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A 44 year old female presents to your clinic 6 days after a fall from a horse. Her primary compliant is headaches and neck pain. She also reports dizziness, sensitivity to light, and mild motion sickness since the fall. After the fall she went to the local emergency room and had cervical radiographs performed, which were negative for fracture. She was sent home to rest and referred for a physical therapy evaluation.
Treat this like a “choose your own adventure” story where you play out the scenario for your initial evaluation.
What are you prioritizing for your evaluation? What do you want to rule out as red flags? Any need for additional referrals?
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I would start by asking questions to determine irritability of her neck pain, and further questioning to rule out red flags and would perform objective tests to rule them out. Then i would want to examine her cervical and thoracic spine for potential musculoskeletal involvement. If patient had high irritability of neck pain then I would want to focus on finding impairments to work on to decrease symptoms. If irritability was low, then I would move straight into tests to examine vestibular/oculomotor function. I would also assess for orthostatic hypotension and autonomic dysfunction based on the CPGs.
Red flags that I would want to rule out are craniovertebral ligament dysfunction and CAD due to the trauma from the fall and symptoms reported. She already had imaging to rule out potential fracture which would have been on my radar due to her MOI.
If the patient denies diplopia, dysphagia, dysarthria, drop attacks, numbness and has negative sharp-purser and alar ligament stress tests then I do not think she needs to be referred out to the ER or back to her PCP. Since I am not confident with concussions, I would refer her to a PT who specializes or has more training to treat patients with concussions. The patient may also benefit from additional mental health services if that was a factor as well.
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I would start this evaluation by determining if the patient is appropriate for PT treatment, while keeping in mind irritability levels due to the acuity of symptoms. I would want to rule out a more serious brain injury, cervical spine injury other than fracture including any ligamentous injury, and cardiac/arterial involvement.
Determining irritability would first involve questioning regarding exacerbation of symptoms with neck movement, then HA and dizziness severity as high irritability of symptoms would limit the tests/measures performed at initial evaluation. I would then clear any ligamentous insufficiency by performing the transverse and alar ligament tests as well as sharp purser.
After determining that the patient’s symptoms are highly irritable and that the ligamentous tests are clear, I would then assess cervical and thoracic regions for any MSK impairments that would require low level exercise/movement to begin treatment. Due to the patient’s HA and dizziness I would perform some oculomotor and vestibular tests (visual tracking – smooth pursuits, saccades, convergence to start); however limit this due to her irritability level.
I would have the pt follow up with her PCP if they were not already involved with her care and refer to a neurologist if a more serious brain injury was suspected.
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Great ideas.
Day 1- a lot of the tests were positive due to high irritably and severity.
With positive cervical/thoracic as well as the vision/headaches/dizziness.
When it is so severe, what would you do first?
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Due to high irritability, I would place a lot of emphasis on patient education, including self-management strategies such as resting when tired and getting an appropriate amount of sleep, initial avoidance of aggravating environments such as loud noise or bright lights, gradual and progressive re-introduction of activity and those aggravating environments as symptoms improve, and stress management (music, meditation, aerobic exercise) as tolerated. I would also educate the patient on the prognosis behind their presentation and that many patients recover quickly after a concussion.
If I notice that symptoms are not improving or potentially getting more severe and I am unable to address any of the cervicothoracic or vestibular/ocular impairments, then I would refer the patient to a concussion specialist.
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Given history of trauma and present signs/symptoms, I would prioritize red flag screening to rule out presence of CAD, upper cervical ligamentous instability, or myelopathy.
If red flags are clear, I would sequence my objective examination based on the level of irritability I determine in the subjective, initially starting with a screen of potential cervical/thoracic MSK impairment before assessing vestibular/oculomotor dysfunction due to the concern for a concussion.
If red flags aren’t clear, referral would be needed back to the ER due to the potential that their presentation could be potentially life altering if untreated immediately.
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Sorry,
that was me, just signed in under my therapist!!Great plans
Lets say this is a concussion with some WAD symptoms
How would you treat based on the research?
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