Pathological Origins of Trunk and s the Neck Pain: Part l l ~ i s o r d e r of Cardiovascular and Pulmonary Systems

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WILLIAM G. BOISSONNAULT, MS, PT,' CHARLES BASS, MD2 Part I1 of this three-pert series on clinical decision making in physical therapy concludes the overview of the organ systems by reviewing conditions of the cardiovascular and pulmonary systems that may be manifested primarily as trunk or neck pain. The cardiovascular system disorders covered include myocardial infarct, coronary and valvular heart disease, vascular aneurysms, vascular inflammatory diseases, and peripheral vascular occlusive disease. The pulmonary system disorders covered include neoplasms and infectious diseases. The authors hope this information will help prevent the physical therapist from overlooking cardiovascular and pulmonary system disorders as a possible source of a patient's symptoms.

This section describes pathology related to the heart and accompanying peripheral vascular system and the lungs. Because of the serious nature of many of the illnesses of these two systems, it is not as likely that the physical therapist or the patient would be fooled by trunk or neck pain masking underlying pathology compared with certain urogenital or gastrointestinal system conditions. The serious nature of these conditions, however, magnifies the importance of early detection of their presence so that the appropriate medical treatment can be initiated. See Table 4 from Part I of this series for a description of possible pain referral patterns for the heart and lungs. Harrison's Principles of Internal Medicine by Braunwald et al. is the primary reference for the following information (2). The heart is a common cause of chest, neck, and arm pain, but can also refer pain to the jaw, posterior thorax, and epigastrium. Upper extremitv ~ a i nmav be unilateral or bilateral, but it is

' Physical therapist at Physical Ttwapy qthopaedic Spedansts. lnc..

2800 Chicago Avenue South. Minneapol~s,MN. 55407. He is also Clinical Assistant Professor. Rograms in Physical Therapy. College of Allied Health Sdences, at Lhiiersity of Tennessee. 602 Dunlop S. Memphis. TN, 38163. Family practitioner at Group Health Incorporated. West Medical Cerr ter. 1533 U t i i Avenue. St. Louis Park. MN. 55416. 0190-601 l p o / 1 2 0 ~ . 0 0 / 0 THEJOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAW Copyright 0 1990 by The OWmpaedii and Sports Physical Therepy Sectioos of the American Physical Therapy Association

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classically found in the C8 distribution and most commonly is left sided. The pain is usually described as a tightness or pressure sensation but can be manifested so as to be confused with more common complaints of gastrointestinal illness or musculoskeletal system dysfunction of the upper quarter including the facial and cranial regions. Angina is pain whose onset is usually associated with activity, and that typically lasts less than 5 minutes and is relieved by rest, but it may occur at rest or when sleeping and may last up to 20-30 minutes. Other symptoms of cardiovascular disease are shortness of breath (dyspnea) including both dyspnea on exertion and paroxysmal nocturnal dyspnea (which may be relieved by sitting up in bed, sleeping with the head elevated by pillows, or sleeping sitting up in a chair). In addition, ankle edema, easy fatigability, palpitations, and loss of consciousness (syncope) may also be a part of the clinical picture of these patients. On physical examination, a resting pulse rate greater than 100 or lower than 50 beats per minute at rest should be considered abnormal (3). Blood pressure greater than 160/90 (consistent on several consecutive readings) is also reason for further medical evaluation. In the elderly, systolic blood pressure tends to be elevated, but readings may be misleading because arteries are hardened and not as compressible by the sphygmomanometer cuff. Selected cardiovascular system diseases will be discussed including coronary

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artery disease, valvular heart disease, pericarditis, aneurysms, and occlusive disease. Coronary artery disease occurs more commonly in men over 40 years of age and in individuals who smoke or are obese or are hyperlipedemic. Peripheral vascular disease is often present with coronary artery disease. Coronary artery disease manifests as angina, myocardial infarction, heart failure, and sudden death. Because angina often precedes infarction, early diagnosis is critical. Any neck, chest, or arm pain associated with dyspnea or sweating is potentially critical and should raise the suspicion of the presence of this serious disease in the therapist's mind. Valvular heart disease may also manifest as angina, especially aortic stenosis and idiopathic hypertrophic subaortic stenosis which is a common cause of sudden death in young athletes. Valvular heart disease occurs in all age groups without sexual predilection. There may be a history of reheumatic fever or of heart murmur in these patients. Mitral valve prolapse is a common disease in young women. Symptoms include prolonged nonspecific chest pain, palpitations, and lightheadedness. Pericarditis, inflammation of the sac surrounding the heart, usually causes a sharp buming pain in the chest or left shoulder region. The pain may be aggravated by coughing or change in body position and may be relieved by leaning forward. Pericarditis has many causes including infection, trauma, cancer, collagen vascular disease, irradiation, and infarction. It may occur at any age and usually occurs when the underlying disease process is easily established. However, a preceding infection may be mild or asymptomatic and may occur several weeks before the onset of pain, so postinfectious pericarditis often occurs in apparently healthy people. Therefore, questions regarding past medical history should provide information pertaining to the patient having been treated for infection prior to the onset of symp toms. Aneurysms are potentially dangerous arterial conditions, especially when the aortic artery is involved. Aortic aneurysms are abnormal wideni n g ~of the aorta caused by destruction of the elastic fibers of the middle layer of the aortic wall. They may also be caused by a tear in the inner lining of the aorta which allows blood to actually enter the wall of the aorta, thus widening it. Most aortic aneurysms occur just caudal to the renal arteries and are asymptomatic, but are found on palpation in the mid abdominal region. A normal aorta can be felt in the abdominal region, especially in slender patients or those with gaseous distension of the intestine. An aortic aneurysm produces a pulsation that is more prominent, broader, and distinct within a confined region compared to a normal aorta (Fig. 1). A palpable JOSPT 12:5 November 1990

pulse which is approximately two inches wide or greater should raise suspicion in the therapist's mind of the presence of an aneurysm (3). Overly vigorous palpation or soft tissue mobilization techniques in the abdominal region could potentially worsen the aneurysm. Symptomatic aortic aneurysms may be manifested solely by a deep, diffuse, throbbing or aching midback, chest, left shoulder, or abdominal pain. The symptoms may be associated with an increased activity level such as stair climbing, fast walking, etc., and then subsequently relieved by rest. Because of the anatomical location of the aorta, numerous structures may be encroached upon by the aneurysm resulting in a multitude of other seemingly unrelated symptoms. These structures include the spinal nerves, the esophagus, and the bronchi (5). Therefore, complaints of difficulty with swallowing or breathing could potentially be a part of the clinical picture of these patients. Aneurysms generally occur in the elderly and slowly enlarge over a period of many years, but once ruptured are rapidly fatal. Occlusivedisease of the arteries is a common problem in the elderly and in smokers. The classic symptom is claudication or pain most often felt in the buttocks, thighs, or calves associated with physical activity and relieved by rest. There is often a consistent relationship between the duration or intensity of muscle activity and the onset of pain. For example, a patient may complain of an aching or cramping pain after walking 9 or 10 blocks which quickly is then relieved by sitting down. If these same symptoms could consistently be provoked by riding a bike for a specific period of time with the lumbar spine in a forward bent posture, then again relieved by rest, vascular claudication would be suspected as opposed to neurogenic claudication resulting from a spinal stenotic condition. Bilateral lower extremity symptoms may occur with involvement of the aorta, whereas unilateral symptoms can be related to occlusion of peripheral vessels such as the iliac or femoral arteries. These symptoms can easily be confused with those of spinal stenosis, herniated disk disease, or degenerative joint disease (6). Besides the symptom of intermittent claudication, diminished or absent pulses, bruits over the pulses, dystrophic nails, skin ulcers, and hair loss of distal extremity parts all suggest involvement of the peripheral vascular system. Arteritis, or inflammation of the arteries, occurs in many diseases including rheumatoid arthritis and systemic lupus erythematosus. Arteritis is usually accompanied by the obvious systemic disorders such as renal and skin diseases. Polymyalgia rheumatics is a vasculitic condition that primarily causes aching and stiffness in numerous regions including the neck, shoulders, trunk, and hips. A disease of the elderly, it is also associated

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ABDOMINAL AORTA

Referral Patterns of Aortal Pain

Figure 1. A, normal location of aorta in relationship to other anatomical structures; B, associated symptoms from an aortic aneurysm.

with malaise, fatigue, weight loss, fever, and extremity claudication. Temporal arteritis is manifested only by headaches which may precede sudden blindness as the temporal artery and then the optic artery become progressively involved. Tenderness with palpation along the course of the temporal artery should alert the therapist to the possible presence of this condition (Fig. 2). Temporal arteritis may occur in the context of polymyalgia rheumatica or without any other obvious systemic vasculitic condition. The lungs and associated structures have the potential to cause local thoracic or chest pain, but can also result in referral of pain to the cervical or shoulder regions. Pulmonary disease, though, is rarely manifested as a pain syndrome without

SUPERFICIAL TEMPORAL ARTERY

J

Figure 2. The temporal artery. 210

associated symptoms of disease being present. Common symptoms accompanying the pain complaints include sore throat, fever, hoarseness, cough, dyspnea, stridor, and wheezing. Smoking increasesthe risk for the most common conditions of the respiratory system including cancer and infection. The pulmonary system diseases to be discussed include pleurisy, cancer and infection. When the pleura or outer lining of the lung is inflamed, a characteristic pleuritic pain occurs. The pain intensity will usually vary with coughing or during the respiratory cycle. The pain overlies the area of inflammation and in the absence of a thorough examination may be confused with chest wall pain of musculoskeletalorigin. As mentioned though, pain from respiratory system disease can present anywhere from the neck and shoulder regions to the midthorax. When the diaphragm is involved, pain may be referred to the shoulder and neck regions. Infectionis the most common problem involving the pulmonary system. Most infections are acute and obviously symptomatic; however, they may be subtle and chronic, especially tuberculosis and fungal infections. Even an acute infection may clear symptomatically but leave an abcess whose location makes it a source of neck, chest, or back pain. Therefore, again, investigation of past medical history should provide information pertaining to the patient having been treated for infection prior to the onset of symptoms. Common symp toms of infection are more likely to be absent in the elderly than in the younger patient. Cancer can also occur anywhere within the

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pulmonary system. Pulmonary cancers of the larynx and lung are common with the lungs being a frequent site of metastatic cancer. Cancer is most prevalent in smokers around the age of 60 (4). If the tumor occurs in the periphery of the lung, the pain syndrome may precede coughing or any noticeable change in a chronic cough. When the apex of the lung is involved (Pancoast's Syndrome) (Fig. 3), pain in the neck, shoulder, and upper extremity may occur. Because of the close proximity of the brachial plexus and accompanying blood vessels to the apex of the lungs, impingement may occur causing thoracic outlet syndrome or cervical neuropathy type symptoms.

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SUMMARY

In summary, patients presenting with pain complaints in the thoracic, cervical, or shoulder region should be questioned regarding the behavior of these symptoms specific to the function of the pulmonary system. Therefore, if the symptoms change during the respiratory cycle or are provoked during coughing or sneezing, suspicion should be raised in the therapist's mind. Additional questions should then be asked regarding a history of smoking, previous history of pulmonary disorders including infection and cancer, prolonged chronic coughing, shortness of breath, sore throat, and hoarseness. These questions will provide the information which should be related to the physician upon referral. Symptoms described as being pressure-like sensations, tightness, throbbing, cramping, and aching should guide the therapist toward asking

Pancoast Tumor-Apex of the Lung

questions regarding the behavior of symptoms. If any of these symptoms appear to be provoked or aggravated by physical activity such as walking, stair climbing, etc., and then subsequently relieved by rest, suspicion should be raised in the therapist's mind that the cardiovascular system may be involved. Other questions should then be included in the history regarding general health including asking for the presence of shortness of breath (dyspnea), palpitations, sweating accompanying the pain complaints, history of smoking, and previous history of cardiovascular disease. Questions should also be included asking for the presence of cardiovascular disease in the patient's family. In addition to the special questions related to the cardiovascularsystem, the therapist should then include specific tests in the objective examination. These tests should include checking the patient's blood pressure, pulses, observation of nails and skin including checking for hair loss of the distal extremity parts. These questions and objective tests will provide the therapist with the information which should be communicated to a physician if the therapist suspects the presence of pathology within the cardiovascular system.

CASE STUDY 1 History

The patient was a 66-year-old retired man who came to the clinic with a diagnosis of right sacroiliac joint pain. His chief complaint was intermittent aching of the right buttock and right calf (see Fig. 4). Walking was the only activity that would pro-

Refenal Pattern of Pancoast Tumor

Figure 3. Pancoast tumor in the apex of the lung and associated symptoms. JOSPT 12:5 November 1990

ORIGINS OF TRUNK AND NECK PAIN-II

preceding this initial evaluation inlcuded roetgenograms, which according to the patient revealed loss of disk space height and possible right lateral stenosis at L5-S1.

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Objective Examination

Figure 4. Chief complaint of right buttock and calf pain.

voke his symptoms. He would be pain free when ambulation was initiated, but consistently, after walking 10-1 5 minutes, his right buttock and calf would begin to ache. If the patient continued to walk, the intensity of the aching increased tremendously, whereas if he sat down, he would be pain free within minutes. The patient also described a periodic sensation of restlessness in his legs after he had been in bed for a short period. Walking short distances would relieve this discomfort. The patient's chief complaint and syrnp tom behavior pattern were consistent from early morning to when he went to bed. The patient's symptoms began insidiously 16 months prior to the initial evaluation. During the 16 months the patient had participated in two 4week courses of physical therapy consisting of lower extremity stretching and strengthening exercises, ultrasound to the right buttock and sacroiliac joint, hot packs to the lumbar and buttock regions, and prone press-up exercises. Except for feeling 'a little looser," the patient's symptoms did not change. He also received cortisone injections to the right sacroiliac joint and to trigger points in the gluteus medius muscle with only a slight, temporary decrease in the intensity of the symp toms. The patient's medical history included lumbar decompression surgery for a herniated nucleus pulposis at the L5-S1 segment in 1963. He stated the only residual effect was low lumbar stiffness. He had also suffered a heart attack in 1981 and received a pacemaker. The patient had smoked one pack of cigarettes daily for the past 50 years. He denied having any bowel or bladder dysfunction. Special tests over the past 16-month period 212

The objective examination revealed slight atrophy of the right gluteal, thigh, and calf muscles with the patient in the standing position. A reduced lumbar lordotic curve and increased midthoracic kyphosis were present. There was no provocation of symptoms with active movements of the trunk in standing nor with overpressures including the quadrant positions. Backward bending and right side bending range of motion were significantly reduced in the low lumbar spine. Right hip internal rotation and the combined motion of hip flexion and adduction were moderately reduced compared with the left hip. Neurological evaluation, sacroiliac joint, and hip provocation test results were negative. Muscle length tests revealed bilateral lower extremity tightness of the hip flexors, external rotators, and adductors with the right side being tighter than the left side. Manual muscle tests revealed weakness of the right hip extensors and abductors. Muscle palpation revealed numerous tender areas with increased tone of the right gluteal and hip external rotator muscles. There was no palpatory tenderness over the posterior sacroiliac joint ligaments nor at the interspinous spaces of the lumbar and thoracic spine. Joint mobility testing revealed hypomobility at the right hip joint, right sacral base, L5, and thoracolumbar junction. There also were no palpable differences between the lower extremity pulses. Because of the therapist's inability to provoke the patient's symptoms, the patient was instructed to walk until the symptoms were severe, just prior to the second physical therapy visit. Despite the presence of the patient's symptoms when he returned for the second visit, the author was unable to aggravate the symptoms by stressing the thoracic or lumbar regions of the spine. Symptoms were also not provoked by stressing the sacroiliac joint and hip joints and the corresponding soft tissue structures. Significantly, however, the therapist experienced greater difficulty in palpating the lower extremity pulses compared with the left side, in contrast to the initial evaluation when the patient was asymptomatic. Assessment and Outcome The refemng physician was contacted after the second physical therapy visit and was informed of the following findings which suggested a vascular occlusive disease as possibly being the

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source of the patient's symptoms: intermittent claudication, weak right lower extremity pulses after ambulation, and a history of smoking and heart attack. Of equal concern was the therapist's inability to provoke symptoms with palpation and active and passive testing. Based on the presence of significant right hip, sacral, and lumbar dysfunction and muscle imbalances which could possibly be related to the symptoms, the therapist and referring physician agreed to an additional 23 week course of physical therapy. Based on how the patient responded to treatment, a decision would then be made regarding the need for additional medical tests. The patient received joint mobilization twice a week for the areas of hypomobility including the right hip, right sacral base, and previously mentioned regions of the lumbar and thoracic spine. In addition, soft tissue mobilization and muscle stretching and strengthening exercises were performed for the involved areas. Objectively, the patient improved; backward bending and right side bending range of motion improved significantly, as did right hip joint mobility. Despite these improvements, however, the behavior of the right buttock and calf symptoms changed little and, thus the patient's tolerance of walking improved only slightly. The patient was referred back to the physician for additional tests which revealed significant occlusion of the right iliac artery. Subsequent treatment of the occlusion completely eliminated the patient's symptoms. This case report demonstrated several important findings discussed in Part I of this series related to general evaluation principles and the possible presence of pathology including insidious onset of symptoms, the inability to provoke the symptoms by stressing the structures of the musculoskeletal system, and the lack of subjective improvement despite significant objective improvement. In addition, numerous symptoms and signs suggested the presence of a vascular condition including intermittent claudication symptoms, the complaint of restless legs, a long history of smoking, having suffered a heart attack, and decreased pulses after ambulating far enough to provoke symptoms. Sufficient dysfunction was present in the patient's lower quarter, however, to indicate a mechanical musculoskeletal dysfunction origin of symptoms as well. At times assessing the significance of musculoskeletal system dysfunction in relation to the patient's complaints can be a very difficult clinical decision. These situations require careful and frequent reassessment of symptoms and signs following treatment to help the clinician decide whether the patient should be assessed medically to rule out the presence of pathology. Communication with the physician regarding clinical findings that have raised suspicion in the therapist's mind is then essential to ensure the proper course of treatment JOSPT 12.5 November 1990

is selected for the patient. In this patient's case, months of symptoms and unnecessary treatments might have been avoided if a more complete and concise evaluation had been performed initially. Fortunately, this patient's condition was successfully treated despite the passage of 16 months of symptoms. For other pathologies, such as cancer, a few months can make a difference in the prognosis for recovery.

CASE STUDY 2 History

The patient was a 47-year-old highway maintenance worker who was referred to the clinic with a diagnosis of mechanical low back pain syndrome. His chief complaints were constant sharp pain across the lumbosacral junction accompanied by a numb feeling in both buttocks and intermittent numbness in the right anterior thigh (Fig. 5). He also complained of intermittent cramping and throbbing pain in the calves bilaterally. The low back and buttocks symptoms were aggravated by sitting for more than 30-45 minutes, standing in one place for more than 5-1 0 minutes, and by transitional movements such as sit to stand. The intensity of these symptoms decreased by assuming a recumbent position or by constantly changing positions. The right anterior thigh and calf symptoms were specifically provoked by walking a distance of 3-4 blocks. The symptoms were then relieved by sitting for short periods of time. The patient described his low

Figure 5. Chief complaint of low lumbar pain, bilateral buttock and right anterior thigh numbness, and bilateral calf pain.

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back condition as originating in 1978 when reaching out of the cab of his truck to pull a rope; he felt a sharp tug in the low lumbar region. He had had constant low back and buttock symptoms since the incident, despite receiving 4-5 separate series of physical therapy sessions. The calf symptoms began in 1985 during the patient's involvement in a fitness program, with just the left calf being symptomatic. This was diagnosed as being a vascular condition and subsequently treated by angioplasty. There was partial relief of the left calf pain following the procedure, but the patient had noted an increase in left calf pain and insidious onset of right calf pain during the past year. The patient's medical history included undergoing three left knee surgeries and bilateral elbow surgery. He suffered a myocardial infarction in 1986. He had a 26-year history of smoking 12 packs of cigarettes per day. Family medical history included his mother dying of a cardiac condition at age 62 and his father dying of a myocardial infarction at age 58. Radiologicaltests of the lumbar spine revealed degenerative facet joint disease from L3 to S1.

Objective Examination Observation revealed a decreased lumbar lordosis and slight lateral shift of the trunk to the right. There appeared to be hair loss of the lower legs and feet. Slight increase in paraspinal muscle tone was noted from L4-S1 bilaterally with palpation. Also weak dorsalis pedis and posterior tibia1artery pulses were noted bilaterally. The low lumbar and buttock symptoms were provoked with active forward and backward bending in standing. All active movements were moderately restricted. Sharp local low back pain was provoked with passive stress on the L5-S1 segment. Significant hypomobility was noted at L5-S1 and at the thoracolumbar junction. The calf and right anterior thigh symptoms were not provoked with active movements or passive overpressures of the trunk and joints of the lower extremities. When the patient was asked to ambulate, these symptoms were provoked by the time he had walked 100150 feet. Sitting down quickly relieved the thigh and calf symptoms. The low back and buttock symptoms did not change during the ambulation or subsequent sitting. The patient was then asked to ride a stationary bike and within 1-2 minutes the right thigh and calf symptoms returned. Shortly after the patient stopped pedaling the symptoms disappeared. Again, as with the ambulation, the low back and buttock symptoms did not change with the bike riding. 214

Assessment and Outcome Patients who present with multiple symptomatic areas are especially challenging when trying to determine the origin of symptoms. Is there a local lesion responsible for each symptomatic area? Is one lesion responsible for all the symptoms? Answering these questions requires a detailed history regarding the behavior and chronological history of each of the symptoms described by the patient. Also, a careful screening of the appropriate body regions with palpation, active and passive movements, resisted testing, and special tests can provide valuable information regarding the source of the various symptoms. It was apparent after the evaluation that this patient's low back and buttock symptoms were related and that the right anterior thigh and bilateral calf symptoms were related. The evaluation findings also suggested that the lumbar and buttock symptoms were the result of mechanical musculoskeletal system dysfunction, while the right thigh and calf symptoms may be related to peripheral vascular system disorder. The lumbar and buttock symptoms were consistently aggravated by sitting, standing, and transitional movements and alleviated by assuming a recumbent position. There was a common precipitating incident for the lumbar and buttock complaints. Both symptoms were provoked with active movements of the trunk and passive stress on the L5S1 segment. The anterior thigh and calf symptoms presented with a different behavior pattern; they were only provoked with a specific amount of activity, walking or biking, then subsequently relieved with sitting. This is the classic pattern of clinical findings associated with intermittent vascular claudication. This finding led to the detailed questions regarding the cardiovascular system. These questions revealed the 26-year history of smoking, the myocardial infarction in 1986, past treatment for peripheral vascular disease, and the significant family history of cardiovascular system disease. In addition, the careful assessment of the lower extremity pulses and observation of skin condition revealed additional signs suggesting possible involvementof the cardiovascular system causing a portion of this patient's complaints. All this information was communicated to the referring physician. Further medical testing was carried out revealing significant peripheral vascular disease being present. While these medical tests and subsequent treatments were being implemented the patient received physical therapy treatment for the dysfunction related to the lumbar and buttock complaints. REFERENCES 1. BoissonnauR WG. Bass C: Pathological origins of hunk and neck pain: Part 1-Pelvic and abdominal visceral disorders. J OrMop Sports Phys Ther 12:192-207. 1990

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3. Malasanos L. Barkauskas V, StMenbW-Alkm K (eds): Haa)th

6. 2%; DA. Mennell JM: Diagnosisand Physical Treatment, pp 205207. Boston: Link Brown. 8 Co.1976

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Assessment. 4th Ed. p 372. St. Louis: CV Mosby. 1990

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