CLINICAL CASE 1 WITH DIFFERENT TREATMENT PLAN
CLINICAL CASE 1 WITH DIFFERENT TREATMENT PLAN
Traitement Général Ostéopathique (TGO)
Octobre 2021
Osteopathic manipulative treatment (OMT) is used to treat a patient’s problem associated with somatic dysfunction: impaired or altered function of related components of the somatic (body framework) system—skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements.
HISTORY: A 25-year-old female has had lower back pain for 1 week since playing indoor football. She has muscle spasm in the right lumbar erector spinae muscles and tenderness on the right L2–5 transverse processes, which are resistant to anterior pressure compared to the left side.
ASSESSMENT: (1) Lumbar strain and sprain; (2) lumbar somatic dysfunction.
PLAN: (1) OMT to lumbar region using counterstrain and indirect myofascial release resulting in reduced tenderness and tension and improved motion; (2) cold pack to low back for 15 minutes 3–4 times a day if needed for pain relief; (3) heating pad to low back for 20 minutes 3–4 times a day if needed for stiffness; and (4) lumbar extensor stretches twice a day if tolerated.
If she failed to improve after 2–3 additional treatments using a variety of techniques over 2 weeks, re-evaluation should be conducted for postural problems, hypermobility, disc and joint problems, and referred pain. Additional treatment options should emerge from this re-evaluation.
Osteopathic manipulative treatment (OMT) is used to treat a patient’s problem associated with somatic dysfunction: impaired or altered function of related components of the somatic (body framework) system—skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements.
HISTORY: A 25-year-old female has had lower back pain for 1 week since playing indoor football. She has muscle spasm in the right lumbar erector spinae muscles and tenderness on the right L2–5 transverse processes, which are resistant to anterior pressure compared to the left side.
ASSESSMENT: (1) Lumbar strain and sprain; (2) lumbar somatic dysfunction.
PLAN: (1) OMT to lumbar region using counterstrain and indirect myofascial release resulting in reduced tenderness and tension and improved motion; (2) cold pack to low back for 15 minutes 3–4 times a day if needed for pain relief; (3) heating pad to low back for 20 minutes 3–4 times a day if needed for stiffness; and (4) lumbar extensor stretches twice a day if tolerated.
If she failed to improve after 2–3 additional treatments using a variety of techniques over 2 weeks, re-evaluation should be conducted for postural problems, hypermobility, disc and joint problems, and referred pain. Additional treatment options should emerge from this re-evaluation.