c3-c4 quadriplegia: pain over neck, shoulder & antr upper chestwall region

Home-visit Day 1 assessment:
Summary:
A 33 yrs. old, male Quadriplegic; C3-C4 level, lives with wife and two young children.

H/o: -quadriplegia following RTA in 1994; treated medically and has undergone intense physiotherapy both in the United Kingdom as well as in the UAE.
-Functionally independent prior to the RTA.
-Old medical reports not available to review

S: P/t c/o pain over shoulder, neck and manubrium (upper anterior chestwall); pain continuously present; pain increases with any movement, active or passive

O: - P/t in a manual wheelchair (pushed by caregiver)
- Breathing shallow, uses the upper resp. tract & use of accessory ms. present; chest clear; decreased air entry basally, bilaterally; very weak cough
- Cervical ROM nearly full & restricted at end ROM due to pain
- Shoulder shrugging present; restricted at end ROM due to weakness.
-Flicker contracion for Deltoid present
- Active ROM for other joints both U/L & L/L not present; passive ROM present and full.
- Increased tightness in TA bilaterally
- Tone is generally flaccid all over affected region except TA where tone is increased
- Balance, co-ordination, proprioception absent
- Sensation and all reflexes NT (only Biceps reflex tested: reflex absent )
- Transfers using full-body hoist
- Unable to assess/observe the p/t in lying position


Rx: 1. Gentle passive ROM exs. for U/L & L/L; twice a day
2. Gentle Deep Neck Flexor (DNF) exs; twice a day X 10 reps
3. Deep breathing exs. every one hour, if possible
4. Active-assisted exs. for Shoulder abductors
5. Plantigrade position for ankle and gentle stretching of TA to maintain ROM.


Analysis: - P/t appears to have sound knowledge to his condition and dictates his therapy
- Prognosis poor-fair
- Level and quality of care has been quite impressive all these years
U/L Biceps reflex suggests LMN lesion


Plan: - Continue with the advised exs.
- Encourage active-assisted exs. for sh. Abductors
- Follow-up: once a week home physio visit; home nurse demonstrated and taught all exs. & proper handling of p/t
- Next visit: Assess transfers and mobility in bed
Assess sensation and L/L reflexes

Short-term goals: 1. To decrease pain
2. Maintain ROM in all joints
3. Increase muscle activity in shoulder, namely deltoid.

Long-term goal: To increase quality of life.

Question:
now my main question: the cause of pain, is the pain present due to hypersensitivity at the c3-c4 level? (fyi, whther complete or incomplete cord lesion was not meniotned on the referral sheet)
also, if anyone could suggest ways to decrease pain over the afftected region?
[observation: neck appears to be slightly flexed resting on the cushion of the wheelchair, which was corrected on visit]

also, in the referral sheet, the diagnosis was spastic quadriplegia,
however, on assessment, i found tone of muscles to be flaccid in nature, except the Tendo Achilles?!? any suggestions?

any other comments, welcome!

thanks in advance!
cheers!

dear therapist
being c3-c4 level surviving with decreased tone may be a case of incomplete case of quardriparesis.you didnot mention the type of pain ,nature ,and whether it is aggravated by exs and reduced with rest and also whether it is unilateral or bilateral pain
where is the exact origin of pain ?pain is starting from neck and radiates downward to shoulder or from shoulder to neck
whether the pain is increased with respiratory movement?
assess carefully and repeat any investigation like MRI or CT to rule out for infection like TB or any Disc prolapse or Cervical spondylosis

but timebeing you can use TENS to reduce pain or Cryotherapy


all the best
http://www.physiobob.com/forum/images/icons/icon12.gif
Wink

footloose,
r u still looking after this quadriplegic patient?

c3-c4 quadriplegia: pain over neck, shoulder & antr upper chestwall region

If yes,

i shall try to brief u.

Rajul
www.brainstrokes.com

Firstly, thank you so much for your replies, Laxmi & Rajul! i've taken too long to reply...

Laxmi: re. the pain, the pain is constant, non-radiating in nature, posteriorly over the neck & shoulders (bilaterally) & it does get aggravated with movements including laboured breathing. He describes pain as "more severe than any joint pain"; due to language barrier he has not been able to be more specific about description of pain.
Rx: he has used heat packs & TENS but to no avail.
Have added an abdominal binder since it aids his laboured breathing; also, isometric exs. for the neck to increase strength of cervical ms.

Rajul: Yes. I'm still looking after this patient. I go for a once a week physio visit and a home care nurse looks after him, along with relatives and performs exs. &/ other suggestions as recommended, on a daily basis. I would be more than happy to hear from you.

Q: is the pain, a result of hypersensitisation at the level of injury?

Thanks again, for your replies!