Comprehensive Study Notes on Screening the Head, Neck, and Back for Physical Therapy

Statistical Prevalence of Pain in the United States and Globally

  • Americans in Pain - Key Prevalence Metrics (Deyo et al., Spine 2006):

    • The prevalence of various pain syndromes in the past 3 months based on a study of n=31,044n = 31,044 (representative of approximately 54 million adults) is as follows:

    • Low Back Pain: 26.4%26.4\%

    • Migraine or Severe Headache: 15.0%15.0\%

    • Neck Pain: 13.8%13.8\%

    • Face or Jaw Pain: 4.6%4.6\%

  • Global Burden of Disease (GBD) 2019 - Years Lived with Disability (YLDs) per 100,000:

    • Low back pain consistently ranks as the number 1 cause of YLDs across various countries including the United States of America, Argentina, Germany, Australia, Japan, Poland, Ukraine, and others.

    • Neck pain ranks as the number 3 cause of YLDs in the USA, Australia, and Brazil, and rank 4 in many others.

    • Migraine ranks as the number 2 cause of YLDs in the USA, Argentina, Germany, and Brazil.

    • Other musculoskeletal disorders, Major depression, and Anxiety disorders also feature heavily in top-ranked disability causes across both sexes and all ages.

Behavioral Model of Healthcare Utilization

  • Conceptual Model (Anderson & Newman):

    • This model identifies three primary categories of characteristics that influence the use of Physical Therapist (PT) services:

      • Need Characteristics: Includes health status, illness severity, and comorbidities.

      • Enabling Characteristics: Includes income, insurance status, and access to other resources.

      • Predisposing Characteristics: Includes demographic factors, social factors, and individual attitudes or beliefs.

  • Predictors for Likelihood of Being Seen by a PT:

    • Specific Diagnoses: Subjects diagnosed with a herniated disk, spinal stenosis, spondylosis, or pain syndrome were 10%10\% to 16%16\% more likely to see a PT than those with a simple sprain or strain.

    • Duration of Symptoms: Subjects with a problem lasting > 3 months were 34%34\% to 39%39\% more likely to see a PT than those with a problem lasting < 3 months.

    • Prior Interventions: Subjects who had previously received injections were 40%40\% more likely to seek PT care.

    • Physician Referral Type:

      • General Practitioner: 22%22\%

      • Neurosurgeon: 20%20\%

      • Orthopedic surgeon: 23%23\%

      • Physiatrist: 44%44\%

      • Rheumatologist: 14%14\%

      • Chiropractor use: 00%00\%

  • Demographic Influences on PT Use:

    • The likelihood of seeing a PT for neck and back pain increases with age.

    • Being male and middle-aged are negatively associated with physical therapy utilization.

The Physical Therapist as a Diagnostician

  • Professional Responsibility: Shirley Sahrmann (JOSPT, 2005) argued that PTs are compromising the respect for the profession by not engendering the responsibility of being a diagnostician in every practitioner.

  • Diagnostic Tools: PTs utilize Evidence-Based and Treatment-Based Classification (TBC) systems and Clinical Practice Guidelines to fulfill this responsibility.

  • Clinical Efficacy: While primary care physicians (PCPs) routinely examine for red flags in less than 5%5\% of initial screens (Bishop & Wing, Sine 2006), PTs possess the skills to screen more effectively.

Case Study: Susan, a 25-Year-Old Woman with Low Back Pain

  • History and Presentation:

    • Sudden and severe onset of left-sided lumbosacral and hip pain occurring 3 weeks prior to exam.

    • Initial ER treatment: Injection of meperidine (narcotic analgesic), NSAIDs, and muscle relaxants.

    • PCP ordered plain film radiographs and MRI of the lumbar spine; both were normal.

    • Orthopedist diagnosed "Acute LBP" and prescribed Percocet, heat, and a back support.

  • PT Interview and Examination Findings:

    • Pain: Constant, severe (7/107/10 at rest, 9/109/10 after 30 mins walking), radiating to the left lower abdominal quadrant, buttock, and anterior thigh.

    • Sleep: Only 1-2 hours at a time due to pain.

    • Aggravators: Walking and prolonged sitting.

    • Observation: Antalgic movements, BMI of 27.327.3 (140 lbs140\,lbs, 5 ft5\,ft).

    • Range of Motion (ROM): Forward flexion and lateral flexion restricted by 25%25\%, extension restricted by 10%10\%.

    • Strength: 4/54/5 MMT in bilateral lower extremities (BLEs).

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

  • Red Flags Identified:

    • Sudden onset with no known cause.

    • Severe, persistent pain (9/109/10).

    • Night pain causing severe sleep deprivation.

    • History of urinary urgency over the past 2 years.

    • Pain pattern not fully consistent with mechanical MSK pain.

  • Clinical Decision: Despite findings suggestive of "extension syndrome," the PT suspected too many red flags. A referral was made to a gynecologist.

  • Outcome: Susan was diagnosed with endometriosis and a left ovarian cyst. She underwent laparoscopic laser surgery. Post-op, she reported 80%80\% improvement in pain and returned to normal bladder function within weeks.

Categorical Classification of "Red Flag" Findings

  • Category I (Immediate Medical Attention Required):

    • Blood in sputum.

    • Loss of consciousness (LOC) or altered mental status.

    • Neurological deficit not explained by monoradiculopathy.

    • Numbness or paresthesia in the perianal region.

    • Pathological changes in bowel and bladder.

    • Symptom patterns not compatible with mechanical pain.

    • Progressive neurological deficits.

    • Pulsatile abdominal masses.

  • Category II (Requires Subjective Questioning & Precautionary Examination):

    • Age > 50.

    • Clonus (possible past CNS disorder).

    • Fever.

    • Elevated sedimentation rate.

    • Gait deficits.

    • History of cancer or metabolic bone disorder.

    • Impairment from recent trauma.

    • Long-term corticosteroid use.

    • Writhing pain.

  • Category III (Requires Further Physical Testing & Differentiation):

    • Abnormal reflexes.

    • Bilateral or unilateral radiculopathy/paresthesia.

    • Unexplained referred pain.

    • Unexplained significant weakness.

Red Flag Screening Perspectives and Limitations

  • OSPRO (Optimal Screening for Prediction of Referral and Outcome): A 97-item bank developed 10- and 23-item tools. The 23-item tool identified 100%100\% of positive red flag symptom responders.

  • Narrative View Critique (Cook et al., 2018):

    • Red flag symptoms often neither rule out nor identify serious pathology definitively.

    • LBP guidelines are sometimes unhelpful, and clinicians often manage the condition rather than screen for underlying pathology.

    • Recommendations include "Watchful Waiting" and linking symptomology directly to health status rather than just diagnostic testing.

Serious Pathologies and Lower Back Red Flags

  • Prevalence of Serious LBP Causes:

    • 90%−95%90\% - 95\% are non-life-threatening conditions.

    • Approximately 1%−2%1\% - 2\% are related to neoplasm, infection, or inflammation.

    • 2%2\% are related to visceral disorders.

    • 97%97\% are suggested to be mechanical spinal causes.

  • Conditions Requiring Medical Management:

    • Referring Pain FROM Lower Back: Pathologic/Sacral stress fractures, Acute spondylolisthesis, Cancer, Infections, Cauda Equina, Ankylosing Spondylitis, Central Sensitization Disorder.

    • Referring Pain TO Lower Back: Aneurysm, Vascular Claudication, Kidney Stone, Genital Pathologies, Gastrointestinal Pathologies.

  • The Ultimate Red Flag: A lack of progress in PT, or an actual decline in status, is considered the primary red flag.

Abdominal Aortic Aneurysm (AAA)

  • Nature: A medical emergency. Diagnosis must be considered proactively as many patients die before reaching care.

  • Symptoms: 50%50\% of patients with ruptured AAA complain primarily of back pain.

  • Signs: Back pain, left lower quadrant pain, flank pain, awareness of a pulse in the abdomen, syncope, or LE motor/sensory loss.

  • Rupture Signs: Acute stabbing pain, drop in BP, tachycardia, lightheadedness, and cold, pulseless lower extremities.

  • Risk Factors: Smoking, Coronary Artery Disease (CAD), age, and heredity.

Spine Infections and Osteoporosis

  • Spine Infection Types: Vertebral Osteomyelitis and Spinal Epidural Abscess.

    • Signs: Focal back pain with an insidious onset, increasing over weeks/months. Neurologic signs indicate an emergency.

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

  • Metabolic Disease - Osteoporosis (OP):

    • Major Risk Factors: Personal history of fragility fractures, smoking, oral corticosteroid use (> 3 months), white race, postmenopausal status, and the "female athlete triad" (disordered eating, amenorrhea, and osteoporosis).

    • Signs and Symptoms: Often asymptomatic until fracture occurs (1/31/3 of fractures are painless). Can lead to height loss, thoracic kyphosis, increased back pain, and reduced distance between the ribcage and pelvis.

Thoracic and Cervical Spine Screening

  • Thoracic Spine: A common site for metastatic tumors due to its length and proximity to the mediastinum (lymph nodes, lung, or breast cancer).

    • Systemic Origins: Cardiac (MI, Aortic Aneurysm), Pulmonary (Pneumonia, Pleurisy), Renal infection, GI (Peptic Ulcer, Gall Bladder, Pancreatic CA).

  • Canadian C-Spine Rule (Mandatory Radiography Factors):

    • Age ≥65\ge 65 years.

    • Dangerous mechanism (e.g., fall > 3 feet/5 stairs, axial load/diving, high-speed MVC > 100\,km/hr, rollover, motorized recreational vehicles).

    • Paresthesias in extremities.

  • Cervical Myelopathy: The most common cause of non-traumatic paraparesis.

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

    • Low Level Symptoms: Weakness, balance loss, and spasticity in LEs.

    • UMN Findings: Hyperactive DTR, ankle/knee clonus, Babinski sign.

  • Vertebrobasilar Insufficiency (VBI): Associated with instabilities, RA, or congenital factors; requires specific VBI testing.

Segmental Arrangement of Visceral Referred Pain

  • Heart: T1−4T_{1-4}

  • Esophagus: C8C_8 to T10T_{10}

  • Stomach, Liver, Gall Bladder: T6−9T_{6-9}

  • Pancreas: T6−11T_{6-11}

  • Small Intestine: T9−11T_{9-11}

  • Appendix: T10−11T_{10-11}

  • Ureter: L1−2L_{1-2}

  • Ascending Colon, Bladder Fundus, Uterine Fundus, Kidney Pelvis: T11−12T_{11-12}, L1L_1

  • Sigmoid and Rectum, Bladder Neck, Cervix: S2−4S_{2-4}

General Screening Tools for Clinical Practice

  • Constitutional Signs: Fever, diaphoresis, nausea, vomiting, diarrhea, fatigue, malaise, dizziness, and unexplained weight loss.

  • Vital Signs: Taking temperature and blood pressure is the easiest and fastest way to screen for systemic illness (Goodman & Snyder, 2007).

  • Pain Characteristics (OLDCAAR): Onset, Location, Duration, Context, Associated Symptoms, Aggravating Factors, Relieving Factors.

  • Clinical Presentation Red Flags:

    • Insidious onset with no known cause.

    • Symptoms unrelieved by rest or treatment.

    • No discernable pattern of symptoms.

    • Night pain that is constant and intense.

    • Colicky pain.