Evaluation and Treatment of Trigeminal Symptoms of Cervical Origin After a Motor-Vehicle Crash: A Case Report With 9-Month Follow-up

Abstract

Objective

The purpose of this case report is to describe the management of a patient with trigeminal symptoms of cervical origin after a motor-vehicle crash (MVC).

Clinical Features

After a head-on MVC, a 65-year-old woman presented with complaints of dizziness, headaches, facial tingling, visual disturbance, tinnitus, loss of cervical motion, and pain in the cervical spine.

Intervention and Outcome

The intervention applied was manipulation of the left C1-C2 and right C2-C3, with targeted exercise to strengthen the cervical musculature. After 4 weeks of treatment, the patient reported improvement in functional tasks and reduction in overall pain, headaches, facial tingling, tinnitus, and dizziness. At a 9-month follow-up, the patient had no report of facial tingling, tinnitus, loss of motion, or eye pain.

Conclusion

This patient with trigeminal symptoms of cervical origin after an MVC responded well to manual therapy to the cervical spine as part of a combination of services.

Introduction

In 2015, there were 6 296 000 motor-vehicle collisions (MVCs) in the United States, resulting in 2.44 million injuries.¹ Although 50% of these individuals recovered within 3 months,² 25% developed chronic complex signs and symptoms such as pain, stiffness, headache, dizziness, disability, and psychological distress.^{2, 3, 4, 5, 6, 7, 8, 9, 10} There has been almost no change in MVC recovery rates over the last 30 years.^{2,4,10, 11, 12}

Relative acceleration and whiplash motion between the head and torso in a front-impact MVC may result in traumatic upper cervical spine extension with lower cervical hyperflexion.^13,14 Pathology after an MVC may include fracture, rim lesion, lower cervical spine annulus trauma, disc herniation, ligamentous rupture, dislocation, muscle strain, cord transection, nerve stress, or vertebral artery dissection.^{15, 16, 17} Active cervical range-of-motion loss, altered muscle recruitment patterns, and alterations in postural control mechanisms such as kinesthesia, balance, and eye control are possible complex symptoms after an MVC.^18,19 There is strong support for the conclusion that chronic whiplash is associated with psychological distress including anxiety, depression, pain catastrophizing, affective disturbance, and fear of movement.^7,20,21 Research suggests that pain catastrophizing and posttraumatic stress may be lessened with appropriate intervention.^22,23

Manual therapy is commonly used in the treatment of neck pain and is associated with immediate improvement in pain and function.^24,25 High-velocity, low-amplitude thrusts (HVLATs) of the cervical spine may be an effective technique, when clinically indicated.^26,27 They may be used to reduce palpable intervertebral joint stiffness and produce a neurophysiologic effect by stimulating the mechanosensitive neurons of the facet joint capsule.^28,29 The pain-relieving effects of HVLATs may be the result of changes in neural plasticity when afferent input alters nociceptive circuits.³⁰

Improved treatment and further research are needed to improve the rate of recovery and reduce the potential of chronic symptoms. The purpose of this study is to describe how HVLATs to C1-C2 and C2-C3, manual therapy, and exercise were used to treat trigeminal symptoms of cervical origin after an MVC.

Case Report

A 65-year-old woman presented to an outpatient physical therapy clinic for evaluation and treatment of neck pain, dizziness, and headache. She had been in an MVC 19 years before seeking care from the therapist. At the time of the MVC she began experiencing intermittent pain, dizziness, and headache, which continued to affect her functional tasks over the following 19 years. She had previous computed tomography imaging that ruled out fracture and severe pathology. In the years after the MVC, she had been seen by the emergency department, an ophthalmologist, a general practitioner, and multiple physical therapists. She stopped working due to her symptoms and became depressed. Approximately 10 months before the current therapist evaluation, she began to feel tingling in the left side of her face, cheek, and jawline. The tingling prompted a return to medical care, and she was cleared of cardiac pathology but remained without a diagnosis. She was referred to physical therapy with a chief complaint of dizziness, lasting 10 seconds, with lying down from a seated position. She also complained of intermittent, sharp pain in the top and left of her cervical spine, headaches that began in the posterior aspect of her head and traveled to her left eye, stiffness and loss of neck motion, itchy pain in her left eye, and left-sided facial tingling. She stated that she felt like she was “looking through a dirty window,” and that it felt better to be in a dark and quiet room. Her current pain level on the Numeric Pain Rating Scale (NPRS) was 8 out of 10 with activity and 2 out of 10 at rest. She would occasionally take ibuprofen for her symptoms, which only minimally helped reduce the pain. Reading for longer than 30 minutes caused neck pain and triggered headaches, which caused pain in her left eye. Due to pain and depression, she had ceased participating in church activities and singing in the choir.

Examination

During the examination, the patient presented with a forward head posture, protracted shoulders, and thoracic kyphosis. An initial screening of the bilateral upper extremities including active range of motion, myotomal strength testing, light touch to dermatomes, and deep tendon reflexes was completed, and all were found to be normal. Because cervical instability was within our differential diagnosis, a cervical ligamentous scan was performed to rule out serious pathology and assess patient response, with negative results for the transverse ligament, no pain with distraction, a negative Sharp-Purser test, and shearing tests to the upper cervical spine. The (Pettman) Hautant, Romberg, and Dix-Hallpike tests were negative.^{31, 32, 33} Cranial nerve examination revealed hyperalgesia and tingling on the left cheek to light touch during trigeminal facial-sensation tests, but motor assessment for the trigeminal nerve was normal. The combination of cervical extension and left cervical side bending in the upper cervical spine reproduced her chief complaint of sharp pain in the upper-left craniovertebral area of the cervical spine (Table 1). We also assessed factors which may be associated with cervical artery dysfunction,³⁴ but blood pressure and positional testing were negative, which suggests a low nature of risk and a potential benefit from manual therapy.³⁴

Table 1.

Cervical Active Range of Motion Through 5 Visits of Physical Therapy

Objective Motion Measurement	Visit 1	Visit 2	Visit 3	Visit 4	Visit 5
Cervical flexion	Normal	Normal	Normal	Normal	Normal
Cervical extension	50% loss of motion with pain	Normal	Normal	Normal	Normal
Right cervical rotation	Normal	Normal	Normal	Normal	Normal
Left cervical rotation	25% loss of motion with pain	25% loss/pain	Normal	Normal	Normal
Right cervical side bending	Normal	Normal	Normal	Normal	Normal
Left cervical side bending	50% loss of motion with pain	Normal	Normal	Normal	Normal

Passive intervertebral motion (PIVM) testing was performed for the entire cervical spine, with the patient sitting on a plinth, and there was visible range-of-motion restriction and reported pain with extension and lateral flexion at the left C2-C3. Passive accessory intervertebral motion (PAIVM) was tested at the left C2-C3 with hypomobility noted into extension (Table 2). Palpation of the bilateral midcervical multifidus indicated atrophy. Poor recruitment of deep cervical flexors was noted in the deep neck-flexion test, with compensatory firing of the sternocleidomastoid musculature.^35,36 Outcome measures were NPRS score, Neck Disability Index (NDI) score, and the Global Rate of Change (GROC) scale score. The NPRS is a self-reported pain scale with a minimal clinically important difference (MCID) of 1 to 2 points.⁹ The NDI provides a useful, reliable, and valid measure of clinical outcomes for patients with neck pain, with an MCID of 19 percentage points.^37,38 The GROC is a 15-point Likert scale used to objectively assess a patient's recovery level, and the MCID is 3 points.^39,40

Table 2.

Mobility Findings and Manual Treatment

Visit	Mobility Findings	Manual Treatment
1	Hypomobile extension PAIVM L C2-C3	HVLAT L C2-3 to improve cervical extension
2	Hypomobile anterior-inferior PAIVM R C1-C2/normalized end feel into extension of L C2-C3	HVLAT R C1-C2 to improve L cervical rotation
3-5	Normalized end feel into extension of L C2-C3/PAIVM and anterior inferior PAIVM R C1-C2	No manual treatment

HVLAT, high-velocity, low-amplitude thrust; L, left; PAIVM, passive accessory intervertebral motion; R, right.

Clinical Impression

Our preliminary clinical impression was central sensitization of the trigeminal nerve, from an abnormal movement pattern of the left C2-C3 zygapophyseal joint (ZJ). Subjectively, the patient reported tingling in the face, tinnitus in her left ear, visual dysfunction of “looking through a dirty window,” left eye pain, headaches, and dizziness with certain movements. She did not have vestibular, neural, or cervical artery dysfunction symptoms. She demonstrated reduced active cervical extension, left lateral flexion range of motion (ROM), and PIVM/PAIVM of extension and lateral flexion of the left C2-C3 ZJ.

Intervention

We felt that education was paramount to help the patient understand trigeminal symptoms of cervical origin and our plan of care.^{41, 42, 43} Table 2 gives a review of assessment and manual treatment. The patient was specifically questioned regarding HVLAT cervical manipulation and gave consent.³⁴

Visit 1

Our proposed manual therapy intervention was an HVLAT manipulation to the left C2-C3 ZJ to improve extension, while protecting potentially sensitive segments below (Fig 1, Fig 2).⁴⁴ The motion barrier was located and a premanipulation hold was performed for 10 seconds; no pain, vascular, neurological, or other symptoms were provoked. The patient gave consent to a treatment plan consisting of C1-C2 ZJ HVLAT manipulation to reduce her pain and improve her left cervical rotation range of motion. A single cavitation was heard and felt under the therapist's index finger. Immediately after the HVLAT manipulation, a hold-relax technique into extension of the segment was performed to facilitate cervical extensor strength, within the perceived new motion at 1 set of 10 repetitions, holding for 3 seconds. Immediately after treatment, the patient had equal lateral flexion, bilaterally, as well as restoration of full and painless cervical extension (Table 3). In addition to the cervical ROM gains, she reported an immediate change in visual symptoms, as if a “film was cleared from her eyes.” Also, there was a cessation of facial tingling and tinnitus in the left ear. She was given a home exercise program of active cervical extension with left lateral flexion and instructed to perform 1 set of 10 repetitions 2 times a day in a sitting position.

Fig 1.

Manipulation to improve extension at the left C2-C3 zygapophyseal joint with potential of an unsound segment below. The patient was set up in the hook-lying position and the author cradled her head in his right elbow while his left hand palpated the left C2-C3 zygapophyseal joint. A craniovertebral lock was performed from above using extension and left lateral flexion down to and into C2-C3. The thrusting hand (left) was placed under the left C3 transverse process, and the right hand was fixed to the table by pushing the right elbow onto the bed. The right hand was pushed into the bed to reduce the potential traction effect of the manipulation. A premanipulation hold was then performed at the barrier to determine if there were any adverse symptoms. The manipulation was performed in a vector toward the patient's right eye to gain relative extension.

Fig 2.

Manipulation to improve left cervical rotation at the right C1-C2 zygapophyseal joint. The author secured the patient's head using the left hand while the right hand palpated the right C1-C2 zygapophyseal joint. A craniovertebral lock was performed from above using right cervical lateral flexion and rotating the head left around the craniovertebral axis. The thrusting hand (right) was placed against the C1 transverse process and the left hand secured the head and helped maintain the right lateral flexion. A premanipulation hold was then performed at the barrier to determine if there were any adverse symptoms. The manipulation was performed in a vector toward the patient's left shoulder and chest.

Table 3.

Summary of Functional Outcome Measures

Outcome Measure	Evaluation	Discharge	3 mo	6 mo	9 mo
Numeric Pain Rating Scale	8	2a	2a	1a	1a
Neck Disability Index	36	14a	8a	6a	2a
Global Rate of Change	−3	1a	2a	3a	4a

^aMet minimum clinically important difference for improvement.

Visit 2 (4 Days Later)

At the next session, the patient reported 80% improvement in facial tingling, tinnitus, and visual impairment. She had improvement of active motion and increased tolerance to functional activities such as applying makeup and combing her hair. She reported sharp pain, rated 4 out of 10, with looking over her left shoulder. There was also dizziness with transferring from sitting to supine that lasted 2 seconds, and she had 2 incidences of headache, lasting a couple hours, since the initial examination. Objectively, she had 25% loss of active left cervical rotation, and manual assessment revealed loss of PAIVM at the right C1-C2 ZJ going into left cervical rotation with a hypomobile end feel, and normal end feel of the left C2-C3 ZJ in extension. The biomechanics of the occipitoatlantal joint and the atlantoaxial ZJ (C1-C2) demonstrate contralateral coupling, which has been widely accepted.^{45, 46, 47, 48} Thus, the patient was educated about the objective results. She gave express consent for HVLAT manipulation, which we performed to the right C1/C2 transverse process in an anterior, medial, and inferior direction to improve left cervical rotation and decrease pain.⁴⁴ Refer to the supplemental file for description of the HVLAT technique. The barrier was located and a 10-second premanipulation hold was performed, in which no pain, vascular, neurological, or other symptoms were provoked. Then the HVLAT manipulation was performed. A single cavitation was heard and felt under the therapist's index finger. Immediately after the HVLAT manipulation, we performed hold-relax techniques to increase strength into left cervical rotation at 1 set of 10 repetitions holding for 3 seconds. Immediately after treatment, the patient had no dizziness, and there was full, painless, cervical active range of motion. Passive accessory intervertebral motion was reassessed, and there appeared to be a normal end feel. The patient was instructed in new exercises (Table 4) and her home exercise program (HEP) was revised.

Table 4.

Description of Exercises

Exercise	Visit 1	Visit 2	Visit 3	Visit 4	Visit 5
Active cervical extension with lateral side bend in sitting position	1 set of 10	2 sets of 10	2 sets of 10	2 sets of 15	2 sets of 15
Craniocervical flexion (nod) at end range of left cervical rotation		1 set of 10	2 sets of 10	2 sets of 15	2 sets of 15
Deep neck flexion training in supine position (nod)		1 set of 10	2 sets of 15
Move eyes to target followed by head, with eyes remaining focused on the target		1 set of 10	2 sets of 10	2 sets of 15	2 sets of 15
Maintain fixed gaze on target while head is actively rotated to the left			1 sets of 10	2 sets of 10	2 sets of 15
Bilateral shoulder flexion in supine position			1 sets of 10	2 sets of 10	2 sets of 10 using 1 lb
Deep neck flexion training in sitting position				1 sets of 10	2 sets of 10
Wall angel in standing position					2 sets of 10

General guidelines: All exercises performed 2 times/d. Stop exercise if any increase of pain with movement.

Visits 3-5 (Weeks 2-4)

The patient reported improvement in functional tasks and reduction in overall pain, headaches, facial tingling, tinnitus, and dizziness. The left C2-C3 and right C1-C2 zygapophyseal joints were assessed using PIVM and PAIVM, and a normal end feel was noted. She was given additional exercises (Table 4) to improve strength in the cervicothoracic region and was discharged to continue with her HEP.

Follow-up at 3 and 6 Months

The patient was contacted via phone for a 3-month follow-up and reported no facial tingling, tinnitus, loss of motion, or eye pain. However, she still had some dizziness, lasting 1 to 2 seconds, with sitting-to-supine transfer, as well as headaches at a frequency of 2 per week that lasted 2 hours. She was still continuing with her HEP as instructed.

She was contacted via phone for a 6-month follow-up and reported no facial tingling, tinnitus, loss of motion, or eye pain. She reported dizziness, lasting 1 second, intermittently, with sitting-to-supine transfer. Her headache frequency was reduced to 1 per week that lasted an hour. She was still continuing with her HEP and had joined her local gym.

Follow-up at 9 Months

The patient presented to the clinic for a 9-month follow-up and had no report of facial tingling, tinnitus, loss of motion, or eye pain. She had complete abolishment of dizziness with sitting-to-supine transfer and reported 2 headaches, lasting 20 minutes each, over the previous 3 months. She was able to read symptom-free for 3 hours, attend her local gym, and return to all church activities, including singing. The patient gave consent to have her personal health information published in this case report.

Discussion

This patient presented with a chronic, complex, and challenging set of symptoms. However, with appropriate clinical reasoning and application of biomechanics, pathoanatomy, exercise, and manual-therapy techniques, she was able to demonstrate immediate improvement in functional outcomes and cervical active range of motion.

She met the MCIDs for the NPRS, NDI, and GROC, which were clinically (Table 4). She had an immediate change in symptoms at the initial examination; such changes have been previously reported in patients with chronic neck pain after a single manual therapy session.⁴⁸ It has been suggested that HVLAT manipulation may affect central pain control through stimulation of descending inhibitory pain mechanisms leading to a presynaptic inhibition of pain, reflex pain inhibition, reflex muscle relaxation, and changes in proprioceptive afferent input.^29,49 It may be that a central sensitization (CS) was created from the aberrant afferent left C2-C3 ZJ hypomobility stimulus entering the trigeminocervical nucleus (TCN). A CS of the ophthalmic branch can produce eye pain, anterior headache, and redness of the eye,^50,51 and in the maxillary branch it can produce symptoms of retro-orbital eye pain, facial sensitivity, and upper tooth pain.^{52, 53, 54, 55} Excitation of the cochlear nucleus can occur with CS of the TCN, which can produce tinnitus.^{56, 57, 58} Once the joint was manipulated, and subsequently followed up with appropriate neuromuscular re-education and strengthening, aberrant stimuli may have been lessened and the sensitization reduced.

At her 9-month follow-up, the patient was still performing her HEP; exercise has been shown to enhance the long-term effects of manual therapy in the cervical spine.⁵⁹

Neurophysiologic models theorize that HVLATs may stimulate or modulate the somatosensory system and evoke neuromuscular reflexes which are thought to inhibit hyperactive musculature and nociceptive activity and improve spinal function.^{60, 61, 62, 63, 64} After whiplash, the C2-C3 ZJ has been found to have the highest prevalence of acute pain, with half of these cases developing chronic pain and just over one-quarter resulting in cervicogenic headaches.^{65, 66, 67}

Central sensitization is a phenomenon where nociceptor inputs may trigger prolonged but reversible increases in the excitability and synaptic efficacy of neurons in central nociceptive pathways.⁶⁸ Painful hypersensitivity, dynamic tactile allodynia, lower pain-pressure hyperalgesia, and aftersensations are typically manifested by CS.⁶⁸ The repetitive noxious input from the C2-C3 ZJ may produce CS of the TCN.^52,69,70

The trigeminal nerve comprises 3 branches: the ophthalmic (which provides sensation to the eyeball, conjunctiva, and cornea), the maxillary (which innervates the middle third of the face, the floor of the orbit, and the maxillary, ethmoid, and sphenoid sinuses), and the mandibular (which provides sensation to the lower third of the face and tongue, jaw, and parts of the external ear). The TCN consists of the sensory afferent fibers of the C1-C3 nerve roots, along with the pars caudalis portion of the trigeminal nucleus.⁷¹

Limitations

There are several limitations with this case report. This was a single case study, and its results cannot be generalized. We acknowledge that while some of the patient's improvement may be due to the treatment, in a case study it is not possible to account for activities outside of treatment or the natural course of symptom improvement. In the assessment, we acknowledge that the validity and reliability of PIVM and PAIVM are not well accepted, so the procedures we used, while clinically relevant, have inconsistent support in the literature.^72,73

While the treatment did yield clinically relevant outcomes, it is impossible to determine the results and efficacy of this program—HVLAT manipulation to C1-C2 and C2-C3 and exercise—from a case study. Further research with larger sample sizes is recommended to determine the efficacy of this intervention strategy.

The outcomes described in this case report are applicable only to this case, and therefore other similar patients may not have similar outcomes. This case report offers a potential benefit of HVLAT manipulation and therapeutic exercise for trigeminal symptoms of cervical origin. While a case report is a lower level of evidence, our results add to the existing support for the use of manipulative care to the upper cervical spine after MVC trauma.^74,75

Conclusion

This case reports details successful treatment of symptoms associated with the upper cervical spine after an MVC. This patient, with trigeminal symptoms of cervical origin after an MVC, responded well to manual therapy to the cervical spine as part of a combination of services.