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Chiropractic Journal of Australia : CJA June 2013
76 Chiropractic Journal of Australia Volume 43 Number 2 June 2013 neck pain after MVA can have a substantial impact on future recurring neck pain and associated disability. In addition, muscle and fascial pain is common following whiplash.8 It has been found that although muscle injury may not be directly responsible for pain following whiplash, it may play an indirect part in post-whiplash pain.8 Therefore, it is speculated that following a traumatic neck injury, neck musculature becomes hypertonic, causing global fxations of the zygapophyseal joints and subluxating the contralateral frst rib. Despite the current evidence being weak, there is some substantiation for chiropractic manipulation improving neck pain and cervical range of motion.9-13 The aim of this paper is to describe two cases of patients presenting with OCS symptomatology, patient management and the outcomes of the intervention. The reporting of this case series may urge practitioners to consider a fnding of this proposed syndrome (OCS) when these signs and symptoms are present. In addition, this paper may encourage researchers to further investigate the theoretical condition of OCS and to compare the effectiveness of Thompson Technique with other manipulative techniques. CASE REPORTS Outlined below are the case histories, physical and radiological exam fndings, treatment plans and outcomes for 2 cases of OCS. The local Institutional Review Board approved this study and written informed consent was obtained from both patients. Case#1 A 22-year-old woman presented for chiropractic care for neck and shoulder pain following a MVA 3 days before. Since the accident she experienced constant neck pain radiating to the left shoulder exacerbated by movement of the cervical spine. On presentation, the patient completed a quadruple visual analogue scale (QVAS) and the Neck Disability Index (NDI). The QVAS is a self-report ranking of (1) Present pain, (2) Typical or Average pain, (3) Pain at its best, and (4) Pain at its worst, where respondents rank their pain from 0 ("No pain") to 10 ("worst pain possible"). Despite little research supporting the temporal facets of the QVAS (2-4), visual analogue scales in general have been found to be valid instruments of pain intensity,14 and sensitive to treatment effects.15 In addition, memory of pain intensities have been found to be accurate, especially in patients with neck pain,16 therefore, the QVAS appears to be a valuable tool for pain assessment. The NDI is a 10-question questionnaire aimed at understanding how a patient's neck pain has impacted his everyday life (e.g.personal care, lifting, concentration, etc.).17 Respondents rate their disability on an ordinal scale from 0 (low) to 5 (high), with a maximum score of 50, and usually reported as a percent (%).17, 18 Although it has been shown that the NDI does not capture the full spectrum of disability following a whiplash-type injury,19 it does demonstrate good test-retest reliability,17,18,20 high internal consistency17,18,20,21 and good concurrent validity.17,20 On the QVAS at intake, this patient reported that her typical pain was 5, current pain was 4, and the pain at its best was 1 and worst, 7. On the initial NDI, the patient scored a 9/50 (or 18%), and reported initially that at presentation she had moderate neck pain, moderate infrequent headaches, and her sleep had been slightly disturbed since the accident. In addition to the QVAS, the patient completed a Numeric Pain Rating Scale (NPRS) at the beginning of each visit. NPRS scores each visit are outlined in Table 1. During the physical exam, the following significant results were found: maximal foraminal encroachment (left) and shoulder depression test (right) both elicited pain. In addition, the patient exhibited normal, but painful, cervical active ranges of motion, with pain in fexion, extension and bilateral lateral fexion. During the postural exam, a high left shoulder and forward head posture were found. In addition, palpation revealed tenderness in the neck bilaterally and along the left trapezius, and hypertonic musculature bilaterally at the cervicothoracic junction. All other orthopedic and neurological testing was normal, including: upper extremity motor testing revealed scores of 5/5 bilaterally for shoulder abductors, elbow fexors, wrist extensors and fexors, fnger extensors and fexors, and hand intrinsic; deep tendon refexes were +2 bilaterally for the biceps, brachioradialis and triceps refexes; C5 to T1 dermatomal testing was unremarkable; Jackson's Compression, and Cervical Distraction Tests revealed no signifcant fndings. In addition, vital signs were recorded and found to be within normal limits: height 1.64 meters, 58.5 kg, Body Mass Index (BMI) 21.8, heart rate 66 beats/minute, respiratory rate 18/minute, normotensive, and body temperature 98.2oF. A radiographic examination of the cervical spine was performed, with anterioposterior (AP), AP open-mouth (APOM), neutral lateral, and posterior oblique views were taken. On the APOM and AP radiograph, marked left deviations of the SPs of C2 and C3 to C7 (respectively) were noted (Figure 2). In addition, the patient brought a CT scan of the cervical spine with her on presentation, which ruled out facet dislocation and other bone and joint pathologies. This case was then reviewed, diagnoses made and a treatment plan recommended. The International Classifcation of Diseases (ICD-9) diagnostic codes for this case are outlined in Table 2. The mechanism of the injury and the clinical presentation made this patient a good candidate for OVERCOMPENSATED CERVICAL SYNDROME (OCS) WELLS • BRINKLEY • JENSEN Figure 1 SIGNS AND SYMPTOMS OF OVERCOMPENSATED CERVICAL SYNDROME (OCS) History Non-resolving or recurring neck pain Diffculty turning to one or both sides (often present) Physical Examination Multiple cervical SP rotation to the painful side Taut and tender ipsilateral trapezius muscle Tender and/or subluxated contralateral 1st rib Radiographic Examination Marked deviation of the axis SP toward painful side Remaining cervical SPs deviating ipsilaterally Progressively diminishing SP deviation from C3 to C7
CJA March 2013
CJA September 2013