Viscerogenic sources of neck pain Several visceral sources of neck pain have been identified. Gastrointestinal, biliary, renal, hepatic, heart, and pulmonary disorders evoke referred pain to the upper quadrant, including the neck (Oliva-Pascual-Vaca et al., 2019). Visceral referred neck pain is linked to the involvement of the vagus and/or phrenic nerves. Nociceptive input from the organs innervated by the vagus nerve sensitizes the trigeminocervical nerve complex that descends to C3 or C4 level with the potential to trigger a headache or neck pain. The phrenic nerve is formed by C3 and C4 roots and either directly or indirectly supplies the diaphragm, pleura, right atrium pericardium, esophagus, peritoneum, stomach, falciform and coronary ligaments of the liver, hepatic vein, inferior vena cava, liver, gallbladder, pancreas, small intestine, and suprarenal glands (Oliva-Pascual-Vaca et al., 2019). As such, these structures can evoke pain referred along the C3–C4 dermatomes via autonomic connections; diaphragmatic pressure; or peritoneal irritation, a phenomenon known as phrenic pain (Oliva-Pascual-Vaca et al., 2019). Viscerogenic pain is characterized by being poorly localized and is often described as being deep, squeezing, or colicky. By contrast, somatic pain is described as well localized; intermittent or constant; and aching, throbbing, or cramping (Lee et al., 2017). Lee et al. (2017) present a case study of a patient who suffered a cervical spinal cord injury due to fracture and dislocation of C5 and C6 during a car crash. He underwent subsequent posterior cervical laminectomy and posterolateral fusion at C3–C7. Two weeks later, the patient began complaining of dull pain in the right side of his neck. This was also accompanied by mild fever and a slight increase in respiratory rate. The patient was given pain medication, which was ineffective in resolving his pain. Further testing revealed an elevated white count with subsequent CT scan. A pulmonary embolism was found in the lower lobe of his right lung. This is a good example of how pulmonary issues can cause neck pain. exertion, the therapist attempted to reproduce the symptoms by having the client exercise. Within four minutes of cardiovascular exercise, the patient reported neck. Upon stopping, his neck pain went away in five minutes. The therapist referred the patient to his primary care physician for cardiac testing. He underwent cardiac bypass for atherosclerosis shortly thereafter. Self-Assessment Quiz Question #25 Angina can present as neck pain. A tell-tale sign of neck pain related to angina is: a. A three- to five-minute lag between an increase in activity and the onset of neck pain. b. Blood pressure that drops sharply with exertion. c. A sharp increase in blood pressure with exertion. d. A drop in oxygen saturation with exertion. Myocardial infarction Heart disease and myocardial infarction (MI) can refer pain to the anterior neck. Age and past medical history are important when screening for angina or MI, and vital signs are key in clinical assessment. There are usually some associated symptoms with angina and MI, including diaphoresis, nausea, vomiting, pallor, dizziness, and/or extreme anxiety (Carvallo Goodman et al., 2018).
being the second most common feature. In fact, neck pain is often one of the earliest symptoms to indicate cervical spine involvement in a patient with rheumatoid arthritis (Kazeminasab et al., 2022). ● Psoriatic arthritis . Psoriatic arthritis develops in some people with arthritis. It is a group of chronic inflammatory joint diseases. One subtype of psoriatic arthritis is psoriatic spondylitis, which affects the spine and can cause pain and stiffness in the neck (Kazeminasab et al., 2022). ● Polymyalgia rheumatica. Polymyalgia rheumatica is a relatively common chronic inflammatory disorder that causes widespread pain and stiffness, including neck pain. The average age of onset is 70 years, and it is rarely found in anyone under age 50. It is often associated with giant cell arteritis (Kazeminasab et al., 2022). ● Ankylosing spondylitis. Ankylosing spondylitis is a debilitating, progressive type of arthritis that mainly results in inflammation of the joints of the spine. Neck pain is common with this diagnosis, due to inflammation of the cervical spine (Kazeminasab et al., 2022). ● Systemic lupus erythematosus . Systemic lupus erythematosus is a fairly severe systemic autoimmune disease that can affect almost any part of the body, including the neck, where inflamed muscles can cause neck pain (Kazeminasab et al., 2022). Other possible systemic sources of neck pain Fibromyalgia and psychiatric disorders (depression, anxiety, posttraumatic stress disorder) have been associated with neck pain, as have viral myalgia, cervical lymphadenitis, and thyroid disease. Self-Assessment Quiz Question #24 Which of the following signs is considered a red flag for the possible presence of cancer?
a. Unexpected weight gain. b. Unexpected weight loss. c. Pain right after eating. d. Pain with exercise and/or exertion.
Screening for vascular/cardiovascular causes of neck pain Vascular pain patterns originate from two possible main sources: Cardiac (heart) and peripheral vasculature (blood vessels). The most common referred pain patterns seen in physical therapy are angina, myocardial infarction, and aneurysm (Carvallaro Goodman et al., 2018). Pain from cardiac sources is referred to different areas based on multisegmental innervation. The heart is innervated by C3 to T4 spinal nerves. Therefore, patients with a heart attack can experience jaw, neck, shoulder, arm, upper back, or chest pain (Carvallaro Goodman et al., 2018). Angina Angina can appear as neck pain (Mathers, 2012). There is typically a three- to five-minute lag time between an increase in activity and the onset of neck pain caused by angina (Carvallaro Goodman et al., 2018). Other possible symptoms of angina include dizziness, fatigue, nausea, shortness of breath, and sweating (Angina - Symptoms and Causes, 2022). Mathers (2012) presents a case study of a 64-year-old male who was referred to physical therapy by a neurosurgeon. This patient has an eight-week history of anterior and posterior neck pain with onset related to running. His past medical history included hypertension, depression, anxiety, dyslipidemia, hypothyroidism, gastroesophageal reflux disease, peptic ulcer disorder, erectile dysfunction, allergic rhinitis, and thyroidectomy. The patient had seen a primary care physician, an otolaryngologist, and a neurosurgeon. The therapist was unable to reproduce the client’s neck pain with clinical examination. Since the pain came with
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