Screening the Head, Neck, and Back

Chapter 14


Screening the Head, Neck, and Back


It is estimated that 80% to 90% of the western population will experience an episode of acute back pain at least once during their lifetime,1 making it one of the most common problems physical therapists evaluate and treat.2–4


It has been suggested that mechanical low back pain (LBP) and leg pain with spinal causes compose approximately 97% of all cases.5 Nonmechanical spinal disease can be attributed to neoplasm, infection, or inflammation in 1% of all cases with another 2% accounted for by visceral disorders (pelvic organs, gastrointestinal [GI] dysfunction, renal involvement, abdominal aneurysms).6


Most cases of back pain in adults are associated with age-related degenerative processes, physical loading, and musculoligamentous injuries. Many mechanical causes of back pain resolve within 1 to 4 weeks without serious problems. It has been estimated that fewer than 2% of individuals presenting with LBP present with significant neurologic involvement or other signs that require referral or imaging.7 Up to 10% of LBP patients have no identifiable cause.8


Sacroiliac (SI) joint dysfunction can mimic LBP and diskogenic disease with pain referred below the knee to the foot. Studies show SI joint dysfunction is the primary source of LBP in 18% to 30% of people with LBP.8–13 As always, when conducting a physical examination the therapist must consider the possibility of a mechanical problem above or below the area of pain or symptom presentation.


A smaller number of people will develop chronic pain without organic pathology or they may have an underlying serious medical condition. The therapist must be aware that many different diseases can appear as neck pain, back pain, or both at the same time (Table 14-1). For example, rheumatoid arthritis affects the cervical spine early in the course of the disease but may go unrecognized at first.14–16 Neck pain may be a feature of any disorder or disease that occurs above the shoulder blades; it is a rare symptom of neoplasm or infection.17



In this chapter, general information is offered about back pain with a focus on clinical presentation, while keeping in mind risk factors and associated signs and symptoms typical of each visceral system capable of referring pain to the head, neck, and back. Neck and back pain may arise in the spine from infection, fracture, or inflammatory, metabolic, or neoplastic disorders.


Additionally LBP can be referred from abdominal or pelvic disease. Nonsteroidal antiinflammatory drug (NSAID) use is a typical cause of intraperitoneal or retroperitoneal bleeding causing LBP. People most often taking NSAIDs have a history of inflammatory conditions such as osteoarthritis.


Although the incidence of back pain from NSAIDs is fairly low (i.e., number of people on NSAIDs who develop GI problems and referred pain), the prevalence (number seen in a physical therapist’s practice) is much higher.18–20 In other words physical therapists are seeing a majority of people with arthritis or other inflammatory conditions who are taking one or more prescription and/or over-the-counter (OTC) NSAID.21


Screening for medical disease is an important part of the evaluation process that may take place more than once during an episode of care (see Fig. 1-4). The clues about the quality of pain, the age of the client, and the presence of systemic complaints or associated signs and symptoms indicate the need to investigate further.



Using the Screening Model to Evaluate the Head, Neck, or Back



Past Medical History


A carefully taken, detailed medical history is the most important single element in the evaluation of a client who has musculoskeletal pain of unknown origin or cause. It is essential for the recognition of systemic disease or medical conditions that may be causing integumentary, muscle, nerve, or joint symptoms.


The history combined with the physical therapy examination provides essential clues in determining the need for referral to a physician or other appropriate health care provider. A history of cancer is most important, however long ago. If a client has had a low backache for years, progressive serious disease is unlikely, though the therapist should not be misled by a chronic history of back pain because the client may be presenting with a new episode of serious back pain. Six weeks to 6 months of increasing backache, often in an older client, may be a signal of lumbar metastases, especially in a person with a past history of cancer.


Watch for history of diabetes, immunosuppression, rheumatologic disorders, tuberculosis, and any recent infection (Case Example 14-1). A history of fever and chills with or without previous infection anywhere in the body may indicate a low-grade infection.



Case Example 14-1   Bilateral Facial Pain


Background: A 79-year-old woman was in a rehabilitation facility following a stroke with resultant left hemiplegia. She told the therapist she was starting to have some new symptoms in her face. She could not smile on her “good” side and was having trouble closing her eyes, which was not a problem after her stroke.


Clinical Presentation: There were no apparent changes in hearing, sensation, or motor control of the right arm. The therapist conducted a new neurologic screening examination and found the following results:


Cranial Nerve VII: Client was unable to raise and lower either eyebrow or close the eyes tightly; there was bilateral facial drooping; as reported, the client was unable to smile with the right side of her face.


There was no change in sensory or motor findings from the initial evaluation post-cerebral vascular accident (post-CVA). However, deep tendon reflexes were absent in both arms, leading the therapist to check deep tendon reflexes in the lower extremities, which were also absent. There were no other significant neurologic changes from the initial evaluation.


The therapist reviewed the Special Questions to Ask: Neck or Back (Pain Assessment and General Systemic) to look for any other screening questions and asked about a recent history of infection. The client reported a mild upper respiratory infection 2 weeks ago. There were no other obvious red flag findings.


Result: The therapist reported the new episode of signs and symptoms. Red flags observed included bilateral symptoms, absent muscle stretch reflexes, and recent history of infection. A medical evaluation was carried out, and a diagnosis of Guillain-Barré was made. The client continued to get worse with involvement of the respiratory muscles, foot drop, and numbness in the hands and feet.


A new episode of care was initiated to include physical therapy to strengthen facial musculature and prevent atrophy on the right side and to prevent pneumonia from respiratory muscle involvement.


Symptoms are likely to appear some time before striking physical signs of disease are evident and before laboratory tests are useful in detecting disordered physiology. Thus an accurate and sufficiently detailed history provides historical clues that can be significant in determining when the client should be referred to a physician or other appropriate health care provider.


The therapist must always ask about a history of motor vehicle accident, blunt impact, repetitive injury, sudden stress caused by lifting or pulling, or trauma of any kind. Even minor falls or lifting when osteoporosis is present can result in severe fracture in older adults (Case Example 14-2). Anyone who cannot bear weight through the legs and hips should be considered for an immediate medical evaluation.21a



Case Example 14-2   Minimal Trauma


Background: An inpatient acute care therapist was working with a 75-year-old woman who was 1-day status post (S/P) right total hip replacement (THR). The patient reported getting out of bed by herself early in the morning and falling against the night stand. She complained of low back pain (LBP) when the therapist arrived to help her sit up in bed and stand. The pain was in the left lumbar area without radiation.


Past Medical History: Past medical history included osteoporosis (treated with bisphosphonate medication, calcium, and vitamin D), breast cancer with mastectomy 30 years ago, and hypothyroidism treated with medication (Synthroid).


Clinical Presentation: No preoperative baseline information was available regarding the client’s physical function, gait pattern, or range of motion (ROM) for the spine or hips. There was moderate tenderness to palpation and percussion of the sacrum on the left side. Mild tenderness was reported with percussion to the upper and lower lumbar spine. There were no apparent skin changes, bruising, warmth, or swelling.


The patient could ambulate slowly with a walker but reported pain in both hips with each step. She could only take small steps, moving approximately 2 to 4 inches forward with each step. Lumbar ROM was very limited in flexion, side bending, and extension. She was unable to straighten up to a fully upright standing position due to her low back/sacral pain.


Outcome: The therapist filed an incident report with the hospital unit clerk and spoke directly with the nursing supervisor requesting an ortho consult before continuing with the standard THR rehabilitation protocol.


The patient was diagnosed with a sacral insufficiency fracture on the left at S3. X-rays and magnetic resonance imaging (MRI) also revealed scoliosis of the lumbosacral spine, moderate degenerative arthritis, marked narrowing of the intervertebral disk spaces throughout the lumbar spine, and old compression fractures at T11 and T12. There was no evidence of bone lesions suggestive of breast cancer metastasis. Moderate foraminal stenosis was observed at the right L3 nerve root.


The client returned to physical therapy with an altered rehabilitation program consisting of weightbearing exercises on the left (to stimulate osteoblastic bone formation) as tolerated given the compromise on both sides. She had a minimally invasive hip procedure, so aquatic therapy was approved when there were no openings in the skin at the incision site (1 week later).


Surgery of any kind can result in infection and abscess leading to hip, pelvic, abdominal, and/or LBP.22 A recent history of spinal procedures (e.g., fusion, diskectomy, kyphoplasty, vertebroplasty) can be followed by back pain, motor impairment, and/or neurologic deficits when complicated by hematoma, infection, bone cement leakage, or subsidence (graft or instrumentation sinking into the bone).23 Infection following spinal epidural injection is an infrequent but potentially serious complication.24,25


A few key questions to ask about the history might include:



image Follow-Up Questions





Risk Factor Assessment


Understanding who is at risk and what the risk factors are for various illnesses, diseases, and conditions will alert the therapist early on as to the need for screening, education, and prevention as part of the plan of care. Educating clients about their risk factors is a key element in risk factor reduction.


Risk factors vary, depending on family history, previous personal history, and disease, illness, or condition present. For example, risk factors for heart disease will be different from risk factors for osteoporosis or vestibular/balance problems. When it comes to the musculoskeletal system, risk factors, such as heavy nicotine use, injection drug use, alcohol abuse, diabetes, history of cancer, or corticosteroid use, may be important.


Always check medications for potential adverse side effects causing muscular, joint, neck, or back pain. Long-term use of corticosteroids can lead to vertebral compression fractures (Case Example 14-3). Fluoroquinolones (antibiotic) can cause neck, chest, or back pain. Headache is a common side effect of many medications.



Case Example 14-3   Corticosteroid Use


Referral: A 73-year-old man was referred to a physical therapist by his family practitioner for evaluation of middle-to-low back pain that started when he stepped down from a curb. He was not experiencing radiating pain or sciatica and appeared to be in good general health. His medical history included bronchial asthma treated with oral corticosteroids and an abdominal hernia repaired surgically 10 years ago. There were no diagnostic imaging tests ordered.


Clinical Presentation: Vital signs were measured and appeared within normal limits for the client’s age. There were no constitutional symptoms, no fever present, and no other associated signs or symptoms reported.


There was a marked decrease in thoracic and lumbar range of motion from T10 to L1 and tenderness throughout this same area. No other objective findings were noted despite a careful screening examination.


The client was treated conservatively over a 2-week period but without change in his painful symptoms and without improvement in spinal movement. A second therapist in the same clinic was consulted for a reevaluation without significant differences in findings. Several suggestions were made for alternative treatment techniques. After 1 more week without change in client symptoms, the client was reevaluated.


What is the next step in the screening process?


Using Table 14-1, the therapist can scan down the Thoracic/Scapular and Lumbar columns for any screening clues. Prostate and testicular cancers are listed along with metastatic lesions. Given the client’s age, questions should be asked about a past history of cancer and any associated urinary signs and symptoms.


Given his age, cardiovascular causes of back pain are also possible. Review past medical history, risk factors, and ask about signs and symptoms associated with angina, myocardial infarction, and aneurysm.


The therapist can continue to review Table 14-1 for potential pulmonary and gastrointestinal causes of this client’s back pain and ask any further questions regarding possible risk factors and past history. Record all positive findings and conduct a final Review of Systems.


Use the Special Questions to Ask: Neck or Back at the end of this chapter to reassess the client’s general health and clinical presentation. Not all questions must be asked; the therapist will use his or her judgment based on known history for this client and current clinical findings.


Result: In this case the client’s age, lack of improvement with a variety of treatment techniques, lack of diagnostic imaging studies to rule out fracture or infection, and history of long-term corticosteroid use necessitated a return to the referring physician for further medical evaluation.


Long-term corticosteroid therapy and radiation therapy for cancer are risk factors for ischemic or avascular necrosis. Hip or back pain in the presence of these factors should be examined carefully.


Radiographic testing demonstrated ischemic vertebral collapse secondary to chronic corticosteroid administration. Diffuse osteopenia and a compression fracture of the tenth thoracic vertebral body were also mentioned in the medical report.


Keep in mind that physical and sexual abuse are risk factors for chronic head, neck, and back pain for men, women, and children (see Appendix B-3).


Age is a risk factor for many systemic, medical, and viscerogenic problems. The risk of certain diseases associated with back pain increases with advancing age (e.g., osteoporosis, aneurysm, myocardial infarction, cancer). Under the age of 20 or over the age of 50 are both red flag ages for serious spinal pathology. The highest likelihood of vertebral fracture occurs in females aged 75 years or older.26


As with all decision-making variables, a single risk factor may or may not be significant and must be viewed in context of the whole patient/client presentation. See Appendix A-2 for a list of some possible health risk factors.


Routine screening for osteoporosis, hypertension, incontinence, cancer, vestibular or balance problems, and other potential problems can be a part of the physical therapist’s practice. Therapists can advocate disease prevention, wellness, and promotion of healthy lifestyles by delivering health care services intended to prevent health problems or maintain health and by offering wellness screening as part of primary prevention.



Clinical Presentation


During the examination the therapist will begin to get an idea of the client’s overall clinical presentation. The client interview, systems review of the cardiopulmonary, musculoskeletal, neuromuscular, and integumentary systems, and assessment of pain patterns and pain types form the basis for the therapist’s evaluation and eventual diagnosis.


Assessment of pain and symptoms is often a large part of the interview. In this final section of the text, pain and dysfunction associated with each anatomic part (e.g., back, chest, shoulder, pelvis, sacrum/SI, hip, and groin) are discussed and differentiated as systemic from musculoskeletal whenever possible.


Characteristics of pain, such as onset, description, duration, pattern, and aggravating and relieving factors, and associated signs and symptoms are presented in Chapter 3 (see Table 3-2; see also Appendix C-7). Reviewing the comparison in Table 3-2 will assist the therapist in recognizing systemic versus musculoskeletal presentation of signs and symptoms.



Effect of Position


When seen early in the course of symptoms, neck or back pain of a systemic, medical, or viscerogenic origin is usually accompanied by full and painless range of motion (ROM) without limitations. When the pain has been present long enough to cause muscle guarding and splinting, then subsequent biomechanical changes occur.


Typically, systemic back pain or back pain associated with other medical conditions is not relieved by recumbency. In fact, the bone pain of metastasis or myeloma tends to be more continuous, progressive, and prominent when the client is recumbent.


Beware of the client with acute backache who is unable to lie still. Almost all clients with regional or nonspecific backache seek the most comfortable position (usually recumbency) and stay in that position. In contrast, individuals with systemic backache tend to keep moving trying to find a comfortable position.


In particular, visceral diseases, such as pancreatic neoplasm, pancreatitis, and posterior penetrating ulcers, often have a systemic backache that causes the client to curl up, sleep in a chair, or pace the floor at night.


Back pain that is unrelieved by rest or change in position or pain that does not fit the expected mechanical or neuromusculoskeletal pattern should raise a red flag. When the symptoms cannot be reproduced, aggravated, or altered in any way during the examination, additional questions to screen for medical disease are indicated.




Associated Signs and Symptoms


After reviewing the client history and identifying pain types or pain patterns, the therapist must ask the client about the presence of additional signs and symptoms. Signs and symptoms associated with systemic disease or other medical conditions are often present but go unidentified, either because the client does not volunteer the information or the therapist does not ask. To assess for associated signs and symptoms, the therapist can end the client interview with the following question:



image Follow-Up Question




The client with back pain and bloody diarrhea or the person with mid-thoracic or scapular pain in the presence of nausea and vomiting may not think the two symptoms are related. If the therapist only focuses on the chief complaint of back, neck, shoulder, or other musculoskeletal pain and does not ask about the presence of symptoms anywhere else, an important diagnostic clue may be overlooked.


Other possible associated symptoms may include fatigue, dyspnea, sweating after only minor exertion, and GI symptoms (see also Appendix A-2 for a more complete list of possible associated signs and symptoms).


If the therapist fails to ask about associated signs and symptoms, the Review of Systems offers one final step in the screening process that may bring to light important clues.



Review of Systems


Clusters of these associated signs and symptoms usually accompany the pathologic state of each organ system (see Box 4-19). As part of the physical assessment, the therapist must conduct a Review of Systems. General questions about fevers, excessive weight gain or loss, and appetite loss should be followed by questions related to specific organ systems. Medications should be reviewed for possible adverse side effects.


Throughout the interview the therapist must remain alert to any yellow (caution) or red (warning) flags that may signal the need for further screening. Review of Systems is important even for clients who have been examined by a medical doctor. It has been reported that only 5% of physicians assess patients for “red flags.”27,28 In contrast, documentation of red flags by physical therapists (at least for patients with LBP) has been reported as high as 98%.29


During the Review of Systems a pattern of systemic, medical, or viscerogenic origin may be seen as the therapist combines information from the client history, risk factors present, associated signs and symptoms, and yellow or red flag findings.



Yellow Flag Findings30


Yellow flags are indicators that findings may be present requiring special attention but not necessarily immediate action. One of the primary yellow flag findings that is prognostically important in individuals with LBP is the presence of psychosocial risk factors (e.g., work, attitudes and beliefs, behaviors, affective presentation).31–34 The presence of these yellow flags suggests a poor response to traditional intervention and the need to address the underlying psychosocial aspects of health and healing. A management approach using cognitive behavioral therapy and/or referral to a mental health professional may be warranted.34a,34b






Affective: Depressed mood, irritability, and heightened awareness of bodily sensations along with anxiety represent affective psychosocial yellow flags (also prognostic of poor outcome for chronic LBP). Other affective yellow flags include feeling useless and not needed, disinterest in outside activities, and lack of family or personal support systems.


The assessment of psychosocial yellow flags should be part of any ongoing management of LBP at any time in the course of the problem. The New Zealand Guidelines34 recommend the administration of a screening questionnaire at 2 to 4 weeks after onset of pain (see Appendix C-4 for a checklist of red/yellow flag indicators).


There is no evidence that this is the optimal time. This is early in the natural history of complaints of LBP, and other interventions may take this long to achieve their effects. In fact, over this time frame, practitioners may still be concerned about red flag conditions, and their time with the client may still be consumed with ensuring compliance with home rehabilitation and analgesics.34


On the other hand, waiting until someone develops chronic pain (3 months) may be too late; the window of opportunity to prevent chronicity will have passed, by definition. Therefore, in anyone with persisting pain, formal exploration of yellow flags should occur no later than 2 months after onset of pain, and possibly by the end of the first month. A practical clinical approach would be to begin screening for yellow flag issues at the 1-month follow-up appointment.35



image Follow-Up Questions





Red Flag Signs and Symptoms


Watch for the most common red flags associated with back pain of a systemic origin or other medical condition (Box 14-1) but be aware that some recommended red flags have high false-positive rates when used in isolation.36 Each condition (e.g., infection, malignancy, fracture) will likely have its own predictive risk factors. A recent systematic review in the (medical) primary care setting reported that only three red flags are associated with fracture (prolonged use of corticosteroids, age older than 70 years, and significant trauma).36 Individuals with serious spinal pathology almost always have at least one red flag that can be missed when the clinician (physician or therapist) assumes the client’s symptoms are the result of mechanical-induced back pain. (See also Appendix A-2.)



Box 14-1   Most Common Red Flags Associated with Back Pain of Systemic Origin




• Age less than 20 or over 50 (malignancy)/over 70 (fracture)*


• Previous history of cancer*


• Constitutional symptoms (e.g., fever, chills, unexplained weight loss*)


• Failure to improve with conservative care (usually over 4 to 6 weeks)*


• Recent urinary tract infection, blood in urine (or stools), difficulty with urination


• History of injection drug use


• Immunocompromised condition (e.g., prolonged use of corticosteroids, transplant recipient, autoimmune diseases)


• Pain is not relieved by rest or recumbency.


• Severe, constant nighttime pain


• Progressive neurologic deficit; saddle anesthesia; urinary or fecal incontinence


• Back pain accompanied by abdominal, pelvic, or hip pain


• History of falls or trauma (screen for fracture, osteoporosis, domestic violence, alcohol use)


• Significant morning stiffness with limitation in all spinal movements (ankylosing spondylitis or other inflammatory disorder)


• Skin rash (inflammatory disorder [e.g., Crohn’s disease, ankylosing spondylitis])


*Recommendations made on the use of red flags to screen for serious pathology have come under scrutiny in recent years. Therapists are advised to make special note of the first four red flags listed above. The presence of any of these signals the need for additional screening (e.g., radiographs and simple blood tests) to detect cancer.111


Key findings are advancing age, significant recent weight loss, previous malignancy, and constant pain that is not relieved by positional change or rest and is present at night, disturbing the person’s sleep. Poor response to conservative care or poor success with comparable care is an additional red flag in the diagnosis and management of musculoskeletal spine pain.37 According to one source, cancer as a cause of LBP can be ruled out with 100% sensitivity when the affected individual is younger than 50 years old, has no prior history of cancer, no unexplained or unintended weight loss, and responds to conservative care.6


According to a recent systematic review, five red flags have been identified to screen for vertebral fractures in clients presenting with acute LBP including age over 70, female sex, major trauma, pain and tenderness, and a distracting painful injury.38 Older females, especially older adults who have used corticosteroids, are predisposed to osteoporosis and increased risk of fracture from even minor trauma.39,40


More recent evidence to suggest that backache is a frequent finding in children and adolescents and is seldom associated with serious pathology has been published.41–43 But back pain in children is still considered a red flag, especially in young children43a and/or if it has been present for more than 6 weeks because of the concern for infection or neoplasm.43b,43c Children are less likely to report associated signs and symptoms and must be interviewed carefully. Ask about any other joint involvement, swelling anywhere, changes in ROM, and the presence of any constitutional and GI symptoms. A recent history of viral illnesses may be linked to myalgias and diskitis. Most common causes of back pain in children are listed in Table 14-2.



Red flags requiring medical evaluation or reevaluation include back pain or symptoms that are not improving as expected, steady pain irrespective of activity, symptoms that are increasing, or the development of new or progressive neurologic deficits such as weakness, sensory loss, reflex changes, bowel or bladder dysfunction, or myelopathy.38


Indications for the use of plain films of the lumbar spine include any of the following features44:



Use the Quick Screen Checklist (see Appendix A-1) to conduct a consistent and complete screening examination.


A few key screening questions might include:



image Follow-Up Questions






Location of Pain and Symptoms


There are many ways to examine and classify head, neck, and back pain. Pain can be divided into anatomic location of symptoms (where is it located?): Cervical, thoracic, scapular, lumbar, and SI joint/sacral (as shown in Table 14-1). For example, intrathoracic disease refers more often to the neck, mid-thoracic spine, shoulder, and upper trapezius areas. Visceral disease of the abdomen and/or pelvis is more likely to refer pain to the low back region. Later in this section, spine pain is presented by the source of symptoms (what is causing the problem?).


Whenever faced with the need to screen for medical disease the therapist can review Table 14-1. First identify the location of the pain. Then scan the list for possible causes. Given the client’s history, risk factors, clinical presentation, and associated signs and symptoms, are there any conditions on this list that could be the possible cause of the client’s symptoms? Is age or sex a factor? Is there a positive family or personal history?


Sometimes reviewing the possible causes of pain based on location gives the therapist a direction for the next step in the screening process. What other questions should be asked? Are there any tests that will help differentiate symptoms of one anatomical area from another? Are there any tests that will help identify symptoms that point to one system versus another?



Head


The therapist may evaluate pain and symptoms of the face, scalp, or skull. Headaches are a frequent complaint given by adults and children. It may not be the primary reason for seeing a physical therapist but is often mentioned when asked if there are any other symptoms of any kind anywhere else in the body.


The brain itself does not feel pain because it has no pain receptors. Most often the headache is caused by an extracranial disorder and is considered “benign.” Headache pain is related to pressure on other structures such as blood vessels, cranial nerves, sinuses, and the membrane surrounding the brain. Serious causes have been reported in 1% to 5% of the total cases, most often attributed to tumors and infections of the central nervous system (CNS).1,46 In the past, headache was viewed as many disorders along a continuum. Better headache classifications have brought about the development of many discrete entities among these disorders.47,48 The International Headache Society (HIS) has published commonly used International Classification of Headache Disorders (second edition, revised), which divides headaches into three parts: primary headache, secondary headache, and cranial neuralgias.49,50


Primary headache includes migraine, tension-type headache, and cluster headache. Secondary headaches, of which there is a large number, are attributed to some other causative disorder specified in the diagnostic criteria attached to them.


The therapist often provides treatment for secondary headache called cervicogenic headache (CGH). This type of headache is defined as referred pain in any part of the head (e.g., musculoskeletal tissues innervated by these nerve roots) caused by spondylitic, fibrotic, or vascular compression or compromise of cervical nerves (C1-C4).51 CGHs are frequently associated with postural strain or chronic tension, acute whiplash injury, intervertebral disk disease, or progressive facet joint arthritis (e.g., cervical spondylosis, cervical arthrosis) (Table 14-3).




Causes of Headaches


Headache can be a symptom of neurologic impairment, hormonal imbalance, neoplasm, side effect of medication,48 or other serious condition (Box 14-2). Headache may be the only symptom of hypertension, cerebral venous thrombosis, or impending stroke.52,53 Sudden, severe headache is a classic symptom of temporal vasculitis (arteritis), a condition that can lead to blindness if not recognized and treated promptly.



Box 14-2   Systemic Origins of Headache









Recognizing associated signs and symptoms and performing vital sign assessment, especially blood pressure monitoring, are important screening tools for vascular-induced headaches (see Chapter 4 for information on monitoring blood pressure).


Stress and inadequate coping are risk factors for persistent headache. Headache can be part of anxiety, depression, panic disorder, and substance abuse.54,55 Headaches have been linked with excessive caffeine consumption or withdrawal in children, adolescents, and adults.56


Therapists often encounter headaches as a complaint in clients with posttraumatic brain injury, postwhiplash injury, or postconcussion injury. A constellation of other symptoms are often present such as dizziness, memory problems, difficulty concentrating, irritability, fatigue, sensitivity to noise, depression, anxiety, and problems with making judgments. Symptoms may resolve in the first 4 to 6 weeks following the injury but can persist for months to years causing permanent disability.57,58



Cancer: The greatest concern is always whether or not there is brain tumor causing the headaches. Only a minority of individuals who have headaches have brain tumors. Risk factors include occupational exposure to gases and chemicals and history of cranial radiation therapy for fungal infection of the scalp or for other types of cancer.


A previous history of cancer, even long past history, is a red flag for insidious onset of head and occipital neck pain. Metastatic lesions of the upper cervical spine are difficult to diagnose. Plain radiographs generally appear negative, which can delay diagnosis of clients with C1-C2 metastatic disease.59


The alert therapist may recognize the need for further imaging studies or medical evaluation. Persistent documentation of clinical findings and nonresponse to physical therapy intervention with repeated medical referral may be required.


Although primary head and neck cancers can cause headaches, neck pain, facial pain, and/or numbness in the face, ear, mouth, and lips are more likely. Other signs and symptoms can include sore throat, dysphagia, a chronic ulcer that does not heal, a lump in the neck, and persistent or unexplained bleeding. Color changes in the mouth known as leukoplakia (white patches) or erythroplakia (red patches) may develop in the oral cavity as a premalignant sign.60


Cancer recurrence is not uncommon within the first 3 years after treatment for cancers of the head and neck; often these cancers are not diagnosed until an advanced stage due to neglect on the part of the affected individual. Cervical spine metastasis is most common with distant metastases to the lungs, although any part of the body can be affected.61 Anyone with a history of head and neck cancer should be screened for cancer recurrence when seen by a therapist for any problem.


As always, prevention and early detection improve survival rates. Education is important because most of the risk factors (tobacco and alcohol use, betel nut, syphilis, nickel exposure, woodworking, sun exposure, dental neglect) are modifiable.


Tension-type or migraine headaches can occur with tumors. Rapidly growing tumors are more likely to be associated with headache and will eventually present with other signs and symptoms such as visual disturbances, seizures, or personality changes.62,63 Headaches associated with brain tumors occur in up to half of all cases and are usually bioccipital or bifrontal, intermittent, and of increasing duration. Presence of tumor headache varies, depending on size, location, and type of tumor.64


The headache is worse on awakening because of differences in CNS drainage in the supine and prone positions and usually disappears soon after the person arises. It may be intensified or precipitated by any activity that increases intracranial pressure such as straining during a bowel movement, stooping, lifting heavy objects, or coughing.


Often, the pain can be relieved by taking aspirin, acetaminophen, or other moderate painkillers. Vomiting with or without nausea (unrelated to food) occurs in about 25% to 30% of people with brain tumors and often accompanies headaches when there is an increase in intracranial pressure. If the tumor invades the meninges, the headaches will be more severe.


Recognizing the need for medical referral for the client with complaints of headaches can be difficult. Past medical history can be complex in adults and screening clues are often confusing. Careful review of the clinical presentation is required. For example, although pain associated with the CGH can be constant (a red flag symptom) the intensity often varies with activity and postures. Sustained posture consistently increases intensity of painful symptoms.



Migraines: Migraine headaches are often accompanied by nausea, vomiting, and visual disturbances, but the pain pattern is also often classic in description. Age is a yellow (caution) flag because migraines generally begin in childhood to early adulthood. Migraines can first occur in an individual beyond the age of 50 (especially in perimenopausal or menopausal women); advancing age makes other types of headaches more likely. A family history is usually present, suggesting a genetic predisposition in migraine sufferers. In addition to the typical clinical presentation, there are usually normal examination results.


Migraines can present with paralysis or weakness of one side of the body mimicking a stroke. A medical examination is required to diagnose migraine, especially in cases of hemiplegic migraines. Medical evaluation and treatment for migraines in general is recommended.


There is a role for the physical therapist because the beneficial effects of exercise on migraine headaches have been documented.65,66 Physical therapy is most effective for the treatment of migraine when combined with other treatments such as biofeedback67 and relaxation training.68


When present, associated signs and symptoms offer the best yellow or red flag warnings. For example, throbbing headache with unexplained diaphoresis and elevated blood pressure may signal a significant cardiovascular event. Daytime sleepiness, morning headache, and reports of snoring may point to obstructive sleep apnea. Headache-associated visual disturbances or facial numbness raises the suspicion of a neurologic origin of symptoms. Other red flags are listed in Box 14-3.



Box 14-3   Red Flag Signs and Symptoms Associated with Headache


The therapist should watch for any of the following red flags (listed in descending order of importance) and report them to a medical doctor. A complete screening interview and examination can establish a baseline of information and aid in the medical referral decision-making process.



• Headache that wakes the individual up or is present upon awakening (e.g., hypertension, tumor)


• Headache accompanied by documented elevated blood pressure changes


• Insidious or new onset of headache (less than 6 months)


• New onset of headache with associated neurologic signs and symptoms (e.g., confusion, dizziness, gait or motor disturbances, fatigue, irritability or mood changes)


• New onset of headache accompanied by constitutional symptoms (e.g., fever, chills, sweats) or stiff neck (infection, arteritis)


• Episodes of “blacking out” during headache (seizures, hemorrhage, tumor)


• Sudden severe headache accompanied by flu-like symptoms, aching muscles, jaw pain when eating, and visual disturbances (temporal arteritis)


• No previous personal or family history of migraine headaches


The therapist is advised to follow the same screening decision-making model introduced in Chapter 1 (see Box 1-7) and reviewed briefly at the beginning of this chapter. Physical examination should include measurement of vital signs, a general assessment of cardiac and vascular signs, and a thorough head and neck examination. A screening neurologic examination should address mental status (including pain behavior), cranial nerves, motor function, reflexes, sensory systems, coordination, and gait (see Chapter 4). Special Questions to Ask: Headache are listed at the end of this chapter and in Appendix B-17.



Cervical Spine


Neck pain is very common and has many mechanical and systemic causes. Neck and shoulder pain and neck and upper back pain often occur together making the differential diagnosis more difficult.


Traumatic and degenerative conditions of the cervical spine, such as whiplash syndrome and arthritis, are the major primary musculoskeletal causes of neck pain.69 The therapist must always ask about a history of motor vehicle accident or trauma of any kind, including domestic violence.


Cervical or neck pain with or without radiating arm pain or symptoms may be caused by a local biomechanical dysfunction (e.g., shoulder impingement, disk degeneration, facet dysfunction) or a medical problem (e.g., infection, tumor, fracture). Referred pain presenting in these areas from a systemic source may occur from infectious disease, such as vertebral osteomyelitis, or from cancer, cardiac, pulmonary, or abdominal disorders (see Table 14-1).


Rheumatoid arthritis is often characterized by polyarthritic involvement of the peripheral joints, but the cervical spine is often affected early on (first 2 years) in the course of the disease. Deep aching pain in the occipital, retroorbital, or temporal areas may be present with pain referred to the face, ear, or subocciput from irritation of the C2 nerve root. Some clients may have atlantoaxial (AA) subluxation and report a sensation of the head falling forward during neck flexion or a clunking sensation during neck extension as the AA joint is reduced spontaneously. Symptoms of cervical radiculopathy are common with AA joint involvement.14


Radicular symptoms accompanied by weakness, coordination impairment, gait disturbance, bowel or bladder retention or incontinence, and sexual dysfunction can occur whenever cervical myelopathy occurs, whether from a mechanical or medical cause. Cervical spondylotic myelopathy has been verified as a potential cause of LBP as well.70 The Babinski test may be the most reliable screening test. There is no single reliable or valid clinical screening test or combination of tests that can be used to confirm spinal cord compression myelopathy.71 An imaging study is usually needed to differentiate biomechanical from medical cause of radicular pain, especially when conservative care fails to bring about improvement.72



Clinical Signs and Symptoms


Cervical Myelopathy




Torticollis of the sternocleidomastoid muscle may be a sign of underlying thyroid involvement. Anterior neck pain that is worse with swallowing and turning the head from side to side may be present with thyroiditis. Ask about associated signs and symptoms of endocrine disease (e.g., temperature intolerance; hair, nail, skin changes; joint or muscle pain; see Box 4-19) and a previous history of thyroid problems.73


Palpate the anterior spine and have the client swallow during palpation. Palpation of a soft tissue mass or lump should be noted. See guidelines for palpation in Chapter 4. Palpation of a firm, fixed, and immoveable mass raises a red flag of suspicion for neoplasm. Visually inspect and palpate the trachea for lateral deviation to either side.74


Anterior disk bulge into the esophagus or pharynx and/or anterior osteophyte of the vertebral body may give the sensation of difficulty swallowing or feeling a lump in the throat when swallowing. Anxiety can also cause a sensation of difficulty swallowing with a lump in the throat. Conduct a cranial nerve assessment for cranial nerves V and VII (see Table 4-9; see also Appendix B-21).


Vertebral artery syndrome caused by structural changes in the cervical spine is characterized by the client turning the whole body instead of turning the head and neck when attempting to look at something beyond his or her peripheral vision. Combined cervical motions, such as extension, rotation, and side bending, cause dizziness, visual disturbances, and nystagmus.


Headache/neck pain may be the early presentation of an underlying vascular pathology. Decreased blood flow to the brain, referred to as cerebral ischemia, may be caused by vertebrobasilar insufficiency (VBI)/cervical arterial dysfunction75 secondary to atherosclerosis or other arterial dysfunction. Arterial compression can also occur when decreased vertebral height, osteophyte formation, postural changes, and ligamentous changes reduce the foraminal space and encroach on the vertebral artery. Premanipulative screening tests for vertebral artery patency and other tests to “clear” the upper cervical spine before using upper cervical manipulative techniques (e.g., cervical rotation, alar and transverse ligament stress tests, tectorial membrane stress test) may help identify the underlying cause of neck pain. Consensus on the need to conduct these tests has not been reached because the validity of tests for VBI has not been established.76,77


Caution is advised with older adults, anyone with a history of hypertension, rheumatoid arthritis, or long-term use of corticosteroids. A careful history, blood pressure measurements, observing for vascular pain patterns, and conducting a neurologic screening exam (possibly including cranial nerves) are advocated by some prior to upper cervical manipulation.



Thoracic Spine


As with the cervical spine and any musculoskeletal part of the body, the therapist must look for the cause of thoracic pain at the level above and below the area of pain and dysfunction. Possible musculoskeletal sources of thoracic pain include muscle strain, vertebral or rib fracture, zygapophyseal joint arthropathy,78 active trigger points, spinal stenosis, costotransverse and costovertebral joint dysfunction, ankylosing spondylitis, intervertebral disk herniation, intercostal neuralgia, diffuse idiopathic skeletal hyperostosis (DISH), and T4 syndrome.79 Shoulder impingement and mechanical problems in the cervical spine also can refer pain to the thoracic spine.


Systemic origins of musculoskeletal pain in the thoracic spine (Table 14-4) are usually accompanied by constitutional symptoms and other associated symptoms. Often, these additional symptoms develop after the initial onset of back pain, and the client may not relate them to the back pain and therefore may fail to mention them.



The close proximity of the thoracic spine to the chest and respiratory organs requires careful screening for pleuropulmonary symptoms in anyone with back pain of unknown cause or past medical history of cancer or pulmonary problems. Thoracic pain can also be referred from the kidney, biliary duct, esophagus, stomach, gallbladder, pancreas, and heart.


Thoracic aortic aneurysm, angina, and acute myocardial infarction are the most likely cardiac causes of thoracic back pain. Usually, there is a cardiac history and associated signs and symptoms such as weak or thready pulse, extremely high or extremely low blood pressure, or unexplained perspiration and pallor.


Tumors occur most often in the thoracic spine because of its length, the proximity to the mediastinum, and direct metastatic extension from lymph nodes with lymphoma, breast, or lung cancer. The client may report symptoms typical of cancer. Tumor involvement in the thoracic spine may produce ischemic damage to the spinal cord or early cord compression since the ratio of canal diameter to cord size is small, resulting in rapid deterioration of neurologic status (Case Example 14-4).



Case Example 14-4   Mid-Thoracic Back Pain


Background: A 55-year-old woman presents with sharp pain in the mid-back region around T5 to T6. The pain started after vacuuming her house last week. She has been taking Tylenol, but the pain is unrelieved. She reports being unable to find a comfortable position; the pain is keeping her awake at night.


History reveals a previous episode of pain in the same area 2 months ago. The pain started after she went grocery shopping and carried the heavy bags into her house. At that time, Tylenol quickly relieved her symptoms. The pain from the previous episode was described as “aching,” not sharp like today.


Past Medical History: Past medical history includes breast cancer 15 years ago, surgical hysterectomy 10 years ago, and hypothyroidism. She does not remember what kind of breast cancer she had. She was treated with a lumpectomy and radiation. She has not had a mammography or clinical breast exam in the past 5 years. She does not perform self-breast examination on a regular or consistent basis.


She takes Synthroid for her thyroid problem but is not taking any other prescription medication. She takes a daily vitamin and 1200 mg of calcium but no other supplements. Tylenol is the only other over-the-counter product she takes.


She does not smoke or drink, even socially. She does not use any other substances of any kind. She reports there are no other symptoms of any kind anywhere else in her body.


Clinical Presentation: Vital signs are normal. There are no visible or palpable lesions in the upper quadrant on either side. Axillary and supraclavicular lymph nodes are not enlarged or palpable. Submandibular lymph nodes are palpable but not tender or hard.


Neurologic screening exam is normal, including bowel and bladder function, although the client reports a sensation of intermittent “weakness” in her left arm. There is exquisite pain on palpation of the thoracic spine from T4 to T6. There was no apparent movement dysfunction observed.


How can you differentiate between a disk problem and bony metastases?


A differential diagnosis of this type is outside the scope of the physical therapist’s practice and requires a medical evaluation. The physician’s differential diagnosis may include mammography, x-rays, and computed tomography (CT) scan or magnetic resonance imaging (MRI) to assist in the diagnosis.


Severe back pain that is unrelieved by rest or change of position and present at night in a woman with a past history of breast cancer requires immediate referral. Breast cancer has a predilection for axial skeletal bony metastases. Metastases can also occur hematogenously to the lungs (see Table 13-5). The therapist can perform a pulmonary system screening examination and ask about specific pulmonary signs and symptoms.


Reviewing Table 14-1 for possible viscerogenic causes of mid-thoracic back pain in a 55-year-old, the screening process can also include a brief cardiovascular examination and questions about GI function. Baseline information of this type can be extremely helpful later when documenting change in status or condition.


Rather than provide physical therapy intervention and assessing the results, immediate medical evaluation is in the best interest of this client. If the medical tests come back negative or if there is a disk problem, then the appropriate physical therapy intervention can be prescribed.

Related posts:

Interviewing as a Screening Tool Pain Types and Viscerogenic Pain Patterns Screening the Sacrum, Sacroiliac, and Pelvis Screening for Hepatic and Biliary Disease Screening for Urogenital Disease Screening for Gastrointestinal Disease

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Mar 20, 2017 | Posted by in MANUAL THERAPIST | Comments Off on Screening the Head, Neck, and Back

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