Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents following a motor vehicle accident (MVA) involving [rear-end/side-impact] collision. Reports onset of cervical pain, stiffness, and restricted range of motion occurring [immediately/within 24 hours] post-trauma. Associated symptoms include occipital headache, paracervical muscle spasms, and radiation of discomfort into the trapezius/interscapular region. Denies neurological deficits, paresthesia, loss of consciousness, or midline bony tenderness.
Clinical Examination Findings
Cervical spine inspection reveals no obvious deformity or ecchymosis. Palpation demonstrates significant tenderness over the paraspinal musculature and trapezius bilateral. Range of motion is restricted in flexion, extension, and rotation secondary to pain. Neurological examination: Cranial nerves II-XII intact. Upper extremity motor strength 5/5, sensation intact to light touch, deep tendon reflexes (biceps, triceps, brachioradialis) 2+ and symmetric. Negative Spurlingโs test; negative Hoffmanโs sign.
Treatment Protocol
Initiate conservative management including short-term use of NSAIDs for inflammation and muscle relaxants for nocturnal spasms. Recommend application of ice packs for the first 48 hours, followed by heat therapy. Early mobilization and gentle cervical range-of-motion exercises are encouraged to prevent stiffness. Referral to physical therapy for postural correction, soft tissue mobilization, and therapeutic ultrasound. Follow-up in 2 weeks if symptoms persist.