Neck Pain / Whip-lash Case Study

This patient was involved in a road traffic incident in June 2012. The car hit her from behind and she was in the driver’s seat with her seat belt on. As she went to get out of the car, she pushed the door open and noticed a pain in her right shoulder. That night she had pain on undressing and could not put her hand up behind her back. Then after two days the shoulder seemed to improve a bit in terms of movement, but then her neck really seized up and she could not look over her right shoulder or take/tilt her head to the left. The pain was keeping her awake at night and affecting her daily activities such as driving and using a computer. She attended the clinic for the first time four weeks post injury.

Daily pattern – her neck is very stiff first thing in the morning for around 30 minutes and then eases a bit. She rates her pain as 7/10 on a numerical rating scale. The evenings are also very uncomfortable.

Medical history – she was using naproxen and co-codymol for pain

Social History – mother of two, works full time in an office based roll, she manages to walk her dog daily for 40 minutes

Observation

On examination there was obvious spasm of the right upper trapezius muscle and she was slightly round shouldered. Her right shoulder blade was slightly winging off her back, compared to the left.

Movement

Her neck movement was restricted to half range in terms of looking over her right shoulder (right rotation) and tilting her head to the left (left side flexion) was very painful in the right upper trapezius muscle (around three quarter range). Looking up and looking down were fully mobile, but were painful to the right of the neck during the last few degrees. The shoulder had recovered full pain free active range of movement.

Muscles

All the shoulder muscles tested strong, but there was pain on testing the rotator cuff, particularly lifting out to the side. The neck muscles upper trapezius and scalenes were in spasm and very painful to touch.

Nerve movement

There was no neural tension through the neck and shoulder that was different to the other side. Pain limited some of the testing reliability. 

Joints

The shoulder joint did not appear restricted however the lower neck joints were stiff on the right and painful. Particularly the bottom three levels C4-7. These joints did not like being compressed together.

Impression

My clinical diagnosis was a whip-lash type sprain of the neck joints/ligaments of C4-7 and strain of the musculature around the right side of the neck. There was also some tendon inflammation of the rotator cuff muscles of the right shoulder. All of which can be a result of a road traffic incident.

Treatment

I discussed the diagnosis with the patient and she was happy with our treatment plan. Our first few sessions concentrated on reducing spasm around the neck musculature using massage techniques, heat, acupuncture and light exercises. At the same time I used some joint mobilising techniques that help to open/stretch the small joints of the neck that were injured. Once her pain and symptoms started to settle after three sessions we started to work on regaining her range of movement to the right and using further manipulatory techniques and soft tissue work to achieve this. Her exercise programme was progressed from basic stretching, to active range of movement work and finally strengthening of the neck muscles that help stabilise the neck.

Home instructions

This patient was advised to do her exercises three times a day as pain allows. She used a hot wheat bag to ease any discomfort she was feeling after her exercises. She did use some paracetamol regularly in the first three weeks of treatment.

Outcome

Following the completion of her physiotherapy this patient’s pain score was 0/10 on a numerical rating scale. She was happy to continue on with her rehabilitation exercises for at least one year from the date of her accident. She did still find her muscles in the right side of her neck became tight at times, but she uses her stretches to ease this out very effectively. I explained to her that whip lash can take up to two years to fully recover from, but with early physiotherapy this period of recovery should be relatively pain free if managed well.

Thoughts

Once again early treatment can ease pain and stiffness in the neck follow a road traffic accident. This is also the case for any neck complaint. It is much more difficult to achieve a full pain free recovery when treatment is delayed by litigation or other reasons. I recommend you see a physiotherapist within four weeks of the injury or onset of symptoms to enable the body to recover fully and as quickly as possible.