Physiotherapy Case Scenario :

A middle-aged man, who lived alone and works as a crane operator, was involved in a head on collision with another vehicle while turning left at an intersection. He had an older vehicle that was not equipped with an airbag.

The right side of his face struck the steering wheel and he dislocated his right shoulder as a result of bracing himself against the impact. The shoulder was relocated at the scene. He was taken to hospital and was diagnosed with a fracture of the right zygomatic arch, whiplash associated disorder and mild concussion, as well as a right shoulder dislocation. He was referred to In-Home Physiotherapy for his shoulder and neck immediately following the accident due to his inability to drive because of concussion symptoms.

During his assessment the client reported he was experiencing balance difficulties, cervicogenic headaches, increased fatigue and neck, shoulder and facial pain. Physiotherapy commenced with:

• pain management of the shoulder, headaches and neck using heat, posture control and education on avoiding aggravating activities and positioning
• shoulder stabilization with tape and isometric strengthening exercises
• maintenance of cervical and thoracic mobility with low grade manual therapy and massage as tolerated
• balance program for instability
• low grade walking program
• referral to Occupational Therapist and family physician for further imaging of the shoulder and for assessment for post-concussion syndrome (PCS).

After six weeks of treatment ,his pain became more manageable, but continued to have persistent post-concussion symptoms and neck pain. He was also experiencing weakness of his whole body from decreased activity. His family physician diagnosed him with PCS. The physiotherapist progressed the treatment to:

• shoulder AROM, proprioception and strengthening program
• increase in cervical proprioception through biofeedback training
• increase in cervical and thoracic mobility with exercise, manual therapy and massage
• balance re-training with habitual exercises
• referral to Rehabilitation Therapist for whole body exercises and to continue with walking program.

After 12 weeks of treatment, he had full range of motion for his shoulder and moderate strength. His concussion symptoms had subsided with the walking program with only occasional onset of symptoms. Physiotherapy then progressed to:

• closed kinetic chain shoulder exercises and plyometrics for strengthening
• work simulated activities for crane operation
• increased cardiovascular program intensity
• continuation of proprioception training of cervical spine
• progression of habitual balance exercises
• maintenance of spinal mobility with manual therapy and massage
• referral for Return-to-Work Assessment and Work Conditioning program

After six months, he returned to modified duties at work, and after twelve months, returned to full duties at work.