CASE STUDY 6 CHIR13009

CASE STUDY AND QUESTIONS: To be completed by the 12 th September.

Week 6: Case 6: Joe

Joe is a 60-year-old who works in IT.

Presenting Complaint
Joe presents with neck and right jaw pain of 3 weeks duration. The patient also
complained of headaches in the temporal area which have been present for the last
6 weeks. Within the last 2 weeks the intensity of the headaches has increased.
These headaches are worse in the mornings. The quality of the pain (of the
headaches) is dull, throbbing, diffuse and aching. The headaches are intermittent
and may last up to 2-3 hours.

History of Presenting Complaint

He was driving home from work when another car ran a red light and struck his car
on the left front fender. He was wearing a seat belt, had some prior warning that the
accident was going to occur, and braced himself but was still thrown violently against
his seat belt. His sunglasses flew off his head. Estimated impact velocity was about
40 km/hr. Extensive damage was done to the front end and the left front fender.
The patient was able to get out of the car and take information from witnesses but by
the next morning he had developed severe midline neck pain and an inability to
move his right shoulder without discomfort.

Physical Examination
 Joe is an obese male.
 Vitals: pulse 80/min, normal volume; BP 160/95; respiratory rate 18/min;
Temp 36.9
 Cervical ROM: He demonstrates limited forward flexion and incomplete
extension of the cervical spine. There is decreased motion on right rotation.
Cervical range of motion is otherwise full.
 The upper extremities demonstrate normal contours and no atrophy.
 There is no point tenderness along the right acromial border.
 Passive range of motion of the right shoulder is comfortable except on forward
flexion beyond 90 degrees where there is pain in the acromial region.
 Upper extremity sensory and motor tests reveal no deficits. Supination of the
forearm against resistance (Yergason’s tests for bicipital tendinitis) is
painless.
 TMJ examination revealing a translation to the right and difficult placing 3
fingers in his mouth. There is crepitus and muscles spasm on palpation of
masseters and temporalis
X-rays
Cervical and shoulder x-rays are unremarkable.
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Questions

1. Describe the mechanism of the neck pain and its relationship to the findings.

AKA Hyper flexion/extension injury and acceleration/deceleration injury.

Mechanisms of injury:
1. Hyper extension/acceleration sudden translation force to trunk
produces acceleration of head
Hyper extension forces focus around C5/6 level – Occiput may strike
shoulders.
Head/neck extends beyond normal range causing over-stretch of
anterior spinal structures and compression of posterior structures.

2. Hyperflexion/deceleration injury – usually less severe injury than

hyperextension. Causes over stretch of posterior structures with
compression anterior to spine. Tends to especially involve sub-occipital
region. May occur in combination with hyperextension i.e. recoil effect

3. Lateral Flexion (“sidelash”)

4. Combinations of the above

2. How do you explain the lack of pain initially followed by severe pain later?

There may be a delay in the onset of symptoms:

65% <6 hours
28% <24 hours
7% < 72 hours
This may be explained by the gradual build up of oedema +/- haematoma
Most patients (75%) will have symptoms which persist more than 6 month
Severity:
-95% of the injuries are classed mild. Px develops after interval of several
hours or days, and then intensifies.
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3. What injuries of the neck and shoulder might occur in this type of accident, and
how would they be ruled in/out?

To establish the clinical picture consider the type of injury and structures damaged: -

Hyper Extension
Muscle strain: Longus colli, SCMs
Ligament sprain: ALL
IVD: Anterior fibres torn/ruptured
Vertebral body: ? Fracture/teardrop avulsion
Facet joints: Impaction  sprain, fracture or dislocation (pillar fractures
documented)
Oesophagus: strain  oedema
Pharynx: Retropharyngeal haemorrhage/oedema
Nerve roots: Traction  oedema
Sympathetic chain: Traction  oedema
Blood vessels: Traction injury of carotid (+ carotid bodies)
TMJ: Sprain
Spinal cord + dura  oedematous impingement and haemorrhage
(moderate/severe injuries)

Hyper Flexion
Muscle strain – U. traps, semispinalis capitis, splenius cervices/capitis, lev.
scapula, posterior scalenes, sub-occipitals.
Ligament sprain – P.LL, interspinous ligaments, Ligament flavum and sub-
occipital ligaments
IVD – posterior tear/rupture
Vertebral Body – fracture, teardrop
Facet joint – distraction sprain.
TMJ – sprain
Spinal cord – oedematous pressure (notably due to PLL damage) and
haemorrhage

4. Does he have hypertension? Explain your answer.

Hyper Extension
Muscle strain: Longus colli, SCMs
Ligament sprain: ALL
IVD: Anterior fibres torn/ruptured

Signs and symptoms

Neck pain
Cervical Muscle spasm
Decreased ROM

Swelling (if oedematous will start to decrease after 72 hour. If not suspect
oedema and haematoma)
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5. What signs would you look for, in order to determine if he has any complications
related to his elevated blood pressure. For each sign named, explain the
pathology which it is related to.

Damage to the sympathetics causing blurred vision, vertigo, tinnitus,

nystagmus, deafness

6. What are the possible causes for his headaches? Do you think that they may be
related to?
a. His recent MVA

Headache – associated with cx facets and injury/irritation to greater occipital

N. (off C2)  May also precipitate migraine attack

b. His elevated blood pressure?

Headache – associated with cx facets and injury/irritation to greater occipital

N. (off C2)  May also precipitate migraine attack

7. How would you treat/manage this patient if he presented to your office

Management:
-Treatment should ideally be initiated no more than 2/3 days after the
onset.
Acute phase (first week): -
Treatment must be aggressive but gentle
Acute phase is that of a severe sprain
-Immediate rest of injured area. Patient may benefit from a well-fitted felt
or soft collar to splint the cx spine and support head posture.
NB. It is very important that the patient remove the collar at
regular intervals to allow normal movement of the neck. It is
useful to have a schedule for this. Soft collars used persistently
for more than 72 hours have been shown to prolong the disability
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due to whiplash. Ideally used during sleep, and stressful

activities eg. prolonged journeys.
- Ice to reduce pain, blood vessel dilation and the production of
histamine like products. (10 minutes per hour is ideal) – better than
U.S/Inter. in acute phase

- Gentle mobilisation – to prevent muscle and ligament contracture and

formation of scar tissue adhesions. Initially it may be best to mobilise
away from the pain and restricted ROMs.

- Adjustment is generally contra-indicated in the acute phase.

- Advice on posture, sleeping position and px killers/NSAIDs
- Traction – (contra indicated if there are associated TMJ symptoms)
- STW

Sub-acute phase (1-7 weeks): Acute phase symptoms usually start to subside
after about 1 week, but tenderness and decreased ROM will normally
persist
- Active exercises to maintain and increase improving ROM are
prescribed.
1st  isotonic exercises to improve active ROM
2nd  isometric exercises to improve muscle strength

- Ice for 10 minutes after exercise followed by (moist) heat for 10

minutes.
This will help to reduce ischaemia within muscle tissue and clear
nociceptive metabolites.
- Adjustments – as indicated, but should be gentle
- Postural and sleeping advice
- Modalities U.S/Inter.

Chronic phase (more than 7 weeks):

-Continuation of the above. A gradual reduction of intensity of Rx
-Studies have shown around 10% of patients involved in rear end
collisions suffer some permanent medical disability or do not
achieve full functional recovery.
-Balla (1980) found most patients would recover within 6 months
and that little difference was noted in the patients’ clinical picture
between 6 months and 2 years.
-Between 40 and 70% retain some “nuisance symptoms” after 6
months

-The prognosis is worse if there is a previous history of cervical dysfunction or

DJD

-The Quebec Taskforce researching whiplash (early 90s) graded whiplash 0-IV
according to the severity of the injury, with 0 being no
complaint/physical signs and IV involving fracture and dislocation of the
spines.
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Their study suggested the average recovery time (i.e. resolution of signs and
symptoms) as follows:
0 < 4 days
I 4-21 days
II 22- 45 days
III 46-180 days
IV > 6 months recovery prognosis

Chiropractic Treatment Protocol for Neck Injury.

Phase 1

Objective – pain reduction, Treatment of inflammation and muscle spasm.

Operational end–point – No pain at rest.
-Acute - ice 24 hours (joints and muscle spasm). A collar may be used in the initial stages of
the acute phase.
-Chronic – heat.
-Decreased heavy manual activity.
-Soft tissue therapy: trigger points and stretching.
-Electrical therapy -acute – codeton, ultrasound (pulse)
-chronic – ultrasound (continuous)
-Manipulation of related areas.
-Education of the patient stressing their abilities.
-Ergonomic: sleeping, posture, back support.
-Nutritional advice for healing and stress
-Exercises: passive for range of motion
-The cervical collar is worn in this phase only. The more severe the degree of whiplash
injury, the longer the cervical collar is worn in phase 1.

Phase 2

Objective – recovery of movement function. Operational end-point-the capacity to

perform unstressed basic daily activities.
-Electrical therapy -acute – codeton, ultrasound (pulse)
-chronic – ultrasound (continuos)
-Ergonomic: sleeping, posture, back support.
-Mobilisation of the specific and traumatised segments: ice.
-Nutritional advice for healing and stress.
-Manipulation of related areas.
- Exercises: active for stretching and passive for range of motion.
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Phase 3

Objective – restore the normal movement patterns along with conditioning of normal
strength and function. Operational end-point-the capacity to perform normal activities
under some constraints and conditions.
-Manipulation to traumatised areas using a lateral break, toggle, Gonstead (technique using
minimal rotation is preferable)
-Begin walking. This improves the C.V.F: increases the endorphins and serotonin causing a
decrease in the pain and patient depression.
-Psychological counselling
-Ergonomic: sleeping, posture.
-Exercises: isometric strengthening for the injured area.

Phase 4

Objective – the return of the patient to full and active lifestyle and help in the
prevention of future episodes.
Operational end–point – the recovery of the full normal, and uncontrollable activities,
and release from active care.
-Manipulation as indicated.
-Soft tissue therapy: trigger points, massage etc.
-Walking for C.V. F.
-Lifestyle management
-Exercises: isotonic or isometric for strengthening

Sources and Further Reading

Souz T.A: Differential Diagnosis and Management for the Chiropractor, Protocols and
algorithms. James and Bartlett Learning, 5th Edition. 2016

Foreman S.M, Croft A.C Whiplash Injuries, 3rd Ed. Whiplash Injuries:
The cervical acceleration/deceleration syndrome, Lippincott Williams and
Wilkins, 2001

Fitz. Ritson D. The Chiropractic Management and Rehabilitation of Cervical Trauma.

Journal of Manipulative Therapeutics Vol 13 (1) Jan 1990
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