Common Presentations and Practical Screening Pathways: Neck Pain, Thoracic Stiffness, Low Back Pain

Three Practical, Repeatable Screening Pathways

This chapter turns the course sequence into three “grab-and-go” pathways you can repeat in busy practice. Each pathway follows the same logic: start broad, narrow quickly based on symptom behavior, choose only the tests that answer a specific question, then reassess to confirm you learned something useful. Use the decision trees to decide whether to proceed, modify testing, or refer.

How to Use These Pathways (Quick Rules)

• One step = one question. Example: “Does active motion reproduce the patient’s familiar pain?”
• Stop adding tests when the next test won’t change your plan.
• Reassess the comparable sign (the movement or symptom you can reliably reproduce) after your key test or quick intervention to confirm relevance.
• Document in a brief, repeatable format so you can compare across visits.

1) Neck Pain Pathway

Decision Tree (Proceed / Modify / Refer)

START: Neck pain presentation (with/without arm symptoms)

1) Observation (guarding, head/shoulder position, willingness to move, irritability)

IF severe distress, rapidly worsening neuro symptoms, or you cannot safely position the patient → REFER / URGENT MEDICAL REVIEW

ELSE → PROCEED

2) Cervical AROM (flex/ext/rot/side-bend; note range, quality, symptom response)

IF marked symptom escalation, dizziness/visual change, or intolerance to testing → MODIFY TESTING (smaller ranges, supported positions) and consider referral if concerning

ELSE → PROCEED

3) Quick neuro screen IF indicated (arm pain/tingling/numbness/weakness, below-elbow symptoms)

IF progressive weakness or multi-domain objective deficits → REFER / EXPEDITE

ELSE → PROCEED

4) Choose targeted tests (each with a rationale)

5) Reassess comparable sign (repeat key AROM or symptom-provoking task)

Step-by-Step Workflow

Step 1: Observation (30–60 seconds)

• What you’re looking for: protective posture, head position, shoulder elevation, facial expression, willingness to rotate, trunk substitution to avoid neck motion.
• Clinical use: sets the irritability level and tells you how aggressively to test AROM.

Step 2: Cervical AROM (your primary screen)

• Do: flexion, extension, rotation L/R, side-bend L/R.
• Record: most limited direction, pain location (central vs unilateral), symptom spread (neck only vs into arm), and quality (smooth vs hinging/jerky).
• Comparable sign: choose one movement that reliably reproduces the main complaint (e.g., right rotation reproduces right neck pain).

Step 3: Quick Neuro Screen (only if indicated)

Indications: arm symptoms, symptoms below the elbow, reported weakness/clumsiness, or pain that behaves like nerve irritation. Keep it brief: choose the minimum set that answers “Is there objective neuro involvement today?”

• Minimum set approach: test 1 key myotome + 1 key dermatome + 1 reflex relevant to the complaint side/level, then expand only if abnormal.
• Interpretation rule: a single mild finding may be monitored; a pattern (motor + sensory + reflex change) increases concern and may change your plan.

Step 4: Test Rationale Choices (pick 1–3, not 8)

Choose tests based on what AROM and symptoms suggest. Each test should answer a specific question.

Step 5: Reassessment (confirm relevance)

• Repeat the comparable sign (e.g., right rotation) after your key test or brief intervention (e.g., posture cue, gentle repeated movement, or unloading position).
• Meaningful change examples: increased range, reduced pain intensity, reduced symptom spread, improved movement quality.

Typical Findings (Neck Pain)

• Local mechanical neck pain: one or two directions limited, pain stays in neck/upper shoulder, neuro screen normal.
• Possible radicular pattern: arm symptoms with neck movement, symptom spread below elbow, provocation/relief tests trend positive, neuro screen may show asymmetry.
• Movement avoidance pattern: very guarded AROM, trunk substitution, inconsistent symptom report—often requires modified testing and slower progression.

Common Errors (Neck Pain)

• Running a full neuro screen on every neck pain patient regardless of symptoms (adds time without changing decisions).
• Adding multiple special tests without a clear question, then over-weighting a single positive test.
• Failing to define and reassess a comparable sign, so you cannot judge whether your testing/intervention was relevant.
• Pushing into high-irritability end ranges when observation suggests low tolerance.

How to Document a Brief Assessment Summary (Neck Pain)

Primary complaint: R neck pain with rotation; no arm symptoms (or: intermittent paresthesia to thumb)

AROM: R rot limited/painful; ext reproduces familiar pain; flex WNL; quality = guarded

Neuro screen (if indicated): key findings only (e.g., C6 myotome 4/5 R; sensation ↓ C6; reflexes symmetric)

Targeted tests + rationale: radicular cluster due to below-elbow symptoms; shoulder clearing due to reaching pain

Comparable sign + reassessment: R rotation pain 6/10 → 3/10 after unloading/positioning

2) Thoracic Stiffness Pathway

Decision Tree (Proceed / Modify / Refer)

START: Thoracic stiffness / mid-back tightness (often posture- or breathing-related)

1) Posture + breathing observation (rib flare, apical vs diaphragmatic pattern, guarded respiration)

IF chest pain, unexplained shortness of breath, systemic unwellness, or symptoms not mechanically influenced → REFER / MEDICAL REVIEW

ELSE → PROCEED

2) Thoracic AROM (rotation, extension, side-bend; symptom response)

IF sharp, non-mechanical pain or rapid escalation with minimal motion → MODIFY TESTING and consider referral if concerning

ELSE → PROCEED

3) Check contribution from neck/shoulder mechanics (quick clearing)

IF neck/shoulder motion reproduces the main thoracic complaint → MODIFY PATHWAY (treat as regional interdependence; screen adjacent region)

ELSE → PROCEED

4) Caution signs check (night pain not changing with position, unexplained weight loss, fever, significant trauma, osteoporosis risk)

IF present → REFER / MEDICAL REVIEW

ELSE → PROCEED

5) Reassess comparable sign (repeat thoracic motion or breathing task)

Step-by-Step Workflow

Step 1: Posture and Breathing Observation (fast but high yield)

• Posture snapshot: thoracic kyphosis, scapular position, rib flare, habitual extension “hinge” at thoracolumbar junction.
• Breathing snapshot: upper chest dominant breathing, breath holding, asymmetrical rib expansion, pain with deep breath.
• Comparable sign options: “deep breath discomfort,” “rotation to the right feels blocked,” or “extension feels stuck.”

Step 2: Thoracic AROM (choose 2–3 key motions)

• Rotation: seated or quadruped; note symmetry and end-feel (stiff vs painful).
• Extension: seated extension over chair back or wall-assisted; watch for lumbar substitution.
• Side-bend: standing; note whether symptoms are local, wrapping around ribs, or referred.

Interpretation shortcut: “Stiff but not painful” often behaves differently from “painful and protective.” Stiffness tends to show a firm end-feel and consistent limitation; protective pain tends to show variable range and guarding.

Step 3: Contribution From Neck/Shoulder Mechanics (regional interdependence check)

Thoracic complaints frequently reflect how the neck and shoulder girdle are moving. You are not doing a full adjacent-region assessment here—just a quick check to avoid missing the driver.

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• Neck contribution check: does cervical rotation/extension reproduce the mid-back complaint or change thoracic rotation?
• Shoulder/scapula contribution check: does arm elevation or scapular retraction/protraction reproduce the thoracic symptoms?
• Decision rule: if the main symptom is reproduced more clearly by neck/shoulder mechanics than by thoracic AROM, shift your focus to that region for deeper testing.

Step 4: Caution Signs (thoracic region deserves respect)

Because thoracic pain can occasionally reflect non-mechanical drivers, build a quick “pause point” into the pathway.

• Modify testing if the patient cannot tolerate deep breathing or rotation due to sharp pain—use smaller ranges, supported positions, and avoid repeated provocation.
• Refer if symptoms are not mechanically modulated, are accompanied by systemic features, or present as concerning chest symptoms.

Step 5: Reassessment

• Repeat the comparable sign: thoracic rotation range/quality, extension tolerance, or a deep breath.
• Look for: easier movement, less rib discomfort, reduced guarding, improved symmetry.

Typical Findings (Thoracic Stiffness)

• Postural stiffness pattern: limited extension and rotation, minimal pain, breath feels “restricted,” lumbar substitution during extension.
• Rib/thoracic irritability pattern: rotation or deep breath reproduces localized or wrapping discomfort; patient guards and avoids full inhalation.
• Adjacent-region driver: thoracic complaint changes substantially when neck posture or scapular position is altered; shoulder elevation reproduces symptoms more than thoracic AROM.

Common Errors (Thoracic Stiffness)

• Assuming “mid-back tightness” is always thoracic joint stiffness and skipping breathing observation.
• Letting the lumbar spine do the work during thoracic extension tests (false negative for thoracic limitation).
• Failing to check whether neck/shoulder mechanics reproduce the complaint, leading to misdirected treatment.
• Over-testing painful rotation/deep breathing when irritability is high.

How to Document a Brief Assessment Summary (Thoracic Stiffness)

Primary complaint: Mid-thoracic stiffness, worse after desk work; deep breath feels restricted; no systemic symptoms reported

Observation: Apical breathing + rib flare; mild kyphosis; scapulae protracted

Thoracic AROM: Rotation R limited with firm end-feel; extension limited with lumbar substitution; pain minimal

Adjacent contribution: Shoulder elevation increases symptoms; cervical AROM does not

Comparable sign + reassessment: Seated rotation R improved after scapular positioning cue; breathing feels easier

3) Low Back Pain Pathway

Decision Tree (Proceed / Modify / Refer)

START: Low back pain (with/without leg symptoms)

1) Functional movements (sit-to-stand, forward bend to reach, gait/step, squat as tolerated)

IF unable to weight-bear safely, severe pain with minimal movement, or rapidly worsening neuro symptoms → MODIFY TESTING and consider referral

ELSE → PROCEED

2) Lumbar AROM (flex/ext/side-glide or side-bend/rotation as you use; note symptom response)

IF marked peripheralization or intolerance → MODIFY TESTING (smaller ranges, supported positions)

ELSE → PROCEED

3) Neuro screen for leg symptoms IF indicated (pain below knee, numbness/tingling, weakness)

IF progressive motor deficit or multi-domain objective deficits → REFER / EXPEDITE

ELSE → PROCEED

4) Choose targeted special tests (each with a rationale)

5) Reassess comparable sign (repeat functional task or lumbar AROM)

Step-by-Step Workflow

Step 1: Functional Movements (start with what matters)

Low back pain is often best understood through tasks the patient actually struggles with. Pick 2–3 movements that are safe and relevant.

• Examples: sit-to-stand, forward bend to mid-shin, picking up a light object, short walk, step-up, squat to chair.
• What to record: pain location, willingness to load, speed, use of hands on thighs, asymmetry/shift, and whether symptoms travel into the leg.
• Comparable sign: the task that most reliably reproduces symptoms (e.g., sit-to-stand causes sharp pain at initiation; forward bend causes leg symptoms).

Step 2: Lumbar AROM (confirm pattern and irritability)

• Do: flexion and extension first; add side-bend/side-glide/rotation depending on your standard.
• Key observation: does pain stay local, centralize, or spread further into the leg?
• Quality markers: painful arc, reversal of lumbopelvic rhythm, lateral shift, guarded return from flexion.

Step 3: Neuro Screen for Leg Symptoms (only if indicated)

Indications: symptoms below the knee, numbness/tingling, reported weakness, or clear nerve-like pain behavior. Keep it targeted and expand only if abnormal.

• Minimum set approach: one key myotome + one key dermatome + one reflex relevant to the symptom distribution; compare sides.
• Escalation rule: objective weakness that is new or worsening should move you toward referral rather than “watch and wait.”

Step 4: Special Test Rationale Choices (choose what answers your question)

Special tests are not a checklist. Choose them to clarify whether leg symptoms are likely neural mechanosensitivity, whether hip/SI region may be contributing, or whether a specific loading direction is provocative/relieving.

Step 5: Reassessment (the “did it matter?” step)

• Repeat the comparable sign: the functional task (sit-to-stand) or the most provocative lumbar AROM direction.
• Meaningful change examples: less pain on initiation, improved hinge strategy, reduced leg symptom spread, improved confidence/speed.

Typical Findings (Low Back Pain)

• Local mechanical LBP: pain stays in back/buttock, predictable with flexion or extension, neuro screen normal.
• Possible radicular involvement: leg symptoms below knee, provocation with lumbar movements, neuro screen may show asymmetry, neural tension test may be positive.
• Load-intolerant pattern: functional tasks provoke more than isolated AROM; patient uses hands to stand, avoids hip hinge, moves slowly and guarded.

Common Errors (Low Back Pain)

• Starting with special tests before watching the patient move (misses the functional driver and irritability level).
• Testing end-range lumbar flexion repeatedly when leg symptoms are easily provoked (unnecessary flare-up risk).
• Interpreting a single positive special test as a diagnosis rather than part of a pattern.
• Skipping reassessment, so you cannot tell whether your chosen test or cue was clinically relevant.

How to Document a Brief Assessment Summary (Low Back Pain)

Primary complaint: Central LBP with sit-to-stand and forward bending; intermittent leg ache to calf (R)

Functional: Sit-to-stand painful at initiation; uses hands; gait WNL

Lumbar AROM: Flexion limited with leg symptom increase; extension reduces leg symptoms (or: increases back pain)

Neuro screen (if indicated): key findings only (e.g., R ankle DF 4/5; sensation ↓ lateral leg; reflex asymmetry)

Targeted tests + rationale: neural tension test due to below-knee symptoms; repeated loading screen due to clear movement response

Comparable sign + reassessment: Forward bend leg symptoms 5/10 → 2/10 after directional loading trial and hinge cue