Neurological Screening in Manual Therapy: A Clinical Case Study

Why Neurological Screening Matters

The vast majority of patients presenting to a manual therapy clinic do so with benign musculoskeletal conditions. The proportion presenting with serious pathology — fracture, malignancy, infection, neurological emergency — is small but non-trivial, and the consequences of missing it are severe. Neurological screening is not a bureaucratic formality; it is the clinical process by which life-threatening conditions are identified before they are inadvertently treated as musculoskeletal dysfunction. This article uses a clinical case study to illustrate both the process and the stakes.

The Case: A Man in His 40s with Sudden Severe Headache

A male patient aged 46 presents to the clinic describing a sudden, severe headache that began approximately three hours prior. He describes it as "the worst headache of my life" — a phrase that has well-recognised clinical significance. He reports accompanying neck stiffness, mild photophobia, and a sensation of pressure behind both eyes. He attributes the headache to tension from prolonged computer use and has booked for remedial massage and dry needling to his cervical paraspinals.

He has no prior history of significant headache disorders, no recent illness, and is otherwise well. His blood pressure on the clinic cuff reads 178/104 — elevated above his reported baseline of 125/80. He appears flushed and mildly uncomfortable but is ambulatory and coherent.

Red Flags and Orthopaedic Testing

The presenting history immediately triggers several neurological red flags that require systematic assessment before any manual therapy is considered. The thunderclap onset — sudden, severe, maximal-intensity headache — is the cardinal feature of subarachnoid haemorrhage (SAH), a life-threatening emergency arising from rupture of a cerebral aneurysm or arteriovenous malformation. The phrase "worst headache of my life" has a sensitivity of approximately 97% for SAH; every practitioner working in manual therapy must recognise it as an immediate contraindication to treatment and an indication for emergency assessment.

Orthopaedic screening proceeds despite the clinical picture already suggesting medical emergency — to characterise the presentation more completely and guide communication with emergency services. Kernig's sign — hamstring resistance and pain on knee extension with the hip at 90 degrees — is positive. Brudzinski's sign — involuntary hip and knee flexion in response to passive neck flexion — is positive. Both signs indicate meningeal irritation, consistent with either subarachnoid haemorrhage or meningitis. Cervical flexion is markedly restricted and painful. Fundoscopic examination, if available, would assess for papilloedema indicating raised intracranial pressure.

Clinical Outcome and the CSF Leak

Emergency services are called. The patient is transported to hospital where CT imaging of the brain demonstrates a small subarachnoid haemorrhage in the basal cisterns. Lumbar puncture — performed after CT to detect xanthochromia (bilirubin staining of the cerebrospinal fluid from red blood cell breakdown) — confirms the diagnosis. Cerebral angiography identifies a 6mm berry aneurysm of the anterior communicating artery. He undergoes endovascular coiling within twelve hours of presentation.

A CSF leak — cerebrospinal fluid leaking from a dural tear or prior to the haemorrhage sealing — may present as a postural headache (worsening when upright, improving when supine), which could superficially resemble cervicogenic or tension-type headache. The critical differentiating feature is the positional character and the history of a recent precipitating event (including thunderclap onset). CSF leaks require neurological co-management and are an absolute contraindication to spinal manipulation.

Clinical Lessons

This case illustrates several principles central to safe clinical practice. First, take the history before placing hands on the patient — the red flags in this case were present and detectable before any physical examination was required. Second, understand the diagnostic significance of pattern — thunderclap onset, worst headache of life, meningism, and elevated blood pressure together produce a clinical picture that unambiguously demands emergency referral regardless of the patient's own attribution of the pain. Third, the safest action is the right action — calling emergency services on a patient who does not require emergency care produces inconvenience; failing to call emergency services on a patient who does produces death or permanent neurological disability. The risk calculus is clear.

Every manual therapist should be comfortable with the principal neurological screening tests (Kernig's, Brudzinski's, Jolt Accentuation, Babinski, clonus assessment, cranial nerve screening), the clinical red flags for serious intracranial pathology, and the emergency referral pathway for their practice setting.