Finally, the client does report involvement of the neck muscles, which is consistent with myofascial or mechanical neck pain conditions. The assessing clinician should assess the left scales, levator scapula, and upper trapezius muscles for tenderness and loss of flexibility. Involvement of the facet joints and soft tissue is typical with a diagnosis of whiplash-associated disorder, although using the diagnoses of left-sided cervical joint dysfunction with left-sided soft tissue involvement is more specific. Case Study: Charles O’Connor Mr. O’Connor is a 62-year-old retired male who presents to physical therapy via referral from his primary care physician to address left temporomandibular joint pain. The client reports that he has constant pain in the left jaw that can get severe at times. He cannot recall any specific trauma or precipitating incident. The pain has been present for about one month. It is worse with turning his head and while sitting for longer periods (driving, reading). He also has pain when he is active, such as when doing yard work and playing golf. His medical history is significant for lower cervical spinal fusion (client does not recall specific level(s)) several years ago. Upon further questioning, the client recalls that a few months ago, he had left-sided head and neck pain that he localizes to the suboccipital, temporal, and mastoid areas. He considers these symptoms minor compared to his main complaint of left jaw pain. Question What might differential diagnosis look like in this case? Discussion The logical initial step, given the client’s complaints, in differential diagnosis for this client is examination of the left temporomandibular joint. This showed that all active motions of the joint—opening and closing the mouth, jaw protrusion and retrusion—were normal, symmetrical, and pain free. He did not have tenderness at the temporomandibular joint, nor did he have tenderness in the masseter or temporalis muscles. The assessing clinician ruled out temporomandibular joint involvement at this point. The next logical step in differential diagnosis is examination of the cervical spine. Examination revealed the following positive findings: Limited motion at C0–C1 (cervical flexion/ head nodding) and limited motion at C1–C2 (flexion– rotation test), both left greater than right. The client exhibited a mild forward head posture with tenderness in the suboccipital muscles. Myotome and dermatome testing in the upper extremities was negative, and bilateral bicep, triceps, and brachioradialis testing was normal. Testing for strength/endurance of the deep neck flexor muscles via the craniocervical flexion test was positive. Keeping in mind that there is a close relationship between temporomandibular joint disorders and the upper cervical spine, the assessing clinician concluded that the client’s jaw symptoms were related to dysfunction of the upper cervical spine (suboccipital muscle tenderness, forward head posture, limited upper cervical spine motion, weak deep neck flexor muscles) and designed an appropriate treatment plan.
have also been implicated (Hayashi et al., 2019). Walton et al. (2019) also list the cervical proprioceptive afferents, the vestibular apparatus, and mild traumatic brain injury as possible contributors. Symptoms associated with WAD include neck pain and stiffness, headache, and radicular symptoms (Hayashi, 2019). WAD injuries can become chronic. According to Hayashi et al. (2109), up to 50% of patients report pain and/or disability 12 months after their injuries. Evidence supports the presence of central sensitization with chronic WAD. Although therapists may easily arrive at the diagnosis of whiplash-associated neck pain based on a history of motor vehicle crash, a deeper understanding of all the factors that are or may be contributing to your client’s ongoing pain and dysfunction is essential to effective treatment. Addressing maladaptive pain beliefs can help with decreasing pain and disability. A dysfunctional stress response may be present and can be addressed via stress management interventions. Case Study: Emma Ellis Ms. Ellis presents to physical therapy complaining of neck and left shoulder pain. She was in an accident one month ago when she was stopped in traffic and rear-ended by an SUV going about 30 miles per hour. She was taken to the emergency department, where an x-ray ruled out cervical fracture. She continued to have significant pain and recently had an MRI that showed a bulging disc at C5–C6 with no neural compromise or spinal cord compression. She presents with ongoing neck and left shoulder pain that does not involve the left upper extremity. She does not have any tingling, numbness, or weakness in her left arm. She has “muscle spasms” in the left posterolateral cervical muscles. Questions What conditions would you consider as you work through the process of differential diagnosis give the mechanism of injury, the location of the client’s symptoms, and the MRI findings? Discussion With the MRI finding of a bulging disc, one of the first considerations is whether this is a case of cervical radiculopathy. However, the client does not have any myotome or dermatome findings. The mechanism of injury with a rear-end collision is extension, while flexion injuries (as in head-on collisions) are more often associated with cervical disc damage. Although there is evidence for a cervical disc bulge, there is no evidence for neural involvement. The disc bulge finding may be incidental. Several further tests can be used to rule out cervical radiculopathy, including reflex testing and the cluster of Spurling’s test, upper limb tension test, distraction test, and cervical rotation less than 60 degrees to the left. Another diagnosis to consider is cervical facet joint dysfunction. A rear-end collision can cause accelerated cervical extension, which, in turn, can lead to facet joint inflammation and pain. As discussed above, facet joint irritation can cause referred pain to the shoulder. This diagnosis can be confirmed by applying a postero– anterior force to each of the left-sided facet joints (positive findings included reproduction of client’s pain and motion restriction), assessment of cervical spine range of motion, and the extension–rotation test.
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