This is an excerpt from Therapeutic Modalities for Musculoskeletal Injuries-4th Edition by Craig R. Denegar,Ethan SalibaS & usan F. Saliba.
Case Scenario 1
A 28-year-old female tennis coach and player is referred for care, complaining of neck pain following a motor vehicle accident 6 days ago. She was at a complete stop when her car was hit from behind. She was transported to the emergency department at a local hospital. She was discharged after being evaluated for injuries. A neurological screen was normal, and concussion assessment and diagnostic imaging were negative. She complains of pain (6 on a scale of 10 with walking and standing) and muscle spasm in her neck and upper back, and intermittent headaches made worse with prolonged sitting and exercise and relieved by oral over-the-counter medication and lying down. She states at times she gets pain that radiates down her right arm.
She states that she is married and has no children. She works as a college tennis coach and director of the campus tennis center. Her medical history is unremarkable other than having sustained a right sprained ankle in high school and having wisdom teeth removed.
On presentation she denies lightheadedness, concentration and memory deficits, tinnitus or vision disturbances, and a history of neck injuries. On examination, the patient’s head is slightly tilted to the left side. The patient has limited active and passive rotation and side-bending to the right side and painful end-range extension. She has tenderness to palpation along the right cervical paraspinal muscles. Upper quarter scan for sensory, strength, and reflex deficits is normal. Physical examination reveals restricted left side-glide at C5-C6, and the patient is evaluated as suffering from a flexed, left rotated, and side-bent facet with soft tissue pain and muscle spasm.
The patient complains that she has difficulty raising her right arm overhead and that her neck and upper back pain increase with prolonged sitting, driving, and lifting and carrying.
The forces involved in motor vehicle accidents can cause catastrophic injuries. The whiplash mechanism of injury may result in fracture, sprain, and muscle strain. The medical history, history of the current condition, and medical and physical examinations conducted in this case provide assurance that serious structural damage has been avoided. A thorough examination and evaluation of all pertinent information is needed before proceeding with a rehabilitation plan of care, especially in conditions involving the spine.
The first step in developing a rehabilitation plan of care is the development of a problem list. It is usually best to build a problem list around the impairments, functional limitations, and participation restrictions identified in the evaluation of the case. From the problem list, mutually agreeable short-term goals can be developed and a goal-directed application of therapeutic modalities, manual therapy, and exercise developed.
What are the problems identified in this case?
- Loss of cervical range of motion
- Reaching overhead and prolonged sitting/driving
- Unable to play tennis or coach effectively due to pain and loss of motion
- Has difficulty with management responsibilities due to poor tolerance of sitting
The clinician has several options to recommend for the problems listed. Pain and muscle spasm could be treated with periodic cold or superficial heat. TENS could be used as needed for the same purposes.
What would you do?
A decision on the treatment needs to be based on any contraindications for an intervention, the current condition, the patient’s preferences, the clinician’s experiences, and existing clinical research. After ruling out contraindications to the treatment options and conferring with the patient about the ability to control pain with oral medications, it is decided to treat her with massage to decrease pain and muscle spasm before performing joint mobilization to restore range of motion. The patient states that a hot shower is soothing and that she has access to superficial heat. She demonstrates a substantial increase in cervical range of motion after the initial treatment. She is instructed in active range of motion exercises and agrees with a plan of 20 to 30 min of superficial heating as needed for relief of pain and spasm and a four-times-per-day regimen of active range of motion, which is also to be performed after heat application. Over two subsequent visits she reports the resolution of pain at rest other than mild aching and stiffness upon rising, and she demonstrates full cervical range of motion. Postural and functional exercises are introduced to increase tolerance to daily activities and return to coaching. Three and a half weeks after her accident she is able to work a normal day, drive, and play tennis for up to an hour without limitations. She is discharged to continue with a postural and tennis function exercise program.
This case illustrates some of the complexities of developing a plan of care. There is not a single correct approach to meeting the needs of many patients. The first mandate is to do no harm. The clinician and patient must then decide which problems are most concerning, discuss the options, and agree on a plan. Once short-term goals are achieved, the intervention progresses. Modalities used to relieve pain and muscle spasm are replaced by exercises aimed at addressing functional limitations and participation restrictions.