Neck Assessment

Subjective Assessment: Patient presents today with a 2-week history of neck pain following a car accident. The mechanism of injury was a whiplash-type movement. The patient reports that the pain is gradually improving with treatment. The pain is described as a dull ache in the neck, radiating to the left shoulder. Aggravated by: Prolonged sitting, looking at a computer screen, and driving. Eased by: Rest, heat, and gentle stretching. Mandatory questions: Night/Constant/Bilateral Pain/Weight Loss: No night pain, constant pain, bilateral pain, or weight loss reported. Dizziness/Vertigo/Drop attacks/Nausea: No dizziness, vertigo, drop attacks, or nausea reported. Dysphasia/Dysarthria/Swallow/Oro-facial: No dysphasia, dysarthria, swallowing difficulties, or oro-facial symptoms reported. Vision/Diplopia/Nystagmus: No vision changes, diplopia, or nystagmus reported. Increased sweating/Night sweats: No increased sweating or night sweats reported. Power loss/Numbness/Pins & needles: Occasional numbness and pins and needles in the left arm. Headaches/Migraine: Occasional headaches. Prolonged steroids/Osteoporosis: No prolonged steroid use or osteoporosis reported. Anti-coagulants: Not taking anti-coagulants. Sleep Disturbance: Difficulty sleeping due to pain. Cough/Sneeze: No cough or sneeze. Metal Implants: No metal implants. Relevant Medical History: Patient has a history of mild asthma, well-controlled with an inhaler. VAS: VAS score of 4/10. Scan/X-rays: X-rays of the cervical spine were taken and showed no fractures or dislocations. PMH: See Relevant Medical History. Patient valued outcomes (PVOs): Patient wants to return to work and be able to drive without pain. Objective Assessment: VBA: Negative. Spurlings: Positive on the left. Posture: Forward head posture. Neck Movements: Reduced range of motion in all directions, especially rotation to the left. Neck Palpation: Tenderness to palpation in the left trapezius and levator scapulae muscles. Thoracic Movements: Within normal limits. Thoracic Palpation: No tenderness. Shoulders: No pain on shoulder movements. Neural: Upper limb tension test positive on the left. Sensory: Decreased sensation to light touch in the left C6 dermatome. Motor: Strength is 5/5 in all myotomes. Other: No other findings. Impression: Cervical sprain/strain with associated myofascial pain. Plan: Continue with physiotherapy treatment, including manual therapy, exercises, and education. Review in one week. Treatment: Manual therapy to the cervical spine and upper thoracic spine. Soft tissue massage to the left trapezius and levator scapulae. Provided education on posture and ergonomics. HEP (Home Exercise Programme): Cervical range of motion exercises, postural correction exercises, and scapular stabilisation exercises. Advice: Advised to avoid prolonged sitting and to take regular breaks. Provided advice on posture and ergonomics. Encouraged to continue with home exercises. Next Day: Continue with current treatment plan.