Case Description - "CC: Upper trapezius tension & pain post-work, 6/10. HPI: Pain onset 6 mos ago. Due to desk setup & computer work. OTC relief temporary. Affected Activities: Difficult left head turn, discomfort looking up."

Subjective:

Chief Complaint (CC): The client reports experiencing tension and pain in the upper trapezius region. The pain intensifies post-work and is rated at a 6 out of 10 on the pain scale.

Pain Description with Location: The client describes the pain as a constant tension and discomfort located in the upper trapezius area. The pain seems to be more intense after a day of work.

Quality of Pain: The client describes the pain as a constant, dull ache that intensifies with certain movements. The pain does not radiate and is localized to the upper trapezius region.

Intensity of Pain: The client rates the pain as a 6 out of 10 on the pain scale. The pain intensifies to this level post-work and decreases slightly with rest.

Duration: The client reports that the pain onset was approximately 6 months ago and has been consistent since then. The pain is more intense post-work and seems to be slightly relieved with rest.

Aggravating Factors: The client reports that the pain is aggravated by their desk setup and computer work. The pain intensifies when turning the head to the left and looking up.

Alleviating Factors: The client reports that over-the-counter (OTC) pain relief provides temporary relief. Rest also seems to slightly decrease the intensity of the pain.

Previous Treatments: The client has been using OTC pain relief for temporary relief of the pain. No other treatments have been tried.

History of Present Illness/Condition: The client reports that the pain onset was 6 months ago. The pain is due to the client's desk setup and computer work. The client has been using OTC pain relief for temporary relief but has not sought any other treatments.

Past Medical History: The client did not report any relevant past medical history.

Goals for the Session: The goal for the session is to reduce the tension and pain in the upper trapezius region, improve range of motion, particularly in turning the head to the left and looking up, and provide strategies for managing the pain post-work.

Objective:

Postural Assessment:
- Forward head posture observed, indicating potential strain on neck and shoulder muscles.
- Rounded shoulders observed, suggesting possible muscle imbalance in the shoulder region.

Range of Motion (ROM):
- Cervical rotation to the left: 45 degrees (Normal: 60-80 degrees)
- Cervical extension: 40 degrees (Normal: 50-60 degrees)

Palpation:
- Tissue Quality: Hypertonicity and trigger points found in upper trapezius.
- Temperature: Normal.
- Sensitivity: Increased sensitivity in the upper trapezius region.
- Texture: Increased muscle tension and fibrous adhesions noted in the upper trapezius.

Special Tests:
- Upper Limb Tension Test: Negative.
- Spurling's Test: Negative.

Gait Analysis:
- Not applicable.

Breathing Patterns:
- Shallow, upper chest breathing observed, indicating potential stress or tension.

Skin:
- No abnormalities observed.

Reflexes:
- Normal.

Joint Mobility:
- Cervical spine: Slightly reduced mobility, particularly in rotation to the left and extension.

Observations During Massage:
- Client exhibited signs of discomfort when pressure was applied to the upper trapezius region.
- Client's muscles in the upper trapezius region were noticeably tense and tight.
- Client reported relief and reduction in pain intensity during and after the massage.

Assessment:

Clinical Impressions: The client presents with chronic tension and pain in the upper trapezius region, likely due to poor posture and strain from computer work. The forward head posture and rounded shoulders suggest muscular imbalances that may be contributing to the discomfort.

Comparison: Compared to the normal range of motion, the client's cervical rotation to the left and extension are reduced, indicating muscular tension and potential joint restriction.

Potential Causes/Contributing Factors: The client's desk setup and computer work, along with poor posture, are likely contributing to the tension and pain in the upper trapezius region.

Potential Contraindications: No contraindications were identified during the assessment.

Relevance of Findings: The findings are relevant as they indicate a potential musculoskeletal issue related to posture and work habits. The hypertonicity and trigger points in the upper trapezius region are consistent with the client's reported pain and discomfort.

Response to Treatment: The client reported relief and a reduction in pain intensity during and after the massage, indicating a positive response to the treatment.

Referral Consideration: If the client's pain persists or worsens, referral to a physical therapist or chiropractor may be beneficial for further evaluation and treatment.

Client's Perceived Progress: The client reported a decrease in pain intensity during and after the massage, indicating perceived progress.

Validation of Treatment Plan: The client's positive response to the massage validates the treatment plan. Continued treatment, along with modifications to the client's work setup and posture, may further improve the client's condition.

Potential for Future Improvement: Given the client's positive response to the massage, there is potential for future improvement. Regular massage therapy, along with postural corrections and ergonomic modifications at work, may help reduce the client's pain and discomfort.

Plan:

Treatment Plan:
- Continue with massage therapy focused on the upper trapezius region, including deep tissue massage, trigger point therapy, and myofascial release to reduce muscle tension and alleviate pain.
- Incorporate gentle neck stretches and range of motion exercises into the sessions to improve cervical rotation and extension.
- Provide education on proper posture and ergonomics to reduce strain from computer work.

Recommended Interventions with Massage Techniques:
- Deep Tissue Massage: To alleviate muscle tension and break down adhesions in the upper trapezius region.
- Trigger Point Therapy: To address specific points of tension and pain in the upper trapezius.
- Myofascial Release: To relieve tension in the fascia surrounding the upper trapezius muscles.

Frequency and Duration:
- Recommend 1-hour sessions once a week for the next 6 weeks, then reassess the client's progress and adjust the treatment plan as necessary.

Home Care Recommendations:
- Encourage the client to perform gentle neck stretches and range of motion exercises daily.
- Suggest the use of heat therapy, such as a warm compress, to help relax the muscles and alleviate pain.

Postural or Lifestyle Recommendations:
- Advise the client on proper desk setup and ergonomics to reduce strain from computer work.
- Recommend regular breaks from sitting and computer work to stretch and move around.

Re-evaluation Date:
- Re-evaluate the client's progress and adjust the treatment plan as necessary after 6 weeks.

Referrals:
- If the client's pain persists or worsens, refer to a physical therapist or chiropractor for further evaluation and treatment.

Potential Barriers to Treatment:
- The client's work habits and desk setup may continue to contribute to the tension and pain in the upper trapezius region.
- The client's commitment to home care recommendations and lifestyle changes will significantly impact the effectiveness of the treatment plan.

Feedback Mechanism:
- Encourage the client to provide regular feedback on their pain levels, any changes in symptoms, and their adherence to home care recommendations. This will help in adjusting the treatment plan as necessary.