Ruling Out Serious Injury At The Neck
Posted By: Andy Barker
He was the driver and was hit side on by another car travelling at high speed.
He had some pretty bad symptoms to his lower back and shoulder…
Neck pain with neural symptoms and weakness…
Along with a heavy concussion.
This type of injury, especially the presence of those neck ‘red flags’ and his concussion, would have got my head in a spin as a New Grad.
Worried that I might make him worse…
Unsure whether or not I needed to refer him to someone else.
But through a simple, structured assessment we were able to rule out any serious pathology…
And we were able to make a big change in his symptoms both in the clinic and over the next few days…
By doing some really simple things.
The same things that you could do with a similar patient if they walked in your clinic door tomorrow…
Even if they had complex symptoms like this.
This blog will walk you through how to tackle neck pain patients, how to rule out sinister pathology, so you can be confident your patient is ok for treatment and rehab and take away that fear that you are going to make their injury worse.
If It Sounds Neural…It Probably Is!
I remember being told at Uni by one of my lecturers that if a patient’s symptoms sounded a bit weird or did not fit an obvious pattern…
It was probably a nerve.
Whilst this is a little general as a rule there is some truth in it.
Nerve injuries often do not present in the same ordered and predicted fashion that a muscle, bone, tendon or ligament injury does.
This is most evident after injury as we see nerve problems follow an often non-linear recovery, very different to those other soft tissue structures.
In short, nerves tend to recover slower and symptoms are much more likely to change during recovery from injury.
That is why you might see those up and down type symptoms with a patient struggling with a nerve based injury in the neck or even with lower back neural problems like sciatica.
This is mainly because nerves are highly irritable structures and as a result, it does not take much to aggravate them.
If you assess a patient and they give you an indication that they MIGHT have some neural based symptoms like numbness, weakness, loss of sensation or strength…
Then you must test for these issues.
Key with any spinal injury is to rule out any sinister pathology before you move on to your treatments and rehab.
Know Your Red Flag Tests
If you do not know your red flag questions and tests or how to do them well, then you might let something serious slip through the net!
The first line red flags objective tests for any spinal injury include your dermatome (sensation testing), myotome (muscle testing) and reflex tests.
For the neck and upper limb injuries you might also include tests specific for vertebral artery dysfunction e.g. Spurlings test, or a variation of an upper limb tension test if your patient symptoms indicated these types of issues.
If you feel like you need to know these tests better or feel like you know the tests, but need to build more confidence conducting these tests, then you need to practice them.
It doesn’t matter if a friend or colleague does not have symptoms you can still use them to practice.
By practicing you will improve your patient handling, competency and confidence with these tests, so you will feel ready when the time comes and you need to do these tests as part of your assessment with a real patient.
Restore ADL First…Before Anything Else
This may seem obvious but a lot of the time we do not do this well as therapists.
Going back to the patient I saw in clinic…
The biggest problem he was having with his activities of daily living (ADL) was sleep.
His neck and arm symptoms were waking him up.
The fact that he prefers sleeping on his left shoulder and had left sided symptoms wasn’t helping.
As part of his rehab in the first session, we spent some time in clinic playing around with different sleep positions, using pillows to support his head to make his sleeping position as comfortable as possible.
We were able to find a comfortable position quite quickly, one that he could lay in and feel no symptoms in his neck or arm.
In short, we used pillows to position his head and neck in a neutral position.
This would mean that his pillows would be a little higher than he would ordinary use, but it worked.
A few days later he messaged me to say he had slept through for the last 2 nights without waking.
The night before his appointment he only had about 3 hours sleep in total, and had woken up, because of the pain around 5 times.
Sleep is a great tool for recovery from injury.
We sleep for around 7-8 hours per night, which is a third of the day.
Improving a patient’s sleep or other ADL like getting out of a chair or bed or getting up and down the stairs, must be a priority.
Keep things simple.
Identify your patients’ big problems.
The problems that firstly are affecting their ADL.
Fix these first.
Then you can work on restoring ROM, strength and movement quality or whatever other problems you identify during your patients assessments.
#1 If It Sounds Neural…It Probably Is – Nerve based injuries often follow a non-linear pattern which is different to those we might associate with a muscle, tendon or ligament injury.
#2 Know Your Red Flag Tests – It is important firstly you know your red flag questions and tests, and then, are competent and confident to use these tests, so you can identify any significant problems that may need immediate attention or referral.
#3 Restore ADL First Before Anything Else – If a patient is having problems with things like sleep, getting out of bed or a chair, or getting up and down the stairs, fix these problems first, before worrying about other issues like range of movement or strength.
Thanks for reading
PS. If red flags and ruling out sinister spinal injuries is something you feel like you need some help with…just let me know.
If you get your assessments wrong, not only could you miss something sinister but you could end up wasting your time, effort and energy (and your patients) on the wrong thing!
I can walk you through the exact questions and tests I commonly use with both neck and lower back pain patients so you are sure you are asking the right questions and doing the right tests.
There is nothing worse than worrying you might have missed something serious and if you do…
You can quite easily make your patients symptoms much worse, very quickly.
For some help with your red flag questioning and testing, book a call Here
On the call I’ll help you make sense of your red flag questions and tests to give you the confidence you need to assess these types of injuries well, so you stop worrying that you might miss something sinister.