treatment (orthodox and unorthodox )over 6 months , but without success.over a period of time the symptoms eased, but he did not become symptom free.Following a fall 3 weeks ago, which exacerbated his disorder, he hada lumbar puncture(which proved negative )and hospital traction for a week .following this ,his low back pain increased .when he first went for physiotherapy his symptoms were as follow s1.He would waken in the moring with back pain and back stiffness ,and the stiffness would last for a few hours.(Unusual for a non-inflammatory musculoskeletal disorder.)2.Coughing caused both back pain and left calf pain3.He was using indomethacin (Indocid)suppositories every night ,and he felt that these wereessential to lessen to level of his pain(Perhaps this means there must be an inflammatory co mponent)4.Bending caused him severe back and leg pain ,both of which eased immediately on standing upright.(this latter fact indicates that a tretment technique that provokes leg pain may notbe a vontraindication to its use;the technique ,to be effective ,may in fact need to provoke leg pain.)5.on standing for 1 minute ,the pain would increase in his back and would spread down his leg.(this indicates that a sustained technique may be required)6.the only neurological change present was calf weakness.the initial physiotherapy treatment,which he had undergone elsewhere ,had improved all of his dymptoms marginally ,this first three of these trratments consisted of PAs on L5 and unilateral PAs to the left of L4.the latter ,he said ,provoked calf pain in rhythm with the technique .on the third treatment interment i ntermittent traction had been introduced, but this did not help himAssessment I saw him for first time 5 days later1.On more positive questioning to determine his area of pain ,it was interesting to note that,although his main lower leg pain was posterior he had what he described as'a different pain' i n the upper posterolateral calf .these tow pains were sometimes present at the same time ,b ut were more frequently felt separately .(this tends to indicate that they may arise from tow different sources-two components.)2.standing (and he could not stand erect,in fact he had a lumbar kyphosis )provoked pain in his le ft leg,and he was unable to bend backwards because of increased leg pain3.He had an ipsilateral list on flexion .(Items(2)and(3)seem to indicate that he has a disc disorder ,which is provoking possible radicular pain.the offending part of the disc is probaby medi al to the nerve root and its sleeve ,and will therefore be harder to help by passive movement techniques. )Neek flexion while he was limited by increased leg pain.(There must be a canal c omponent in his disorder .)It did not increase his back pain .(The cause of his back pain is pro bably not causing his leg pain.Tow aspects of the one structure perhaps? The disc?)4.While still in the flexed position ,rotation to the left increased his leg pain by about 100%.Rotati on to the right in flexion decreased the leg symptoms ,slightly but definitely .(it is very helpful fro m a treament point of view to have different responses with the different directions of rotation.)I n this man's circumstances it is wise ,when considering the selection of technique to choose the relieving position while performing the relieving direction for the rotation.5.In the upright position ,performing a lateral shift of his trunk towards the left decreased hispain ;shift to the right slightly increased the symptoms.(Because of this pain response ,the lis t must be directly related to his disorder.)6.Straight leg raise on the left was 35du, causing posterior leg pain. On the right it was 70du,and he said it caused an uncomfortable tight feeling, plus tingling, in the left foot laterally.(Crossed SLR response-treatment may need to include mobilizing the right SLR.)7.Testing the power of his calf in standing demonstrated some weakness, which may havebeen a neurological weakness but may also have been a pain inhibition reaction.8.Attempting to stand, from sitting only a short time (half a minute), he had back pain and asevere lumbar kyphosis, which took some 15 seconds or more (a long time) to dissipate.(Because the kyphosis developed so quickly, this meant that the disorder causing his back pain was very mobile.)9.His leg pain was minimal on first standing but then gradually increased in intensity and alsoin the pain referral down his leg.(This meant that the disorder causing his leg pain had a latent component.)10.His leg pain and his back pain could be provoked separately.(This meant that there wereat least two components to his disorder. With the added information in number (1)above, he has at least three components. Number(4)above makes it four components.)11.Tingling was felt either in the big toe or the lateral border of his foot.(This indicated thepossibility of two nerve roots being involved. This could mean that two intervertebral discsmay be involved, or the patient may have an anatomically abnormal formation of the nerve roots.)12.He also had canal movement abnormalities as well as intervertebral joint movement abnormalities.Mr L's disorder was obviously atypical. The disccomponent seemed to be causing him more d isability than the radicular aspect but obviously the radicular aspect took higher priority .Being atypical means that one has to be very quick to notice the changes in the examination signsof the separate components ,and raect with appropriate technique changes.TreatmentBecause it seemed to be discogennic (getting up from sitting )with a nerve -root irritation:1.The choice of technique would be roation ,as the symptoms and signs are clearly unilateral2.The roation would be performed in the 'symptom-relieving' position and direction to avoidprovoking pain3.Thinking ahead to further treament technique ,it seemed possible that canal signs wouldnot improve in parallel with the joint signs ,and that therefore SLR stretching may be required la terMr L ws positioned lying on his left side with a support (folded towel)under his iliac crest to g ain a lateral shift to the left position (him comfortable shift position ,see item(5)above).He w as also positioned in a degree of flexion to keep his lumbar spine away from the painful and markedly limited extension position .A rotation of this thorax to the right in relation to the pe lvis was also adopted ,and his right leg was kept up on couch to avoid any canal tensioning (w hich would occur if his right leg were allowed to hang over the edge ).The technique was to r otate his pelvisto the left (that is ,the same direction as thoravic rotation to the right, but performed from below upwards) as a sustained (sustained because of the latent component) grade IV.During the performing of the technique he felt an easing of his leg symptoms, which was a favourable indication.On reassessing his movemengts after the technique, the joint movements were improved but SLR was unchanged.The technique was repeated, but more firmly and for a longer sustained period. During the performing of this technique all tingling in his foot disappeared. Following the technique movements had further improved, but◎SLR was still unchanged◎Symptomatically, he felt more comfortable and felt he could stand straighter.After four such treatments Mr L was greatly improved, but SLR , although improved, was nowhere near as much improved as were the joint movements. Sitting was also improved.His calf power was normal. During this stage of treatment, a scan revealed posterior disc protrusions slightly lateral to the left of the posterior longitudinal ligament both the L4/5 and L5/S1 levels.Because the, discogenic, component was improved, and also the radicular symptoms were less(plus calf power improvement), left SLR was used as a technique and after four treatment sessions of this his left SLR became full range and pain free. However,the right SLR still felt tight and did provoke minimal left leg symptoms. It was decided to do right SLR as the treatment technique .The tightness cleared and remained clear for 4 hours.The next treatment session consisted of performing SLR on each leg and ending the session with a repeat of the previous positioning and rotation technique. It was decided to stop treatment(unless he had an exacerbation) and review all aspects in a month. The assessment after a month revealed that he had not only retained all of the improvement from treatment but also found he could sit, stand and be much more active. His movements were full and almost free of any discomfort. He was reviewed again after 2 months and discharged. Aspects of ‘back care’, especially in relation to the ‘weak link’, the capacity for harm to accumulate painlessly and the need to be aware of predisposing factors (see Appendix 4) were forcibly emphasized.This presentation emphasizes that the manipulative physiotherapist must understand the pathology that may be involved in such a patient’s disorder, yet she must take most notice of the changes in symptoms and signs. For example, the fact that his disorder may have been progressing towards a nerve-root compression did not prevent SLR being used as treatment, because the possible nerve condition signs were improving and the possible radicular symptoms were also improving. Nevertheless, the first SLR mobilization had to be done only once, and that once was a mild stretch. The 24-hours assessment indicate that it should be continued with care.。