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Case Summary

Patient Name: KF Intern Name: Chelsea Graving

New Patient Case Write up Supervisor Comments

This section must be completed and
presented to the clinical supervisor within
seven days of the completion of the
examination

Pertinent History (chief complaint, history,

past medical history, psychosocial, and
family history)

The patient presented with a chief complaint

of headaches and neck pain located on the
right side of upper cervicals after her plane
flight 3 days prior. She noted a constant
aching type pain that's slightly increased in
severity over the past few days. She has
complained of feeling restricted when rotating
her head to the right. No radiculopathy
present. The patient mentioned she had
experienced this type of pain in the past after
flying or studying for exams. Past medical
history is unremarkable other than a slight
levoscoliosis (17 degrees) with apex at T5
presenting during her teen years, as
adolescent idiopathic scoliosis. No relevant
family history or psychosocial factors present.
The patient is not currently taking any
medications and does not consume alcohol or
smoke.

Differential Diagnosis

Working Diagnosis: sub-acute moderate right

C2/3 facet joint sprain
Complications/associations: with associated
paraspinal myofascial dysfunction.
DDX1: Acute mild (grade 1) Cervical Muscle
sprain (R Levator Scapulae)
Complications/associations: slight
Levoscoliosis causing mechanical/muscular
imbalance.
DDX2: Cervicogenic headache
Complications/associations: paraspinal
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muscle dysfunction (lev scap + temporalis).

Pertinent Physical Examination

On observation of gait, an elevated right

shoulder was noted and decreased right arm
swing. PROM and AROM were moderately
restricted in right rotation notably at the
C2/C3 Facet joint. Pain and moderate
restriction were present on palpation of C2/C3
facet joint. Levator Scapulae and Trapezius
hypertonicity. There was a reduction in motor
strength for C2 Myotome and slight
dermatomal abnormalities in sensation for C2
region. All other neurological examinations of
upper limbs were unremarkable. +ve cervical
compression test and distraction, +ve right
odonaghue’s (sprain), +ve Right sided
Jackson's and Spurling's, +ve right sided
shoulder depression test, -ve valsalva , +ve
Adam’s forward bending. No further
Investigations.

Diagnosis

Sub-acute moderate right sided C2/3 facet

joint sprain
Complications/associations: with associated
paraspinal myofascial dysfunction
exaggerated by levoscoliosis.

Treatment Plan Inc Interventions

Treatment will involve 8 treatments over a 6

week period.

Week 0-2 : 2 visits per week for wks 0-2 or

until Neck disability index has decreased by
20%.
Adjust C2/C3 facet right rotation restriction if
pain allows. Treatment for associated cervical
m. sprain - prescribe soft tissue therapies,
gentle traction. ice first 24 hrs/ muscle cream.
At home exercises: take micro breaks
regularly, ROM exercises 3 times per day for
10 mins.
Week 2-4: 1 visit per week for weeks 2-4.
Reassess joint restriction and adjust if
indicated. Introduce cervicothoracic and other
indicated regions for spinal manipulation if
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indicated. Active Rehab specific exercises for

15 mins, 4 times/day, monitor progress,
continual use of muscle cream. Regular desk
breaks and AROM continued.

Weeks 4-6: Continue with 1 visit per week up

until week 6. Continue care, AROMS and
adjustments as indicated. Complete PROM’s
again and monitor progress.

Prognosis Inc Barriers to recovery

Young fit and healthy 21-year-old with no

comorbidities. This presenting condition has a
good prognosis for complete recovery over
the course of 6 weeks treatment. According to
the neck pain research summary, the relevant
grade 1-2 non-traumatic neck pain, there is
evidence that proves it is ‘highly likely’ that
manipulation, mobilisation and soft tissue
therapies will enable a good prognosis
(Guerriero, Crowther, Lee & Rajwani, 2010). In
addition, a review done by Cochrane on
manipulation and mobilisation for neck pain
found that for acute and subacute neck pain,
multiple sessions of cervical manipulation
were more effective than certain medications
in improving pain and function at immediate
and long-term followup (Langevin, Gross,
Burnie & Bédard-Brochu, 2016). Barriers to
recovery could be patient appointment
attendance and cooperation with exercises
and tissue sparing.

Outcome Measures

Neck disability index and Headache diary

Further Investigations (if relevant)

No history or exam findings indicated further

investigations or imaging at this stage.

Suggested references and further reading

Guerriero, R., Crowther, E., Lee, G., & Rajwani,

M. (2010). Neck Pain and Evidence Summary -
Institute for Work and Health. Presentation,
Central Queensland University Brisbane.

Langevin, P., Gross, A., Burnie, S., & Bédard-

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Brochu, M. (2016). Manipulation and mobilisation

for neck pain contrasted against an inactive
control or another active treatment: Update of a
Cochrane review. Manual Therapy, 25, e98-e99.
doi: 10.1016/j.math.2016.05.172

The Neck Disability Index: A study of reliability and

validity. Journal of Manipulative and Physiological
Therapeutics. 14, 409-415

National Headache foundation: Headache Diary