Screening the Head, Neck, and Back

Prevalence of Pain Syndromes in the United States

Statistical data provided by Deyo et al. in the 2006 publication of Spine analyzed a sample size of $n = 31,044$ (representing approximately $54$ million adults) regarding the prevalence of pain syndromes over a three-month period. The findings are as follows:

• Low Back Pain: $26.4\%$

• Migraine or Severe Headaches: $15.0\%$

• Neck Pain: $13.8\%$

• Face or Jaw Pain: $4.6\%$

Global Rankings of Years Lived with Disability (YLDs) per 100,000 (2019 data)

The global burden of musculoskeletal conditions is ranked among other health disorders across various nations. Low back pain consistently ranks as the primary cause of YLDs in many developed and developing nations.

• United States of America: Low back pain (Rank $1$), Other musculoskeletal (Rank $4$), Migraine (Rank $3$), Neck pain (Rank $4$).

• Germany: Low back pain (Rank $1$), Other musculoskeletal (Rank $4$), Migraine (Rank $3$).

• Japan: Low back pain (Rank $1$), Other musculoskeletal (Rank $3$), Migraine (Rank $4$), Neck pain (Rank $12$).

• Brazil: Low back pain (Rank $2$), Other musculoskeletal (Rank $5$), Migraine (Rank $3$), Neck pain (Rank $6$).

• India: Low back pain (Rank $2$), Other musculoskeletal (Rank $4$), Migraine (Rank $3$), Neck pain (Rank $4$).

Other notable rankings in the US include Diabetes type 2 (Rank $20$), Opioid use disorders (Rank $61$), Major depression (Rank $7$), and Anxiety disorders (Rank $9$).

Behavioral Model of Healthcare Use (Anderson & Newman)

This conceptual model identifies three main categories of characteristics that influence the use of physical therapy (PT) services:

• Need Characteristics: Related to health status, including illness severity and the presence of comorbidities.

• Enabling Characteristics: Practical resources such as income, health insurance coverage, and other available health-related resources.

• Predisposing Characteristics: Individual background factors such as demographics (age, sex), social factors, and personal attitudes or beliefs regarding healthcare.

Factors Influencing Physical Therapist Utilization

Data indicates specific diagnostic and clinical factors that increase the likelihood of a person seeking PT care:

• Specific Diagnoses: Patients with a diagnosis of a herniated disk, spinal stenosis, spondylosis, or general pain syndromes were $10\%$ to $16\%$ more likely to see a PT than those diagnosed with a simple sprain or strain.

• Duration of Problem: Subjects with symptoms lasting longer than $3$ months were $34\%$ to $39\%$ more likely to utilize PT services than those with acute problems (< 3 months).

• Previous Interventions: Subjects who had already received injections were $40\%$ more likely to see a PT than those who had not.

• Physician Referral Source: The type of physician seen significantly impacts PT use rates:

  • Physiatrist: $44\%$

  • Orthopedic surgeon: $23\%$

  • General Practitioner: $22\%$

  • Neurosurgeon: $20\%$

  • Rheumatologist: $14\%$

  • Chiropractor: $0\%$

• Demographic Trends: Older patients are more likely to see a PT for neck and back pain. Conversely, being male or middle-aged is negatively associated with PT use.

The Physical Therapist as a Diagnostician

Shirley Sahrmann (JOSPT, 2005) emphasized that the profession must embrace the responsibility of being diagnosticians to ensure recognition and respect within the healthcare field. Failing to fulfill this responsibility seriously compromises the profession's standing.

Clinical Case Study: Susan (Low Back Pain and Differential Diagnosis)

Patient Profile and History

• Patient: $25$-year-old woman.

• Chief Complaint: Sudden onset of severe left-sided lumbosacral pain and hip pain (began $3$ weeks prior to exam).

• Initial Medical Management: ER visit involving an injection of meperidine (narcotic analgesic), NSAIDs, and muscle relaxants. Follow-up with PCP resulted in normal plain film radiographs and a normal MRI of the lumbar spine.

• Current Status: Referred to an orthopedic surgeon. While waiting, she experienced severe, persistent low back pain (LBP) and remained bed-bound. The orthopedist diagnosed "Acute LBP" and prescribed Percocet, NSAIDs, muscle relaxants, moist heat, and a back support before referring to PT.

Physical Therapist Interview Findings

• Pain Pattern: Constant, severe pain in the left lumbosacral region, occasionally radiating to the left lower abdominal quadrant, left buttock, and anterior thigh. Onset was sudden without a clear cause (no heavy lifting associated).

• Functional Impact: Sleeps only $1$-$2$ hours at a time. Unable to work. Pain worsens with walking and prolonged sitting. No change with coughing or sneezing.

• Review of Systems (ROS): Intermittent LBP over $5$ years (attributed to sitting at work). Increased urinary urgency over the past $2$ years. Negative for dysmenorrhea. Non-smoker, social drinker.

• Vitals and Physical Exam:

  • Pulse: $68\,pps$; Blood Pressure: $112/70\,mmHg$.

  • Weight/Height/BMI: $140\,lbs$, $5\,ft$, $BMI: 27.3$.

  • Pain Scale: $7/10$ at rest; $9/10$ after $30$ minutes of walking.

  • Oswestry Disability Index (ODQ): $56\%$.

  • Posture: Increased lumbar lordosis and thoracic kyphosis.

  • AROM: Restricted Forward Flexion (FF) and Left Flexion (LF) by $25\%$. Extension (EX) restricted by $10\%$.

  • MMT: $4/5$ in bilateral lower extremities (BLEs), pain-free.

  • Reflexes/Sensation: Normal DTRs and sensation. Straight Leg Raise (SLR): $70^{\circ}$ on right, $60^{\circ}$ on left with a "pull."

  • Palpation: Marked tenderness over the left abdominal quadrant proximal to the ASIS and left lumbar paraspinal region.

Evaluation and Outcome

• Initial PT Assessment: Findings appeared consistent with a musculoskeletal (MSK) mechanical disorder (extension syndrome).

• Differential Flags: The constant, severe nature of the pain, severe night pain, and urinary urgency stood out as non-mechanical Red Flags. Age, sex, and BMI indicated a risk for pelvic disorders.

• Conclusion: The PT recommended a referral to a gynecologist. Intervention included one week of PT (interferential, extension exercises) while awaiting medical tests.

• Final Diagnosis: Endometriosis and a left ovarian cyst. Following laparoscopic laser surgery and medication, the patient reported an $80\%$ improvement immediately and a return of normal bladder function within weeks.

Red Flag Categorization (Sizer et al., 2007)

Category I: Immediate Medical Attention Required

• Blood in sputum.

• Loss of consciousness or altered mental status.

• Neurological deficit not explained by monoradiculopathy.

• Numbness/paresthesia in the perianal region.

• Pathological changes in bowel and bladder.

• Non-mechanical symptom patterns on physical exam.

• Progressive neurological deficit.

• Pulsatile abdominal masses.

Category II: Subjective Questioning & Precautionary Examination

• Age > 50.

• Clonus (history of CNS disorder).

• Fever, elevated sedimentation rate.

• History of cancer, metabolic bone disorder, or trauma.

• Long-term corticosteroid use.

• Unexplained weight loss; nonhealing sores.

• Writhing pain.

Category III: Further Physical Testing and Differentiation

• Abnormal reflexes.

• Unilateral or bilateral radiculopathy/paresthesia.

• Unexplained referred pain or significant limb weakness.

Evolving Perspectives on Red Flag Screening

Cook et al. (2018) provided a narrative view suggesting that standard red flag symptoms often neither rule out nor effectively identify serious pathology because of broad definitions. They recommend:

1. Watchful Waiting: Monitoring the patient over time.

2. Value-Based Care: Linking symptomology directly to health status rather than automatic diagnostic testing.

3. The Ultimate Red Flag: A lack of progress or a decline in status during PT is considered the most significant clinical red flag.

Specific Causes of Back Pain

General Categories

• Rheumatologic, Cancer, Infections, Vascular/Hematologic, Endocrine/Metabolic, Referred Pain, and Mechanical.

Pathologies referring pain FROM the lower back

• Pathologic or Sacral stress fractures.

• Acute Spondylolisthesis, Cancer, Infections.

• Cauda Equina, Ankylosing Spondylitis, Central Sensitization Disorder.

Pathologies referring pain TO the lower back

• Abdominal Aortic Aneurysm (AAA).

• Vascular Claudication.

• Kidney Stones.

• Genital or Gastrointestinal (GI) pathologies.

Serious Spinal Infections

1. Vertebral Osteomyelitis.

2. Spinal Epidural Abscess.

• Risk Factors: Recent surgery or infection, IV drug use, immunosuppression.

• Signs/Symptoms: Focal back pain with insidious onset (increasing over weeks/months). Intermittent dull ache progressing to severe constant pain. Neurologic signs indicate an emergency.

Abdominal Aortic Aneurysm (AAA)

• Prevalence: $50\%$ of patients with ruptured AAA complain primarily of back pain. Many die before reaching care.

• Risk Factors: Smoking, CAD, recent infection, age, and heredity.

• S&S of Aneurysm: Back pain, flank pain, left lower quadrant pain, syncope, awareness of a pulse in the abdomen.

• S&S of Rupture: Acute stabbing pain, cold/pulseless LEs, drop in BP, tachycardia, nausea and lightheadedness.

Thoracic Spine Considerations

• Metastatic Tumors: High occurrence in the thoracic spine due to its length and proximity to the mediastinum and lymph nodes (lung, breast, lymphoma).

• Systemic Causes of Scapular Pain: Cardiac (MI, aneurysm), Pulmonary (pneumonia, pleurisy), Renal (infection), Metabolic (osteoporosis), GI (gall bladder, peptic ulcer), and Cancer (pancreatic, bronchial).

Osteoporosis (OP) and Bone Health

• Major Risk Factors: History of fragility fractures (self or first-degree relative), low body weight, smoking, white race, female, postmenopausal, and oral corticosteroid use (over $3$ months).

• Additional Factors: Dementia, low calcium, alcohol (> 2 drinks/day), and the "Female Athlete Triad" (disordered eating, amenorrhea, and osteoporosis).

• S&S: Often asymptomatic until fracture. Signs include loss of height, thoracic kyphosis, and reduced distance between the ribcage and pelvis.

Neck Pain and Headaches

Canadian C-Spine Rule

Radiography is mandated if ANY High-Risk Factors are present:

• Age $\ge 65\,years$.

• Dangerous Mechanism (e.g., fall > 3\,ft, axial load, high-speed MVC).

• Paresthesias in extremities.

Cervical Myelopathy

• The most common cause of non-traumatic paraparesis and tetraparesis.

• Symptoms: Insidious onset, stiff neck, numb/clumsy hands.

• Examination Findings: Hyperactive DTRs, Clonus (ankle/knee), Spasticity, and a positive Babinski sign.

Vertebrobasilar Insufficiency (VBI)

• Often related to congenital factors, instabilities (RA), or trauma.

• Requires specific VBI testing if suspected.

Headache Red Flags

• Waking up with a headache or being woken up by one (High BP, tumor).

• Headache accompanied by confusion, dizziness, fatigue, or mood changes.

• Insidious or new onset in the absence of a migraine history.

• Flu-like symptoms (potentially Temporal Arteritis).

Visceral Referred Pain Patterns

• Heart: $T1-T4$.

• Esophagus: $C8$ to $T10$.

• Stomach/Liver/Gall Bladder: $T6-T9$.

• Pancreas: $T6-T11$.

• Kidney/Bladder Fundus: $T11-T12, L1$.

• Ureter: $L1-L2$.

• Cervix: $S2-S4$.