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 problems, reduced activity levels, and the presence of a compensation claim as factors that make coping with and recovering from neck pain more difficult.
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 symptoms began four days ago at a soccer game. The client was playing goalie when an opposing player ran into her and knocked her over, with the back of her neck striking the goal post. The client reports 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 tenderness 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 tenderness. Further evaluation, including imaging, is warranted . and neck (Boissonnault & Bass, 1990). Pulmonary conditions that can refer symptoms to the neck include lung cancer (including Pancoast’s tumor), tracheobronchial irritation, chronic bronchitis, pneumothorax, and pleuritis involving the diaphragm. Gastrointestinal Gastroesophageal reflux disease involves movement of the gastric contents into the esophagus so that the contents irritate the mucosal surfaces of the upper digestive tract (Ahuja et al., 1999). An estimated 20%–60% of patients with gastroesophageal reflux disease (GERD) have head and neck symptoms without any appreciable heartburn (Ahuja et al., 1999). GERD can be distinguished from other sources of neck pain because GERD symptoms include pain after eating and with a supine position. Other gastrointestinal conditions that can cause neck pain include esophagitis and esophageal cancer. Osseous abnormalities Crowned dens syndrome , also known as pseudogout of the cervical spine, is defined by calcifications in a crownlike configuration around the odontoid process. It is accompanied by acute pain in the cervico-occipital region along with neck stiffness, fever, and raised inflammatory markers (Younis, 2017). Chiari malformation is a condition where the skull is misshapen or smaller than typical, so the brain tissue extends into the spinal canal (Chiari Malformation - Symptoms and Causes, 2021) Although many people with Chiari malformation have no signs or symptoms, neck pain is a potential issue when this condition is symptomatic. Eagle syndrome is an abnormality of ossification/ morphology of the styloid process. This can be painful when it causes direct pressure on the nearby vessels and arteries. In addition to neck pain, otalgia, tinnitus, and dysphagia may be present (Priyamvada et al., 2021). Infection Infection conditions that can cause neck symptoms include vertebral osteomyelitis, meningitis, Lyme disease, retropharyngeal abscess, and epidural abscess (poststeroid injection). Autoimmune diseases: ● Rheumatoid arthritis . Rheumatoid arthritis is a chronic inflammatory disease that typically affects the bones, joints, and ligaments, although it can affect almost every body system. A common early symptom is peripheral joint swelling, with chronic inflammation of the cervical spine
Systemic causes of neck pain Cancer
A history of tumor or neoplasm should always lead a clinician to consider whether cancer might explain the etiology of the patient’s presenting problem. Malignancy is typically accompanied by unexplained weight loss, sudden loss of appetite, dysphagia, and/or headache. The failure of neck pain to respond to treatment in an expected manner might also be a warning sign. Both leukemia and Hodgkin’s disease have the potential for metastatic lesions to the neck (Cavallaro Goodman et al., 2018). Primary tumors of cervical bone and the cervical spinal cord should be ruled out, although primary spinal tumors are 10 times less common than primary cranial tumors (Samartzis et al., 2015). Several other types of cancer can present as neck pain. Lung cancer, including Pancoast’s tumor (a type of non-small cell lung cancer that develops in the apex of the lung), can refer symptoms to the neck. A case study by Akhavan et al. (2017) describes a 61-year-old male with a medical history of chronic neck pain with a one-month worsening of symptoms. Images of the cervical spine showed evidence of disc degeneration. When pain medications failed to decrease his pain symptoms, magnetic resonance imaging (MRI) showed stage IV adenocarcinoma of the lung with widespread metastases. Healthcare consideration: Since neck pain (along with upper back and shoulder pain) can be a symptom of lung cancer, the assessing clinician should be familiar with symptoms that are often present with this type of cancer. According to Johns Hopkins Medicine, these symptoms are chronic cough, shortness of breath, voice hoarseness, and chronic infections such as bronchitis (Lannon, 2021). Esophageal and thyroid cancer have also been shown to have the potential to cause neck pain (Cavallaro Goodman et al., 2018). Cardiovascular The following cardiovascular conditions may refer pain to the neck: Angina, myocardial infarction, aortic aneurysm, occipital migraine, cervical artery ischemia or dissection, and arteritis. Pulmonary Pain from respiratory disease can present anywhere from the neck and shoulder regions to the mid-thorax. When the diaphragm is involved, pain may be referred to the shoulder
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