CASE STUDY V

PATIENT HISTORY:

Charles M. – 36 year old male who was the seat-belted driver in a motor vehicle accident. The patient was rear ended at a high speed and struck his head on the front windshield and rear view mirror. The patient reports neck pain and headaches that radiates into both shoulders and mid back. Patient also reports discomfort in his low back that radiates down to his buttocks. The neck pain and headaches is reported as 6 out of 10 on pain scale. The low back discomfort is reported as 4 out of 10 on pain scale. The patient indicates the neck pain to be a sharp lancinating type pain where as the low back pain presents in a dull aching fashion. Patient reports difficulty in all ranges of motion, his activities of daily living, and sleeping. He also reports discomfort while at work and standing for prolonged periods of time. All other patient history is unremarkable.

EXAMINATION FINDINGS:

Positive Orthopedic Tests indicating cervical&lumbar strain/sprain, cervicogenic headaches, and associated generalized muscle spasms due to trauma. (+Cervical Compression, +Cervical Distraction, +Shoulder Depression, +Maximum Cervical Compression, +5/5 Upper Extremity Muscle Tests, Sensory Deficit on Right Arm; +Kemps, +Straight/Well Leg Raise, +3/5 Muscle Strength on Iliopsoas and Piriformis, +Milgrams, All Reflexes within Normal Limits)X-rays indicate change of curvature in both cervical and lumbar spine with soft tissue swelling. Early onset of degenerative changes were noted at multiple levels in the cervical spine. Malposition of vertebrae at multiple levels was noted with associated subluxation rotations.

DIAGNOSIS:

Cervical Sprain/Strain with Radiculopathy, Lumbar Sprain/Strain, and Associated Hypertonicity in Paraspinal Musculature.

TREATMENT PLAN:

2 Months

1^st Week– treated patient a total of 5 times. Each visit consisted of ice therapy to reduce the inflammation in the soft tissue and pre-modulated interferential therapy for pain relief. Ancillary therapy was followed by a gentle manipulation to the cervical and lumbar spine. Once the patient’s pain reduced to lower than 5 out of 10 on pain scale, therapy was changed from ice to heat therapy to address low grade soreness and tightness.

2^nd Week – treated patient a total of 4 times.Each visit consisted of heat therapy to reduce the tightness in the soft tissue and pre-modulated interferential therapy to provide pain relief. Ancillary therapy was followed by a gentle manipulation. A protocol of Cervical Traction Decompression was prescribed on the 6^th and 7^th visits to relieve radiating signs/symptoms.

3^rd – 5^th Week – treated patient a total of 9 times. Each visit consisted of heat therapy to reduce the tightness in the soft tissue and Russian stimulation therapy to provide pain relief and strengthening of associated musculature. Ancillary therapy was followed by a gentle manipulation. Patient was given a protocol of cervical and lumbar stretches/exercises to address residual tightness. Myofacial Release was performed on the patient’s suboccipital region on the 10^th through 12^th visit to address localized pain and tightness.

6^th – 8^th Week – treated patient a total of 5 times. Each visit consisted of heat therapy to reduce the tightness in the soft tissue and Russian stimulation therapy for pain relief and strengthening of associated musculature. Ancillary therapy was followed by a gentle manipulation to the cervical and lumbar spine.

OUTCOME:

Complete resolution of headaches, neck pain, and low back pain. Patient was released and returned to full gainful employment with no permanent nor partial impairment.