Journal of Orthopaedic & Sports Physical Therapy - Susan Mais Requejo, DPT

Thoracic Spine Dysfunction in Upper Extremity Complex Regional Pain Syndrome Type I

Jeanine Yip Menck, Susan Mais Requejo, Kornelia Kulig
Study Design: Case study. Objective: To demonstrate the importance of assessment and treatment of the thoracic spine in the management of a patient with signs and symptoms of upper extremity Complex Regional Pain Syndrome Type I (CRPS-I). Background: The patient was a 38-year-old woman who suffered a traumatic injury to her left hand. Five months after injury, she presented with severe pain, immobility of the left arm, and associated dystrophic changes. She was unable to work and needed help in some activities of daily living. Methods and Measures: The patient was treated for 3 months in 36 visits. Initial treatment consisted of cutaneous desensitization, edema management, and gentle therapeutic exercises. However, further examination indicated hypomobility and hypersensitivity of the upper thoracic spine. Joint manipulation of the T3 and T4 segments was implemented. The patient's status was monitored and range of motion, strength, temperature, and skin moisture were measured. Results: Immediately after the vertebral manipulation, there was a significant increase in the left hand's skin temperature and a decrease in hyperhydrosis as measured by palpation. Shoulder range of motion increased from 135-175� and the patient reported reduced pain from 6/10 to 3/10 on a scale from 0 to 10, where 0 represents no pain. The decrease in the patient's dystrophic and allodynic symptoms permitted further progress in functional reeducation. The patient was discharged with full return to independence and initiation of a vocational retraining program. Conclusion: Assessment and treatment of the thoracic spine should be considered in patients with upper extremity CRPS-I. J Orthop Sports Phys Ther. 2000;30(7):401-409. Key Words: manipulation, manual therapy, reflex sympathetic dystrophy

Management of Foot Pain Associated With Accessory Bones of the Foot: Two Clinical Case Reports

Ward Mylo Glasoe, Susan Mais Requejo, David B. Thordarson, Kornelia Kulig
Study Design: Case study. Objectives: To discuss the differential diagnosis, the nonsurgical and postoperative management of common accessory bones of the foot. Background: Accessory bones of the foot that are formed during abnormal ossification are commonly found in asymptomatic feet. Two of the most common accessory bones are the accessory navicular and the os peroneum. Their painful presence must be considered in the differential diagnosis of any acute or chronic foot pain. The optimal treatment for the conservative and postoperative management of painful os peroneum and accessory navicular bones remains undefined. Methods and Measures: Therapeutic management of the fractured os peroneum included bracing, taping, and foot orthotics to allow healing of involved tissues, and stretching. The focus of the postoperative management of the accessory navicular was joint mobilization and progressive strengthening. Dependent variables included level of pain with provocation and alleviation tests of joint and soft tissue; girth and sensory tests of the foot and ankle; goniometric measures of foot and ankle; strength of ankle and hip muscles; functional tests; and patient's self-reported pain status. Results: The patient with the fractured os peroneum was treated in 13 visits for 10 weeks. At discharge from physical therapy, the patient had the following outcomes relative to the noninvolved side: 100% return of normal sensation tested by light touch and vibration; pain decreased from 6/10 to 1/10; 100% reduction of swelling with ankle girth to normal; 100% range of motion of ankle and subtalar joints. Strength in plantar flexion and eversion remained 20% impaired (80% return to normal) secondary to pain. Upon discharge, he still reported mild pain when walking but was able to return to previous leisure activities. The second patient with the accessory navicular was treated in 18 visits over 9 weeks. Relative to the uninvolved side, she was discharged with the following: 70% return of range of motion in the foot and ankle, 100% of strength in hip and ankle, and 100% return of balance. She could squat and jump without pain and she returned to full premorbid activity level. Conclusions: Rehabilitative management of both cases addressed specific impairments and was successful in improving the patients' activity limitation. Clinicians should be aware that these accessory bones are possible sources of disability, secondary to foot pain. J Orthop Sports Phys Ther. 2000;30(10):580-594. Key Words: accessory bones, accessory navicular, foot pain, neurodynamics, os peroneum, os tibiale externum

The Use of a Modified Classification System in the Treatment of Low Back Pain During Pregnancy: A Case Report

Susan Mais Requejo, Robert Barnes, Robert F. Landel, Susana Gonzalez, Kornelia Kulig
Study Design: Case study. Objective: To describe the use of a classification approach in the evaluation and treatment of a pregnant patient with low back pain (LBP). Background: The patient was a 28-year-old primigravida in her 20th week of pregnancy. She presented with a chief complaint of LBP without precipitating trauma. Her pain limited her sitting to 20 minutes or less and restricted her ability to bend forward. Methods and Measures: This patient was treated 4 times during a period of 2 weeks. The patient was classified as stage 1 extension syndrome. Because of the patient’s pregnancy, treatment with active extension exercises commonly prescribed for this syndrome was deemed inadequate. Therefore, manual joint mobilization was applied to the symptomatic vertebral segment. Additional intervention included moist heat, soft tissue mobilization to the thoracolumbar paraspinals, manual stretching of the hip flexors, abdominal bracing, and wall squat exercises. Results: After 4 treatments, the patient was able to bend forward without pain, sit longer than 1 hour without discomfort, and work with minimal discomfort. She improved from a stage 1 classification to a stage 3 classification. Conclusion: This case illustrates the use of a classification system to guide physical therapy intervention. It also demonstrates an effective and safe use of manual techniques in the treatment of a pregnant patient.

J Orthop Sports Phys Ther. 2002; 32(7):318–326.

Key Words: extension syndrome, manual therapy, thoracic spine