Patient interview and history

Jane is a 32-year-old woman who is married with one two-year-old child. She works full-time as a personal assistant to a chief executive officer of an advertising company.

History: Jane was on her way home from work 10 days ago when her car was struck from behind while stopped at a red traffic light. Jane felt slight pain in her neck at the time of the accident and, after organising the car to be towed away, she went home. That night she could feel her neck getting stiff and when she awoke the next morning, she could barely turn her neck. Jane took the following two days off work (sick leave) as she found sitting at the computer aggravated her neck pain. Even though her pain then improved and she returned to work, Jane reported that by the end of the day, her neck pain was worse. Jane is usually very active and goes to gym classes three times a week, as well as playing hockey on the weekends, but has not been able to do so since the car accident. However, she has been able to ride a stationary bike at home for about 15 minutes at a time. Jane presents to the physiotherapist 10 days after the accident as she feels that her neck should be better by now and she is worried since a friend of hers experienced a similar injury and was unable to play any sport for 12 months. She also asked whether or not she should lodge a compensation claim for her injury.

Jane has not had any radiological investigations. She has taken paracetamol as necessary with some reported relief. Jane’s sleep is not disturbed by pain.

Current symptoms and function

Pain: Left-sided neck pain (visual analogue scale [VAS]: 5/10), left-sided frontal headache (VAS: 4/10). There was no reported dizziness, paraesthesia or anaesthesia.

Her functional status, as measured by the Patient-Specific Functional Scale (PSFS),¹ is outlined below. For this instrument, 0/10 means unable to perform the activity and 10/10 means able to perform the activity at pre-injury levels:

Neck Disability Index (NDI):² 28/100, indicating mild-to-moderate levels of pain and disability.³

On listening to Jane’s responses in the patient interview, the clinician decided that there were no indications of post-traumatic stress symptoms, depression or pain-related distress, such as fear of movement—Jane is attempting to exercise within her pain limits and she has returned to work. On this basis, no additional questionnaires were administered. There was also little to suggest the presence of central hyperexcitability in Jane’s clinical presentation.

Physical examination

Jane’s posture was unremarkable. Her range of left cervical rotation was limited to 50 degrees and the movement reproduced her neck pain. All other directions of movement were full and pain-free. The physiotherapist noted several indications of impaired muscle control of the neck and upper quadrant,⁴ including: poor control of return from cervical extension, altered muscle recruitment patterns with craniocervical flexion in supine (craniocervical flexion test) and impaired control of the scapula with arm movement. On manual examination of the cervical spine, local hyperalgesia over the left C2–C3 segment was noted. Clinical neurological examination (sensation, muscle power, reflexes) was normal and there was full and pain-free elbow extension with the brachial plexus provocation test. This test has been proposed as a useful clinical test of centrally augmented motor responses evident by bilaterally limited elbow extension with the test.⁵

Indications of prognosis

Jane’s reported pain levels and NDI scores are moderate and the presence of moderate levels of pain and disability is a prognostic indicator for poor functional recovery.^{6, 7} However, Jane’s levels of psychological distress are low; there is no evidence of central hyperexcitability and neck range of movement is not markedly restricted. Therefore, it would be expected that Jane should recover well.

Management plan

At this stage, the physiotherapist should be able to undertake the management of this patient. There is little to indicate that referral to other healthcare providers is indicated.

Educational management should include providing: assurance about prognosis and that full recovery is expected; awareness of mechanisms underlying the condition; an explanation to Jane of the proposed management plan (see below) and its expected effects.

Physical management should be a multimodal approach. This would primarily involve improvement of cervical movement, retraining of motor control, progressing rapidly to functional and weight-bearing activities. This approach to management has been shown to be beneficial for patients without signs of central hyperexcitability.⁸ Gentle manual therapy at the C2–C3 level could also be included for its hypoalgesic effect on the cervical spine.⁹ As pain and disability decreases, a graduated cardiovascular fitness program could be introduced, with the aim of restoring full sporting activities.

In this case, this is little to indicate a prolonged recovery. Therefore, it would be expected that improvements would be seen quickly (as determined by clinically relevant changes on pain and functional outcomes) and that physiotherapy treatment would not be of a long-term nature. In response to Jane’s question about claim lodgement, she could be advised not to lodge a claim and reassured that treatment sessions will be minimal. Claim lodgement in a patient following Jane’s favourable recovery trajectory has been shown to be associated with a significant worsening of the clinical pathway.¹⁰

Patient interview and history

History: Six weeks ago, Patricia was involved in a motor vehicle crash, in which her car was hit on the rear passenger driver’s side by a car that ran a red light. She felt immediate sharp pain in her neck. The car was extensively damaged and she was taken to hospital, where X-rays revealed no fracture or dislocation, and she was sent home with analgesics. Patricia went to her general practitioner the next day as her pain had spread into her right arm and was reaching an intolerable level. She was prescribed diclofenac and paracetamol and codeine (forte) and advised to take a week off work. After this time, Patricia then attempted to return to work but this exacerbated her pain; she could not concentrate and was experiencing some lightheadedness. She has since not returned to work. She is not sleeping well due to neck pain and reports that she cannot get to sleep due to thoughts about the accident. Prior to the accident, Patricia led a busy life with part-time work and caring for her children. She usually finds time to walk approximately 5 kilometres, three times a week, but has been unable to do this since the accident. Patricia has returned to her general practitioner for further advice. She feels that the pain is getting worse, is worried that something is seriously wrong with her neck and that she will never be able to return to her former busy lifestyle.

Current symptoms and function

Pain: Constant neck (VAS: 8/10) and right arm (VAS: 6/10) pain. Intermittent paraesthesia (VAS: 3/10) in the right hand.

Her functional status as measured by the PSFS¹ is outlined below.

NDI:² 52/100, indicating moderate-to-severe levels of pain and disability.³

The general practitioner notes clues in Patricia’s interview that are suggestive of post-traumatic stress (not sleeping due to thoughts about the accident) and pain-related psychological responses, for example, catastrophisation (there is something seriously wrong). For these reasons, the general practitioner opts to administer the Impact of Events Scale-Revised (IES-R)¹¹ and the Pain Catastrophising Scale (PCS) tests.¹² Patricia’s scores were moderate for the intrusion and hyperarousal subscales of the IES-R and her score on the PCS was 32, which is consistent with pain catastrophising.¹³ The general practitioner also noted features that are suggestive of the presence of central hyperexcitability of nociceptive processing, such as pain at night, and that Patricia’s pain is easily provoked. In view of these reports, the S-LANSS was also administered and Patricia scored 24 on this instrument. A score over 12 is an indication of a neuropathic component to the pain.¹⁴