by Nick Kossor
Patient was a 40 year old female who entered the clinic with complaints of neck pain from a whiplash mechanism of injury 1 month ago. One week after the initial onset the patient visited a chiropractor who provided a thrust manipulation which aggravated symptoms severely. At the time of the initial evaluation, the patient was at least 50% limited in cervical active range of motion in all planes and reported intermittent left medial scapular pain. Pt also reported intermittent numbness/tingling in the left thumb and index finger. For differential diagnosis, the patient presented with negative tests for carpal tunnel. The patient presented with the following objective measures: < 60 degrees rotation to the left, symptom reproduction with compression, symptom alleviation with distraction or left facet opening, distal UE symptoms, positive median nerve tension test. These objective findings suggest strongly that the patient was suffering from cervical radiculopathy associated with the whiplash injury.
Session 1
Baseline measures were obtained and differential diagnosis confirmed we should be focusing on the neck. The rest of the session was spent on tone reduction and pain control via manual therapy to the neck/scapular musculature. The patient was also educated on the nature of her symptoms, associated anatomy, home exercises, and the expected timeline of healing.
Session 2
The patient returned with decreased frequency of distal symptoms in the hand. Active range of motion was improved and less painful at end range. After more manual therapy, the patient was given light interventions to target the neuro-muscular control of both shoulder blades to avoid further guarding.
Session 3
No exercise progressions were made today and manual therapy focused more heavily on joint mobilizations in addition to soft tissue work on the neck musculature. Manual therapy also extended into the thoracic spine in the form of Grade 2-3 posterior – anterior.
Session 4
The patient entered the clinic with significant reductions of pain overall with alleviation of symptoms in the left hand. Objective measurements of active and passive range of motion were near full and nearly pain free. Remaining limitations included left sided neck pain with left side bending active movement. Progression of scapular interventions were prescribed along with addition of deep cervical flexor training. An updated home exercise program was also prescribed. With symptoms around 1/10 in severity, no distal upper extremity symptoms, near full active and passive range of motion in all planes, the patient was educated on an independent plan of care and instructed to return to PT if symptoms flare up. After two weeks with no reports of a flare up, the patient was discharged.
This patient had an internal locus of control and is a perfect example of the benefits of combining patient education (on pain science and anatomy), home exercise compliance, and targeted manual therapy.
