From the Guidelines
The patient's treatment plan should focus on conservative management with physical therapy, over-the-counter pain relievers like Ibuprofen and/or Tylenol, and the prescribed muscle relaxant, as this approach is supported by strong recommendations and moderate-quality evidence from the American College of Physicians and the American Pain Society 1. The patient was involved in a motor vehicle accident and is experiencing neck strain and thoracolumbar back pain.
Key Components of the Treatment Plan
- Physical therapy referrals have been placed to address musculoskeletal pain and promote functional recovery.
- The patient is advised to use over-the-counter pain relievers like Ibuprofen and/or Tylenol as needed for pain management, along with the muscle relaxant prescribed in the emergency room, considering the potential benefits and risks, including gastrointestinal and cardiovascular risks associated with NSAIDs 1.
- Home exercises should be performed according to the handouts provided during the office visit to enhance recovery and reduce the risk of chronic disabling back pain.
- The patient should alternate ice and heat therapy appropriately to help reduce inflammation and muscle tension.
- If symptoms don't improve within 6 weeks, further imaging such as X-rays of the cervical spine may be considered, following the guideline that diagnostic imaging and testing should be performed when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected 1.
Education and Follow-Up
- The patient has been educated about red flag symptoms that would warrant immediate emergency care, emphasizing the importance of monitoring for severe or progressive neurologic deficits.
- A follow-up appointment is scheduled for approximately June 9,2025, to reassess the patient's condition and adjust the treatment plan as necessary, ensuring that the patient receives timely and appropriate care for their musculoskeletal injuries.
From the Research
Assessment and Plan for MVA
The patient was involved in a motor vehicle accident and was evaluated in the ER, where she was discharged with a muscle relaxer for neck strain and back pain. The following points outline the assessment and plan for the patient's condition:
- The patient was restrained with a seatbelt and did not lose consciousness or hit her head during the accident.
- The patient was prescribed OTC Ibuprofen and/or Tylenol for pain management, as well as a muscle relaxant that was prescribed in the ER 2, 3.
- The patient was referred to physical therapy for strain of neck muscle and back pain of the thoracolumbar region.
- The patient was educated on appropriate home exercises, the use of ice and heat, and neck and back pain red flags and ER precautions.
Medication Management
The patient's medication management plan includes:
- OTC Ibuprofen and/or Tylenol for pain management, which has been shown to be effective for acute mild to moderate pain 3.
- A muscle relaxant, which may be useful for acute low back pain 4.
- The patient was advised to take the prescribed muscle relaxant and OTC pain medication as directed.
Follow-up and Further Evaluation
The patient is scheduled to follow up in 6 weeks to assess the improvement of symptoms. If there is no improvement, further imaging, including X-rays of the cervical spine, may be considered. The patient's understanding of the treatment plan is crucial for effective management of her condition, and factors such as empathy and quality of communication between the physician and patient can impact patient satisfaction and knowledge of the diagnoses and treatment plan 5.