Spinal Motion Restriction Is a Pain in the Neck: Just Make Them Comfortable
In the case of possible spine injuries, standard practice in most American EMS systems involves a selective protocol to clear a patient’s spine. These protocols reliably rule out spine injuries. However, when a patient’s spine cannot be cleared after a mechanism of injury, most EMS protocols direct responders to prevent the patient from moving as much as possible, in a process known as spinal motion restriction (SMR).
The theory has been that if a patient could have a spine injury, further motion could cause paralysis, or—if already paralyzed—even worse paralysis. Pretty much all protocols in the U.S. direct EMS personnel to do something to the patient to restrict movement as a means of protecting the potentially injured spine. Mostly these protocols dictate that patients be placed flat-supine and wear a rigid cervical collar.
Some EMS protocols direct the placement of a rigid c-collar and allow conscious patients to move themselves to a supine position on the ambulance stretcher. This self-extrication became allowable after repeat studies showed that self-movement while wearing a c-collar results in less movement than when rescuers facilitate the movement.1
It’s worth noting that spinal immobilization and SMR protocols didn’t originate from studying the outcomes of patients with spine injuries before and after the birth of EMS. These protocols originated as “good ideas.” Today, the theory remains that with a suspected spine injury, allowing motion is dangerous and SMR is protective.
With the adoption of evidence-based guidelines, many dogmatic Truths (with a capital T) have died. Oral screws are gone. Patients no longer receive high-flow oxygen unless they need it. Patients with severe hemorrhage no longer receive gallons of intravenous crystalloid fluid.
The evidence has all but eliminated backboards from SMR protocols, and the evidence of the risks of rigid cervical collars continues to stack up. It’s time to examine if it’s still best practice—when a spine cannot be cleared—to force patients into rigid c-collars and place them flat-supine on ambulance stretchers with “padding” that is dense enough to allow for CPR.
Full Package Versus No Package
In 1998, researchers at the University of New Mexico (UNM) conducted a retrospective population comparison study.2 They compared trauma patients delivered by EMS to the UNM ED to a near-identical population of patients arriving to a similarly equipped hospital in Kuala Lumpur, Malaysia. 100% of the patients arriving to UNM were “fully immobilized” compared to 0% of such patients in Malaysia (Malaysia didn’t have a comprehensive EMS system at the time). The patients in Malaysia had slightly better neurologic outcomes; in the authors’ words, “This corresponds to a <2% chance that immobilization has any beneficial effect,” according to the study authors.
The authors wrote, “These results undoubtedly seem counterintuitive to most physicians who have been taught that spinal motion causes neurologic injury. However, technically only the transfer of energy can physically alter material. Acute neurologic injury occurs when excessive energy is deposited in the spinal cord or its vascular structures. ... Movement within the spine’s normal range of motion requires little energy and is hence unlikely to result in significant energy deposition to the cord.”2
The authors recommended further such studies, but it does not appear that anyone conducted them. If one can accept that Malaysians are orthopedically similar to New Mexicans, and if the different prehospital care yielded functionally identical results, then it seems possible that unrestricted motion is not highly dangerous.
Just Make Them Comfortable
Many well-meaning EMS personnel believe that SMR protocols are good for patients. After enough time on the job, these personnel have also seen how uncomfortable patients are with SMR, wearing a rigid cervical collar and lying supine without a pillow. EMS personnel explain that this torture is a precaution and try to coach patients to remain calmly uncomfortable.
For other orthopedic injuries, the prehospital goal is to splint injuries in a position of comfort and anatomic function. Why not do similarly for potentially injured spines and just make patients comfortable? This would result in a variety of positions based on a patient’s complaints, and near-completely eliminate c-collars. This would mean doing not-much for suspected spine injuries, other than extra pillows and blankets.
Fear is the primary explanation for how SMR endures. Emergency healthcare providers are afraid of patients becoming paralyzed if they do nothing. Somehow a well-documented case of an otherwise uninjured patient becoming paralyzed because of EMS care seems to have been missed in mainstream EMS conversations.3 In this case, “just making them comfortable” would have yielded a better outcome.
Signals
A common paramedic textbook claims that placing a patient in a c-collar and/or other spinal motion restriction devices sends a signal to other healthcare providers to move the patient gently. “A backboard and collar remind everyone who comes in contact with the patient that there is an unresolved question as to the presence of injury and stability of the spinal column. ... It is also possible that someone will not think about the need to employ spinal precautions during a transfer and move the patient in a way that results in permanent devastating neurologic injury.”4
The absence of signals doesn’t promote deliberate thrashing of a patient, but for such a signal, Australian Ambulance Services have shifted to using soft cervical collars with a bright yellow label on the anterior aspect that say, “C-spine not cleared.”
Soft Versus Rigid
When Australian EMS systems transitioned from rigid c-collars to soft c-collars, they collected data to see if patients would have worse outcomes. These studies revealed no adverse outcomes from the shift to soft collars, and patients tolerate the soft collars better.5,6 That said, soft cervical collars allow more motion than rigid cervical collars.7
If allowing motion is dangerous, it should have logically followed that patients in Australia experienced worse outcomes resulting in a course reversal, but that didn’t happen, and the Queensland Ambulance Service’s current Clinical Practice Procedure specifically discourages the use of rigid cervical collars in favor of soft collars.
Maybe It’s Not The Motion
In the UNM study, the patients in Malaysia didn’t have worse outcomes than the patients in New Mexico. With more meticulous consideration of data, patients in Australia didn’t suffer adverse effects due to the transition from rigid c-collars to soft c-collars. Both treatments allowed for more motion than rigid c-collars and backboards, but it’s possible that while these patients are allowed to move more, they might not actually move more. Conscious patients who are injured try not to move their injured parts, and it’s possible that people move less when they’re more comfortable, anyway.
Another explanation is that motion itself doesn’t cause injury. Traumatic injuries result from forces acting on the body in a manner that the body cannot absorb or dissipate those forces. An amount of force is required for movement, but this doesn’t automatically mean the force to cause movement is enough to cause an injury. Injury can happen with great force and minimal movement, as some arm wrestlers have experienced. Nearly all EMS personnel have watched agitated patients flexing against rigid C-collars; not only do such patients move, but the resistance against the collar counterproductively deposits more force into the spine in the process.
A Word About Secondary Injuries
EMS personnel are taught that SMR protocols prevent secondary injuries. The theory remains that someone who has experienced an injury could sustain secondary injuries because of any further movement. The reality is that secondary spinal injuries are a result of the body’s organic processes like inflammation,8,9 not from minimal motion like nodding affirmative to questions.
To the extent that EMS actions could even prevent secondary spinal cord injuries, it seems unlikely that SMR is helpful. It seems more likely that SMR could exacerbate secondary spinal cord injuries; maintaining patients in dysfunctional positions with uncomfortable devices will not alleviate the inflammation that leads to secondary spinal injuries.
What Now?
It appears increasingly likely that SMR does nothing to improve neurologic outcomes for patients with spine injuries and is not risk-free. To the extent that SMR treats anything at all, it might only be the fear of doing nothing felt by emergency medical professionals.
It has never made much sense that SMR protocols dictate flat-supine positioning. If the goal is to prevent motion, this reduction of motion can be accomplished in many positions, most of which are more comfortable and functional than flat-supine.
Conscious patients can often articulate what is most comfortable for them; experience indicates that patients with obvious back injuries prefer not to lie directly on their backs. It also makes sense that patients with suspected brain injuries should have the head of the stretcher elevated to decrease intracranial pressure.10
Similarly, unconscious patients could be maintained in a position of function with blankets, pillows, and a soft cervical collar. For airway safety in non-intubated patients, just as with non-injured unconscious patients, the recovery position, with padding, seems more appropriate than supine.
Increasingly, data support increased comfort for patients, basic padding and support of identified injuries, and just moving injured patients gently. In places where this is the standard of care, patients do just fine.
References
[1] Shafer, J. S., & Naunheim, R. S. (2009). Cervical spine motion during extrication: a pilot study. The western journal of emergency medicine, 10(2), 74–78. Retrieved 17 July 2025 from https://pmc.ncbi.nlm.nih.gov/articles/PMC2691505/
[2] Hauswald, M., Ong, G., Tandberg, D. and Omar, Z. (1998), Out-of-hospital Spinal Immobilization: Its Effect on Neurologic Injury. Academic Emergency Medicine, 5: 214-219. https://doi.org/10.1111/j.1553-2712.1998.tb02615.x
[3] Maarouf, A., McQuown, C. M., Frey, J. A., Ahmed, R. A., & Derrick, L. (2017). Iatrogenic Spinal Cord Injury in a Trauma Patient with Ankylosing Spondylitis. Prehospital Emergency Care, 21(3), 390–394. https://doi.org/10.1080/10903127.2016.1263369
[4] Mejia, A (Ed.) (2023) Nancy Caroline’s Emergency Care in the Streets; Ninth Edition. Jones and Bartlett Learning. Kindle Version, Volume 1 and Volume 2, Chapter 35, p. 5612. Print edition ISBN 9781284256789.
[5] Mitra, B., Bernard, S., Yankoff, C., Somesh, A., Stewart, C., Koolstra, C., Talarico, C., Nehme, Z., Fitzgerald, M. C., & Cameron, P. A. (2024). Change from semi-rigid to soft collars for prehospital management of trauma patients: An observational study. Journal of the American College of Emergency Physicians open, 5(4), e13239. https://doi.org/10.1002/emp2.13239
[6] Baker, R., Klim, S., Poonian, J., Ritchie, P., Ng, S. and Kelly, A.-M. (2023), SOFTLY: Comparison of outcomes of rigid versus soft collar during emergency department investigation for potential cervical spine injury in low-risk blunt trauma patients – A pilot study. Emergency Medicine Australasia, 35: 652-656. https://doi.org/10.1111/1742-6723.14195
[7] Barati, K., Arazpour, M., Vameghi, R., Abdoli, A., & Farmani, F. (2017). The Effect of Soft and Rigid Cervical Collars on Head and Neck Immobilization in Healthy Subjects. Asian spine journal, 11(3), 390–395. https://doi.org/10.4184/asj.2017.11.3.390
[8] Margetis K, Das JM, Emmady PD. Spinal Cord Injuries. [Updated 2025 Jun 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560721/
[9] Borgens, R. B., & Liu-Snyder, P. (2012). Understanding secondary injury. The Quarterly review of biology, 87(2), 89–127. https://doi.org/10.1086/665457.
[10] Schulz-Stübner, S., & Thiex, R. (2006). Raising the head-of-bed by 30 degrees reduces ICP and improves CPP without compromising cardiac output in euvolemic patients with traumatic brain injury and subarachnoid haemorrhage: a practice audit. European journal of anaesthesiology, 23(2), 177–180. https://doi.org/10.1017/S0265021505232118
