Complex Cervical Pain

Case Description: The patient is a 58 y/o female with a long hx of neck surgeries including fusion procedures from C7 to C3 over the span of 15 years.  At initial evaluation she reported being depressed about the state of her life, only able to tolerate sitting for several minutes.  She was taking relatively high doses of opioid medications several times/day and felt like she could not function without them.  She was very apprehensive to wean off them, which had been advised by her PCP.   

Objective Measures: The patient was seen for 18 physical therapy visits over a 2 month period and 1 follow-up visit 3 months later.

Tests and Measures	Initial Evaluation	Day of Discharge from Physical Therapy
VAS for Pain	5-8/10	2/10
Neck Disability Index	51% disability	28% disability
Cervical Rotation	R Rotation: 40°   L Rotation: 45°(both with severe neck pain)	R Rotation: 50°   L Rotation: 50°(No pain, now able to drive)
Opioid Use	3x daily hydrocodone (more when active)	Fully weaned from all opioids at 3 month follow-up

Summary: The patient was discharged from physical therapy with increased cervical range of motion to within functional limits, improved overall ability to perform daily household/work tasks, and empowerment to continue with her individualized home exercise program.  She fully weaned from her opioid medications and was walked through the entire process, with significant focus on pain neuroscience education.  

Patient Comments at Discharge: “1 – My mental picture of what was possible has changed. 2 – I have very little ROM and now move as freely as my body will allow. 3 – I am not spending all my time thinking about how much pain I have, but rather on what I am going to do with my life today!”

Sincerely,

Luke Vander Zouwen, DPT
Full Potential Physical Therapy