A 48-year-old male presented to our clinic with persistent lower back pain and hip stiffness stemming from a prior motor vehicle accident. The pain had been present for several years and was aggravated by prolonged sitting, lifting, and extended workdays. The patient also reported cervical tension, reduced neck mobility, and postural fatigue that interfered with both daily comfort and productivity.
He described the pain as dull, achy, and occasionally sharp at its worst, reaching up to 8–9/10 in intensity. The discomfort prevented him from walking or standing for more than a few minutes without stiffness and disrupted normal physical activity and sleep.
His goal was to regain mobility, reduce pain, and restore his ability to remain active without limitation.
Chief Complaints
- Lower Back Pain and Stiffness: Chronic since the motor vehicle accident; aggravated by sitting and bending.
- Cervical Tension and Reduced Range of Motion: Neck stiffness and pain radiating to the upper back.
- Functional Limitations: Difficulty performing daily activities, exercise, and work-related tasks due to pain and fatigue.
- Frequency: Daily, with intermittent flare-ups.
Medical & Lifestyle History
- Past Trauma: Prior motor vehicle accident resulting in chronic low back and neck issues.
- Previous Care: History of physical therapy, steroid injections, and prior chiropractic treatment over a decade ago.
- Occupation: Business management, involving 8–10 hours of sitting per day.
- Exercise: Limited due to pain; stretching and home heat therapy provided temporary relief.
- Medications: None currently reported.
Examination Findings
Initial X-rays and chiropractic examination revealed significant restriction in both the cervical and lumbar spine.
Lumbar Spine Range of Motion (Initial)
- Flexion: 45° (Normal 60° – restricted)
- Extension: 15° (Normal 25° – restricted)
- Lateral Flexion Left: 20° (Normal 25° – restricted)
- Lateral Flexion Right: 15° (Normal 25° – restricted)
- Rotation Left: 20° (Normal 30° – restricted)
- Rotation Right: 15° (Normal 30° – restricted)
Cervical Spine Range of Motion (Initial)
- Flexion: 25° (Normal 50° – restricted)
- Extension: 40° (Normal 60° – restricted)
- Lateral Flexion Left: 25° (Normal 45° – restricted)
- Lateral Flexion Right: 35° (Normal 45° – restricted)
- Rotation Left: 70° (Normal 80° – restricted)
- Rotation Right: 60° (Normal 80° – restricted)
Summary:
Both the cervical and lumbar regions demonstrated measurable movement restrictions across all planes. Neurological findings were normal with symmetrical reflexes and no radicular symptoms.
Orthopedic testing elicited mild to moderate pain with lumbar flexion and extension. Neurological and reflex testing were within normal limits.
Customized Care Plan
To address both the root cause and the compensatory patterns resulting from the motor vehicle accident, the patient began a 3-month corrective care plan that included:
Plan Summary:
- 36 Chiropractic Adjustments
- 36 Soft Tissue Therapy Sessions
- 3 Re-evaluation
- 1 Follow-up X-ray
- 1 Neck Traction Support
- 1 Ergonomic and Postural Recommendations
- 4 Home Stretching and Exercise Instruction Sessions
The patient was educated on proper body mechanics, workstation ergonomics, and home exercises to enhance spinal stability and support recovery.
Post-Treatment Results
After completing 36 visits over 3 months, significant improvements were documented.
Lumbar Spine Range of Motion (Post-Treatment)
- Flexion: 60° (Normal 60° – normal)
- Extension: 25° (Normal 25° – normal)
- Lateral Flexion Left: 25° (Normal 25° – normal)
- Lateral Flexion Right: 25° (Normal 25° – normal)
- Rotation Left: 30° (Normal 30° – normal)
- Rotation Right: 30° (Normal 30° – normal)
Cervical Spine Range of Motion (Post-Treatment)
- Flexion: 45° (Normal 50° – mild restriction)
- Extension: 55° (Normal 60° – mild restriction)
- Lateral Flexion Left: 40° (Normal 45° – mild restriction)
- Lateral Flexion Right: 40° (Normal 45° – mild restriction)
- Rotation Left: 80° (Normal 80° – normal)
- Rotation Right: 80° (Normal 80° – normal)
Patient-Reported Outcome:
The patient reported 95–98% improvement overall, describing significant reductions in pain and stiffness, improved mobility, and better sleep quality. He noted feeling stronger, more relaxed, and more alert overall.
Maintenance Plan
A preventive maintenance schedule was recommended to sustain long-term results:
- 12 chiropractic adjustment visits per year
- Continued adherence to home stretching and exercise program
- Periodic ergonomic reassessments to prevent recurrence
Final Outcome
Following his corrective care plan, the patient’s lumbar and cervical mobility returned to near-normal levels. Pain was reduced to only mild, occasional discomfort after playing sports such as basketball.
He is now on a maintenance plan of 12 chiropractic visits, aimed at maintaining spinal alignment, preventing re-injury, and supporting long-term spinal health.