At follow-up 1 month after her initial visit, the patient reported an overall improvement in her pain and greater ability to ambulate. She reported continued pain in the low back, particularly the left lumbosacral region, as well as pain in the right forehead. The patient reported reduced pain in her knees. Her bowel function had not changed. She had tried a new medication prescribed by her gastroenterologist but did not tolerate the side effects, and her gastroenterologist recommended pelvic floor therapy.
Review of systems was notable for abdominal bloating and back pain but was otherwise unremarkable. Physical examination was notable for hypertonicity of the occipitoatlantal region; asymmetric tissue texture changes, tenderness, and hypertonicity of the cervical paraspinal muscles; reduced excursion of the rib cage with respiration particularly in the upper right region; mild tenderness to palpation in the abdomen without guarding or rebound; a hypertonic left quadratus lumbor um muscle; and reduced mobility, tenderness, hyper tonicity, and tissue texture changes of paraspinal muscles at the cervical, thoracic, and lumbar spinal levels. Neurologic examination revealed equal strength in the lower extremities.
Osteopathic structural examination revealed a right sphenobasilar synchondrosis torsion. The C3 vertebra was flexed, rotated, and sidebent right. Rib 2 on the right was exhaled. Examination findings also included a flexed, rotated, and sidebent right T4 vertebra and a flexed, rotated, and sidebent right L5 vertebra. Also found were left innominate posterior rotation, right-on-right sacral torsion, myofascial strain of the right serratus anterior muscle, ligamentous strain of the right talus, myofascial strain of the left quadratus lumborum muscle, fascial restriction of the right hemidiaphragm, and decreased motility of the stomach and liver.
It was suspected that the patient's back strain was secondary to continued autonomic involvement of the superior mesenteric ganglia, pelvic splanchnic, and vagus areas, and that thoracic cage movement was linked to her core strains involving the abdominal, diaphragmatic, and visceral structures.
Her diagnoses included somatic dysfunction of the following regions: head, cervical, upper extremity, rib cage, thoracic, abdomen, lumbar, pelvic, sacral, and lower extremity. In addition, the patient was diagnosed as having lumbosacral strain, rib strain, and sacroiliac strain.
The patient was treated using the OMT systems of high-velocity, low-amplitude; muscle energy; OCF; myofascial release; facilitated positional release; balanced ligamentous tension; and visceral manipulation. Again, the patient stated her pain had improved immediately after OMT.
The patient was counseled on seeking additional alternative modalities for the management of visceral dysfunctions such as acupuncture and homeopathy. She was also provided with a handout on Fulford exercises and was instructed to perform the exercises 1 to 2 times daily.
9 She was scheduled for re-evaluation in 2 weeks.