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1.    Introduction:

This case report was prepared as part of the educational requirement of Module A Cervical spine and upper limb of the Society’s Diploma in Musculoskeletal Medicine. The aim of this case is to demonstrate the knowledge and skills in diagnosis and management of upper extremities musculoskeletal condition. This case report summarized the clinical presentation of the case, clinical findings, diagnosis approaches, treatment option, follow up visit, and discussion on the relevance of this case to the epidemiological and clinical studies.

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2.    History:

A 39-year-old Arab female dentist presented to the general practice clinic with a gradual onset neck pain on the left side for two weeks. The pain was mild and can be tolerated but has been extended to the scapula in the last two days. She can’t fully turn her neck to the left side. Patient reported that the pain and stiffness increase through the day till get worse in the evening during the work in the clinic but not in the night. Specific postures aggravated the pain and stiffness such as setting next to the patient on the dental chair, working on the computer for more than one hour, and using mobile phone. Pain and stiffness were relieved for some times by using hot compress, massage, and lying on back for some time. No history of weight loss, headache, nausea, vomiting, visual disturbance, dizziness, tinnitus, dysphagia, dysarthria, numbness, loss of sensation, or weakness. Patient has no history of trauma. There is no history of other joints pain or stiffness.  Patient has no chronic medical problems hypertension, hypercholesterolemia, cardiac or cerebral disease or using medication such as steroids or anticoagulants. Patient confirmed that she is not pregnant.

3.   Clinical examination:

Vital signs:

Height = 171 cm, weight = 77.5 kg, Body Mass Index (BMI) = 26.5, Physical activity vital sing (PAVS) = 180 minutes/ week

Type of exercise: 40 minutes of aerobic exercises week and 20 minutes spinning class for tree times a week.

Neck and back examination:

Inspection: on standing patient’s neck has no antalgic position or muscle wasting. Patient has protruded chin and cervical lordosis.

Palpation:  No tenderness but left side necks muscles were slight stiff in compression to the right side.

Active movement: Although the patient has normal active extension, she has limited active rotation to the left side, limited side flexion to the left. Right side has normal side flexion and side rotation.

In passive movements: passive left side flexion and rotation were limited. Right side is normal. Passive extension is normal.

Resisted movement:  normal resisted extension and flexion. Patient can’t do resisted side flexion and rotation in the left side.

Shoulder: Active and passive elevation were normal.

Other resisted tests: shoulder elevation, abduction, lateral and medial rotations were normal. Flexion and extension at elbow and wrist were normal.  Thumb and fingers adduction were normal. Upper limb’s’ skin sensation and reflexes were normal,

Musculoskeletal Health Questionnaire (MSK-HQ) was 34.

4.    Clinical diagnosis:

According to neck pain classification used by The Society Of Musculoskeletal Medicine (SOM), this case represents the clinical model 2: Sub-acute neck pain.  

 Radiological:

Cervical X-Ray was normal.

Diagnosis: Sub-acute neck pain.

5.    Treatment plan:

Patient has the following treatment plan:

•            Cervical traction.

•            Manual traction and rotation and lateral glide manipulations.

•            Acetaminophen 500 mg, 2 tablets per mouth every 6 hours when needed

•            The patient was referred to the physiotherapist for more physiotherapy treatment.

•            The patient was educated about the correct posture for the neck and back.

•            The patient was educated about stretching and motor control exercise for neck muscles.

•            Follow up appointment after 4 weeks.

After the agreement on the treatment plan and consent was obtained from the patient to do the mobilization procedures, it was done for the patient at the clinic.

6.    Re-assessment:

After 24 hours:

Patient was followed up by phone call and patient reported some improvement in the pain and neck movement. And she started stretching exercises get an appointment with physiotherapist within the same week. Musculoskeletal Health Questionnaire (MSK-HQ) was 40.

 

.After one week:

Changes in the symptoms and behaviour:

The patient came to the clinic after one week reporting improvement in symptoms after the manipulation done in the clinic and she is doing the stretching exercises prescribed. In addition to that she did the first session with her physiotherapist. In another follow up after 4 weeks, patient reported improvement in symptoms. She had good compliance with stretching exercise and she is doing swimming three times per week.

Changes in the clinical examination:

Height=171 cm, weight= 77.7 kg, Body Mass Index (BMI)=26.6, Physical activity vital sing (PAVS) = 180 minutes/ week.

Neck and back examination:

Inspection: on standing patient’s neck has no antalgic position or muscle wasting. Patient’s posture was better than the 1st fist but still has slight protruded chin and cervical lordosis.

Palpation:  No tenderness and left side necks muscles were normal as the right side. 

Active movement: all were normal.

 Passive movements: all were normal

Resisted movement: all were normal.

Musculoskeletal Health Questionnaire (MSK-HQ) was 52.

Management plan: Patient has been advised to continue the good posture, stretching exercise, and doing regular exercise.

7.    Discussion and evaluation:

Neck pain is a common problem seen in the general practice and accounts for 15% of musculoskeletal problems in primary health care setting. (epidemiology)  It is considered as the fourth leading cause of disability as measured by years lived with disability (YLDs), with prevalence 30% in general population.(Mayo, BMJ).

For the purpose of reaching diagnosis and prescribing the appropriate management, cervical lesions have been classified in to four clinical models based on the onset and duration of the pain, history of aggravated and reliving factors, referral of the pain, and presence of the neurological signs,   In this case report, all findings in history and the clinical examination from symptoms, signs, to patient characteristics suggest a classical presentation of clinical model-2 of neck pain, which is a sub-acute neck pain. The patient is middle age female presented with unilateral neck pain with less severs intensity and gradual onset with duration of 3 weeks of pain. According to the definition of sub-acute pain, sub-acute neck pain lasts more than 7 days but less than 3 months, while chronic neck pain has a duration of 3 months or more.(Mils ). In addition to the duration, the pattern of pain support the clinical model 2 as it is extended to the scapula with absence of any trauma history or risk factor flags. The movement limitation pattern is non-capsular pattern with no neurological signs.

The age and gender of the patient in this case reflects the demography of the population at risk to develop neck pain. Most of the epidemiological studies showed a higher incidence of neck pain among women with increased risk of developing neck pain among 35-49-year age group. (Hoy). On the clinical examination, limitation was unilateral in side flexion and rotation and indicates non-capsular pattern of cervical lesion.

It is well known that neck pain is a condition characterized by a course marked by periods of remission and exacerbation (Cote), therefore sub-acute neck pain need to be treated effectively to stop the transition to chronic pain. The effective management of neck pain starts with good history and examination to ends with effective treatment plan.

In musculoskeletal medicine, choose the therapeutic technique depends on the examination finding and patho-anatomical diagnosis, and the clinician’s skills. (Khan). In this case we designed the treatment plan for the less severe and less irritable pain, which is sub-acute pain (clinical model 2). For this patient we have used mobilization and manipulation is indicated to be part of the treatment plan.(book). Mobilization and manipulation techniques usually produce immediate result in one to three sessions.(book) and this was seen the patient as the pain was relived after the first application of the techniques. A recent Cochrane review found moderate quality evidence to support the use of the both mobilization and manipulation for sub-acute and chronic neck pain (95 Khan page 331) in addition to pain relief, effective treatment can reduce the transition from sub-acute to chronic neck pain. (epidemiology)

 

 

Manual therapy is indicated as treatment method for neck pain.(khan)

Before the treatment patient was counselled about the benefit of the mobilization and manipulation, then consent obtained. Screening for contraindication to cervical mobilization has been done in this case through searching for red flags in the history and the clinical examination. These red flags related to circulatory, osseous, inflammatory, neurological, and serious conditions (book).

Following each session of treatment, advice was given about neck care, general posture, and sleeping posture. Maintenance exercise is given to prevent recurrence.(book) Education about posture and stretching exercise is  a very important part of the treatment plan, as the neck pain is a result of  the complex interaction of muscular and ligamentous factors related to posture, sleep habits, ergonomics such as computer monitor and work postion, stress, chronic muscle fatigue, postural adaptation to other primary pain sources

 

In the small number of studies examining the temporal pattern of neck pain, most have focused on either acute or chronic patterns, with minimal focus on sub-acute pain. Nevertheless, a better understanding of sub-acute neck pain may help to stop the transition to chronic pain. Yellow flags, which are discussed later in this review, may be important to address, to reduce the transition from acute to sub-acute or even chronic neck pain. (epidemiology)

In this case, the history of gradual onset of symptoms with duration of less than 3 months makes the patient candidate for the cervical manipulation, a screening for absolute contraindications of cervical mobilization and manipulation was done and other contraindications such as: cervical arterial dysfunction symptoms,  upper motor neuron lesion signs , recent trauma-suspected fracture, unexplained weight loss, blood clotting disorders, anticoagulants intake, rheumatoid arthritis were eliminated. Apart from the suitability of the patient age for manipulation, screening for relative contraindication such as pregnancy, osteoporosis, hypertension, hypercholesterolemia, or steroid use were negative.

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A Cochrane review found that multiple cervical manipulation sessions for acute and subacute neck pain may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up (Cochrane)

 

The use of Musculoskeletal Health Questionnaire (MSK-HQ) in this case aimed at measuring the and monitoring the impact from musculoskeletal symptoms on the patient (Hill). the total pre-treatment MSK-HQ score was 34 in the first appointment. In the follow up appointment the score increased to 52 with clear improvement in the symptoms, function, and impact on the daily activities. However the huge change was positively seen in understanding the condition and confidence in managing the condition.

 

In the follow up appointment, this case has reported improvement in the symptoms by using cervical tractions and mobilization as indicated for sub –acute neck pain. Patient showed good compliance in controlling factors such as correcting posture, sleeping position, and stretching exercise.