Self-Assessment Quiz Question #2 A patient presents for evaluation of neck pain related to a car crash that happened four weeks ago. She describes severe pain, rating it a 12 on a scale of 1 to 10. She reports that this neck pain has ruined her life and she is no longer able to work. Both x-rays and magnetic resonance imaging (MRI) were negative, but she insists that her doctor was a “quack.” Her medical history is significant for hypothyroidism and hypertension. She is hoping that you, her physical therapist, can find out what is wrong with her neck. Is this a red, orange, or yellow flag situation, and what should the evaluating therapist consider as a helpful next course of action? a. This is a red flag, and the client should be immediately referred back to her physician. b. This is an orange flag, as the client obviously has a psychiatric disorder. c. This is a yellow flag, and the client should be referred back to her physician. d. This is a yellow flag, and the physical therapist should proceed with treatment, incorporating the appropriate pain education strategies to address the patient’s maladaptive coping strategies. Medical screening
Discussion All forms of cancer are capable of metastasizing to the bone, including lung cancer, which is part of this client’s medical history. Lung cancer is a red flag in this situation. Another finding that is a red flag (which is covered later in this course) is the fact that there is not a precipitating incident. Shoulder pain is often accompanied by a single precipitating incident, such as a fall, or a repetitive stress, such as a weekend warrior playing 36 holes of golf. Night pain is also relevant. In this case, it was later found that the client had metastases from his lung cancer to the proximal humerus. ● Recent infection in the past six weeks, especially when followed by neurologic symptoms one to three weeks later . Systemic infections can spread to the bones, a condition called osteomyelitis (Osteomyelitis - Symptoms and Causes, 2022b). Acute osteomyelitis is associated with inflammatory bone changes caused by pathogenic bacteria. Common symptoms include erythema, soft tissue swelling or joint effusion, decreased joint range of motion, and bony tenderness (Hatzenbuehler et al., 2011). The symptoms of osteomyelitis have a lot in common with the types of conditions that are effectively treated by physical therapy. For example, an overuse injury of the knee may present as redness, swelling, tenderness, and decreased range of motion—which are some of the same symptoms found when an infection is present. A history of recent infection should prompt the clinician to take a closer look at the possible link between the patient’s presenting symptoms and a recent infection. ● Recurrent colds or flu with a cyclical pattern (better, worse, better, and so on). A typical cold will usually run its course in a week to 10 days ( Common Cold: Symptoms, Cold Vs. Flu, How Long It Lasts, Treatment, n.d.-b). Although patients typically do not seek our services for treatment of a cold or the flu, if it occurs concurrently with a musculoskeletal injury in a recurrent pattern, referral to the physician may be indicated to eliminate a possible systemic origin of presenting symptoms. ● Recent history of trauma such as a fall or a motor vehicle crash, or any minor trauma in older adults . In neck pain patients, any recent trauma could cause a cervical spine fracture. In older adults, the precipitating trauma can be relatively minor (Garg et al., 2021. Another consideration is any trauma to the head that is related to headache onset. Healthcare consideration: Older adults experience falls more frequently than younger individuals. In this population, even minor falls can result in significant injury. In terms of headaches, special attention should be paid to those who have a headache related to a fall and are on blood thinners. In this case, trauma to the head can cause bleeding in the brain, with the possibility of a subdural hematoma. In terms of neck injuries, older adults with osteoporosis who experience a fall can suffer fractures to the cervical spine.
A thorough medical screening is typically the starting point in effective physical therapy evaluation and differential diagnosis. As mentioned above, many systemic diseases mimic neuromuscular or musculoskeletal dysfunction (Carvallaro Goodman et al., 2018). For example, peptic ulcers, gallbladder disease, liver disease, and myocardial ischemia are a few examples of systemic diseases that can cause shoulder or back pain (Carvallaro Goodman et al., 2018). Combining the client’s past medical history with their clinical presentation and pain pattern can lead to effective medical screening. Outlined below is a list of medical screening items that may indicate a systemic origin of pain. These items apply not only to patients with headaches and neck pain, but to any patient seen in physical therapy. ● Past medical history. Certain aspects of the client’s or client’s family history can alert the therapist to a possible systemic cause of their symptoms. ● Personal or family history of cancer. The recurrence of cancer is always a concern, even in clients who have been pronounced cancer free. Recurrence rates vary widely between cancer types according to stage, histology, genetic facts, patient-related factors, and treatment. For example, glioblastoma recurs in nearly all patients, while the recurrence rate for some types of breast cancers is 5% to 9% (Primeau, 2019b). Metastasis to the bones should be considered, as almost all types of cancers are capable of spreading to these structures (Bone Metastasis - Symptoms and Causes, 2022b). Healthcare consideration: Cancer recurrence is a concern for anyone who has had a history of cancer. When a patient’s medical history includes cancer, the assessing clinician should always consider and rule out the possibility that cancer might be the source of the pain/issue the client presents with. Case Study: Mr. Jim Abbotts Mr. Abbotts is a 67-year-old male who presents to the physical therapy clinic with right shoulder pain with no known precipitating cause. He has pain that is constant at 2/10 but increases to 6/10 with shoulder elevation. He states that he awakens each night with shoulder pain. He is unable to sleep on his right shoulder. He has functional strength in all major shoulder muscles. Passive range of motion is full with pain at end range flexion and abduction. Active range of motion shows full internal and external shoulder rotation with the arm in neutral but is limited to approximately 50% with the arm in 90- degree abduction. Active shoulder flexion and abduction are limited to approximately 85 degrees. Medical history includes hypertension and lung cancer. Questions Why is lung cancer a red flag in this situation? What other are red flags are present, and how would you proceed?
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Book Code: PTNY1024
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