With a 2:1 mentor program through my internship, I am able to get the students to work together on projects to better attain information, but to ask more questions and think outside the box than if taught individually.  Here is a recent case (albeit it is made up), that got them going to look up upper cervical spine instability test’s clinical utility.  I think they had fun and learned quite a bit. What would your argument be??


Patient is a 42 year old female who presents with neck pain.  Her symptoms started 5 years ago after she fell off of a horse.  She landed on her bottom and thinks she just “jarred” her neck.  After the incident, she went to the emergency room and had a full set of cervical spine radiographs, which were all unremarkable for a fracture.  Initial medical management was muscle relaxers and Naproxen (NSAID), which cleared up her symptoms after a few weeks.  The symptoms slowly came back on slowly over the years and finally went to her primary care physician for a check-up, which he recommended she try physical therapy and referred her to our clinic.  Her symptoms are predominantly on the right side of her upper cervical spine and radiating occassionally to the zygoma and retro-orbital on right eye.  This gives her headaches, which are daily in nature and last about an hour.  Pain rating is 8/10 at worse with her headaches and a constant 3/10.  Only relief is by taking an anti-inflammatory and lying down on her bed.  It gets worse the more she moves around at home to perform chores and sitting at the computer (she is a stay at home mom).  No other information from medical history or subjective questioning is remarkable.

You decided to perform an upper cervical spine mobilization (grade 4) to C1-2 in prone position.  After the treatment, patient reported having parasthesias in bilateral upper extremities going down to elbows, which you (as the therapist) attribute to soreness from lying prone for a sustained period of time as she has not been prone for many years (she sleeps on her back with 2 pillows since the accident).  Patient calls back leaving a message on office voicemail that night of the treatment saying she was going to the emergency room as her symptoms are worse and she is continuing to have worsening symptoms into the bilateral upper extremities.  She was referred to emergency surgery after having a MRI due to on-call neurologist clinically diagnosing her as having upper cervical spine instability and had emergency surgery to stabilize this area through a fusion.

Several months later, you receive a summon for court as this patient is sueing you for negligence as she had to have surgery since your intervention.

Your task as prosecutor is to cite evidence based on this case that the therapist should have performed upper cervical spine instability tests prior to manual treatment to prevent this injury.

 Your task as the defense attorney is to cite evidence based on this case to defend the therapist saying this could not have been avoided.

Good luck!



  1. The maitland courses always say it doesn’t matter if the tests are crappy, they are the best we have and provided as routine screening by international standards and therefore should be used as a CYOA.

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