Evidence-based practice: Age of onset of musculo- skeletal symptoms can help the evaluating clinician de- termine the source and severity of a patient’s condition. For neck pain, new onset neck pain before age 20 or after age 55 can be associated with a serious underly- ing cause, especially when accompanied by weakness involving more than one myotome or loss of sensation involving more than one dermatome (McCartney et al., 2018). Red flags for neck pain The presence of red flags in the cervical spine can alert the evalu- ating clinician to the possibility of significant underlying pathol- ogy. Teichtahl et al. (2015) have identified the following neck pain red flags: ● Significant trauma. This includes motor vehicle crashes, falls from a significant height, and some types of sports injuries. However, in older adults even a relatively simple fall can result in injury to the neck. These types of injuries can cause fractures and/or ligamentous disruption. ● History of rheumatoid arthritis . Rheumatoid arthritis is a chronic inflammatory disease that often affects the cervical spine. According to Gillick et al. (2015), rheumatoid arthritis can affect the cervical spine via atlantoaxial instability, cranial settling, or subaxial subluxation (Gillick et al., 2015). ● Infective symptoms, including fever, meningism, history of immunosuppression, or intravenous drug use . These find- ings may indicate the presence of conditions such as epidural abscess or discitis. ● Neurological symptoms such as upper motor neuron signs . Upper motor neuron signs can indicate the presence of cer- vical cord compression. In addition, neurological signs may indicate a demyelinating process. ● A ripping or tearing sensation in the neck . Arterial dissec - tion, either of the carotid or vertebral artery, can create these symptoms. Yellow flags cervical spine The psychosocial factors that are predictive of neck pain chronicity and disability are similar to those presented above for headache yellow flags. Diagnoses that have shown to be associated with a tendency toward pain chronicity and disability include depres- sion, anxiety, posttraumatic stress disorder, and substance misuse and dependence. Certain symptom beliefs have been shown to be maladaptive in managing pain, including the belief that pain is a signal of damage, activity should be avoided when pain is present, pain leads to disability and is uncontrollable, and pain is a permanent condition (Adams et al., 2015). In addition, anger, pain hypervigilance, perceived helplessness, low self-efficacy, and psychological inflexibility have all been shown to correlate with maladaptive coping with pain (Adams et al., 2015). As mentioned earlier, pain neuroscience education offers clinicians valuable knowledge and skills in working with clients’ yellow flag issues. Teichtahl et al. (2015) specifically mention an attitude that one’s neck pain is potentially severely disabling, social or financial prob- lems, reduced activity levels, and the presence of a compensation claim as factors that make coping with and recovering from neck pain more difficult.
● Concurrent chest pain, shortness of breath, and diaphore- sis . These symptoms can indicate cardiac involvement, such as myocardial ischemia. Carvallaro Goodman et al. (2018) have also constructed a list of neck pain red flags. These include: ● Night pain unrelieved by rest or change in position; made worse by recumbency; sensory and motor deficits in adoles- cents; these findings may indicate the presence of a tumor. ● Fever, chills, and/or sweating, which are symptoms of a pos- sible infection. ● Unremitting throbbing pain, which may be caused by an aortic aneurysm. ● Morning stiffness that improves as the day goes on; may indi- cate the presence of inflammatory arthritis. ● Neck pain accompanied by “stocking glove” numbness (which is a characteristic pattern of numbness where the distal aspect of the nerves is first affected, without regard to root or nerve trunk distribution), which may be a sign of peripheral neuropathy such as that accompanying diabetes; it may also be sign of nonorganic pain, as in the patient who states, “My whole hand goes numb,” in the absence of any accompanying neurological signs. ● Global pain that is not localized to a specific structure (or structures) and does not follow typical neurological or muscu- loskeletal patterns. ● Exquisite tenderness over the spinous process, which may in- dicate the presence of tumor, fracture, or infection. Case Study: Jane Johnson Jane Johnson is a 24-year-old female who presents to physical therapy via direct access to address neck pain. The onset of symp- toms began four days ago at a soccer game. The client was play- ing goalie when an opposing player ran into her and knocked her over, with the back of her neck striking the goal post. The client re- ports that she had immediate onset of pain and momentarily “saw stars” but then “shook it off and kept playing.” She presents with pain that is localized to the lower cervical spine. The pain is worse with activity, especially with moving her head. She holds her head in a neutral guarded position. Palpation reveals exquisite tender- ness with palpation over the spinous processes of C5 and C6. Question Which two red flags are present in this scenario? Given the details of this case, can you name a possible diagnosis? Discussion One red flag in this case is the presence of significant trauma, namely the mechanism of injury where the client struck her neck on a hard, immoveable surface. Exquisite tenderness over the C5 and C6 spinous processes is another red flag. One possible diagnosis is lower cervical fracture, as this is consistent with the mechanism of injury and the finding of spinous process tender - ness. Further evaluation, including imaging, is warranted .
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