Screening the Head, Neck, and 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.

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

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:

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.

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.

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:

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.

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).

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

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).

Peptic ulcer can refer pain to the mid-thoracic spine between T6 and T10. The therapist should look for a history of NSAID use and ask about blood in the stools and the effect of eating food on pain and bowel function (see further discussion in Chapter 2).

Scapula

Most causes of scapular pain occur along the vertebral border and result from various primary musculoskeletal lesions. However, cardiac, pulmonary, renal, and GI disorders can cause scapular pain.

Specific questions to rule out potential systemic or medical origin of symptoms are listed in each individual chapter. For example, if the client reports any renal involvement, the therapist can use the questions at the end of Chapter 10 to screen further for urologic involvement. Appendix A contains a series of screening questions based on the presence of specific factors (e.g., sex, joint pain, night pain, shortness of breath).

Lumbar Spine

Low back pain (LBP) is very prevalent in the adult population, affecting up to 80% of all adults sometime in their lifetimes. In most cases, acute symptoms resolve within a few weeks to a few months. Individuals reporting persistent pain and activity limitation must be given a second screening examination.

As Table 14-1 shows, there is a wide range of potential systemic and medical causes of LBP. Older adults with more comorbidities are at increased risk for LBP. Bone and joint diseases (inflammatory and noninflammatory), lung and heart diseases, and enteric diseases top the list of conditions contributing to LBP in older adults.^11,80

Pain referred to the lumbar spine and low back region from the pelvic and abdominal viscera may come directly from the organ structures, but some experts suspect the referred pain pattern is really produced by irritation of the posterior abdominal wall by pus, blood, or leaking enzymes. If that is the case, the pain is not referred but rather arises directly from the anterior aspect of the back.³⁰

Sacrum/Sacroiliac

Sacral or SI pain in the absence of trauma and in the presence of a negative spring test (posterior-anterior glide of sacrum between the innominates) must be evaluated more closely. The most common etiology of serious pathology in this anatomic region comes from the spondyloarthropathies (disease of the joints of the spine) such as ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis, and arthritis associated with chronic inflammatory bowel (enteropathic) disease.

Spondyloarthropathy is characterized by morning pain accompanied by prolonged stiffness that improves with activity. There is limitation of motion in all directions and tenderness over the spine and SI joints. The most significant finding in ankylosing spondylitis is that the client has night (back) pain and morning stiffness as the two major complaints, but asymmetric SI involvement with radiation into the buttock and thigh can occur.

In addition to back pain, these rheumatic diseases usually include a constellation of associated signs and symptoms, such as fever, skin lesions, anorexia, and weight loss, that alert the therapist to the presence of systemic disease or other medical conditions. Such symptoms present a red flag identifying clients who should be referred to a physician.

Age, sex, and risk factors are important in assessing for systemic origin of symptoms associated with any of these inflammatory conditions. Clients with these diseases have a genetic predisposition to these arthropathies, which are triggered by a number of environmental factors such as trauma and infection. Each of these clinical entities has been discussed in detail in Chapter 12.

Polymyalgia rheumatica and fibromyalgia syndrome are muscle syndromes associated with lumbosacral pain. Fibromyalgia syndrome refers to a syndrome of pain and stiffness that can occur in the low back and sacral areas with localized tender areas. Both these disorders are also discussed in Chapter 12.

Anyone under the age of 45 with low back, hip, buttock, and/or sacral pain lasting more than 3 months should be asked these four questions:

There is a 70% sensitivity and 81% specificity for inflammatory back pain if two of the four questions are positive. Sensitivity drops to 33% if three of the four questions are answered “yes” but the specificity increases to nearly 100%.^80a

Viscerogenic

Visceral pain is not usually confused with pain originating in the head, neck, and back because sufficient specific symptoms and signs are often present to localize the problem correctly. It is the unusual presentation of systemic disease in the therapist’s practice that will make it more difficult to recognize.

LBP is more likely to result from disease in the abdomen and pelvis than from intrathoracic disease, which usually refers pain to the neck, upper back, and shoulder. Disorders of the GI, pulmonary, urologic, and gynecologic systems can cause stimulation of sensory nerves supplied by the same segments of the spinal cord, resulting in referred back pain.⁸¹ As discussed in Chapter 3, the CNS may not be able to distinguish which part of the body is responsible for the input into common neurons.

Back pain can be associated with distention or perforation of organs, gynecologic conditions, or gastroenterologic disease. Pain can occur from compression, ischemia, inflammation, or infection affecting any of the organs (Fig. 14-1).

Referred pain can also originate in organs that share pain innervation with areas of the lumbosacral spine. Colicky pain is associated with spasm in a hollow viscus. Severe, tearing pain with sweating and dizziness may originate from an expanding abdominal aortic aneurysm. Burning pain may originate from a duodenal ulcer.

Muscle spasm and tenderness along the vertebrae may be elicited in the presence of visceral impairment. For example, spasm on the right side at the 9th and 10th costal cartilages can be a symptom of gallbladder problems. The spleen can cause tenderness and spasm at the level of T9 through T11 on the left side. The kidneys are more likely to cause tenderness, spasm, and possible cutaneous pain or sensitivity at the level of the 11th and 12th ribs.

Most often, past medical history, clinical presentation, and associated signs and symptoms will alert the therapist to an underlying systemic origin of musculoskeletal symptoms. Any client older than 50 with back pain, especially with insidious onset or unknown cause, must have vital signs taken, including body temperature.

Careful questioning can elicit important information that the client withheld, thinking it was irrelevant to the problem, such as LBP alternating with abdominal pain at the same level or back pain alternating with bouts of bloody diarrhea.

The therapist should look for clusters of signs and symptoms that may suggest involvement of a particular system. The Review of Systems chart in Chapter 4 (see Box 4-19) can be very helpful in identifying visceral sources of symptoms.

Neurogenic

Neurogenic pain is not easily differentiated. Radicular pain results from irritation of axons of a spinal nerve or neurons in the dorsal root ganglion, whereas referred pain results from activation of nociceptive free nerve endings (nociceptors) in somatic or visceral tissue.

Neurologic signs are produced by conduction block in motor or sensory nerves, but conduction block does not cause pain. Thus, even in a client with back pain and neurologic signs, whatever causes the neurologic signs is not causing the back pain by the same mechanism. Therefore finding the cause of the neurologic signs does not always identify the cause of the back pain.³⁵ The therapist must look further.

Conditions, such as radiculitis, may cause both pain and neurologic signs, but in that case the pain occurs in the lower limb, not in the back or in the upper extremity, not in the neck. If root inflammation also happens to involve the nerve root sleeve, neck or back pain might also arise. In such a case the individual will have three problems each with a different mechanism: neurologic signs due to conduction block, radicular pain due to nerve-root inflammation, and neck or back pain due to inflammation of the dura.³⁵

Identifying a mechanical cause of pain does not always rule out serious spinal pathology. For example, neurogenic pain can be caused by a metastatic lesion applying pressure or traction on any of the neural components. Positive neural dynamic tests do not reveal the underlying cause of the problem (e.g., tumor versus scar tissue restriction). The therapist must rely on history, clinical presentation, and the presence of any neurologic or other associated signs and symptoms to make a determination about the need for medical referral.

Sciatica alone or sciatica accompanying back pain is an important but unreliable symptom. Although 90% of cases of sciatica are caused by a herniated disk,⁸² there are those other 10% the therapist must also be aware of in the screening process. For example, diabetic neuropathy can cause nerve root irritation. Prostatic metastases to the lumbar and pelvic regions or other neoplasms of the spine can create a clinical picture that is indistinguishable from sciatica of musculoskeletal origin (see Tables 16-1 and 16-6). This similarity may lead to long and serious delays in diagnosis. Such a situation may require persistence on the part of the therapist and client in requesting further medical follow-up.

Spinal stenosis caused by a narrowing of the vertebral (spinal) canal, lateral recess, or intervertebral foramina may produce neurogenic claudication (Fig. 14-2). The canal tends to be narrow at the lumbosacral junction, and the nerve roots in the cauda equina are tightly packed. Pressure on the cauda equina from tumor, disk protrusion, spinal fracture or dislocation, infection, or inflammation can result in cauda equina syndrome, which is a neurologic medical emergency.^83,84 Cauda equina syndrome is defined as a constellation of symptoms that result from damage to the cauda equina, the portion of the nervous system below the conus medullaris (i.e., lumbar and sacral spinal nerves descending from the conus medullaris).

The medical diagnosis of cauda equina syndrome is not always straightforward. Abnormal rectal tone may be delayed in individuals presenting with cauda equina syndrome. This is because sensory nerves are smaller and more sensitive than motor nerves; even so, some people present with abnormal rectal tone (motor) without saddle anesthesia.⁸⁵

The emerging nerve root exits through a shallow lateral recess and also may be compressed easily. Any combination of degenerative changes, such as disk protrusion, osteophyte formation, and ligamentous thickening, reduces the space needed for the spinal cord and its nerve roots (see Fig. 14-2).

Confusion with spinal stenosis syndromes may occur when atheromatous change in the internal iliac artery results in ischemia to the sciatic nerve. The subsequent sciatic pain with vascular claudication-like symptoms may go unrecognized as a vascular problem. The therapist may be able to recognize the need for medical intervention by combining a careful subjective and objective examination with knowledge of vascular and neurogenic pain patterns (Table 14-6). This is especially true in the treatment of unusual cases of sciatica or back pain with leg pain.

The client with a neurogenic source of back pain may develop a characteristic pattern of symptoms, with back pain, discomfort in the buttock, thigh, or leg and numbness and paresthesia in the leg developing after the person walks a few hundred yards (neurogenic claudication). The person may be forced to stop walking and obtains relief after long periods of rest. The pattern of symptoms is similar to that of intermittent claudication associated with vascular insufficiency, the major differences being immediate response to rest and position of the spine (see Fig. 14-4; see also Fig. 14-2).

The vertebral canal is wider when the spine is flexed, so relief from neurogenic pain may be obtained when the spine is flexed forward. Some individuals will bend over or squat as if to tie their shoelaces to assume a flexed spine position in public situations. Position of the spine (e.g., flexion, extension, side bending, or rotation) does not affect symptoms of a cardiac origin.

Vasculogenic

Pain of a vascular origin may be mistaken for pain from a wide variety of musculoskeletal, neurologic, and arthritic disorders. Conversely, in a client with known vascular disease, a primary musculoskeletal disorder may go undiagnosed (e.g., diskogenic disease, spinal cord tumor, peripheral neuritis, arthritis of the hip) because all symptoms are attributed to cardiovascular insufficiency.

Vasculogenic pain can originate from both the heart (viscera) and the blood vessels (soma), primarily peripheral vascular disease. Back pain has been linked to atherosclerotic changes in the posterior wall of the abdominal aorta in older adults.⁸⁶ The therapist can rely on special clues regarding vasculogenic-induced pain in the screening process (Box 14-4).

Vascular injury to the great vessels, which are in proximity to the vertebral column, can occur during lumbar disk surgery or can present as a complication postoperatively. In rare cases, severe bleeding can result in back pain and hypotension in the acute care phase. Late complications of back pain from pseudoaneurysms are rare (less than 0.05%) but can occur years after spine surgery (diskectomy).^87,88

Once the history has been reviewed, the therapist assesses the pain pattern present on clinical examination, asks about associated signs and symptoms, and conducts a Review of Systems.

Vascular back pain may be described as “throbbing” and almost always is increased with any activity that requires greater cardiac output and diminished or even relieved when the workload or activity is stopped. A “throbbing” headache may be a vascular headache from a variety of causes.

Women in the perimenopausal and menopausal states may experience vascular headaches from fluctuating hormonal levels. Clients on cardiac medication, such as glyceryl trinitrate (which relaxes smooth muscle, especially blood vessels) and is used to prevent angina, may also report episodes of throbbing headaches. Vascular symptoms of this kind require medical evaluation.

Atherosclerosis and the resulting peripheral arterial disease are the underlying causes of most vascular back pain. Often, the client history will reveal significant cardiovascular risk factors such as smoking, hypertension, diabetes, advancing age, or elevated serum cholesterol (see Table 6-3 and discussion of peripheral vascular disease in Chapter 6).

Older age is an important red flag when assessing for pain of a vasculogenic origin. Most often, clients with back pain and any of the vascular clues listed are middle-aged and older. A personal or family history of heart disease is a second red flag. Continuous mid-thoracic pain can be a symptom of myocardial infarction, especially in a postmenopausal woman with a positive family history of heart disease.

Older clients with long-term nonspecific lower back pain may have occluded lumbar/middle sacral arteries associated with disk degeneration. Back pain and neurogenic symptoms in the presence of high serum low-density lipoprotein (LDL) cholesterol levels raises a red flag.⁸⁹

Spondylogenic

Bone tenderness and pain on weight bearing usually characterize spondylogenic back pain (or the symptoms produced by bone lesions). Associated signs and symptoms may include weight loss, fever, deformity, and night pain. There are numerous conditions capable of producing bone pain, but the most common pathologic disorders are fracture from any cause, osteomalacia, osteoporosis, Paget’s disease, infection, inflammation, and metastatic bone disease (Case Example 14-5).

The acute pain of a compression fracture superimposed on chronic discomfort, often in the absence of a history of trauma, may be the only presenting symptom. The client may recall a “snap” associated with mild pain, or there may have been no pain at all after the “snap.” More intense pain may not develop for hours or until the next day.

Back pain over the thoracic or lumbar spine that is intensified by prolonged sitting, standing, and the Valsalva maneuver may resolve after 3 or 4 months as the fractures of the vertebral bodies heal. Clients who undergo kyphoplasty or vertebroplasty often have immediate pain relief.

The pain of untreated vertebral compression fractures may persist because of microfractures from the biomechanical effects of deformity. Other symptoms include pain on percussion over the fractured vertebral bodies, paraspinal muscle spasms, loss of height, and kyphoscoliosis.

When asking about the presence of any associated symptoms the therapist must keep in mind that older adults with vertebral compression fractures or kyphotic posture for any reason may report other pulmonary, digestive, and skeletal problems. These symptoms may not be indicative of back pain from a systemic or medical cause but rather organic dysfunction from a skeletal cause (i.e., somato-visceral response from the effects of a forward bent, kyphotic posture on the viscera).⁹⁰

Sacral stress fractures should be considered in LBP of postmenopausal women with risk factors and athletes, particularly runners, volleyball players, and field hockey players (see further discussion on spondylogenic causes of sacral pain in Chapter 15).

Psychogenic

Psychogenic pain is observed in the client who has anxiety that amplifies or increases the person’s perception of pain. Depression has been implicated in many painful conditions as the primary underlying problem. The prevalence of depression in physical therapy patients being treated for LBP has been reported as high as 26%.⁹¹ There is a concern that depression may go unrecognized or inappropriately managed. Screening for depression can be done quickly and easily with the following two questions:

This two-question tool has been proved to have a 96% sensitivity with a negative likelihood ratio (LR−) of 0.07, and a negative predictive value of 98%. Specificity was reported at 57% with a LR+ of 2.2, and a positive predictive value of 33%.^92,93 A yes response to either or both of these questions warrants further evaluation.⁹¹ (See additional questions in Appendices B-9 and B-10.)

Anxiety, depression, and panic disorder (see Chapter 3 for further discussion of anxiety, depression, and panic disorder) can lead to muscle tension, more anxiety, and then to muscle spasm. Signs and symptoms of these conditions are listed in Tables 3-9 and 3-10. Other signs of psychogenic-induced back pain may be:

The client may use words to describe painful symptoms characterized as “emotional.” Recognizing these descriptors will help the therapist identify the possibility of an underlying psychologic or emotional etiology. An “exploding” or “vicious” headache, “agonizing” neck pain, or “punishing” backache are all red-flag descriptors of psychogenic origin (see Table 3-1).

The client who is unable to concentrate on anything except the symptoms and who reports that the symptoms interfere with every activity may need a psychologic/psychiatric referral. The therapist can screen for illness behavior as described in Chapter 3. Recognizing illness behavior helps the therapist clarify the physical assessment and alerts the therapist to the need for further psychologic assessment.¹

Many studies have now shown a link between psychosocial distress and chronic neck or back pain.^94-99 Factors associated with chronic LBP may include job dissatisfaction, depression, fear-avoidance behavior, and compensation issues.^100,101 It may be necessary to conduct a social history to assess the client’s recent life stressors and history of depression or drug or alcohol abuse.

The presence of psychosocial risk factors does not mean the pain is any less real nor does it reduce the need for symptom control. The therapist concentrates on pain management issues and improving function. Tools to screen for emotional overlay and fear-avoidance behavior are available in Chapter 3 of this text.

Past Medical History

Prompt identification of malignancy is important, starting with knowledge of previous cancers. Past history of cancer anywhere in the body is a red flag warning that careful screening is required. Always ask clients who deny a previous personal history of cancer about any previous chemotherapy or radiation therapy.

Early recognition and intervention does not always improve prognosis for survival from metastatic cancer, but it does reduce the risk of cord compression and paraplegia. It is important to remember that the history can be misleading. For example, almost 50% of clients with back pain from a malignancy have an identifiable (or attributable) antecedent injury or trauma¹⁰⁶ (Case Example 14-6).

It is unclear if this is a coincidence or merely reflective of weakness in the musculoskeletal system leading to loss of balance and strength and ultimately an injury. If the trauma results in significant injury (e.g., fracture), then the underlying cancer is usually identified right away. But if soft tissue injury does not necessitate an x-ray or other imaging study, then the underlying oncologic cause may go undetected. Once again the therapist may be the first to recognize the cluster of clinical signs and symptoms and/or red flag findings to suggest a more serious underlying pathology.

Red Flags and Risk Factors

A combination of age (50 or older), previous history of cancer, unexplained weight loss, and failure to improve after 1 month of conservative care has a reported sensitivity of 100%.¹⁰⁴ Of these four red flags, a previous history of cancer is the most informative with a pooled LR+ of 23.7 compared with a LR+ of 3 for the other three.⁹⁹

Until now, there has been an emphasis in this text on advancing age as a key red flag. Back pain at a young age (younger than 20 years old) may be considered a red flag as well. As a general rule, persistent backache due to extraspinal causes is rare in children. As mentioned, mechanical back pain in children is possibly linked with heavy backpacks,^107,108 sports, and sedentary lifestyle. However, primary bone cancer occurs most often in adolescents and young adults, hence the addition of this red flag: Age younger than 20 years. Bones of the appendicular skeleton (limbs) are affected more than the spine in this age group, but secondary metastases to the vertebrae can occur.

Clinical Presentation

Back pain associated with cancer is usually constant, intense, and worse at night or with weight-bearing activities, although vague, diffuse back pain can be an early sign of non-Hodgkin’s lymphoma and multiple myeloma. Pain with metastasis to the spine may become quite severe before any radiologic manifestations appear.¹⁰³

Back pain associated with malignant retroperitoneal lymphadenopathy from lymphomas or testicular cancers is characterized as persistent, poorly localized LBP present at night but relieved by forward flexion. Pain may be so excruciating while lying down that the person can sleep only while sitting in a chair hunched forward over a table.

Palpate the midline of the spinous processes for any abnormality or tenderness. Perform a tap test (percussion over the involved spinous process).¹¹⁰ Reproduction of pain or exquisite tenderness over the spinous process(es) is a red-flag sign requiring further investigation and possible medical referral.

Neoplasm (whether primary or secondary) may interfere with the sympathetic nerves; if so, the foot on the affected side is warmer than the foot on the unaffected side. Paresis in the absence of nerve root pain suggests a tumor. Severe weakness without pain is very suggestive of spinal metastases. Gross muscle weakness with a full range of SLR and without a history of recent acute sciatica at the upper two lumbar levels is also suggestive of spinal metastases.

A careful assessment of motor strength, sensory levels, proprioception, and reflexes is recommended. These findings can provide a baseline against which to compare future responses that might represent deterioration or undiagnosed lesions at other levels. Abnormal or new findings should be reported.¹⁰³

A short period of increasing central backache in an older person is always a red-flag symptom, especially if there is a previous history of cancer. The pain spreads down both lower limbs in a distribution that does not correspond with any one nerve root level. Bilateral sciatica then develops, and the back pain becomes worse.

X-rays do not show bone destruction from metastatic lesions until the lytic process has destroyed 30% to 50% of the bone. The therapist cannot assume metastatic lesions do not exist in the client with a past medical history of cancer now presenting with back pain and “normal” x-rays.^111-113

Associated Signs and Symptoms

Clinical signs and symptoms accompanying back pain from an oncologic cause may be system related (e.g., GI, GU, gynecologic, spondylogenic), depending on where the primary neoplasm is located and the location of any metastases (Case Example 14-7).

The therapist must ask about the presence of constitutional symptoms, symptoms anywhere else in the body, and assess vital signs as part of the screening process. Unexplained weight loss is a common feature in anyone with tumors of the spine. Review the red flags in Box 14-1 and conduct a Review of Systems to identify any clusters of signs and symptoms.

Angina

Angina may cause chest pain radiating to the anterior neck and jaw, sometimes appearing only as neck and/or jaw pain and misdiagnosed as temporomandibular joint (TMJ) dysfunction. Postmenopausal women are the most likely candidates for this type of presentation. If the jaw pain is steady, lasts a long time, or is worst when first waking up in the morning, it could be that the individual is grinding the teeth while sleeping. But jaw pain that comes and goes with physical activity or stress may be a symptom of angina.

Angina and/or myocardial infarction can appear as isolated mid-thoracic back pain in men or women (see Figs. 6-4 and 6-8). There is usually a lag time of 3 to 5 minutes between increase in activity and onset of musculoskeletal symptoms caused by angina.

Myocardial Ischemia

Heart disease and myocardial infarction (MI), in particular, can be completely asymptomatic. In fact, sudden death occurs without any warning in 50% of all MIs. Back pain from the heart (cardiac pain pattern) can be referred to the anterior neck and/or mid-thoracic spine in both men and women.

When pain does present, it may look like one of the patterns shown in Fig. 6-9. There are usually some associated signs and symptoms such as unexplained perspiration (diaphoresis), nausea, vomiting, pallor, dizziness, or extreme anxiety. Age and past medical history are important when screening for angina or MI as possible causes of musculoskeletal symptoms. Vital sign assessment is a key clinical assessment (Case Example 14-8).

Abdominal Aortic Aneurysm

On occasion, an abdominal aortic aneurysm (AAA) can cause severe back pain (see Fig. 6-11 and additional discussion in Chapter 6). An aneurysm is an abnormal dilation in a weak or diseased arterial wall causing a saclike protrusion. Prompt medical attention is imperative because rupture can result in death. Aneurysms can occur anywhere in any blood vessel, but the two most common places are the aorta and cerebral vascular system. AAA occurs most often in men in the sixth or seventh decade of life.

• Bilateral buttock and/or leg pain or discomfort

• Weakness and fatigue of the lower extremities

• Atrophy of the leg muscles

• Absent lower extremity pulses

• Color and/or temperature changes in the feet and lower legs

Back Pain: Vascular or Neurogenic?

The medical differential diagnosis is difficult to make between back pain of a vascular versus neurogenic origin. Frequently, vascular and neurogenic claudication occurs in the same age group (over 60 and even more often, after age 70). Sometimes clients are referred to physical therapy to help make the differentiation (Case Example 14-9).

Vascular and neurogenic disease often coexists in the same person with an overlap of symptoms of each. There are several major differences to look for but especially response to rest (i.e., activity pain), position of the spine, and the presence of any trophic (skin) changes (see Tables 14-6 and 16-5).

Vascular-induced back and/or leg pain or discomfort is alleviated by rest and usually within 1 to 3 minutes. Conversely, activity (usually walking) brings the symptoms on within 1 to 3, sometimes 3 to 5 minutes. Neurogenic-induced symptoms often occur immediately with use of the affected body part and/or when adopting certain positions. The client may report the pain is relieved by prolonged rest or not at all.

What is the effect of changing the position of the spine on pain of a vascular nature? Are the vascular structures compromised in any way by forward bending, side bending, or backward bending (Fig. 14-4)? Are we asking the diseased heart or compromised blood vessels to supply more blood to this area?

It is not likely that movements of the spine will reproduce back pain of a vascular origin. What about back pain of a neurogenic cause? Forward bending opens the vertebral canal (vertebral foramen) giving the spinal cord (through L1) additional space. This is important in preventing painful symptoms when spinal stenosis is present as a cause of neurogenic claudication.

Unless there is a spinal neuroma, a true stenosis with spinal cord pressure does not occur in the lumbar region since the spinal cord ends at L1 in most people. Neural symptoms at L1 to L3 are rare and more likely indicate a spinal tumor rather than disk or facet pathology. Nerve pressure leading to radicular symptoms (e.g., pain, numbness, myotomal weakness) below L2 is not true stenosis of the vertebral canal but rather intervertebral foraminal stenosis with encroachment of the peripheral nerve as it leaves the spinal canal through the neural foramina.

The position of comfort for someone with back pain associated with spinal stenosis is usually lumbar flexion. The client may lean forward and rest the hands on the thighs or lean the upper body against a table or cupboard.

Past Medical History

A recent history of one of these disorders in a client with neck, shoulder, chest, or back pain raises a red flag of suspicion. In keeping with the model for screening the therapist should review (1) past medical history, (2) risk factors, (3) clinical presentation, and (4) associated signs and symptoms (Box 14-5).

Clinical Presentation

Pulmonary pain patterns vary in their presentation based in part on the lobe(s) or segment(s) involved and on the underlying pathology. Several different pain patterns are presented in Chapter 7 (see Fig. 7-10).

Autosplinting is considered a valuable red flag of possible pulmonary involvement. Autosplinting occurs when the client prefers to lie on the involved side. Because pain of a pulmonary source is referred from the ipsilateral side, putting pressure on the involved lung field reduces respiratory movements and therefore reduces pain. It is uncommon for a person with a true musculoskeletal problem to find relief from symptoms by lying on the involved side.

The therapist should perform the following tests for clients with back pain who have a suspicious history or concomitant respiratory symptoms:

Although reproducing pain or increased pain on respiratory movements is considered a hallmark sign of pulmonary involvement, symptoms of pleural, intercostal, muscular, costal, and dural origin all increase with coughing or deep inspiration.

Only pain of a cardiac origin is ruled out when symptoms increase in association with respiratory movements. For this reason the therapist must always carefully correlate clinical presentation with client history and associated signs and symptoms when assessing for pulmonary disease.

Forceful coughing from an underlying pulmonary problem can cause an intercostal tear, which can be palpated. Even if some symptoms can be reproduced with palpation, the problem may still be pulmonary-induced, especially if the cause is repeated, forceful coughing from a pulmonary etiology.

Pancoast’s tumors of the lung may invade the roots of the brachial plexus causing entrapment as they enlarge, appearing as pain in the C8 to T1 region, possibly mimicking thoracic outlet syndrome. Faulty data collection leads to inaccurate findings or incorrect diagnosis and treatment, resulting in less than optimal outcomes.¹²³ Other signs may include wasting of the muscles of the hand and/or Horner’s syndrome with unilateral constricted pupil, ptosis, and loss of facial sweating (see the section on lung cancer in Chapter 7).

Tracheobronchial irritation can cause pain to be referred to sites in the neck or anterior chest at the same levels as the points of irritation in the air passages (see Fig. 7-2). This irritation may be caused by inflammatory lesions, irritating foreign materials, or cancerous tumors.

Associated Signs and Symptoms

Assessing for associated signs and symptoms will usually bring to light important red flags to assist the therapist in recognizing an underlying pulmonary problem. Neck or back pain that is reproduced, increased with inspiratory movements, or accompanied by dyspnea, persistent cough, cyanosis, or hemoptysis must be evaluated carefully. Clients with respiratory origins of pain usually also show signs of general malaise or constitutional symptoms.

Origin of Pain Patterns

As discussed in Chapter 3, there can be at least three possible explanations for visceral pain patterns, including embryologic development, multisegmental innervation, and direct pressure on the diaphragm.

All three of these mechanisms are found in the urologic system. The embryologic origin of urologic pain patterns begins with the testicles and ovaries. These reproductive organs begin in utero where the kidneys are in the adult and then migrate during fetal development following the pathways of the ureters. A kidney stone down the pathway of the ureter causes pain in the flank radiating to the scrotum (male) or labia (female).

Evidence of the influence of multisegmental innervation is observed when skin pain over the kidneys is reported. Visceral and cutaneous sensory fibers enter the spinal cord close to each other and converge on the same neurons. When visceral pain fibers are stimulated, cutaneous fibers are stimulated, too. Thus visceral pain can be perceived as skin pain.

None of the components of the lower urinary tract comes in contact with the diaphragm, so the bladder and urethra are not likely to refer pain to the shoulder. Lower urinary tract impairment is more likely to refer pain to the low back, pelvic, or sacral areas. However, the upper urinary tract can impinge the diaphragm with resultant referred pain to the costovertebral area or shoulder.

Past Medical History

Kidney disorders such as acute pyelonephritis and perinephric abscess of the kidney may be confused with a back condition. Most renal and urologic conditions appear with a combination of systemic signs and symptoms accompanied by pelvic, flank, or LBP.

The client may have a history of recent trauma or a past medical history of UTIs to alert the clinician to a possible renal origin of symptoms.

Clinical Presentation

Acute pyelonephritis, perinephric abscess, and other kidney conditions appear with aching pain at one or several costovertebral areas, posteriorly, just lateral to the muscles at T12 to L1, from acute distention of the capsule of the kidney.

The pain is usually dull and constant, with possible radiation to the pelvic crest or groin. The client may describe febrile chills, frequent urination, hematuria, and shoulder pain (if the diaphragm is irritated). Percussion to the flank areas reveals tenderness; the therapist can perform Murphy’s percussion (punch) test (see Fig. 4-54). Although this test is commonly performed, its diagnostic value has never been validated. Results of at least one Finnish study¹²⁴ suggested that in acute renal colic loin tenderness and hematuria (blood in the urine) are more significant signs than renal tenderness.¹²⁵ A diagnostic score incorporating independent variables, including results of urinalysis, presence of costovertebral angle tenderness and renal tenderness, duration of pain, appetite level, and sex (male versus female), reached a sensitivity of 0.89 in detecting acute renal colic, with a specificity of 0.99 and an efficiency of 0.99.¹²⁴

Nephrolithiasis (kidney stones) may appear as back pain radiating to the flank or the iliac crest (see Fig. 10-7) (Case Example 14-10). Kidney stones may occur in the presence of diseases associated with hypercalcemia (excess calcium in the blood) such as hyperparathyroidism, metastatic carcinoma, multiple myeloma, senile osteoporosis, specific renal tubular disease, hyperthyroidism, and Cushing’s disease. Other conditions associated with calculus formation are infection, urinary stasis, dehydration, and excessive ingestion or absorption of calcium.

Ureteral colic, caused by passage of a kidney stone (calculus), appears as excruciating pain that radiates down the course of the ureter into the urethra or groin area. The pain is unrelieved by rest or change in position. These attacks are intermittent and may be accompanied by nausea, vomiting, sweating, and tachycardia. Localized abdominal muscle spasm may be present. The urine usually contains erythrocytes or is grossly bloody.

Urinary tract infection affecting the lower urinary tract is related directly to irritation of the bladder and urethra. The intensity of symptoms depends on the severity of the infection. Although LBP may be the client’s chief complaint, further questioning usually elicits additional urologic symptoms. The therapist should ask about

Clients can be asymptomatic with regard to urologic symptoms, making the physical therapy diagnosis more difficult.

Screening Questions: Renal and Urologic System

It is important to ask questions about the presence of urologic symptoms (see Appendix B-5). Many people (therapists and clients alike) are uncomfortable discussing the details of bladder (or bowel) function. If presented in a professional manner with a brief explanation, both parties can be put at ease. For example, the interview may go something like this:

“I’m going to ask a few other questions that may not seem like they fit with the back pain (shoulder pain, pelvic pain) you’re having. There are many possible causes of back pain and I want to make sure I don’t leave anything out.

If I ask you anything you don’t know, please pay attention over the next few days and see if you notice something. Don’t hesitate to bring this information back to me. It could be very important.”

To the therapist: The important thing to look for is CHANGE. Many people have problems with incontinence, nocturia, or frequency. If someone has always experienced a delay before starting a flow of urine, this may be normal for him (or her).

Many women have nocturia after childbirth, but most men do not get up at night to empty their bladders until after age 65. They may not even be aware that this has changed for them. Often, it is the wife or partner who answers the question about getting up at night as “yes!” Likewise, if a man has always had a delay in starting a flow of urine, he may not be aware that the delay is now twice as long as before. Or he may not recognize that being unable to continue a flow of urine is not “normal” and in fact, requires medical evaluation.

Pseudorenal Pain

Sometimes clients appear to have classic symptoms of a kidney problem but without any associated signs and symptoms. Such a situation can occur with someone who has a mechanical derangement of the costovertebral or costotransverse joint or irritation of the costal nerve (radiculitis, T10-T12).

What does this look like in the clinic? How does the therapist make the differentiation? Use the same guidelines for decision making in the screening process presented throughout this text (e.g., history, risk factors, associated signs, and symptoms).

Past Medical History and Risk Factors

Taking a closer look at past medical history, risk factors, and clinical presentation and asking about associated signs and symptoms may reveal important red flags and clues pointing to the GI system. The most significant and common history is one of long-term or chronic use of NSAIDs. Risk factors and assessment of risk for NSAID-induced gastropathy are discussed in detail in Chapter 8.

Other significant risk factors in the history include the long-term use of immunosuppressants, past history of cancer, history of Crohn’s disease (also known as regional enteritis), or previous bowel obstruction.

Signs and Symptoms of Gastrointestinal Dysfunction

The most common signs and symptoms associated with the GI system are listed in Box 14-6 and discussed in greater detail in Chapter 8. Back pain (as well as hip, pelvic, sacral, and lower extremity pain) with any of these accompanying features should be considered a red flag for the possibility of GI impairment.

Anterior neck (esophageal) pain may occur, usually with a burning sensation (“heartburn”) or other symptoms related to eating or swallowing (e.g., dysphagia, odynophagia). Esophageal varices associated with chronic alcoholism may appear as anterior neck pain but usually occur at the xiphoid process and are attributed to heartburn.

Anterior neck pain can also occur as a result of a diskogenic lesion requiring a careful history and neurologic screening to document findings. Clients with eating disorders who repeatedly binge and then purge by vomiting may report anterior neck pain without realizing the correlation between eating behaviors and symptoms.

When assessing neck pain, the therapist should look for other associated signs and symptoms, such as sore throat; pain that is relieved with antacids, the upright position, fluids, or avoidance of eating; and pain that is aggravated by eating, bending, or recumbency.

Dysphagia or difficulty swallowing, odynophagia (painful swallowing), and epigastric pain are indicative of esophageal involvement. Certain types of drugs (e.g., antidepressants, antihypertensives, asthma medications) can make swallowing difficult, requiring a careful evaluation during the client interview.

Early satiety (the client takes one or two bites of food and is no longer hungry) is another red-flag symptom of the GI system (Case Example 14-11). In general, back pain made better, worse, or altered in any way by eating is a red-flag symptom. If the change in symptom(s) occurs immediately to within 30 minutes of eating, the upper GI tract or stomach/duodenum may be a possible cause. Change in symptoms 2 to 4 hours after eating is more indicative of the lower GI tract (intestines/colon).

Bloody diarrhea, fecal incontinence, and melena are three additional signs of lower GI involvement. It is important to ask the client about the presence of specific signs that may be too embarrassing to mention (or the client may not see the connection between back pain and bowel smears on the underwear). Asking someone with back pain about bowel function can be accomplished in a very professional manner. The therapist may tell the client:

“I am going to ask you a series of questions about your bowels. This may not seem like it is connected to your current problem, so just bear with me. These are important questions to make sure we have covered every possibility. If you do not know the answer to the question, pay attention over the next day or two to see how everything is working. If you notice anything unusual or different, please let me know when you come in next time.”

Again, when it comes to something like bowel smears on the underpants, it is important to distinguish between pathology and poor hygiene. The key to look for is change such as the new appearance of a problem that was not present before the onset of back pain or other symptoms. With blood in the stools, a medical doctor must differentiate between internal versus external bleeding.

Melena is a dark, tarry stool caused by oxidation of blood in the GI tract (usually the upper GI tract, but it can be the lower GI tract). The most common causes of abdominal bleeding are chronic use of NSAIDs, leading to ulceration, Crohn’s disease, or ulcerative colitis, and diverticulitis or diverticulosis. Anyone with a history of these problems presenting with new onset of back pain must be screened for medical disease.

Hemorrhage or visible blood in the toilet may be a sign of anal fissures, hemorrhoids, or colon cancer. The etiology must be determined by a medical doctor. Be aware that there is an increased incidence of rectal bleeding from anal fissures and local tissue damage associated with anal intercourse. This occurs predominantly in the male homosexual or bisexual population but can be seen in heterosexual partners who engage in anal intercourse. There are also increasing reports of adolescents engaging in oral and anal intercourse as a form of birth control.

It may be necessary to take a sexual history. The therapist should offer the client a clear explanation for any questions concerning sexual activity, sexual function, or sexual history. There is no way to know when someone will be offended or claim sexual harassment. It is in the therapist’s best interest to maintain the most professional manner possible.

There should be no hint of sexual innuendo or humor injected into any of the therapist’s conversations with clients at any time. The line of sexual impropriety lies where the complainant draws it and includes appearances of misbehavior. This perception differs broadly from client to client.¹¹⁰

You may need to include the following questions (see also Appendix B-32). Always offer an explanation for taking a sexual history. For example, “There are a few personal questions I’ll need to ask that may help sort out where your symptoms are coming from. Please answer these as best you can.”

Back pain from any cause may impair sexual function. Many health care professionals do not address this issue; the therapist can offer much in the way of education, pain management, improved function, and proper positioning for work and recreation. Some publications are available to assist therapists in discussing sexual function and pain control for the client with back pain.^127,128

Esophagus

Esophageal pain will occur at the level of the lesion and is usually accompanied by epigastric pain and heartburn. Severe esophagitis (see Fig. 8-13) may refer pain to the anterior cervical or more often, the mid-thoracic spine.

The pain pattern will most likely present in a band of pain starting anteriorly and spreading around the chest wall to the back. Rarely, pain will begin in the mid-back and radiate around to the front. Referred pain to the mid-thoracic spine occurs around T5-6.

As with cervical pain of GI origin, there may be a history of alcoholism with esophageal varices, cirrhosis, or an underlying eating disorder. If liver impairment is an underlying factor, there may be signs such as asterixis (liver flap or flapping tremor), palmar erythema, spider angiomas, and carpal (tarsal) tunnel syndrome (see discussion in Chapter 9).

Keep in mind that this same type of mid-thoracic back pain can occur with thoracic disk disease. Look for a history of trauma and neurologic changes typically associated with disk degeneration (e.g., bowel and bladder changes, numbness and tingling or paresthesias in the upper extremities); these are not usually present with esophageal impairment. Lower thoracic disk herniation can cause groin pain, leg pain, or mimic kidney pain.

Stomach and Duodenum

Long-term use of NSAIDs is the most common cause of back pain referred from the stomach or duodenum. Ulceration and bleeding into the retroperitoneal area can cause pain in the back or shoulder. The primary and referred pain patterns for pain of a stomach or duodenal source are shown in Fig. 8-14.

The referred pain to the back is at the level of the lesion, usually between T6 and T10. For the client with mid-thoracic spine pain of unknown cause or which does not fit the expected musculoskeletal presentation, ask about associated signs and symptoms such as

The pain of peptic ulcer (see Figs. 8-8 and 8-14) occasionally occurs only in the mid-thoracic back between T6 and T10, either at the midline or immediately to one side or the other of the spine. Posterior penetration of the retroperitoneum with blood loss and resultant referred thoracic pain is most often caused by long-term use of NSAIDs. The therapist should look for a correlation between symptoms and the timing of meals, as well as the presence of blood in the feces or relief of symptoms with antacids.

Small Intestine

Diseases of the small intestine (e.g., Crohn’s disease, irritable bowel syndrome, obstruction from neoplasm) usually produce midabdominal pain around the umbilicus (see Fig. 8-2), but the pain may be referred to the back if the stimulus is sufficiently intense or if the individual’s pain threshold is low (see Fig. 8-15) (Case Example 14-12).

For the client with LBP of unknown cause or suspicious presentation, ask if there is ever any abdominal pain present. Alternating abdominal/LBP at the same level is a red flag that requires medical referral. Since both symptoms do not always occur together, the client may not recognize the relationship or report the symptoms. The therapist must be sure and ask appropriate screening questions (Case Example 14-13).

Look for a known history of Crohn’s disease (regional enteritis), irritable bowel syndrome, bowel obstruction, or cancer. Low back, sacral, or hip pain may be a new symptom of an already established disease. The client may not be aware that 25% of the people with GI disease have concomitant back or joint pain.

Enteric-induced arthritis can be accompanied by a skin rash that comes and goes. A flat red or purple rash or raised skin lesion(s) is possible, usually preceding the joint or back pain. The therapist must ask the client if he/she has had any skin rashes in the last few weeks.

The therapist may treat joint or back pain when there is an unknown or unrecognized enteric cause. Palliative intervention for musculoskeletal symptoms or apparent movement impairment can make a difference in the short-term but does not affect the final outcome.

Eventually the GI symptoms will progress; symptoms that are unrelieved by physical therapy intervention are red flags. Medical treatment of the underlying disease is essential to correcting the musculoskeletal component.