Interesting Whiplash patient

Dear members of the forum
I had an interesting whiplash patient and would like to share it.
1. Patient’s profile
44 years old female. She is a nurse aid. When her car was stopping at a signal it was struck from behind. Before the accident her neck had already turned left.
2. Examination
(1)Active ROM
Flex 45(stretch feeling in the posterior neck)
Ext 30(pain in the mid cervical)
Side flex (R) 35 (L)15
Rot (R) 35 （L）45
(2)Palpation
Spasm over left C2~C6 facet joint
Tenderness in C4/5 in P-A mobilization
(3)PIVMS
Hitching feeling in C4/5 in side flexion
3. Treatment
At first treatment I performed P-A mobilization, PAIVM(side flex),left downslide mobilization. After that active ROM of side flex(L) improved 40.But there remained hitching feeling.
At forth treatment I performed A-P mobilization with traction and hitching feeling disappeared.

There are two reasons why I think she was interesting.
One is she asked me to get rid of all symptoms in the neck only within four treatments. Second is that she told me to how to mobilize her cervical spine. She told me to perform A-P mobilization with cervical traction. Of course she didn’t know the technical terms but she told me to push there in that way. In A-P mobilization with traction, especially C4/5, she said “Good feeling!”
Considering she had limitation of ROM in extension I designed to perform P-A mobilization at first. But my clinical reasoning proved to be wrong.
It is very rare the patient direct the number of the treatments and how to mobilize.
But it is very helpful for novice PT like me the patient tell the way to mobilize in Japan.
I would like to ask you two questions.
1.When the patient has limitation of ROM in extension, is it natural to perform A-P mobilization?
2. Have you ever treat the patient according to the patient’s direction?
In Mckenzie technique, PT endeavors to find a directional preference. So I think there may be possible.

Best regards,
Novice PT

Thanks a lot for you post. It is nice to see someone who offers us an insight into what they did as a treatment approach and what worked and what did not. I should menton that AP's on the cervical spine are a very commonly used technique and are often very successful in almost all neck issues. After all the neck is so easily extended and a PA isn't going to mobilise a segment that won't retract and extend as well as an AP mobilization will. That said they are less well tolerated and there is a skill in handling the neck so as not to cause to much discomfort.

Perhaps the best comment you have made is asking the client what they feel you should be doing. The body often senses what is good movement and what is aggravating movement. We must all talk to the client during treatment and not be embarassed to ask them what they feel is the best movement. This is not showing incompedence rather it is using all the feedback available to us in the treatment of the problem. And there's nothing better than getting it straight from the horses mouth :)

Dear physiobob
I greatly appreciate you give me a kind reply so quickly again.
I would ask further more if possible.
Novice PT like me couldn’t find the cause of hitching in the neck.
If he or she is expert skilled physio like Maitland, L.Twomey, M.Jones, he can find the segment of hypomobility in flexion and extension of PIVMS test, can he? And the result of his clinical reasoning will guide him to mobilize A-P without the direction of the patient.
I did test but I couldn’t find it. If so, I should train my assessing skill in PIVMS.

Best regards,
Novice PT

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