Case Profile: Myofasciitis – Cervical Spine

Author: Fred Kahn MD, FRCS (C)
Source: Meditech International Inc.

O.B. is a 17-year-old student, who complains of concussion-type symptoms since September 2013. At that time, she headed a soccer ball, which resulted in the diagnosis of concussion. On March 15th, 2014 while skiing downhill, she collided with another individual. The contact was head-on. She does not recall whether there was a specific loss of consciousness after the second event, however symptoms became acute shortly after this episode and have persisted. They consist of headaches daily, memory loss, irritability, inability to concentrate, vertigo, fatigue, irregular sleeping patterns and blurry vision.

She consulted several specialists including a neurosurgeon who provided some vitamins and trained her in meditation. This was helpful in relieving symptoms to some degree and occasionally arresting the headaches. The latter usually began at some point throughout the course of the day and would last up to several hours. They were primarily located in the fronto-temporal area and were predominantly on the right side. She generally goes to bed around 11 pm but is unable to sleep until 3 am and then sleeps until 10 am, however with periodic interruptions.

The patient had also undergone a course of acupuncture over a 5 week period, osteopathic manipulation, massage therapy and chiropractic therapy. None provided any lasting benefit.


  • The patient is right-handed. The right grip is 70 and the left, 50 lbs.
  • There is a normal range of motion of both shoulders.
  • Flexion, extension, lateral rotation and lateral flexion of the cervical spine is only 60% of normal.
  • A moderate degree of peri–cervical muscle spasm is noted to be present.
  • There is no evidence of motor impairment or sensory deficit. Reflexes are within normal limits.


  • Concussion – Post-Trauma
  • Myofascitis – Cervical Spine


This patient, following the second concussion, was unable to continue to attend school and missed a total of 16 weeks of attendance. Laser Therapy was initially applied to the cervical spine, including the brainstem and cerebellum.


After the initial 3 treatment sessions, the patient indicated that she had not experienced any headaches in the past 2 days. She also was able to sleep for 6 hours without interruption.

UPDATE – JUNE 16th, 2014

After 5 treatment sessions the headaches had disappeared completely and the range of motion of the cervical spine had improved to 80% of normal.

FINAL EVALUATION – July 5th, 2014:

At this point a total of 10 Laser Therapy sessions had been administered.

All symptoms relating to the episodes of brain trauma had disappeared completely, with the exception of a mild degree of persisting long-term memory loss. Overall, the loss of memory has been reduced by 80% and improvement is still in progress. The range of motion of the cervical spine has returned to normal and no tenderness or muscle spasm is present.

The patient was obtaining 8 hours of deep sleep each night without interruption and returned to the gym 4 days ago resuming her exercise programme. She plans to return to school in September and is not utilizing any medication at this time.

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