Case: The 26-year-old weekend warrior

The patient is a 26-year-old male presenting to PT with complaints of neck pain of traumatic onset three weeks ago. He reports falling on his head while attempting to do a handstand push-up after finishing a CrossFit workout. He describes feeling a jolt through his head and neck followed by a period of neck stiffness. He rates his initial neck pain as 4/10 that increased to 6/10 the next day on the numeric pain rating scale. He denies any use of medications for pain and has refrained from working out at CrossFit since. He is having difficulty sleeping and has begun to experience headaches. He works full time as a clinical assistant at a physician’s office where he receives phone calls and helps with intake information for patient visits. He has difficulty driving, reading, and concentrating for extended periods of time.

Imaging was performed after visiting his primary care physician and x-rays were unremarkable

 f/u Questions for you

1. Do you have enough information to determine if this patient appropriate for physical therapy?
2. Based on the information listed above, are we able to establish any hypotheses?
3. If so, what are some competing diagnoses for this patient?
4. What additional subjective information would you like to know for this case to assist you in establishing a physical therapy diagnosis?

Part 1 summary

After further investigation, the patient reveals a sense of being lightheaded and having blurred vision immediately after landing on his head. He denied any loss of consciousness, dizziness or double vision. He has returned to exercising, but has limited himself to walking on the treadmill for up to 15 minutes and only use of light free weights at the gym. He feels more tired at work and averages about 4 to 5 hours of sleep a night. His neck pain has limited his ability to drive due to turning his head so he has limited driving outside of work and getting food. He tells you he feels like his neck just needs to be manipulated. He continues to experience blurred vision and attributes these symptoms to his lack of sleep and feeling tired. He denies any history of head/neck trauma.

f/u questions for you based on summary

1. Based on this information, what subjective outcome measures would be appropriate for this patient?
2. Are referrals to a specialist needed?
3. Based on the patient’s age and mechanism of injury or would you like any additional imaging for this patient? If so what type?
4. Considering moving forward with an objective exam, what red flag information would you want to rule out and where would you start with your exam?

Objective Exam

The patient's history does not suggest any signs of an upper motor neuron lesion or a multi-level nerve root pathology. He does not have a history of hypertension, smoking, cancer, connective tissue or autoimmune disorders, or recent infections. He has self manipulated his neck in the past after falling asleep on the couch while watching television and experiencing similar symptoms.

You decide to start with a screen of his cervical spine for potential cervical artery dysfunction and upper cervical instability that could compromise vascular and neurological structures.  You determine increased laxity in the left alar ligament, with other ligamentous testing being unremarkable in regards to symptom provocation or abnormal end-feel. You examine his willingness to move and discover he has limited cervical rotation active range of motion bilaterally. He also lacks the ability to perform proper cranio-vertebral flexion. You find this information to be clinically relevant, but you are pushed for time and want to make sure you screen other systems.

You finish your physical examination with vestibular ocular motor screening and conclude that he has visual motion sensitivity with reported symptoms of headache and fogginess, scores of 4/10 and 5/10, respectively.

Being constrained due to time, you make the decision to incorporate additional objective outcome measures in the patient's second visit to be thorough. Take some time to consider what measures you feel are clinically relevant for this patient.