(Carvallaro Goodman et al., 2018). Symptoms of an impending or actual rupture of an aortic aneurysm include rapid onset of neck or back pain; pain that radiates to the chest, between the scapulae, or to the posterior thighs; pain is not relieved by change in position; and pain described as “tearing” or “ripping” (Carvallaro Goodman et al., 2018). Case Study: Arnold Anderson Mr. Anderson, a 71-year-old retired male, presents to physical therapy as a walk-up client, and he complains of sudden-onset neck pain that began this morning. During the intake process, the client filled out a pain body diagram that shows his pain is not only located in his neck; it is also present in the area between his scapulae. The pain is intense and constant. He cannot describe anything that relieves his pain. When asked, he states that his pain does not increase with activity, nor is it relieved by rest or a change in position. Question What red flags are present in this case? What diagnosis might explain these symptoms? Discussion The client’s age is a red flag, as onset of neck pain in the sixth or seventh decade of life is associated with possible abdominal aortic aneurysm. Other red flags include sudden onset of severe neck pain and the report that his pain is not relieved by rest or a change in position. All these signs and symptoms are consistent with a diagnosis of abdominal aortic aneurysm. One sign/ symptom that can further solidify the possibility of an abdominal aortic aneurysm is the presence of a pulsating feeling in the belly (Symptoms, 2018). Arteritis Arteritis is inflammation of the arteries and occurs in many diseases, including rheumatoid arthritis and systemic lupus erythematosus (Boissonnault et al., 1990). This arteritis can be a potential source of neck pain. Polymyalgia rheumatica is a vasculitic disease that causes aching and stiffness in numerous regions of the body, including the neck. Discussion One red flag for this client is the presence of a cough. This is a hallmark of pulmonary disease. Another red flag is the fact that there is no specific pattern to his neck pain; the client cannot identify what makes it better or worse. One question that might be helpful with differential diagnosis is whether the client has a history of pulmonary disease (including cancer). Another important question is whether the client is or was a smoker, and whether he is experiencing any shortness of breath. Again, these symptoms are consistent with pulmonary disease. Examination findings that might point toward the presence of a pulmonary origin of neck pain include full neck range of motion, lack of muscle involvement, and lack of tenderness over the facet joints or spinous processes, as these findings are consistent with musculoskeletal cervical spine issues (Cavallaro Goodman et al., 2018). Pulmonary symptoms Autosplinting, where the client prefers to lie on the involved side, is considered a valuable red flag of possible pulmonary involvement. This is effective because lying on the involved side puts pressure on the lungs, reducing respiratory movement and pain. Other important signs for differential diagnosis include dyspnea, persistent cough, cyanosis, hemoptysis, and general malaise. Vital sign assessment and assessment for the effect of respiratory movement such as coughing or deep breathing for reproducing the painful symptoms can be revelatory. In addition, no pain with performance of neck range of motion may help determine that neck symptoms are not originating from cervical structures (Carvallaro Goodman et al., 2018).
Case Study: Mr. George Goodmanson Mr. Goodmanson is a 68-year-old client who is obese and who presents to physical therapy for treatment of his anterior neck pain. He states that he could not get in to see his doctor for over a week, so he made a physical therapy appointment instead because he could get in the next day. The onset of pain began yesterday while he was playing golf. Mr. Goodmanson states that the pain began at about the 10th hole and got worse by the time he finished 18 holes. It subsided on the drive home. Today the pain is worse with activity and better when the client sits. Question What red flags are present in this case? What other questions or observations might be used to confirm the presence of angina? Discussion The location of the pain along the anterior neck is a red flag, as this is a possible symptom of angina. Most cervical conditions, such as facet joint dysfunction, radiculopathy, and mechanical strain, create pain in the posterior or lateral aspects of the neck and/or the upper back/upper extremities. Another red flag is the fact that the pain came on while the patient was active and that it continues to be exacerbated by activity and relieved by rest. Again, these symptoms are associated with cardiac problems. Questions the therapist might ask include whether the client has a history of cardiac disease, what medications he is taking (to help determine if medications are being used to address cardiac risk factors such as hyperlipidemia or hypertension), and whether any symptoms are present in the jaw or upper extremity (which might, again, indicate cardiac involvement). Important observations include the presence of shortness of breath, dizziness, fatigue, nausea, and sweating, which are also associated with angina. Finally, obesity is a risk factor associated with heart disease (Obesity and Heart Disease: What You Should Know, n.d). Abdominal aortic aneurysm This condition is rare compared to myocardial ischemia (Carvallo Goodman et al., 2018). Abdominal aortic aneurysm occurs most often in men in the sixth or seventh decade of life Screening for pulmonary causes of neck pain When screening for a possible pulmonary cause of neck pain, medical history of cancer; recurrent upper respiratory infection or pneumonia; or recent scuba diving, accident, trauma, or overexertion (pneumothorax) is relevant. Risk factors include smoking; prolonged immobility; chronic immunosuppression; malnutrition; dehydration; chronic diseases such as diabetes, chronic lung disease, or cancer; and upper respiratory infection or pneumonia (Carvallaro Goodman et al., 2018). According to Boissonnault et al. (1990), pulmonary disease rarely manifests itself a pain syndrome without associated symptoms of disease being present. These symptoms include sore throat, fever, hoarseness, cough, dyspnea, stridor, and wheezing. Case Study: Larry Lane Mr. Lane is a 56-year-old male who presents to physical therapy via referral from his primary care provider. He has had neck pain for “a couple of months.” He is unable to describe a specific pattern to his neck pain in terms of what makes it worse and better. When questioned about accompanying symptoms, the client hesitantly reports that he has had a persistent cough for the last few months. Question What red flags are present in this case? Based on the presentation and history, what are questions/processes that might assist with a differential diagnosis? What examination findings might further increase your suspicion that the client’s symptoms do not originate from pulmonary structures?
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