David L. Graziano, PT, DPT, MTC
Wanda Nitsch, PT, PhD, MTC
Peter A. Huijbregts, PT, DPT, OCS, FAAOMPT, FCAMT
Abstract: This case report describes the diagnosis and management of a 43-year-old female patient who had sustained an injury to her neck in a motor-vehicle accident two years earlier. The major symptoms described by the patient included headache and neck pain, but history and examination also revealed signs and symptoms potentially indicative of cervical artery compromise. Physical therapy management initially consisted of soft tissue and non-thrust joint manipulation of the lower cervical and thoracic spine, specific exercise prescription, and superficial heat. Cervical vascular compromise was re-evaluated by way of the sustained extension-rotation test. When at the fifth visit this test no longer produced symptoms potentially indicative of vascular compromise, upper cervical diagnosis and management consisting of soft tissue and non-thrust joint manipulation was added. A positive outcome was achieved both at the impairment level and with regard to limitations in activities, the latter including increased performance at work, a return to previous reading activities, improved length and quality of sleep, and greater comfort while driving. At discharge, the patient reported only occasional pain and mild limitations in activities. This report describes the positive outcomes in a patient with chronic whiplash syndrome; however, its main emphasis lies in the discussion and critical evaluation of clinical reasoning in the presence of diagnostic uncertainty with regard to cervical artery compromise.
Key Words: Whiplash Syndrome, Physical Therapy, Cervical Artery, Vertebral Artery, Diagnostic Uncertainty, Clinical Reasoning
In the United States alone, over one million people annually incur acceleration-deceleration or whiplash injuries to the cervical spine1. Cervical spine trauma is estimated to occur in 20% of motor-vehicle accidents2. Headache and neck pain are common complaints after a whiplash injury but symptoms may also include thoracic, temporomandibular, facial, and limb pain and stiffness, dizziness, nausea, visual disturbances, tinnitus, malaise, dysequilibrium, anxiety, and depression3-9.
There is significant controversy with regard to the natural history of whiplash-associated disorder (WAD). Based on prospective inception cohort studies, prevalence for chronic neck pain in patients with whiplash injuries of 14–42% has been reported10. Barnsley et al10 also noted that approximately 10% of these patients report indefinite but constant and severe pain. A more recent prospective cohort study11 similarly found that only 51.7% of subjects reported being recovered at 2 years. In contrast, Partheni et al12 reported a 90% recovery rate in a prospective cohort of patients with grade I and II WAD at a 4-week follow-up. Obelieniene et al12 reported no between-group differences at a 1-year follow-up for a prospective cohort of patients with WAD and matched controls with regard to frequency and intensity of neck pain and headache. This controversy clearly positions clinicians and researchers who regard chronic whiplash syndrome as a mainly cultural and psychosocial phenomenon against those who consider it to be at least partly related to ongoing neuromusculoskeletal dysfunction and, therefore, amenable to physical therapy and medical management.
Neuromusculoskeletal lesions implicated in the etiology of chronic WAD include dysfunctions of the cervical zygapophyseal joints, disks, cartilaginous endplates, muscles, ligaments, vertebrae, and nervous systems structures including nerve roots, spinal cord, brain, and sympathetic nervous system, temporomandibular joints, acromioclavicular joints, the peripheral vestibular system, and—most importantly for this case report—the cervical arteries including the internal carotid and vertebral arteries10,14-25. Kerry and Taylor25 suggested whiplash injury as a cause of intimal injuries to the cervical arteries, predisposing these arteries to subsequent dissection. In a retrospective analysis, Beaudry and Spence24 attributed 70 of 80 traumatically induced cases of vertebrobasilar ischaemia to motor-vehicle accidents. There is an absence of data on the diagnostic or predictive validity for commonly used history items or physical tests or even clear criteria as to what constitutes positive history or physical examination findings indicative of cervical artery compromise. At the same time, because of the potential for traumatically induced cervical artery dysfunction, the clinician is faced with diagnostic uncertainty when dealing with patients with WAD who report symptoms potentially related to vertebral or internal carotid artery dysfunction.
The goal for this case report was to describe and critically evaluate the physical therapy diagnosis and management of a patient with chronic post-whiplash complaints who presented with signs and symptoms potentially indicative of cervical artery compromise. Cervical artery in this case report is understood to include both vertebral and internal carotid arteries.