Case
- Ongoing neck & back pain since "whiplash" (hit overhead w/ chair) @ 15 y.o.
- Ongoing headaches & migraines |
Back
- Between shoulder blades under scapular
- Constant during the day & dull
- 3-4/10
- Remained same since onset
- Feels worse in the evening |
Neck
- From Tx spine to base of head
- Stiff feeling
- Worst in the evening at 5/10
- Worse since started studying at uni & especially over the past few weeks |
AF: Prolonged sitting & prolonged exercise
- RF: Stretching from side to side
- AA: Difficult to fall asleep (not waking due to pain) |
Headaches
- No headaches before accident at 15 y.o.
- No dizziness w/ headache
- Headaches are worse at the end of the day |
Extras
- After initial injury: MRI of "spine" told a slight curvature; CT (brain) for concussion
- OCP (progesterone only) since 16 y.o.
- 10 units of alcohol / week
- Mother: had bowel & breast cancer
- IBS
- Irregular & heavy menses |
Physical Examination Findings
General observations
- Rounded shoulders
- Anterior head carriage
- Scapula protraction |
Posture/stance
- Toeing out on R
- Slight scapular protraction bilaterally & winging on L |
Clinical tests
ROM
- Cx ROM: 75° rot bilaterally; 40° flex & ext; 50° lat flex bilaterally
- Tx ROM: 25° rot bilaterally; 30° flex; 20° ext; 25° lat flex bilaterally |
Tx region exam
- Ott sign (measures ROM of Tx; identifies degenerative inflammatory process): flexion 2cm; ext 0cm |
TTP
- R lev scap
- Suboccipitals bilat
- R rhomboids
- L scalenes
- upper traps bilaterally
- L Tx ES
- SCM bilaterally
- L masseter |
Beighton's score (hypermobility): 2/9 |
Cx spine exam
- Max Cx compression: "pressure" at base of neck w/ RRE
- Cx distraction, Roo's, Bakody's: no change to symptoms
- Shoulder depression test: "tight bilaterally"; no arm symptoms |
Functional screen
- Poor scapula retraction
- Poor Tx ext on Wall Angel
- No winging on push up |
Discussion
Working diagnosis
- Chronic WAD
- Mechanical/MSK
- Chronic pain of 4 yrs |
- Mechanism of injury: most likely caused axial compression, or an element of axial compression of Cx spine
→ dangerous mechanism of injuryw/ risk of unstable fracture & neurological compromise
- Canadian C-spine rule: would indicate immediate imaging & would not do any examination
→ pt should be kept still w/ their Cx spine immobilised & an ambulance called; hospital would x-ray, CT & MRI |
Headache Hx
- Insufficient Hx
- Cannot suggest a working diagnosis
- Not uncommon for pts to have more than one type of headache |
Management
- Consider what exercises & functional management could be beneficial
- Co-management w/ a health psychologist |
Additional questions
- Is irregular & heavy period normal for pt & has it been checked?
- Is there something theft does in the evening that aggravates the HA specifically?
- Any side effects w/ OCP?
- Has period change since taking OCP? |
Learning Outcomes
Presentation of common headaches & those important not to miss, & the important Hx questions that should be asked
⏺ Common headaches:
- Tension-type: most common; dull, non-pulsating pain that's often described as a tight band around the head; mild-moderate intensity & not aggravated by physical activity
- Migraine: recurrent, mild-severe throbbing or pulsating pain, usually one side of head; often accompanied by Sx like nausea/vomiting, sensitivity to light & sounds (photo/phonophobia)
- Cluster: rare but extremely painful that occur in clusters/cycles; cause severe, piercing pain on one side of head, usually around eye or temple area; often accompanied by Sx like redness & tearing of the eye, nasal congestion, & restlessness
⏺ Not to miss:
- Thunderclap: sudden & severe, reaches its max intensity within secs-mins; can indicate potentially life-threatening condition like subarachnoid haemorrhage, cerebral venous sinus thrombosis, or ruptured aneurysm
- HA w/ neurological symptoms: any headache w/ Sx like sudden weakness or paralysis, difficulty speaking, confusion, vision changes, or seizures; may indicate serious underlying condition like stroke, meningitis, or brain tumour
- New-onset HA in older pts: >50 experiencing a new-onset headache; important to consider temporal arteritis (giant cell arteritis), characterised by inflammation of blood vessels; requires immediate medical attention to prevent vision loss & other complications
⏺ Important Hx questions:
- Description: quality, location, intensity, duration, & if there are any associated Sx
- Headache triggers: such as any foods, stress, hormonal changes, or environmental factors
- Frequency & pattern: how often HA occur, how long they last, & about any specific patterns
- PMHx: assess relevant medical conditions like hypertension, head/neck trauma, sinus infections, or previous neurological disorders
- Medications & lifestyle factors: medication that may contribute; sleep patterns, caffeine intake, & stress levels
- FHx: of migraines or other headache disorders |
Chronic pain, it's impact on pts, management & prognosis
⏺ Impact:
- Physical: limitations in physical functioning & mobility (causing difficulties in ADLs); may result in muscle tension, fatigue, sleep disturbances, & decreased overall quality of life
- Emotional: leads to emotional distress like frustration, anxiety, depression, irritability, & reduced sense of control
- Social: may lead to social isolation, withdrawal from social engagements, & challenges in maintaining employment or fulfilling family roles
⏺ Management:
- Multidisciplinary approach
- Medications
- Physical therapy:
- Psychological interventions: CBT
- Interventional procedures: nerve blocks, epidural injections, or radio frequency ablation
- Complementary & alternative therapies: acupuncture, massage therapy, relaxation techniques, mindfulness
Prognosis:
- Varies depending on underlying cause, individual factors, & the effectiveness of treatment approaches
- Pain elimination may not befall possible, but the goals often to improve pain control, functional ability, & overall quality of life
- Many pts experience significant improvements w/ comprehensive & personalised approach
- Co-management is crucial |
When are smear tests & mammograms offered as screening tests in the UK
- Smear tests: 25-64 y.o.; every 3-5 years
- Mammograms:
- 50-70 y.o.; every 3 yrs
- >70 y.o. need to request appointments |
Different types of OCPs, their indications, contraindications & side effects:
⏺ Combined oral contraceptive (COCs):
- Indications: Contain oestrogen & progestin; pregnancy prevention; cycle regulation; acne treatment; prevention of ovarian & endometrial cancer
- Contraindications: Hx of blood clots; smokers aged 35+; uncontrolled hypertension; migraine w/ aura; liver disease; known/suspected pregnancy; breast Ca; Hx of heart disease or stroke
- Side effects: nausea, breast tenderness, irregular bleeding, mood changes, & headache
⏺ Progestin-only pills (POPs):
- Indications: pregnancy prevention; breast-feeding women; migraine w/ aura; smokers over 35+
- Contraindications: known/suspecvted pregnancy, liver disease, breast Ca, Hx of blood clots, abnormal vaginal bleeding, lupus
- Side effects: irregular periods, spotting, acne, HA, weight gain |
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