The following are actual case studies on clients who have been seen at Gaston Rehab Associates, Inc.

Case Study Number One:

Referral Diagnosis: Neck and Shoulder Pain

History: 62 year old male that was referred from his Neurosurgeon with a diagnosis of Cervicalgia (neck pain) and shoulder pain. Client had reported that for quite some time (months) that he was having pain in his neck, shoulder and sometimes numbness and tingling into his right arm. Client reported that he felt the pain the worst anytime he attempted to drive, but felt better when being active (playing golf especially).

Diagnostic Testing: Testing showed a mild bone spur on the C-5 bone of the spine in the neck

Objective signs: Client reported pain in neck, right shoulder, and numbness and tingling into right arm. Client was not limited in motion of neck and had full range of motion in right shoulder. Client was noted to have a forward head, rounded shoulders, and tipped and rotated shoulder blades on both sides. Upon further examination client was noted to have limited movement in his thoracic spine (mid-back) when pressure was applied to the bones in the spine.

Working Diagnosis: Based on the symptoms the client reported, the objective signs that were found, and available research, the therapist decided to treat the thoracic spine for hypomobility (decreased movement) and to address the clients posture to restore muscle balance in the front and back of the chest wall.

Treatment: The client was seen for a total of 10 visits over a period of 6 weeks.  The client received mobilizations to increase the movement of the thoracic spine, was instructed in exercises to address postural balance, and was progressed from lying down to standing up functional activity that incorporated exercises to improve his golf game.

Outcomes: After the 10th visit the client reported 95% improvement overall, no pain while driving, only slight numbness and tingling and only when moving in certain directions. Client reported no more pain was present and was very pleased with his results. Client was provided with a home exercise program after the first visit and exercises were added as he tolerated them. Client continued on with his exercises at home and during a 4 week follow up call reported that he was feeling great, had only mild numbness and tingling and felt much stronger.