康复诊疗思路病例总结

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定病人进行问诊、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（哼I噪美辛），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）o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Pl、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P3O

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（lateralshifttoleft）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P3o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，在其左骼

靖上垫毛巾卷，躯干秘屈曲，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。

U4tLonF

项目结果

疼痛位置Pl、P2、P3、P4

站立P3

躯干后伸P3

身体向左持续旋转P3+

颈屈位P3-

然后身体再向右旋转

躯干向左侧移P3-

身体直立P3+

躯干向右侧移

左35°P3

直腿抬高

P3

右75°

小腿站立能力减弱

独立站立PlP3

原文：11isusefultoincludehereanexampleofhowthemanipulative

physiotherapistthinksherwaythroughapatient'sdifficultyandatypical

spinalproblem.Thisparticularexampledemonstrateshowtolinkthetheorywith

theclinicalpresentationitalsodemonstratesthedifferentcomponentsa

patient*sproblemmayhave,andhowonecomponentsmayimproveandanother

not.thispatient5disorderdemonstrateshowthetherapistmustadapther

techniquestotheexpectedandunexpectedchangesinthesymptomsandsigns.The

examplealsodemonstrateshowopen-mindedshemustbe,andhowdetailedand

inquiringher

mindmustbeinmakingassessmentof

changesandinterpretingthem.

MrL

Eighteenmonthsago,a34-year-oldfit,well-builtman(MrL)withnohistory

ofpreviousbackproblem,wakened\vithpaininhisleftbuttockareaoverthe

previous2dayshehadsufferedverybadlowlumbarbackache,whichhisdoctor

haddiagnosedasbeingviralbecausehealsohadgeneralachinginotherparts

ofhisbodyMrLdidsaythat,althoughhehad'f1u-1ikeachesal1over',his

lowerbackwastheworstareahehadbeenonholidayduringtheprevious

weekandhaddonealolof1iflingandbeenwind-surfing(anewexperiencefor

him).

Twodaysaftertheonsetofhisbuttockpainitspread,ovenight,d

owntheleftlegwithtinglingintothebigtoeareaofhisleft

foot(L5radicularsymptom).Somedayslater,thebigtoetingling

alternatedwithtinglingalongthelateralborderofhisfootandintothelateral

two

toes(SIradicularsymptom).

Atnotimepi'iorto18monthsagohadheeverhadanybacks

ymptoms,andtherewasnofamilialcomponents

Uehadundergonenumerousformsoftreatment(orthodoxandunortho

dox)over6months,butwithoutsuccess,

overaperiodoftimethesymptomseased,

buthedidnotbecomesymptomfree.Followingafall3weeksago,

whichexacerbatedhisdisorder,hehad

alumbarpuncture(whichprovednegative)andhospitaltractionfor

aweek.followingthis,hislowbackpainincreased.whenhef

irstwentforphysiotherapyhissymptomswereasfollows

wouldwakeninthemoringwithbackpainandbackstiffness,a

ndthestiffnesswouldlastforafewhours.(Unusualforanon-i

nflammatorymusculoskeletaldisoi'der.)

causedbothbackpainandleftcalfpain

wasusingindoirethacin(Indocid)suppositorieseverynight,andhe

feltthatthesewereessentialtolessentolevelofhispai

n(Perhapsthismeanstheremustbeaninflammatorycomponent)

causedhimseverebackandlegpain,bothofwhicheasedimmed

latelyonstandingupright,(thislatterfactindicatesthataLret

menttechniquethatprovokeslegpainmaynotbeavontraindica

tiontoitsuse;thetechnique,tobeeffective,mayinfactneed

toprovokelegpain.)

standingfor1minute,thepainwouldincreaseinhisbackand

wouldspreaddewnhisleg.(thisindicatesthatasustainedtechn

iquemayberequired)

onlyneurologicalchangepresentwascalfinitialphysiotherapy

treatment,whichhehadundergoneelsewhere,hadimprovedallof

hisdymptomsmarginally,thisfirstthreeofthesetrratmentsco

nsistedofPAsonL5andunilateralPAstotheleftoflatt

er,hesaid,prevokedcalfpaininrhythmwiththetechnique.on

thethirdtreatmentintermentintermittenttractionhadbeenintr

oduced,butthisdidnothelphim

AssessmentIsawhimforfirsttime5dayslater

morepositivequestioningtodeterminehisareaofpain,itwas

interestingtonotethat,althoughhisnainlowerlegpainwasp

osteriorhehadwhathedescribedas*adifferentpain*intheup

perposterolateralcalf.thesetowpainsweresometimespresentat

thesametime,butweremorefrequentlyfeltseparately.(this

tendstoindicatethattheymayarisefromtowdifferentsources-

twocomponents.)

(andhecouldnotstanderect,infacthehada1umbarkyphosis)p

rovokedpaininhisleftleg,andhewasunabletobendbackwardsbe

causeofincreasedlegpain

hadanipsilaterallistonflexion.(Iterns(2)and(3)seemtoindica

tethathehasadiscdisorder,whichisprovokingpossibleradi

cularoffendingpartofthediscisprobabymedialtothenerv

erootanditssleeve,andwi11thereforebehardertohelpby

passivemovementtechniques.)Neekflexionwhilehewaslimited

byincreasedlegpain.(Theremustbeacanalcomponentinhisdi

sorder.)Itdidnotincreasehisbackpain.(Thecauseofhisb

ackpainisprobablynotcausinghislegaspectsoftheones

tructureperhapsThedisc)

stillintheflexedposition,rotationtotheleftincreasedhis1

egpainbyabout100%.Rotationtotherightinflexiondecreasedthe

legsymptoms,slightlybutdefinitely.(itisveryhelpfulfroma

treamentpointofviewtohavedifferentresponseswiththedifferent

directionsofrotation.)Inthisman,scircumstancesitiswise,when

consideringtheselectionoftechniquetochoosetherelievingpos

itionwhileperformingtherelievingdirectionfortherotation.

theuprightposition,performingalateralshiftofhistrunkt

owardstheleftdecreasedhispain;shifttotherightslightly

increasedthesyirptoms.(Becauseofthispainresponse,thelistmu

stbedirectlyrelatedtohisdisorder.)

legraiseontheleftwas35du,causingposteriorlegpain.Ontherightit

was70du,andhosaiditcausedanuncomfortabletightfeeling,plustingling,

intheleftfootlaterally.(CrossedSLRresponse-treatmentmayneedtoinclude

mobilizingtherightSLR.)

thepowerofhiscalfinstandingdemonstratedsomeweakness,whichmayhave

beenaneurologicalweaknessbutmayalsohavebeenapaininhibitionreaction.

tostand,fromsittingonlyashorttime(halfaminute),hohadbackpainand

aseverelumbarkyphosis,whichtooksome15secondsormore(alongtime)to

dissipate.(Becausethekyphosisdevelopedsoquickly,thismeantthatthe

disordercausinghisbackpainwasverymobile.)

legpainwasminimalonfirststandingbutthengraduallyincreasedinintensity

andalsointhepainreferraldownhisleg.(Thismeantthatthedisordercausing

hislegpainhadalatentcomponent.)

legpainandhisbackpaincouldbeprovokedseparately.(Thismeantthatthere

wereatleasttwocomponentstohisdisorder.Withtheaddedinformationinnumber

(1)above,hehasatleastthreecomponents.Number(4)abovemakesitfour

components.)

wasfelteitherinthebigtoeorthelateralborderofhisfoot.(Thisindicated

thepossibilityoftwonerverootsbeinginvolved.Thiscouldmeanthattwo

intervertebraldiscsmaybeinvolved,orthepatientmayhaveananatomically

abnormalformationofthenerveroots.)

alsohadcanalmovementabnormalitiesaswellasintervertebral

jointmovementabnormalities.

MrL'sdisorderwasobviouslyatypical.Thedisccomponentseemedt

obecausinghinmoredisabilitythantheradicularaspectbuto

bviouslytheradicularaspecttookhigherpriority.Beingatypical

meansthatonehastobeveryquicktonoticethechangesin

theexaminationsignsoftheseparatecomponents,andraectwith

appropriatetechniquechanges.

Treatment

Becauseitseemedtobediscogonnic(gettingupfromsitting;wit

hanerve-rootirritation:

choiceoftechniquewouldberoation,asthesymptomsandsigns

areclearlyunilateral

roationwouldbeperformedinthe*synptom-relieving,positionan

ddirectiontoavoidprovokingpain

aheadtofurthertreamenttechnique,itseemedpossiblethatcan

alsignswouldnotimpi'oveinparallelwiththejointsigns,and

thatthereforeSLRstretchingmayberequiredlater

MrLwspositionedlyingonhisleftsidewithasupport(folde

dtowel)underhisiliaccresttogainalateralshifttothele

ftposition(himcomfortableshiftposition,seeitem(5)above).Hew

asalsopositionedinadegreeofflexiontokeephislumbarsp

ineawayfromthepainfulandmarkedlylimitedextensionposition

.Arotationofthisthoraxtotherightinrelationtothepe

Iviswasalsoadopted,andhisright19gwaskeptuponcouch

toavoidanycanaltensioning(whichwouldoccurifhisrightle

gwereallowedtohangovertheedge).Thetechniquewastorot

atehispelvistotheleft(thatis,thesamedirectionasthorav

icrotationtotheright,butperformedfrombelowupwards)asasustained

(sustainedbecauseofthelatentcomponent)gradeIV.

Duringtheperformingofthetechniquehefeltaneasingofhislegsymptoms,

whichwasafavourableindication.

Onreassessinghismovemengtsafterthetechnique,thejointmovementswere

improvedbutSLRwasunchanged.

Thetechniquewasrepeated,butmorefirmlyandforalongersustainedperiod.

Duringtheperformingofthistechniquealltinglinginhisfootdisappeared.

Followingthetechniquemovementshadfurtherimproved,but

◎SLRwasstillunchanged

◎Symptomatically,hefeltmorecomfortableandfelthecouldstand

straighter.

AfterfoursuchtreatmentsMrLwasgreatlyimproved,butSLR,althoughimproved,

wasnowherenearasmuchimprovedaswerethejointmovements.Sittingwasalso

improved.Iliscalfpowerwasnormal.Duringthisstageoftreatment,ascan

revealedposteriorciscprotrusionsslightlylateraltotheleftoftheposterior

longitudinalligamentboththeL4/5andL5/S1levels.

Becausethe,discogenic,componentwasimproved.andalsotheradicularsymptoms

wereless(pluscalfpowerimprovement),leftSLRwasusedasatechniqueand

afterfourtreatmentsessionsofthishisleftSLRbecamefullrangeandpain

free.However,therightSLRstillfelttig