Case study 8 – Mary (case study contributed by her physiotherapist)


Showing the benefit of treatment by an experienced physiotherapist

Clinical History:

Mary is in her sixties, a retired healthcare worker and she was referred for treatment of pain and limited movement of her neck, back and left shoulder with tingling down her left arm to her fingers.

Mary had been suffering from vertigo for three weeks for which she had been seeing a specialist. She also had tinnitus in both ears (bilateral), but worse on the left. Patient scored the tinnitus severity as 7 out of 10 with it being worst at night when trying to go to sleep.

Mary had poor quality sleep between 3 and 5 nights per week mainly due to the tinnitus.

Results of examination (summary):

Mary suffered a neck injury 35 years ago with her tinnitus starting 10 years later. Mary also has vertigo (dizziness).

Postural tension especially in the thorax and neck including previous episodes of dysfunction and pain in her back and neck.

Significant tension in the muscles of the shoulder girdle, neck, upper back, head and face.

Treatment approach, frequency, duration and the overall results:

Resolving the tension in her shoulder girdle, neck, back, head and face and in the nerves of her upper and lower limbs restored normal function.

In the process her tinnitus severity reduced (from 7 out of 10) to be scored by the patient now as between zero and 2 out of 10 and her vertigo also ceased. The treatment duration was 3 months.

The treatment frequency was initially twice per week, reducing to weekly then once a fortnight.

I saw Mary 2 years later with knee dysfunction. Her tinnitus remained at 0-2, a level which did not bother her. It was more likely to be noticed at 2/10 on waking from a deep sleep. She had no further symptoms in her neck, back or arm and continued with prescribed maintenance exercises.

Factors contributing to the successful outcome included:

Mary was focused on taking the time & effort to follow through with the prescribed care and exercises. She also had relatively low levels of stress in her life.

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