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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