A . T O T A L R E D B L O O D CELL (RBC) C O U N T ; H E M O G L O B I N A N D H E M A T O C R I T V A L U E S FOR ADULTS T o t a l RBC Count Women
4 to 5.5 million/mm
Men
4.5 to 6.2 million/mm
3
3
H e m a t o c r i t (HCT)
Hemoglobin (HGB)
Sed Rate (ESR; m/hr)
36-46%
12-15 g/dl
1-25 (increases during pregnancy)
42%-52%
14-16.5 g/dl
0-17
B . T O T A L W H I T E B L O O D CELL ( L E U K O C Y T E ) C O U N T A N D D I F F E R E N T I A L C O U N T I N A D U L T S A N D CHILDREN OVER 2 Y E A R S OF AGE T o t a l W B C Count
4,500-11,000/mm
3
Differential C o u n t Granulocytes Segs (segmented neutrophils; mature)
45%-62%
Bands of stabs (immature neutrophils)
3%-5%
EOs (eosinophils)
l%-3%
BASOs (basophils)
0-0.75%
Monos (monocytes)
3%-7%
Lymphs (lymphocytes)
25%-33%
C. P L A T E L E T ( T H R O M B O C Y T E ) C O U N T A d u l t a n d Child ( o v e r 1 y e a r of age)
150,000-400,000/mm
Critical low
Less than 30,000/mm
Critical high
Greater than 1,000,000/mm
URINE ANALYSIS (URINALYSIS) Test
3
3
3
RENAL FUNCTION BLOOD STUDIES
Normal Result
Test
Normal Result
Significance o f Findings
General
Color
Yellow-amber
Measurements
Turbidity
Clear to faintly hazy
pH
4.5-8.0 (average: 5.5-6.0)
Specific gravity
1.003-1.030 (usually 1.016-1.022)
Other
Glucose
None or levels to determine the need for supplemental oxygen during exercise * Vital signs: Is the blood pressure stable?
FUPs: * Was the patient seen by a physical therapist preoperatively? • Were there any unrelated preoperative conditions? • Was the surgery invasive, a closed procedure via arthroscopy, fluoroscopy, or other means of imaging, or virtual by means of computerized technology? • How long was the procedure? Were there any surgical complications? • How much fluid and/or blood products were given? • What position was the patient placed in and for how long? * Physician's report • What are the short-term and long-term medical treatment plans? • Are there precautions or contraindications for treatment? • Are there weight-bearing limitations? * Associated or additional problems, such as diabetes, heart disease, peripheral vascular disease, respiratory involvement FUPs: * Are there precautions or contraindications of any kind that may affect exercise? * If diabetic, what are the current blood glucose levels (normal range: 70 to 100mg/dl)? • When is insulin administered? (Use this to avoid the peak insulin levels in planning an exercise schedule.) • Medications (what, when received, what for, potential side effects) FUPs: • Is the patient receiving oxygen or receiving fluids/medications through an intravenous line? • Restrictions: Are there any dietary or fluid restrictions?
• Spontaneous p o s t m e n o p a u s a l bleeding • A growing mass, whether painful or painless • Persistent rise or fall in blood pressure • Hip, sacroiliac, pelvic, groin, or low b a c k pain in a w o m a n w i t h o u t t r a u m a t i c etiologic complex who reports fever, night sweats, or an association between menses and symptoms
FUPs: • If no, consider initiating standing with a tilt table or monitoring the blood pressure before, during, and after treatment. Nursing Assessment • Medical status: What is the patient's current medical status? * Pain: What is the nursing assessment of this p a t i e n t ' s p a i n level a n d pain tolerance? • Physical status: Has the patient been up at all yet? FUPs: * If yes, is the patient sitting, standing, or walking? How long and (if walking) what distance, and how much assistance is required? • Patient orientation: Is the patient oriented to time, place, and person? (Does the patient know the date and the approximate time, where he or she is, and who he or she is?) • Discharge plans: Are there any known or expected discharge plans? FUPs: * If yes, what are these plans and when will the patient be discharged? • Final question: Is there anything else that I should know before exercising the patient?
• M a r k e d loss of hip motion and referred pain to the groin in a client on l o n g - t e r m systemic corticosteroids • A positive f a m i l y / p e r s o n a l history of breast cancer in a w o m a n with chest, b a c k , or shoulder pain of u n k n o w n cause • Elevated blood pressure in any w o m a n taking birth control pills; this should be closely m o n i tored by her physician
SECTION I
102
I N T R O D U C T I O N TO THE S C R E E N I N G PROCESS
K E Y P O I N T S T O REMEMBER / The
process of screening
for medical
disease before
establishing a diagnosis by the physical therapist and plan of care requires a broad range of knowledge.
and ask the appropriate questions based on the individual circumstances. / W h e n screening for domestic violence, sexual dysfunc-
/ T h r o u g h o u t the screening process, a medical diagnosis
tion, incontinence, or other conditions, it is important to
is not the goal. T h e therapist is screening to make
explain that a standard set of questions is asked and
sure
that
the
client
does
indeed
have
a
primary
N M S problem w i t h i n the scope of a physical therapist practice.
that some may not apply. / W i t h the older client, a limited number of presenting symptoms
/ T h e screening steps begin with the client interview, but screening does not end there. Screening questions may be needed throughout the episode of care. T h i s is especially true when
progression of disease results
in a
changing clinical presentation, perhaps with the onset of new symptoms or new red flags after the treatment intervention has been initiated.
often
underlying
predominate—no
disease
is—including
matter
what
acute
confusion,
the
depression, falling, incontinence, and syncope. / A
recent
kidney,
history vaginal,
of
any
upper
infection
(bladder,
respiratory),
uterine,
mononucleosis,
influenza, or colds may be an extension of a chronic health pattern or systemic illness. / T h e use of fluoroquinolones (antibiotic) has been linked
/ T h e client history is the first and most basic skill needed for screening. M o s t of the information needed to determine the cause of symptoms is contained w i t h i n the subjective assessment (interview process).
with tendinopathies, especially in older adults w h o are also taking corticosteroids. / Reports of d i z z i n e s s , loss of balance, or a history of falls require further screening, especially in the presence of
/ T h e Family/Personal H i s t o r y form can be used as the
other neurologic signs and symptoms such as headache,
first tool to screen clients for medical disease. A n y " y e s "
confusion, depression, irritability, visual changes, weak-
responses should be followed up w i t h appropriate ques-
ness, memory loss, and drowsiness or lethargy.
tions. T h e therapist is strongly encouraged to review the
/ Special Questions for W o m e n and Special Questions for
form with the client, entering the date and his or her o w n
M e n are available to screen for gynecologic or urologic
initials. T h i s form can be used as a document of base-
involvement for any w o m a n or man with back, shoul-
line information.
der,
/ Screening
examinations
(interview
and
vital
signs)
should be completed for any person experiencing back,
hip, g r o i n , or sacroiliac
symptoms of unknown
o r i g i n at presentation. / Consider the possibility of physical/sexual
assault or
shoulder, scapular, hip, g r o i n , or sacroiliac symptoms of
abuse in anyone with an unknown cause of symptoms,
unknown cause. T h e presence of constitutional symptoms
clients w h o take much longer to heal than expected, or
will almost always w a r r a n t a physician's referral but
any combination of physical, social, or psychologic cues
definitely requires further follow-up questions in making that determination.
listed. / In screening for systemic origin of symptoms, review the
/ It may be necessary to explain the need to ask such
subjective information in light of the objective findings.
detailed questions about o r g a n systems seemingly unre-
Compare the client's history with clinical presentation and look for any associated signs and symptoms.
lated to the musculoskeletal symptoms. / N o t every question provided in the lists offered in this text needs to be asked; the therapist can scan the list
CHAPTER 2
CASE
INTRODUCTION TO THE INTERVIEWING PROCESS
103
STUDY
REFERRAL
A 28-year-old white man was referred to physical therapy with a medical diagnosis of progressive idiopathic Raynaud's syndrome of the bilateral upper extremities. He had this condition for the last 4 years. The client was examined by numerous physicians, including an orthopedic specialist. The client had complete numbness and cyanosis of the right second, third, fourth, and fifth digits on contact with even a mild decrease in temperature. He reported that his symptoms had progressed to the extent that they appear within seconds if he picks up a glass of cold water. This man works almost entirely outside, often in cold weather, and uses saws and other power equipment. The numbness has created a very unsafe job situation. The client received a gunshot wound in a hunting accident 6 years ago. The bullet entered the posterior left thoracic region, lateral to the lateral border of the scapula, and came out through the anterior lateral superior chest wall. He says that he feels as if his shoulders are constantly rolled forward. He reports no cervical, shoulder, or elbow pain or injury. PHYSICAL THERAPY INTERVIEW
Note that not all of these questions would necessarily be presented to the client because his answers may determine the next question and may eliminate some questions. Tell me why you are here today. (Open-ended question) PAIN
• Do you have any pain associated with your past gunshot wound? If yes, describe your pain. FUPs: Give the client a chance to answer and prompt only if necessary with suggested adjectives such as "Is your pain sharp, dull, boring, or burning?" or "Show me on your body where you have pain." To pursue this line of questioning, if appropriate: FUPs: What makes your pain better or worse? • What is your pain like when you first get up in the morning, during the day, and in the evening? • Is your pain constant or does it come and go? • On a scale from 0 to 10, with zero being no pain and 10 being the worst pain you have ever expe-
• • •
• •
rienced with this problem, what level of pain would you say that you have right now? Do you have any other pain or symptoms that are not related to your old injury? If yes, pursue as above to find out about the onset of pain, etc. You indicated that you have numbness in your right hand. How long does this last? FUPs: Besides picking up a glass of cold water, what else brings it on? How long have you had this problem? You told me that this numbness has progressed over time. How fast has this happened? Do you ever have similar symptoms in your left hand?
ASSOCIATED SYMPTOMS
Even though this client has been seen by numerous physicians, it is important to ask appropriate questions to rule out a systemic origin of current symptoms, especially if there has been a recent change in the symptoms or presentation of symptoms bilaterally. For example: • What other symptoms have you had that you can associate with this problem? • In addition to the numbness, have you had any of the following? • Tingling • Nausea • Burning • Dizziness • Weakness • Difficulty with swallowing • Vomiting • Heart palpitations or fluttering • Hoarseness • Unexplained sweating or night sweats • Difficulty • Problems with your vision with breathing • How well do you sleep at night? (Open-ended question) • Do you have trouble sleeping at night? (Closedended question) • Does the pain awaken you out of a sound sleep? Can you sleep on either side comfortably? MEDICATIONS
• Are you taking any medications? If yes, and the person does not volunteer the information, probe further: What medications? Why are you taking this medication? When did you last take the medication?
* Adapted from Bailey W, Northwestern Physical Therapy Services, Inc. Titusville, Pennsylvania.
104
CASE
SECTION I
INTRODUCTION TO THE SCREENING PROCESS
STUDY* —cont'd
Do you think the medication is easing the symptoms or helping in any way? Have you noticed any side effects? If yes, what are these effects? PREVIOUS MEDICAL TREATMENT
• Have you had any recent medical tests, such as x-ray examination, MRI, or CT scan? If yes, find out the results. • Tell me about your gunshot wound. Were you treated immediately? • Did you have any surgery at that time or since then? If yes, pursue details with regard to what type of surgery and where and when it occurred. • Did you have physical therapy at any time after your accident? If yes, relate when, for how long, with whom, what was done, did it help? • Have you had any other kind of treatment for this injury (e.g., acupuncture, chiropractic, osteopathic, naturopathic, and so on)?
ACTIVITIES OF DAILY LIVING (ADLs)
• Are you right-handed? • How do your symptoms affect your ability to do your job or work around the house? • How do your symptoms affect caring for yourself (e.g., showering, shaving, other ADLs such as eating or writing)? FINAL QUESTION
• Is there anything else you feel that I should know concerning your injury, your health, or your present situation that I have not asked about? Note: If this client had been a woman, the interview would have included questions about breast pain and the date when she was last screened for cancer (cervical and breast) by a physician.
PRACTICE QUESTIONS 1. What is the effect of NSAIDs (e.g., naprosyn, motrin, anaprox, ibuprofen) on blood pressure? a. No effect b. Increases blood pressure c. Decreases blood pressure 2. Most of the information needed to determine the cause of symptoms is contained in the: a. Subjective examination b. Family/Personal History Form c. Objective information d. All of the above e. a and c 3. With what final question should you always end your interview? 4. A risk factor for NSAID-related gastropathy is the use of:
a. Antibiotics b. Antidepressants c. Antihypertensives d. Antihistamines After interviewing a new client, you summarize what she has told you by saying, "You told me you are here because of right neck and shoulder pain that began 5 years ago as a result of a car accident. You also have a 'pins and needles' sensation in your third and fourth fingers but no other symptoms at this time. You have noticed a considerable decrease in your grip strength, and you would like to be able to pick up a pot of coffee without fear of spilling it."
CHAPTER 2
INTRODUCTION
TO
THE
INTERVIEWING
PROCESS
105
PRACTICE QUESTIONS—cont'd This is an example of: a. An open-ended question b. A funnel technique c. A p a r a p h r a s i n g t e c h n i q u e d. None of the above 6. Screening for alcohol use w o u l d be appro¬ priate when the client reports a history of accidents. a. True b. False 7. W h a t is the significance of night sweats? a. A sign of systemic disease b. Side effect of c h e m o t h e r a p y or other medications c. Poor ventilation while sleeping d. All of the above e. None of the above 8. Spontaneous uterine bleeding after 12 consec¬ utive months without m e n s t r u a l b l e e d i n g requires medical referral. a. True b. False 9. Which of the following are red flags to consider when screening for systemic or viscerogenic causes of n e u r o m u s c u l a r and m u s c u l o s k e l e t a l signs and s y m p t o m s : a. Fever, night sweats, dizziness b. S y m p t o m s are out of proportion to the injury c. Insidious onset d. No position is comfortable e. All of the above
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10. A 52-year-old man with low b a c k pain and sci¬ atica on the left side has been referred to you by his family p h y s i c i a n . He has had a discect o m y and l a m i n e c t o m y on two separate occa¬ sions about 5 to 7 years ago. No i m a g i n g studies have been p e r f o r m e d (e.g., x-ray exam¬ ination or M R I ) since that t i m e . W h a t followup questions should y o u ask to screen for medical disease? 11. You should assess clients w h o are receiving N S A I D s for which p h y s i o l o g i c effect associated with i n c r e a s e d risk of h y p e r t e n s i o n ? a. D e c r e a s e d heart rate b. Increased diuresis c. Slowed peristalsis d. Water retention 12. Instruct clients with a history of h y p e r t e n s i o n and arthritis to: a. Limit physical activity and exercise b. Avoid o v e r - t h e - c o u n t e r m e d i c a t i o n s c. Inform their p r i m a r y care p r o v i d e r of both conditions d. Drink plenty of fluids to avoid e d e m a 13. Alcohol screening tools should be: a. Used with every client s o m e t i m e during the episode of care b. Brief, easy to administer, and nonthreatening c. Deferred w h e n the client has been drinking or has the smell of alcohol on the breath d. C o n d u c t e d with one other family m e m b e r present as a witness
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CHAPTER 2
INTRODUCTION TO THE
61. Fowler K: PTs confront minority health and health disparities. PT Magazine 12(5):42-47, 2004. 62. Probst JC, Moore CG, Glover SH, et al. Person and place: The compounding effects of race/ethnicity and rurality on health, Am J Public Health 94(10):1695-1703, 2004. 63. Urban Indian Health Institute. Health status of urban American Indians, 2004. Available at: http:// www.uihi.org/. Accessed May 30, 2005. 64. Bach PB, Schrag D, Brawley OW: Survival of blacks and whites after a cancer diagnosis, JAMA 287:2106-2113, 2002. 65. Smedley B, Stith A, Nelson A, editors: Unequal treatment—confronting racial and ethnic disparities in health care, Washington, DC, 2002, National Academy Press. 66. Morgenstern LB, Smith MA, Lisabeth LD, et al: Excess stroke in Mexican Americans compared with non-Hispanic whites, Am J Epidemiol 160(4):376-383, 2004. 67. Lisabeth LD, Kardia SL, Smith MA, et al: Family history of stroke among Mexican-American and non-Hispanic white patients with stroke and TIA: Implications for the feasibility and design of stroke genetics research, Neuroepidemiology 24(l-2):96-102, 2005. 68. U.S. National Library of Medicine and the National Institutes of Health. African-American Health. Available at: www.nlm.nih.gov/medlineplus/africanamericanhealth. html May 2005. Accessed May 30, 2005. 69. Intercultural Cancer Council (ICC). Cancer fact sheets. Available at: http://iccnetwork.org/cancerfacts/. Accessed June 1, 2005. 70. Beals KA: Disordered eating and body-image disturbances in male athletes, Health & Fitness, ACSM, March/April 2003. 71. Beals KA: Disordered eating among athletes. A comprehensive guide for health professionals, Champaign, IL, 2004, Human Kinetics. 72. Kaminski PL, Chapman BP, Haynes SD, et al: Body image, eating behaviors, and attitudes toward exercise among gay and straight men, Eat Behav 6(3):179-187, 2005. 73. Long MJ, Marshall BS: The relationship between selfassessed health status, mortality, service use, and cost in a managed care setting, Health Care Manage Rev 4:20-27, 1999. 74. Gold DT, Burchett BM, Shipp KM, et al: Factors associated with self-rated health in patients with Paget's disease of bone, J Bone Miner Res 14 (Suppl 2):99-102, 1999. 75. Idler EL, Russell LB, Davis D: Survival, functional limitations, and self-rated health in the NHANES I Epidemiologic Follow-up Study 1992: First national health and nutrition examination survey, Am J Epidemiol 9:874-883, 2000. 76. Long MJ, McQueen DA, Bangalore VG, et al: Using selfassessed health to predict patient outcomes after total knee replacement, Clin Ortho Rel Res 434:189-192, 2005. 77. Storr CL, Trinkoff AM, Anthony JC. Job strain and nonmedical drug use, Drug Alcohol Depend. 55(1-2): 45-51, 1999. 78. National Institute on Drug Abuse (NIDA). NIDA InfoFacts: Nationwide trends. Available at: http://www.nida. nih.gov/infofacts/nationtrends.html. Accessed Junel4, 2005. 79. Lapeyre-Mestre M, Sulem P, Niezborala M, et al: Taking drugs in the working environment: A study in a sample of 2106 workers in the Toulouse metropolitan area, Therapie 59(6):615-623, 2004. 80. Kolakowsky-Hayner SA: Pre-injury substance abuse among persons with brain injury and persons with spinal cord injury, Brain Inj 13(8):571-581, 1999. 81. Bleicher J: Personal communication, 2003. 82. Soft-tissue infections among injection drug users, MMWR 50(19):381-384, 2001.
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107
83. Clark T, McKenna LS, Jewell MJ: Physical therapists' recognition of battered women in clinical settings, Phys Ther 76(1): 12-19, 1996. 84. Bastiaens L, Francis G, Lewis K: The RAFFT as a screening tool for adolescent substance use disorders, Am J Addict 9:10-16, 2000. 85. Goodman CC, Boissonnault WG: Pathology: implications for the physical therapist, ed 2, Philadelphia, 2003, WB Saunders. 86. Center for Advanced Health Studies: Substance abuse. A guide for health professionals, ed 2, Glendive, 2001, American Academy of Pediatrics. 87. University of Washington Alcohol and Drug Abuse Institute (ADAI). Available at: http://adai.washington.edu/ instruments/. Accessed July 8, 2005. 88. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Alcohol Alert. Publications. Available at http://www.niaaa.nih.gov/. Accessed June 15, 2006. 89. Cook RL, Chung T, Kelly TM, et al: Alcohol screening in young persons attending a sexually transmitted disease clinic, J Gen Intern Med 20(l):l-6, 2005. Available on-line at: www.medscape.com/viewarticle/500027. 90. Babor TF, de la Fuente JR, Saunders J, et al: AUDIT (The Alcohol Use Disorders Identification Test): Guidelines for use in primary health care, 1992, World Health Organization. Available: http://whqlibdoc.who.int/hq/ 1992/WHO_PSA_92.4.pdf. Accessed June 15, 2005. 91. Shapira D: Alcohol abuse and osteoporosis, Semin Arthritis Rheum 19(6): 371-376, 1990. 92. Simons DG, Travell JG, Simons LS: Myofascial pain and dysfunction. The trigger point manual. Volume 1. Upper half of body, Baltimore, 1999, Williams & Wilkins. 93. Mukamal KJ, Ascherio A, Mittleman MA, et al: Alcohol and risk for ischemic stroke in men: The role of drinking patterns and usual beverage. Ann Intern Med 142(1):1119, 2005. 94. Pittman HJ: Recognizing "holiday heart" syndrome, Nursing 2004 34(12):32cc6-32cc7, 2004. 95. Henderson-Martin B: No more surprises: Screening patients for alcohol abuse, Nursing 2000 100(9):26-32, 2000. 96. Selzer ML: A self-administered Short Michigan Alcoholism Screening Test (SMAST), J Stud Alcohol 36(1):117-126, 1975. 97. Ashman TA, Schwartz ME, Cantor JB, et al. Screening for substance abuse in individuals with traumatic brain injury, Brain Inj 18(2):191-202, 2004. 98. Carlat DJ: The psychiatric review of symptoms: A screening tool for family physicians, Am Fam Physician 58(7):1617-1624, 1998. 99. Sturm R, Stein B, Zhang W, et al: Alcoholism treatment in managed private sector plans. How are carve-out arrangements affecting costs and utilization? Recent Dev Alcohol 15:271-84, 2001. 100. Dunn C: Hazardous drinking by trauma patients during the year after injury, J Trauma 54(4):707-712, 2003. 101. Gentilello LM: Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence, Ann Surg 230(4):473-483, 1999. 102. American Physical Therapy Association (APTA): Substance Abuse HOD 06-93-25-49 (Program 32, Practice Department), June 2003. 103. Majid PA, Cheirif JB, Rokey R, et al: Does cocaine cause coronary vasospasm in chronic cocaine abusers? A study of coronary and systemic hemodynamics, Clin Cardiol 15(4): 253-258, 1992. 104. American Cancer Society (ACS): Health benefits over time. Available at: www.cancer.org [In the search box, type in: When Smokers Quit]. Accessed June 21, 2005. 105. Travell JG, Simons DG: Myofascial pain and dysfunction: The trigger point manual: The lower extremities, vol 2, Baltimore, 1992, Williams & Wilkins.
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106. Kim KS, Yoon ST, Park JS, et al: Inhibition of proteoglycan and type II collagen synthesis of disc nucleus cells by nicotine, J Neurosurg: Spine 99(3 Suppl):291-297, 2003. 107. Akmal M, Kesani A, Anand B, et al: Effect of nicotine on spinal disc cells: A cellular mechanism for disc degeneration, Spine 29(5):568-575, 2004. 108. Frymoyer JW, Pope MH, Clements JH, et al: Risk factors in low back pain, J Bone Joint Surg 65-A: 213-218, 1983. 109. Holm S, Nachemson A: Nutrition of the intervertebral disc: acute effects of cigarette smoking. An experimental animal study, Upsala J Med Sci 83: 91-98, 1998. 110. Hughes JR, Oliveto AH, Helzer JE, et al: Should caffeine abuse, dependence, or withdrawal be added to DSM-rV and ICD-10? Am J Psychiatry 149(1): 33-40, 1992. 111. Hughes JR, Oliveto AH, Liguori A, et al: Endorsement of DSM-IV dependence criteria among caffeine users, Drug Alcohol Depend 52(2): 99-107, 1998. 112. Kerrigan S, Lindsey T: Fatal caffeine overdose. Forensic Sci Int 153(l):67-69, 2005. Epub ahead of print, May 31, 2005. 113. Sudano I, Binggeli C, Spieker L: Cardiovascular effects of coffee: Is it a risk factor? Prog Cardiovasc Nurs 20(2):6569, 2005. 114. Corti R, et al: Coffee acutely increases sympathetic nerve activity and blood pressure independently of caffeine content: Role of habitual versus nonhabitual drinking, Circulation 106(23):2935-2940, 2002. 115. Mikuls TR, Cerhan JR, Criswell LA, et al: Coffee, tea, and caffeine consumption and risk of rheumatoid arthritis: Results from the Iowa Women's Health Study, Arthritis Rheum 46(1):83-91, 2002. 116. Position of the American Dietetic Association (ADA): Use of nutritive and nonnutritive sweeteners, J Amer Dietetic Assocl04(2):255-275, 2004. Available at: http ://w w w. eatright.org/ 117. Blaylock R: Excitotoxins: The taste that kills, Albuquerque, 1996, Health Press. 118. Roberts HJ: Aspartame disease: The ignored epidemic, West Palm Beach, 1995, Sunshine Sentinel Press. 119. Roberts HJ: Defense against Alzheimer's disease, Palm Beach, 2001, Sunshine Sentinel Press. 120. Newman LS: Occupational illness, N Engl J Med 333: 1128-1134, 1995. 121. Radetsky P: Allergic to the twentieth century: The explosion in environmental allergies, Boston, 1997, Little, Brown. 122. Frumkin H: Agent orange and cancer: An overview for clinicians, Cancer j Clin 53(4):245-255, 2003. 123. Veterans Health Administration (VHA): Gulf War Illnesses. Available at: www.va.gov/gulfwar/. Accessed July 1, 2005 124. Marshall L, Weir E, Abelsohn A, et al: Identifying and managing adverse environmental health effects: Taking an exposure history. Canadian Medical Association Journal 166(8):1049-1054, 2002 (www.cmaj.ca/cgi/reprint/166/8/1049.pdf). 125. Cross J, Trent R: Public health and aging: Nonfatal fallrelated traumatic brain injury among older adults, MMWR 52(13):276-278, 2003. 126. Boulgarides LK, McGinty SM, Willett JA, et al: Use of clinical and impairment-based tests to predict falls by community-dwelling older adults. Physical Therapy 83(4):328-339, 2003. 127. Kario K, Tobin JN, Wolfson LI, et al: Lower standing systolic blood pressure as a predictor of falls in the elderly: A community-based prospective study, J Am Coll Cardiol 38(l):246-252, 2001. 128. Lawlor DA, Patel R, Ebrahim S: Association between falls in elderly women and chronic diseases and drug use: Cross sectional study, BMJ 327(7417):712-717. 129. Weiner D, Duncan P, Chandler J, et al: Functional reach: A marker of physical frailty, Journal of the American Geriatrics Society 40(3):203-207, 1992.
130. Newton R: Validity of the multi-directional reach test: A practical measure for limits of stability in older adults, Journal of Gerontological and Biological Science and Medicine 56(4):M248-M252, 2001. 131. Vellas BJ, Wayne S, Romero L, et al: One-leg balance is an important predictor of injurious falls in older persons, J Amer Geriatr Sco. 45:735-738, 1997. 132. Berg K, Wood-Dauphinee S, Williams JI, Gayton D: Measuring balance in the elderly: Preliminary development of an instrument, Physiotherapy Canada 41:304-311, 1989. 133. Berg K, Wood-Dauphinee S, Williams JI, Maki, B: Measuring balance in the elderly: Validation of an instrument. Can. J. Pub. Health 83(Supplement 2):S7-11, 1992. 134. Mathias S, Nayak U, Isaacs B: Balance in elderly patients: The "Get-Up and Go Test," Archives of Physical & Medical Rehabilitation 67:387-389, 1986. 135. Podsiadlo D, Richardson S: The timed "Up & Go": A test of basic functional mobility for frail elderly persons, J Am Geriatr Soc 39:142-148, 1991. 136. Thompson M, Medley A: Performance of community dwelling elderly on the timed up and go test, Physical and Occupational Therapy in Geriatrics 13(3):17-30, 1995. 137. Tinetti ME, Mendes de Leon CF, Doucette JT, et al: Fear of falling and fall-related efficacy in relationship to functioning among community-living elders, J Gerontol 49:M140-147, 1984. 138. Tinetti ME, Richman D, Powell LE: Falls efficacy as a measure of fear of falling, J Gerontol 45:P239-P243, 1990. 139. Powell LE, Myers AM: The Activities-Specific Balance Confidence (ABC) Scale, J Gerontol A Biol Sci Med Sci 50:M28-M34, 1995. 140. Myers AM, Fletcher PC, Myers AH: Discriminative and evaluative properties of the Activities-specific Balance Confidence Scale, J Gerontol 53:M287-294, 1998. 141. Hotchkiss A, Fisher A, Robertson R, et al: Convergent and predictive validity of three scales to falls in the elderly, Am J Occup Ther 58(l):100-3, Jan-Feb 2004. 142. American Physical Therapy Association (APTA): Guidelines for recognizing and providing care for victims of domestic abuse, 1997. Available at: www.apta.org [1-800999-2782, ext. 3395. Accessed June 6, 2005. 143. Cyriax JH: Textbook of orthopedic medicine, Philadelphia, 1998, W.B. Saunders. 144. American Physical Therapy Association (APTA): New position on family violence outlinesphysical therapy role, Alexandria, 2005, APTA. 145. Ketter P: Physical therapists need to know how to deal with domestic violence issues, PT Bulletin 12(31): 6-7, 1997. 146. Janssen PA, Nicholls TL, Kumar RA, et al: Of mice and men: Will the intersection of social science and genetics create new approaches for intimate partner violence? J Interpers Violence 20(1):61-71, 2005. 147. Goldberg WG, Tomlanovich MC: Domestic violence victims in the emergency department, JAMA 251:3259-3264, 1984. 148. George MJ: A victimization survey of female perpetrated assaults in the United Kingdom, Aggressive Behavior 25:67-79, 1999. 149. Owen SS, Burke TW: An exploration of prevalence of domestic violence in same sex relationships, Psychol Rep 95(1):129-132, 2004. 150. Feldhaus K: Accuracy of 3 brief screening questions for detecting partner violence in the emergency department, JAMA 277(17):1357-1361, 1997. 151. Dong M, Giles WH, Felitti VJ, et al: Insights into causal pathways for ischemic heart disease: Adverse childhood experiences study, Circulation 110(13):1761-1766, 2004. 152. Friedman MJ, Wang, S, Jalowiec JE, et al: Thyroid hormone alterations among women with posttraumatic stress disorder due to childhood sexual abuse, Biol Psychiatry 57(10):1186-1192, 2005.
CHAPTER 2
INTRODUCTION TO THE INTERVIEWING PROCESS
153. Sachs-Ericsson N, Blazer D, Plant EA, et al: Childhood sexual and physical abuse and the 1-year prevalence of medical problems in the National Comorbidity Survey, Health Psychol 24(l):32-40, 2005. 154. Cunningham J: Childhood sexual abuse and medical complaints in adult women, J of Interpersonal Violence 3:131144, 1988. 155. Drossman DA: Sexual and physical abuse in women with functional or organic gastrointestinal disorders, Annals of Internal Medicine 113:828-833, 1990. 156. Felitti VJ: Long-term medical consequences of incest, rape, and molestation, Southern Medical J 84(3):328-331, 1991. 157. Keely BR: Could your patient—or colleague—become violent? Nursing 2002 32(12):32ccl-32cc5, 2002. 158. Doody L: Defusing workplace violence, Nursing 2003 33(8):32hnl-32hn3, 2003. 159. Kimmel D: Association of physical abuse and chronic pain explored, ADVANCE for Physical Therapists, February 17, 1997. 160. Myers JE, Berliner L, Briere J, et al. The APSAC handbook on child maltreatment,Thousand Oaks, 2002, Sage Publications. 161. Feldhaus KM: Fighting domestic violence: An intervention plan, J Musculoskel Med 18(4):197-204, 2001. 162. Burroughs VJ, Maxey RW, Levy RA: Racial and ethnic differences in response to medicines, J Natl Med Assoc 94(10Suppl):l-26, 2002. 163. Morrison A, Levy R: Toward individualized pharmaceutical care of East Asians: The value of genetic testing for polymorphisms in drug-metabolizing genes, Pharmacogenomics 5(6):673-689, 2004. 164. Gandhi M, Aweeka F, Greenblatt RM, et al: Sex differences in pharmacokinetics and pharmacodynamics, Annu Rev Pharmacol Toxicol 44:499-523, 2004. 165. Meredith S, Feldman PH, Frey D, et al: Possible medication errors in home healthcare patients, J Am GeriatrSoc 49(6):719-724, 2001. 166. Food and Drug Administration (FDA): Center for Drug Education and Research: NSAIDs. Available at: www.fda.gov. Posted June 15, 2005. Accessed June 17, 2005. 167. Boissonnault WG, Meek PD: Risk factors for antiinflammatory drug or aspirin induced GI complications in individuals receiving outpatient physical therapy services, J Ortho Sports Phys Ther 32(10):510-517, 2002. 168. Biederman RE: Pharmacology in rehabilitation: Nonsteroidal anti-inflammatory agents, JOSPT 35(6):356-367, 2005. 169. Lefkowith JB: Cyclooxygenase-2 specificity and its clinical implications, Am J Med 106:43S-50S, 1999. 170. Reuben SS: Issues in perioperative use of NSAIDs, J Musculoskel Med 22(6):281-282, 2005. 171. Huerta C: Nonsteroidal antiinflammatory drugs and risk of acute renal failure in the general population, Am J Kidney Dis 45(3):531-539, 2005. 172. Goldstein JL: Personal communication, 2004. 173. Cryer B: Gastrointestinal safety of low-dose aspirin, Am J Manag Care 8(22 Suppl):S701-708, 2002. 174. Curhan GC, Willett WC, Rosner B: Frequency of analgesic use and risk of hypertension in younger women, Archives of Internal Medicine 162(19):2204-2208, 2002. 175. Schiodt FV, Rochling FA: Acetaminophen toxicity in an urban country hospital, NEJM 337(16):1112-1117, 1997.
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176. Acello B: Administering acetaminophen safely, Nursing 2003 33(11):18, 2003. 177. Buntin-Mushock C, Phillip L, Moriyama K: Agedependent opioid escalation in chronic pain patients, AnesthAnalg 100(6):1740-1745, 2005. 178. Burkman R, Schlesselman JJ, Zieman M: Safety concerns and health benefits associated with oral contraception, Am J Obstet Gynecol 190(4 Suppl):S5-22, 2004. 179. Barclay L, Lie D: Bone loss from Depot Medroxyprogesterone acetate may be reversible, Arch Pediatr Adolesc Med 159:139-144, 2005. 180. Filippucci E, Farina A, Bartolucci F, et al: Levofloxacininduced bilateral rupture of the Achilles tendon: Clinical and sonographic findings, Rheumatiso 55(4):267-269, 2003. 181. Melhus A: Fluoroquinolones and tendon disorders, Expert Opin Saf 4(2):299-309, 2005. 182. Khaliq Y, Zhanel GG: Fluoroquinolone-associated tendinopathy: A critical review of the literature, Clin Infect Dis 36(11):1404-1410, 2003. 183. Kelly JP, Kaufman DW, Kelley K, et al: Recent trends in use of herbal and other natural products, Arch Intern Med 165(3):281-286, 2005. 184. Trapskin P, Smith KM: Herbal medications in the perioperative orthopedic surgery patient, Orthopedics 27(8):819822, 2004. 185. Ciccone CD: Geriatric pharmacology. In Guccione AA, editor: Geriatric physical therapy, St. Louis, 1993, Mosby. 186. Graedon J, Graedon T: The people's pharmacy guide to home and herbal remedies, New York, 2002, St. Martin's Press. 187. Gruenwald G: PDR for herbal medicines, ed 3, Stamford, 2004, Thomson Healthcare. 188. Ciccone CD: Pharmacology in rehabilitation, ed 3, Philadelphia, 2002, FA Davis. 189. Mold JW, Roberts M, Aboshady HM: Prevalence and predictors of nigh sweats, day sweats, and hot flashes in older primary care patients, Ann Fam Med 2(5):391-397, 2004.
BIBLIOGRAPHY Clark RJ et al: Physical therapists' recognition of battered women in clinical settings, Physical Therapy 76(1):12-19, 1996. Dalton A: Family violence: Recognizing the signs, offering help, PT Magazine 13(l):34-40, 2005. Ganley AL: A trainer's manual for health care providers Published by Family Violence Prevention Fund, 1998. Available at http://endabuse.org/ or 1-415-252-8900. Johnson C: Handling the hurt: Physical therapy and domestic violence, PT Magazine 5(l):52-64, 1997. Neufeld B: SAFE Questions: Overcoming barriers to the detection of domestic violence, American Family Physician 53(8): 2575-2580, 1996. Rosenblatt DE et al: Reporting the mistreatment of older adults: The role of physicians, Journal of the American Geriatrics Society 44(l):65-70, 1996. Schachter CL, Stalker CA, Teram E: Toward sensitive practice: Issues for physical therapists working with survivors of childhood sexual abuse, Physical Therapy 79(3):248-261, 1999. Warshaw C: Improving the health care response to domestic violence: A resource manual for health care providers, ed 2, Pennsylvania Coalition Against Domestic Violence, 1998. Available at: www.pcadv.org
Pain Types and Viscerogenic Pain Patterns
P
ain is often the primary symptom in many physical therapy practices. Pain assessment is a key feature in the physical therapy interview. Pain is now recognized as the "fifth vital sign" along with blood pressure, temperature, heart rate, and respiration. Recognizing pain patterns that are characteristic of systemic disease is a necessary step in the screening process. Understanding how and when diseased organs can refer pain to the neuromusculoskeletal (NMS) system helps the therapist identify suspicious pain patterns. This chapter includes a detailed overview of pain patterns that can be used as a foundation for all the organ systems presented. Information will include a discussion of pain types in general and viscerogenic pain patterns specifically. Each section discusses specific pain patterns characteristic of disease entities that can mimic pain from musculoskeletal or neuromuscular disorders. In the clinical decision-making process the therapist will evaluate information regarding the location, referral pattern, description, frequency, intensity, and duration of systemic pain in combination with knowledge of associated symptoms and relieving and aggravating factors. This information is then compared with presenting features of primary musculoskeletal lesions that have similar patterns of presentation. Pain patterns of the chest, back, shoulder, scapula, pelvis, hip, groin, and sacroiliac joint are the most common sites of referred pain from a systemic disease process. These patterns are discussed in greater detail later in this text (see Chapters 14 to 18). A large component in the screening process is being able to recognize the client demonstrating a significant emotional overlay. Pain patterns from cancer can be very similar to what we have traditionally identified as psychogenic or emotional sources of pain. It is important to know how to differentiate between these two sources of painful symptoms. To help identify psychogenic sources of pain, discussions of conversion symptoms, symptom magnification, and illness behavior are also included in this chapter. 1
MECHANISMS OF REFERRED VISCERAL PAIN The neurology of visceral pain is not understood at this time. Proposed models are based on what is known about the somatic sensory system. Scientists have not found actual nerve fibers and specific nociceptors in organs. We do know the afferent supply to internal organs is in close proximity to blood vessels along a path similar to the sympathetic nervous system. Viscerosensory fibers ascend the anterolateral system to the thalamus with fibers projecting to several regions of the brain. These regions encode the site of origin of visceral pain, although they do it poorly because of low 2
110
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111
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
receptor density, large overlapping receptive fields, and extensive convergence in the ascending pathway. Thus, the cortex cannot distinguish where the pain messages originate from. Studies show there may be multiple mechanisms operating at different sites to produce the sensation we refer to as "pain." The same symptom can be produced by different mechanisms and a single mechanism may cause different symptoms. In the case of referred pain patterns of viscera there are three separate phenomena to consider. These are: • Embryologic development • Multisegmental innervation • Direct pressure and shared pathways 3,4
5
Embryologic Development Each system has a bit of its own uniqueness in how pain is referred. For example the viscera in the abdomen comprise a large percentage of all the organs we have to consider. When a person gives a history of abdominal pain, the location of the pain may not be directly over the involved organ (Fig. 3-1). Functional magnetic resonance imaging (fMRI) and other neuroimaging methods have shown activation of the inferolateral postcentral gyrus by visceral pain so the brain has a role in visceral pain
patterns. ' However, it is likely that embryologic development has the primary role in referred pain patterns for the viscera. Pain is referred to a site where the organ was located in fetal development. Although the organ migrates during fetal development, its nerves persist in referring sensations from the former location. Organs such as the kidneys, liver, and intestines begin forming by 3 weeks when the fetus is still less than the size of a raisin. By day 19, the notochord forming the spinal column has closed and by day 21, the heart begins to beat. Embryologically, the chest is part of the gut. In other words, they are formed from the same tissue in utero. This explains symptoms of intrathoracic organ pathology frequently being referred to the abdomen as a viscero-viscero reflex. For example, it is not unusual for disorders of thoracic viscera such as pneumonia or pleuritis to refer pain that is perceived in the abdomen instead of the chest. Although the heart muscle starts out embryologically as a cranial structure, the pericardium around the heart is formed from gut tissue. This explains why myocardial infarction or pericarditis can also refer pain to the abdomen. Another example of how embryologic development impacts the viscera and the soma, consider 6 7
2
2
F i g . 3-1 • Common sites of referred pain from the abdominal viscera. When a client gives a history of referred pain from the viscera, the pain's location may not be directly over the impaired organ. Visceral embryologic development is the mechanism of the referred pain pattern. Pain is referred to the site where the organ was located in fetal development. (From Jarvis C: Physical examination and health assessment, Philadelphia, 1992, WB Saunders.)
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INTRODUCTION TO THE SCREENING PROCESS
the ear and the kidney. These two structures have the same shape since they come from the same embryologic tissue (otorenal axis of the mesenchyme) and are formed at the same time (Fig. 3-2). When a child is born with any anomaly of the ear(s) or even a missing ear, the medical staff knows to look for possible similar changes or absence of the kidney on the same side. A thorough understanding of fetal embryology is not really necessary in order to recognize red flag signs and symptoms of visceral origin. Knowing that it is one of several mechanisms by which the visceral referred pain patterns occur is a helpful start. However, the more you know about embryologic development of the viscera, the faster you will recognize somatic pain patterns caused by visceral dysfunction. Likewise, the more you know about anatomy, the origins of anatomy, its innervations, and the underlying neurophysiology, the better able you will be to identify the potential structures involved. This will lead you more quickly to specific screening questions to ask. The manual therapist will especially benefit from a keen understanding of embryologic tissue derivations. An appreciation of embryology will help the therapist localize the problem vertically.
A Fig.
B 3-2
•
The
ear
and
since they a r e f o r m e d
the
kidney
have
the
at the s a m e time a n d
same
shape
f r o m the s a m e
e m b r y o l o g i c tissue ( o t o r e n a l a x i s of t h e m e s e n c h y m e ) . This is just o n e e x a m p l e o f h o w fetal d e v e l o p m e n t i n f l u e n c e s f o r m a n d function. W h e n a child
is b o r n with a d e f o r m e d or missing
ear, the m e d i c a l staff looks for a s i m i l a r l y d e f o r m e d or missing k i d n e y on
nursing
the s a m e side.
& allied health
(From A n d e r s o n
dictionary,
ed
5,
St.
K N : Mosby's medical,
Louis,
1988,
M o s b y ; A-
39; a n d f r o m Seidel H M , Ball J W , D a i n s JE, et a l : Mosby's physical
examination
handbook,
St.
Louis,
2003,
Mosby.)
MULTISEGMENTAL INNERVATION Multisegmental innervation is the second mechanism used to explain pain patterns of a viscerogenic source (Fig. 3-3). The autonomic nervous system (ANS) is part of the peripheral nervous system. As shown in this diagram, the viscera have multisegmental innervations. The multiple levels of innervation of the heart, bronchi, stomach, kidneys, intestines, and bladder are demonstrated clearly. Pain of a visceral origin can be referred to the corresponding somatic areas. The example of cardiac pain is a good one. Cardiac pain is not felt in the heart, but is referred to areas supplied by the corresponding spinal nerves. Instead of actual physical heart pain, cardiac pain can occur in any structure innervated by C3 to T4 such as the jaw, neck, upper trapezius, shoulder, and arm. Pain of cardiac and diaphragmatic origin is often experienced in the shoulder, in particular, because the C5 spinal segment supplies the heart, respiratory diaphragm, and shoulder.
Direct Pressure and Shared Pathways A third and final mechanism by which the viscera refer pain to the soma is the concept of direct pressure and shared pathways (Fig. 3-4). As shown in this illustration, many of the viscera are near the respiratory diaphragm. Any pathologic process that can inflame, infect, or obstruct the organs can bring them in contact with the respiratory diaphragm. Anything that impinges the central diaphragm can refer pain to the shoulder and anything that impinges the peripheral diaphragm can refer pain to the ipsilateral costal margins and/or lumbar region (Fig. 3-5). This mechanism of referred pain through shared pathways occurs as a result of ganglions from each neural system gathering and sharing information through the cord to the plexuses. The visceral organs are innervated through the autonomic nervous system. The ganglions bring in good information from around the body. The nerve plexuses decide how to respond to this information (what to do) and give the body fine, local control over responses. Plexuses originate in the neck, thorax, diaphragm, and abdomen, terminating in the pelvis. The brachial plexus supplies the upper neck and shoulder while the phrenic nerve innervates the respiratory diaphragm. More distally, the celiac plexus supplies the stomach and intestines. The neurologic supply of the plexuses is from
Fig.
3-3
•
Sympathetic a n d parasympathetic divisions
of the a u t o n o m i c
nervous
system.
The visceral
afferent
fibers m e d i a t i n g p a i n travel w i t h the sympathetic nerves, except for those f r o m the pelvic o r g a n s , w h i c h f o l l o w the parasympathetics organs
have
of
the
pelvic
multisegmental
nerve.
Major
innervations
innervations o f somatic structures. Visceral referred
to
the
corresponding
somatic
visceral
overlapping pain can
area
be
because
sensory fibers for the viscera a n d somatic structures enter the s p i n a l c o r d a t t h e s a m e levels c o n v e r g i n g o n t h e s a m e neurons.
(From
Anderson
KN:
Mosby's
allied health dictionary, ed 5, St. Louis,
Fig.
3-4
•
medical,
nursing
Direct pressure from a n y inflamed,
obstructed o r g a n
in
contact with
&
1 9 9 8 , Mosby.)
infected, or
the respiratory d i a p h r a g m
c a n refer p a i n to the ipsilateral shoulder. N o t e the location of each
of
the
viscera.
The
spleen
is
tucked
up
under
the
d i a p h r a g m o n t h e left s i d e s o a n y i m p a i r m e n t o f t h e s p l e e n c a n c a u s e left s h o u l d e r p a i n . T h e t a i l o f t h e p a n c r e a s c a n c o m e in
contact with
the
diaphragm
on
the
left
side
potentially
c a u s i n g r e f e r r e d p a i n t o t h e left s h o u l d e r . T h e h e a d o f t h e p a n -
Fig.
creas c a n
(inside)
i m p i n g e the
right side of the d i a p h r a g m c a u s i n g
referred p a i n to the right side. The g a l l b l a d d e r (not shown) is
3-5
•
Irritation
surface
of
of the the
peritoneal
central
area
(outside) of
the
or
pleural
respiratory
d i a p h r a g m can refer s h a r p p a i n to the u p p e r trapezius muscle,
located up u n d e r the liver on the right side w i t h c o r r e s p o n d i n g
neck, a n d supraclavicular fossa. The p a i n pattern is ipsilateral
right referred shoulder p a i n possible. O t h e r o r g a n s that c a n
to the a r e a of irritation. Irritation of the p e r i p h e r a l p o r t i o n of
c o m e i n c o n t a c t w i t h the d i a p h r a g m i n this w a y i n c l u d e the
the d i a p h r a g m c a n refer s h a r p p a i n to the costal m a r g i n s a n d
heart a n d the kidneys.
lumbar region (not shown).
1 14
SECTION I
INTRODUCTION TO THE SCREENING PROCESS
parasympathetic fibers from the vagus and pelvic splanchnic nerves. The plexuses work independently of each other, but not independently of the ganglia. The ganglia collect information derived from both the parasympathetic and the sympathetic fibers. The ganglia deliver this information to the plexuses; it is the plexuses that provide fine, local control in each of the organ systems. For example, the lower portion of the heart is in contact with the center of the diaphragm. The spleen on the left side of the body is tucked up under the dome of the diaphragm. The kidneys (on either side) and the pancreas in the center are in easy reach of some portion of the diaphragm. The body of the pancreas is in the center of the human body. The tail rests on the left side of the body. If an infection, inflammation, or tumor or other obstruction distends the pancreas, it can put pressure on the central part of the diaphragm. Since the phrenic nerve (C3-5) innervates the central zone of the diaphragm as well as part of the pericardium, the gallbladder, and the pancreas, the client with impairment of these viscera can present with signs and symptoms in any of the somatic areas supplied by C3-5 (e.g., shoulder). In other words, the person can experience symptoms in the areas innervated by the same nerve pathways. So a problem affecting the pancreas can look like a heart problem, a gallbladder problem, or a mid-back/scapular or shoulder problem. Most often, clients with pancreatic disease present with the primary pain pattern associated with the pancreas (i.e., left epigastric pain or pain just below the xiphoid process). The somatic presentation of referred pancreatic pain to the shoulder or back is uncommon, but it is the unexpected, referred pain patterns that we see in a physical or occupational therapy practice. Another example of this same phenomenon occurs with peritonitis or gallbladder inflammation. These conditions can irritate the phrenic endings in the central part of the diaphragmatic peritoneum. The client can experience referred shoulder pain due to the root origin shared in common by the phrenic and supraclavicular nerves. Not only is it true that any structure that touches the diaphragm can refer pain to the shoulder, but even structures adjacent to or in contact with the diaphragm in utero can do the same. Keep in mind there has to be some impairment of that structure (e.g., obstruction, distention, inflammation) for this to occur (Case Example 3-1). 2
2
ASSESSMENT OF PAIN AND SYMPTOMS The interviewing techniques and specific questions for pain assessment are outlined in this section. The information gathered during the interview and examination provides a description of the client that is clear, accurate, and comprehensive. The therapist should keep in mind cultural rules and differences in pain perception, intensity, and responses to pain found among various ethnic groups. Measuring pain and assessing pain are two separate issues. A measurement assigns a number or value to give dimension to pain intensity. A comprehensive pain assessment includes a detailed health history, physical exam, medication history (including nonprescription drug use and complementary and alternative therapies), assessment of functional status, and consideration of psychosocial-spiritual factors. The portion of the core interview regarding a client's perception of pain is a critical factor in the evaluation of signs and symptoms. Questions about pain must be understood by the client and should be presented in a nonjudgmental manner. A record form may be helpful to standardize pain assessment with each client (Fig. 3-6). To elicit a complete description of symptoms from the client, the physical therapist may wish to use a term other than pain. For example, referring to the client's symptoms or using descriptors such as hurt or sore may be more helpful with some individuals. Burning, tightness, heaviness, discomfort, and aching are just a few examples of other possible word choices. The use of alternative words to describe a client's symptoms may also aid in refocusing attention away from pain and toward improvement of functional abilities. If the client has completed the McGill Pain Questionnaire (see discussion of McGill Pain Questionnaire in this chapter), the physical therapist may choose the most appropriate alternative word selected by the client from the list to refer to the symptoms (see Table 3-1). 8
9
10
11
Pain Assessment in the Older Adult Pain is an accepted part of the aging process but we must be careful to take the reports of pain from older persons as serious and very real and not discount the symptoms as part of aging. Well over half the older adults in the United States report chronic joint symptoms. We are likely to see pain more often as a key feature among older adults as our population continues to age. 12
CHAPTER 3
CASE EXAMPLE
3-1
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
M e c h a n i s m of R e f er r e d
A 72-year-old woman has come to physical therapy for rehabilitation after cutting her hand and having a flexor tendon repair. She uses a walker to ambulate, reports being short of breath "her whole life," and takes the following prescription and over-the-counter medications: Feldene Vioxx* Ativan Glucosamine Ibuprofen "on bad days" Furosemide And one other big pill once a week on Sunday "for my bones" During the course of evaluating and treating her hand, she reports constant, aching pain in her right shoulder and a sharp, tingling, burning sensation behind her armpit (also on the right side). She does not have any associated bowel or bladder signs and symptoms, but reports excessive fatigue "since the day I was born." You suspect the combination of Feldene and Ibuprofen along with long-term use of Vioxx may be a problem. What is the most likely mechanism of pain: embryologic development, multisegmental innervation of the stomach and duodenum, or direct pressure on the diaphragm?
115
Pain
Even though Vioxx is a Cox-2 inhibitor and less likely to cause problems, gastritis and GI bleeding are still possible, especially with chronic long-term use of multiple nonsteroidal antiinflammatory drugs (NSAIDs). Retroperitoneal bleeding from peptic ulcer can cause referred pain to the back at the level of the lesion (T6 to T10) or right shoulder and/or upper trapezius pain. Shoulder pain may be accompanied by sudomotor changes such as burning, gnawing, or cramping pain along the lateral border of the scapula. The scapular pain can occur alone as the only symptom. Side effects of NSAIDs can also include fatigue, anxiety, depression, paresthesia, fluid retention, tinnitus, nausea, vomiting, dry mouth, and bleeding from the nose, mouth, or under the skin. If peritoneal bleeding is the cause of her symptoms, the mechanism of pain is blood in the posterior abdominal cavity irritating the diaphragm through direct pressure. Be sure to take the client's vital signs and observe for significant changes in blood pressure and pulse. Poor wound healing and edema (sacral, pedal, hands) may be present. Ask if the same doctor prescribed each medication and if her physician (or physicians) knows which medications she is taking. It is possible that her medications have not been checked or coordinated from before her hospitalization to the present time.
Removed from the market by Merck & Co., Inc. in 2004 due to reports of increased risk of cardiovascular events.
The American Geriatrics Society reports the use of over-the-counter analgesic medications for pain, aching, and discomfort is common in older adults along with routine use of prescription drugs. Many older adults have taken these medications for 6 months or more. Older adults may avoid giving an accurate assessment of their pain. Some may expect pain with aging or fear that talking about pain will lead to expensive tests or medications with unwanted side effects. Fear of losing one's independence may lead others to underreport pain symptoms. Sensory and cognitive impairment in older, frail adults makes communication and pain assessment more difficult. The client may still be able to report pain levels reliably using the visual ana13
13
logue scales in the early stages of dementia. Improving an older adult's ability to report pain may be as simple as making sure the client has his or her glasses and hearing aid. The Verbal Descriptor Scale (VDS) (Box 3-1) may be the most sensitive and reliable among older adults, including those with mild to moderate cognitive impairment. But these and other pain scales rely on the client's ability to understand the scale and communicate a response. As dementia progresses, these abilities are lost as well. A client with Alzheimer's type dementia loses short-term memory and cannot always identify the source of recent painful s t i m u l i . The Alzheimer's Discomfort Rating Scale may be more helpful for older adults who are unable to 14
1516
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Pain Assessment Record Form Client's name:
Date:
O n s e t o f p a i n (circle o n e ) : W a s t h e r e a n : Accident
Injury
T r a u m a (violence)
S p e c i f i c activity
If y e s , d e s c r i b e :
Characteristics of pain/symptoms: L o c a t i o n (Show me exactly where your pain/symptom is located):
Do y o u have any pain or s y m p t o m s a n y w h e r e else?
Yes
No
D e s c r i p t i o n (If y e s , w h a t d o e s i t f e e l like):
Circle any other w o r d s that describe the client's s y m p t o m s : Knifelike
Dull
Aching
Boring
Burning
Throbbing
Heaviness
Discomfort
Sharp
Stinging
Tingling
F r e q u e n c y (circle o n e ) :
Constant
I f c o n s t a n t : D o y o u h a v e this p a i n right n o w ?
Other (describe):
Stabbing Intermittent ( c o m e s a n d g o e s ) Yes
No
If i n t e r m i t t e n t : H o w o f t e n is t h e p a i n p r e s e n t (circle all t h a t a p p l y ) : Hourly
Once/daily
Intensity:
Twice/daily
Numeric Rating Scale a n d
the
Unpredictable
Other (please describe):.
Faces Pain Scale
I n s t r u c t i o n s : O n a s c a l e f r o m 0 t o 1 0 w i t h z e r o m e a n i n g ' N o p a i n ' a n d 1 0 for ' U n b e a r a b l e p a i n , ' h o w w o u l d y o u rate y o u r p a i n right n o w ? Pain A s s e s s m e n t Scale
0 1 None
Fig. 3-6
2 Mild
•
3
4
5
6
7
8
9
10 10+
Nagging Miserable Intense Unbearable
Pain A s s e s s m e n t R e c o r d F o r m . Use this f o r m to c o m p l e t e the p a i n h i s t o r y a n d o b t a i n a d e s c r i p t i o n of the p a i n p a t t e r n .
T h e f o r m i s p r i n t e d i n t h e A p p e n d i x f o r y o u r u s e . T h i s f o r m m a y b e c o p i e d a n d u s e d w i t h o u t p e r m i s s i o n . (From Carlsson A M : Assessm e n t o f c h r o n i c p a i n . I . Aspects o f the r e l i a b i l i t y a n d v a l i d i t y o f the visual a n a l o g u e scale, Pain 16(1 ) : 8 7 - 1 0 1 , 1 9 8 3 . Used w i t h permission.)
CHAPTER 3
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
Duration: H o w long d o e s y o u r pain ( n a m e t h e s y m p t o m ) last?
Pattern H a s the pain c h a n g e d since it first b e g a n ?
Yes
No
If y e s , p l e a s e e x p l a i n :
A s s o c i a t e d s y m p t o m s ( W h a t o t h e r s y m p t o m s h a v e y o u h a d w i t h this p r o b l e m ? )
Burning
Difficulty b r e a t h i n g
Shortness of breath
Cough
Skin rash (or o t h e r lesions)
C h a n g e in bowel/bladder
Difficulty s w a l l o w i n g
Painful s w a l l o w i n g
Dizziness
Heart palpitations
Hoarseness
Nausea/vomiting
Diarrhea
Constipation
B l e e d i n g of a n y kind
Sweats
Numbness
Problems with vision
Tingling
Weakness
Joint pain
Weight loss/gain
Other:
F i n a l q u e s t i o n : A r e t h e r e a n y o t h e r pain o r s y m p t o m s o f a n y kind a n y w h e r e e l s e i n y o u r b o d y t h a t w e h a v e not t a l k e d a b o u t y e t ?
For t h e therapist: Follow up questions can include: A r e t h e r e a n y positions t h a t m a k e i t f e e l better? W o r s e ? H o w d o e s rest affect t h e p a i n / s y m p t o m s ? H o w d o e s activity affect t h e p a i n / s y m p t o m s ? H o w h a s this p r o b l e m affected y o u r d a i l y life a t w o r k o r a t h o m e ? H a s this p r o b l e m affected y o u r ability t o c a r e for y o u r s e l f w i t h o u t a s s i s t a n c e ( e . g . d r e s s , b a t h e , c o o k , d r i v e ) ? H a s this p r o b l e m affected y o u r s e x u a l f u n c t i o n o r activity? Therapist's evaluation: C a n y o u r e p r o d u c e the p a i n b y s q u e e z i n g o r p a l p a t i n g t h e s y m p t o m a t i c a r e a ? D o e s resisted m o t i o n r e p r o d u c e t h e p a i n / s y m p t o m s ? I s the client t a k i n g N S A I D s ? E x p e r i e n c i n g i n c r e a s e d s y m p t o m s after t a k i n g N S A I D s ? If taking N S A I D s , is t h e client at risk for peptic ulcer? C h e c k all that a p p l y : •
A g e > 6 5 years
• History of p e p t i c ulcer d i s e a s e or Gl d i s e a s e
•
Smoking, alcohol use
• Oral corticosteroid use
•
A n t i c o a g u l a t i o n or u s e of o t h e r a n t i c o a g u l a n t s ( e v e n w h e n u s e d for heart p a t i e n t s at a l o w e r d o s e , e.g., 81 to 3 2 5 mg a s p i r i n / d a y )
•
Renal c o m p l i c a t i o n s in clients w i t h h y p e r t e n s i o n or c o n g e s t i v e heart failure ( C H F ) or w h o u s e d i u r e t i c s or A C E inhibitors
•
N S A I D s c o m b i n e d w i t h s e l e c t i v e s e r o t o n i n r e u p t a k e inhibitors ( S S R I s ; a n t i d e p r e s s a n t s s u c h a s P r o z a c , Zoloft, C e l e x a , Paxil)
•
Use of acid s u p p r e s s a n t s ( e . g . , H - r e c e p t o r a n t a g o n i s t s , a n t a c i d s ) 2
Other areas to consider: • S l e e p quality
• Bowel/bladder habits
• D e p r e s s i o n or a n x i e t y s c r e e n i n g s c o r e
• C o r r e l a t i o n of s y m p t o m s w i t h p e a k effect of m e d i c a t i o n s ( d o s a g e , t i m e of d a y ) • E v a l u a t i o n of joint p a i n ( s e e A p p e n d i x : S c r e e n i n g Q u e s t i o n s for J o i n t Pain) Fig.
3-6
•
cont'd
• For w o m e n : c o r r e l a t i o n of s y m p t o m s w i t h m e n s t r u a l c y c l e
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Verbal
INTRODUCTION TO THE SCREENING PROCESS
Descriptor Scale (VDS)
Directions: Show the scale to your client. Read the descriptors and ask the client to point to the one that best matches his or her pain (achiness, soreness, or discomfort) today. Give the client at least 30 seconds to respond. A verbal reply is acceptable. It is best if the client is sitting upright facing the interviewer. Provide the client with good lighting, his or her eyeglasses, and/or hearing aid(s) if appropriate. 0 1 2 3 4 5 6
TODAY I HAVE: = NO PAIN = SLIGHT PAIN = MILD PAIN = MODERATE PAIN = SEVERE PAIN = EXTREME PAIN = PAIN AS BAD AS IT CAN BE
B O X 3-2
• • • • • • • • • • • • • •
communicate their pain. The therapist records the frequency, intensity, and duration of the client's discomfort based on the presence of noisy breathing, facial expressions, and overall body language. Another tool under investigation for Pain Assessment in Advanced Dementia is the PAINAD scale. The PAINAD is a simple, valid, and reliable instrument for measurement of pain in noncommunicative clients developed by the same author as the Alzheimer's Discomfort Rating Scale. Facial grimacing, nonverbal vocalization such as moans, sighs, or gasps, and verbal comments (e.g., ouch, stop) are the most frequent behaviors among cognitively impaired older adults during painful movement (Box 3-2). Bracing, holding onto furniture, or clutching the painful area are other behavioral indicators of pain. Alternately, the client may resist care by others or stay very still to guard against pain caused by movement. Untreated pain in an older adult with advanced dementia can lead to secondary problems such as sleep disturbances, weight loss, dehydration, and depression. Pain may be manifested as agitation and increased confusion. Older adults are more likely than younger adults to have what is referred to as atypical acute pain. For example, silent acute myocardial infarction (MI) occurs more often in the older adult than in the middle-aged to early senior adult. Likewise, the older adult is more likely to experience appendicitis without any abdominal or pelvic pain.
Symptoms o f Pain i n Clients with Cognitive Impairment
Verbal comments such as ouch or stop Nonverbal vocalizations (e.g., moans, signs, gasps) Facial grimacing or frowning Audible breathing independent of vocalization (labored, short or long periods of hyperventilation) Agitation or increased confusion Unable to be consoled or distracted Bracing or holding onto furniture Decreased mobility Lying very still; refusing to move Clutching the painful area Resisting care provided by others; striking out; pushing others away Sleep disturbance Weight loss Depression
17
18
19
15
20
Pain Assessment in the Young Child Many infants and children are unable to report pain. Even so the therapist should not underesti-
mate or prematurely conclude that a young client is unable to answer any questions about pain. Even some clients (both children and adults) with substantial cognitive impairment may be able to use pain-rating scales when explained carefully. The Faces Pain Scale (FACES or FPS) for children (see Fig. 3-6) was first presented in the 1980s. It has since been revised (FPS-R) and presented concurrently by other researchers with similar assessment measures. Most of the pilot work for the FPS was done informally with children from preschool through young school age. Researchers have used the FPS scale with adults, especially the elderly, and have had successful results. Advantages of the cartoon type FPS scale are that it avoids gender, age, and racial biases. Research shows that use of the word "hurt" rather than pain is understood by children as young as 3 years o l d . Use of a word such as "owie" or "ouchie" by a child to describe pain is an acceptable substitute. Assessing pain intensity with the FPS scale is fast and easy. The child looks at the faces, the therapist or parent uses the simple words to describe the expression, and the corresponding number is used to record the score. A review of multiple other measures of selfreport is also available as well as a review of pain measures used in children by age including neonates. When using a rating scale is not possible, the therapist may have to rely on the parent or care21
22
23
24
25
26,27
25
9
28
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
CHAPTER 3
giver's report and/or other measures of pain in children with cognitive or communication impairments and physical disabilities. Look for telltale behavior such as lack of cooperation, withdrawal, acting out, distractibility, or seeking comfort. Altered sleep patterns, vocalizations, and eating patterns provide additional clues. In very young children and infants, the Child Facial Coding System (CFCS) and the Neonatal Facial Coding System (NFCS) can be used as behavioral measures of pain intensity. Facial actions and movements such as brow bulge, eye squeeze, mouth position, and chin quiver are coded and scored as pain responses. This tool has been revised and tested as valid and reliable for use post-operatively in children ages 0 to 18 months following major abdominal or thoracic surgery. Vital signs should be documented, but not relied upon, as the sole determinant of pain (or absence of pain) in infants or young children. The pediatric therapist may want to investigate other pain measures available for neonates and infants. ' 29,30
31
32
33
Characteristics of Pain It is very important to identify how the client's description of pain as a symptom relates to sources and types of pain discussed in this chapter. Many characteristics of pain can be elicited from the client during the Core Interview to help define the source or type of pain in question. These characteristics include: • Location • Description of sensation • Intensity • Duration • Frequency and Duration • Pattern Other additional components are related to factors that aggravate the pain, factors that relieve the pain, and other symptoms that may occur in association with the pain. Specific questions are included in this section for each descriptive component. Keep in mind that an increase in frequency, intensity, or duration of symptoms over time can indicate systemic disease.
Location of Pain Questions related to the location of pain focus the client's description as precisely as possible. An opening statement might be as follows: Follow-Up
Questions
• Show me exactly where your pain is located. Follow up questions may include
119
• Do you have any other pain or symptoms anywhere else? • If yes, what causes the pain or symptoms to occur in this other area? If the client points to a small, localized area and the pain does not spread, the cause is likely to be a superficial lesion and is probably not severe. If the client points to a small, localized area but the pain does spread, this is more likely to be a diffuse, segmental, referred pain that may originate in the viscera or deep somatic structure. The character and location of pain can change and the client may have several pains at once so repeated pain assessment may be needed.
Description of Pain To assist the physical therapist in obtaining a clear description of pain sensation, pose the question: Follow-Up
Questions
• What does it feel like? After giving the client time to reply, offer some additional choices in potential descriptors. You may want to ask: Is your pain/Are your symptoms: Knifelike Dull Boring Burning Throbbing Prickly Deep aching Sharp Follow-up questions may include: • Has the pain changed in quality since it first began? • Changed in intensity? • Changed in duration (how long it lasts)? When a client describes the pain as knifelike, boring, colicky, coming in waves, or a deep aching feeling, this description should be a signal to the physical therapist to consider the possibility of a systemic origin of symptoms. Dull, somatic pain of an aching nature can be differentiated from the aching pain of a muscular lesion by squeezing or by pressing the muscle overlying the area of pain. Resisting motion of the limb may also reproduce aching of muscular origin that has no connection to deep somatic aching.
Intensity of Pain The level or intensity of the pain is an extremely important, but difficult, component to assess in the overall pain profile. Psychologic factors may play a role in the different ratings of pain intensity measured between African Americans and Caucasians. African Americans tend to rate pain as more
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unpleasant and more intense than whites, possibly indicating a stronger link between emotions and pain behavior for African Americans compared with Caucasians. The same difference is observed between women and m e n . ' Likewise, pain intensity is reported as less when the affected individual has some means of social or emotional support. Assist the client with this evaluation by providing a rating scale. You may use one or more of these scales, depending on the clinical presentation of each client (see Fig. 3-6). Show the pain scale to your client. Ask the client to choose a number and/or a face that best describes his or her current pain level. You can use this scale to quantify symptoms other than pain such as stiffness, pressure, soreness, discomfort, cramping, aching, numbness, tingling, and so on. Always use the same scale for each follow-up assessment. The Visual Analog Scale (VAS) ' allows the client to choose a point along a 10-centimeter (100 mm) horizontal line (see Fig. 3-6). The left end represents "No pain" and the right end represents "Pain as bad as it could possibly be" or "Worst Possible Pain." This same scale can be presented in a vertical orientation for the client who must remain supine and cannot sit up for the assessment. "No pain" is placed at the bottom and "Worst pain" is put at the top. The VAS scale is easily combined with the numeric rating scale with possible values ranging from 0 (no pain) to 10 (worst imaginable pain). It can be used to assess current pain, worst pain in the preceding 24 hours, least pain in the past 24 hours, or any combination the clinician finds useful. The numerical rating scale (NRS) (see Fig. 3-6) allows the client to rate the pain intensity on a scale from 0 (no pain) to 10 (the worst pain imaginable). This is probably the most commonly used pain rating scale in both the inpatient and outpatient settings. It is a simple and valid method of measuring pain. Although the scale was tested and standardized using 0 to 10, the plus is used for clients who indicate the pain is "off the scale" or "higher than a 10." Some health care professionals prefer to describe 10 as "worst pain experienced with this condition" to avoid needing a higher number than 10. This scale is especially helpful for children or cognitively impaired clients. In general, even adults without cognitive impairments may prefer to use this scale. An alternative method provides a scale of 1 to 5 with word descriptions for each number and asks: 34
35
36
37
38
39
11
Follow-Up
Questions
• How strong is your pain? 1 = Mild 2 = Discomforting 3 = Distressing 4 = Horrible 5 = Excruciating This scale for measuring the intensity of pain can be used to establish a baseline measure of pain for future reference. A client who describes the pain as "excruciating" (or a 5 on the scale) during the initial interview may question the value of therapy when several weeks later there is no subjective report of improvement. A quick check of intensity by using this scale often reveals a decrease in the number assigned to pain levels. This can be compared with the initial rating, thus providing the client with assurance and encouragement in the rehabilitation process. A quick assessment using this method can be made by asking: Follow-Up
Questions
• How strong is your pain? 1 = Mild 2 = Moderate 3 = Severe The description of intensity is highly subjective. What might be described as "mild" for one person could be "horrible" for another person. Careful assessment of the person's nonverbal behavior (e.g., ease of movement, facial grimacing, guarding movements) and correlation of the person's personality with his or her perception of the pain may help to clarify the description of the intensity of the pain. Pain of an intense, unrelenting (constant) nature is often associated with systemic disease. The 36-Item Short-Form Health Survey discussed in Chapter 2 includes an assessment of bodily pain along with a general measure of healthrelated quality of life. Nurses often use the PQRST mnemonic to help identify underlying pathology or pain (Box 3-3).
Frequency and Duration of Pain The frequency of occurrence is related closely to the pattern of the pain, and the client should be asked how often the symptoms occur and whether the pain is constant or intermittent. Duration of pain is a part of this description.
CHAPTER 3
B O X 3-3
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
Nursing Assessment o f Pain (PQRST)
Provocation and palliation. What causes the pain and what makes it better or worse? Quality of pain. What type of pain is present (aching, burning, sharp)? Region and radiation. Where is the pain located? Does it radiate to other parts of the body? Severity on a scale from 0 to 10. Does the pain interfere with daily activities, mood, function? Timing. Did the pain come on suddenly or gradually? Is it constant or does it come and go (intermittent)? How often does it occur? How long does it last? Does it come on at the same time of the day or night?
Follow-Up
Questions
• How long do the symptoms last? For example, pain related to systemic disease has been shown to be a constant rather than an intermittent type of pain experience. Clients who indicate that the pain is constant should be asked: • Do you have this pain right now? • Did you notice these symptoms this morning immediately when you woke up? Further responses may reveal that the pain is perceived as being constant but in fact is not actually present consistently and/or can be reduced with rest or change in position, which are characteristics more common with pain of musculoskeletal origin.
Pattern of Pain After listening to the client describe all the characteristics of his or her pain or symptoms, the therapist may recognize a vascular, neurogenic, musculoskeletal (including spondylogenic), emotional, or visceral pattern (Table 3-1). The following sequence of questions may be helpful in further assessing the pattern of pain, especially how the symptoms may change with time. Follow-Up
Questions
• Tell me about the pattern of your pain/ symptoms. • Alternate question: When does your back/shoulder (name the involved body part) hurt?
TABLE
3-1
Vascular
Throbbing Pounding Pulsing Beating
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R e c o g n i z i n g Pain Patterns Neurogenic
Musculoskeletal
Emotional
Sharp Crushing Pinching Burning Hot Searing Itchy Stinging Pulling Jumping Shooting Pricking Gnawing Electrical
Aching Sore Heavy Hurting Dull Cramping Deep
Tiring Miserable Vicious Agonizing Nauseating Frightful Piercing Dreadful Punishing Torturing Killing Unbearable Annoying Cruel Sickening Exhausting
From Melzack R: The McGill Pain Questionnaire: major properties and scoring methods, Pain 1:277, 1975.
• Alternate question: Describe your pain/ symptoms from first waking up in the morning to going to bed at night. (See special sleeprelated questions that follow.) Follow-up questions may include: • Have you ever experienced anything like this before? • If yes, do these episodes occur more or less often than at first? • How does your pain/symptom(s) change with time? • Are your symptoms worse in the morning or evening? The pattern of pain associated with systemic disease is often a progressive pattern with a cyclical onset (i.e., the client describes symptoms as being alternately worse, better, and worse over a period of months). When there is back pain, this pattern differs from the sudden sequestration of a discogenic lesion that appears with a pattern of increasingly worse symptoms followed by a sudden cessation of all symptoms. Such involvement of the disk occurs without the cyclical return of symptoms weeks or months later, which is more typical of a systemic disorder. If the client appears to be unsure of the pattern of symptoms or has "avoided paying any attention" to this component of pain description, it may be useful to keep a record at home assisting the client to take note of the symptoms for 24 hours. A chart such as the McGill Home Recording Card 11
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Fig. 3-7
SECTION |
•
INTRODUCTION TO THE SCREENING PROCESS
M c G i l l H o m e R e c o r d i n g C a r d . W h e n assessing c o n s t a n t p a i n , h a v e the client c o m p l e t e this f o r m for 2 4 t o 4 8 h o u r s .
P a y a t t e n t i o n t o t h e c l i e n t w h o d e s c r i b e s a loss o f s l e e p b u t w h o i s n o t a w a k e e n o u g h t o r e c o r d m i s s e d o r i n t e r r u p t e d s l e e p . This m a y help the p h y s i c i a n in differentiating b e t w e e n a sleep d i s o r d e r a n d sleep d i s t u r b a n c e . You m a y w a n t to ask the client to record s e x u a l a c t i v i t y a s a m e a s u r e o f f u n c t i o n a n d p a i n levels. I t i s n o t n e c e s s a r y t o r e c o r d d e t a i l s , just w h e n t h e c l i e n t p e r c e i v e d h i m o r h e r s e l f a s b e i n g s e x u a l l y a c t i v e . ( F r o m M e l z a c k R : The M c G i l l Pain Q u e s t i o n n a i r e : m a j o r p r o p e r t i e s a n d s c o r i n g m e t h o d s , Pain 1 : 2 9 8 , 1975.)
(Fig. 3-7) may help the client outline the existing pattern of the pain and can be used later in the episode of care to assist the therapist in detecting any change in symptoms or function. Medications can alter the pain pattern or characteristics of painful symptoms. Find out how well the client's current medications reduce, control, or relieve pain. Ask how often medications are needed for breakthrough pain. When using any of the pain rating scales, record the use of any medications that can alter or reduce pain or symptoms such as antiinflammatories or analgesics. At the same time remember to look for side effects or adverse reactions to any drugs or drug combinations. Watch for clients taking nonsteroidal antiinflammatory drugs (NSAIDs) who experience an increase in shoulder, neck, or back pain several hours after taking the medication. Normally, one would expect symptom relief from NSAIDs so any
increase in symptoms is a red flag for possible peptic ulcer. A client frequently will comment that the pain or symptoms have not changed despite 2 or 3 weeks of physical therapy intervention. This information can be discouraging to both client and therapist; however, when the symptoms are reviewed, a decrease in pain, increase in function, reduced need for medications, or other significant improvement in the pattern of symptoms may be seen. The improvement is usually gradual and is best documented through the use of a baseline of pain activity established at an early stage in the episode of care by using a record such as the Home Recording Card (or other pain rating scale). However, if no improvement in symptoms or function can be demonstrated, the therapist must again consider a systemic origin of symptoms. Repeating screening questions for medical disease is encouraged throughout the episode of care even
CHAPTER 3
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
if such questions were included in the intake interview. Because of the progressive nature of systemic involvement, the client may not have noticed any constitutional symptoms at the start of the physical therapy intervention that may now be present. Constitutional symptoms (see Box 1-3) affect the whole body and are characteristic of systemic disease or illness.
Aggravating and Relieving Factors A series of questions addressing aggravating and relieving factors must be included such as: Follow-Up
Questions
• What brings your pain (symptoms) on? • What kinds of things make your pain (symptoms) worse (e.g., eating, exercise, rest, specific positions, excitement, stress)? To assess relieving factors, ask: • What makes the pain better? Follow-up questions include: • How does rest affect the pain/symptoms? • Are your symptoms aggravated or relieved by any activities? • If yes, what? • How has this problem affected your daily life at work or at home?
123
• How has this problem affected your ability to care for yourself without assistance (e.g., dress, bathe, cook, drive)? The McGill Pain Questionnaire also provides a chart (Fig. 3-8) that may be useful in determining the presence of relieving or aggravating factors. Systemic pain tends to be relieved minimally, relieved only temporarily, or unrelieved by change in position or by rest. However, musculoskeletal pain is often relieved both by a change of position and by rest.
Associated Symptoms These symptoms may occur alone or in conjunction with the pain of systemic disease. The client may or may not associate these additional symptoms with the chief complaint. The physical therapist may ask: Follow-Up
Questions
• What other symptoms have you had that you can associate with this problem? If the client denies any additional symptoms, follow up this question with a series of possibilities such as: Burning Heart Numbness/ palpitations Tingling
Indicate a plus ( + ) for aggravating factors or a minus ( -) for relieving factors.
Fig. 3 - 8 • Factors aggravating and relieving pain. (From
Liquor
Sleep/rest
Stimulants (e.g., caffeine)
Lying down
Eating
Distraction (e.g., television)
Heat
Urination/defecation
Cold
Tension/stress
Weather changes
Loud noises
Massage
Going to work
Pressure
Intercourse
No movement
Mild exercise
Movement
Fatigue
Sitting
Standing
M e l z a c k R: The M c G i l l Pain Q u e s tionnaire: scoring 1975.)
major
properties
methods,
Pain
and
1:277,
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SECTION I
Difficulty in breathing Difficulty in swallowing Dizziness
INTRODUCTION TO THE SCREENING PROCESS
Hoarseness Nausea
Problems with vision Vomiting
Night sweats
Weakness
Whenever the client says "yes" to such associated symptoms, check for the presence of these symptoms bilaterally. Additionally, bilateral weakness, either proximally or distally, should serve as a red flag possibly indicative of more than a musculoskeletal lesion. Blurred vision, double vision, scotomas (black spots before the eyes), or temporary blindness may indicate early symptoms of multiple sclerosis or may possibly be warning signs of an impending cerebrovascular accident. The presence of any associated symptoms, such as those mentioned here, would require contact with the physician to confirm the physician's knowledge of these symptoms. In summary, careful, sensitive, and thorough questioning regarding the multifaceted experience of pain can elicit essential information necessary when making a decision regarding treatment or referral. The use of pain assessment tools such as
TABLE
3-2
Fig. 3-6 and Table 3-2 may facilitate clear and accurate descriptions of this critical symptom.
SOURCES OF PAIN Between the twentieth and twenty-first centuries the science of clinical pain assessment and management made a significant paradigm shift from an empirical approach to one that is based on identifying and understanding the actual mechanisms involved in the pathogenesis of pain. The implications of this are immense as we move from classifying pain on the basis of disease, duration, and body part or anatomy to a mechanism-based classification. In this approach the major goal of assessment is to identify the pathophysiological mechanism of the pain and use this information to plan appropriate intervention. ' Physical therapists frequently see clients whose primary complaint is pain, which often leads to a loss of function. However, focusing on sources of pain does not always help us to identify the causes of tissue irritation. The most effective physical therapy diagnosis will define the syndrome and address the causes of pain rather than just identifying the sources of 5 40
C o m p a r i s o n of Systemic versus Musculoskeletal Pain Patterns Systemic
pain
Musculoskeletal
pain
• Recent, sudden • Does not present
May be sudden or gradual, depending on the history • Sudden: Usually associated with acute overload stress, traumatic event, repetitive motion; can occur as a side effect of some medications (e.g., statins) • Gradual: Secondary to chronic overload of the affected part; may be present off and on for years
Description
•
Knifelike quality of stabbing from the inside out, boring, deep aching Cutting, gnawing Throbbing Bone pain Unilateral or bilateral
Intensity
• • • • • Related
• Local tenderness to pressure is present • Achy, cramping pain • May be stiff after prolonged rest, but pain
to the degree of noxious stimuli; usually unrelated to presence of anxiety Dull to severe Mild to severe
Duration
• • • Constant,
• May • May
Onset
as observed for years without progression of symptoms
no change, awakens the person at night
level decreases unilateral
• Usually
be mild to severe depend on the person's anxiety level— the level of pain may increase in a client fearful of a "serious" condition
• May •
be constant but is more likely to be intermittent, depending on the activity or the position Duration can be modified by rest or change in position
CHAPTER 3
TABLE
3-2
pain
• Although constant, may come • Gradually progressive, cyclic • Night pain
Musculoskeletal
in waves
° ° ° °
• •
Aggravating Factors
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C o m p a r i s o n of Systemic versus Musculoskeletal Pain Patterns—cont'd Systemic
Pattern
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
• •
Location: chest/shoulder Accompanied by shortness of breath, wheezing Eating alters symptoms Sitting up relieves symptoms (decreases venous return to the heart: possible pulmonary or cardiovascular etiology) Symptoms unrelieved by rest or change in position Migratory arthralgias: Pain/symptoms last for 1 week in one joint, then resolve and appear in another joint Cannot alter, provoke, alleviate, eliminate, aggravate the symptoms Organ Dependent (Examples): ° Esophagus—eating or swallowing affects symptoms » GI—peristalsis (eating) affects symptoms ° Heart—cold, exertion, stress, heavy meal (especially when combined) bring on symptoms
pain
• Restriction of active/passive/accessory movement(s) observed • One or more particular movements "catch" the client and aggravate the pain
• Altered by movement; pain may become worse with movement or some myalgia decreases with movement
Relieving Factors
• Organ
• Symptoms reduced or relieved by rest or change in position • Muscle pain is relieved by short periods of rest without resulting stiffness, except in the case of fibromyalgia; stiffness may be present in older adults • Stretching • Heat, cold
Associated Signs and Symptoms
• Fever, chills • Night sweats • Unusual vital signs • Warning signs of cancer (see Chapter 13) • GI symptoms: Nausea, vomiting, anorexia,
• Usually none, although stimulation of trigger points may cause sweating, nausea, blanching
Dependent (Examples): ° Gallbladder—leaning forward may reduce symptoms o Kidney—leaning to the affected side may reduce symptoms o Pancreas—sitting upright or leaning forward may reduce symptoms
unexplained weight loss, diarrhea, constipation
• Early satiety (feeling full after eating) • Bilateral symptoms (e.g., paresthesias, • • • • • • •
weakness, edema, nail bed changes, skin rash) Painless weakness of muscles: More often proximal but may occur distally Dyspnea (breathlessness at rest or after mild exertion) Diaphoresis (excessive perspiration) Headaches, dizziness, fainting Visual disturbances Skin lesions, rashes, or itching that the client may not associate with the musculoskeletal symptoms Bowel/bladder symptoms ° Hematuria (blood in the urine) ° Nocturia Urgency (sudden need to urinate) ° Frequency ° Melena (blood in feces) Fecal or urinary incontinence ° Bowel smears 0
0
SECTION I
126
INTRODUCTION TO THE SCREENING PROCESS
pain. Usually, a careful assessment of pain behavior is invaluable in determining the nature and extent of the underlying pathology. The clinical evaluation of pain usually involves identification of the primary disease/etiological factor(s) considered responsible for producing or initiating the pain. The client is placed within a broad pain category usually labeled as nociceptive (e.g., pinprick), inflammatory (e.g., tissue injury), or neuropathic pain (see Table 3-4). We further classify the pain by identifying the anatomical distribution, quality, and intensity of the pain. Such an approach allows for physical therapy interventions for each identified mechanism involved. From a screening perspective we look at the possible sources of pain and types of pain. When listening to the client's description of pain, consider these possible sources of pain (Table 3-3): • Cutaneous • Somatic • Visceral • Neuropathic • Referred
and subcutaneous tissue. The pain is well localized as the client can point directly to the area that "hurts." Pain from a cutaneous source can usually be localized with one finger. Skin pain or tenderness can be associated with referred pain from the viscera or referred from deep somatic structures. Impairment of any organ can result in sudomotor changes that present as trophic changes such as itching, dysesthesia, skin temperature changes, or dry skin. The difficulty is that biomechanical dysfunction can also result in these same changes, which is why a careful evaluation of soft tissue structures along with a screening exam for systemic disease is required. Cutaneous pain perception varies from person to person and is not always a reliable indicator of pathologic etiology. These differences in pain perception may be associated with different pain mechanisms. For example, differences in cutaneous pain perception exist based on gender and ethnicity. There may be differences in opioid activity and baroreceptor-regulated pain systems between the sexes to account for these variations.
Cutaneous Sources of Pain
Somatic Sources of Pain
Cutaneous pain (related to the skin) includes superficial somatic structures located in the skin
Somatic pain can be superficial or deep. Somatic pain is labeled according to its source as deep
41
5
TABLE
3-3
Sources
Cutaneous Deep somatic Visceral Neuropathic Referred
35
Sources of Pain, Pain Types, a n d Pain Patterns Types
Characteristics/patterns
Myofascial pain • Muscle tension • Muscle spasm • Muscle trauma • Muscle deficiency (weakness and stiffness) • Trigger points (TrPs) Joint pain • Drug-induced • Chemical exposure • Inflammatory bowel disease • Septic arthritis • Reactive arthritis Radicular pain Arterial, pleural, tracheal Gastrointestinal pain Pain at rest Night pain Pain with activity Diffuse pain Chronic pain
Client describes: • Location/onset • Description • Intensity • Duration • Frequency Therapist recognizes the pattern • Vascular • Neurogenic • Musculoskeletal/spondylotic • Visceral • Emotional
CHAPTER 3
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
somatic, somatovisceral, somatoemotional (also referred to as psychosomatic), or viscerosomatic. Most of what the therapist treats is part of the somatic system whether we call that the neuromuscular system, the musculoskeletal system or the neuromusculoskeletal (NMS) system. When psychologic disorders present as somatic dysfunction, we refer to these conditions as psychophysiologic disorders. Psychophysiologic disorders, including somatoform disorders are discussed in detail elsewhere. " Superficial somatic structures involve the skin, superficial fasciae, tendons sheaths, and periosteum. Deep somatic pain comes from pathologic conditions of the periosteum and cancellous (spongy) bone, nerves, muscles, tendons, ligaments, and blood vessels. Deep somatic structures also include deep fasciae and joint capsules. When we talk about the "psycho-somatic" response, we refer to the mind-6ody connection. Deep somatic pain is poorly localized and may be referred to the body surface, becoming cutaneous pain. It can be associated with an autonomic phenomenon, such as sweating, pallor, or changes in pulse and blood pressure, and is commonly accompanied by a subjective feeling of nausea and faintness. Pain associated with deep somatic lesions follows patterns that relate to the embryologic development of the musculoskeletal system. This explains why such pain may not be perceived directly over the involved organ (see Fig. 3-1). Parietal pain (related to the wall of the chest or abdominal cavity) is also considered deep somatic. The visceral pleura (the membrane enveloping the organs) is insensitive to pain, but the parietal pleura is well supplied with pain nerve endings. For this reason it is possible for a client to have extensive visceral disease (e.g., heart, lungs) without pain until the disease progresses enough to involve the parietal pleura. Somatoemotional or psychosomatic sources of pain occur when emotional or psychologic distress produces physical symptoms either for a relatively brief period or with recurrent and multiple physical manifestations spanning many months or years. The person affected by the latter may be referred to as a somatizer, and the condition is called a somatization disorder. Two different approaches to somatization have been proposed. One method treats somatization as a phenomenon that is secondary to psychological distress. This is called presenting somatization. The second defines somatization as a primary event characterized by the presence of medically 42
44
127
unexplained symptoms. This model is called functional somatization.' Alternately, there are viscerosomatic sources of pain when visceral structures affect the somatic musculature, such as the reflex spasm and rigidity of the abdominal muscles in response to the inflammation of acute appendicitis or the pectoral trigger point associated with an acute myocardial infarction. These visible and palpable changes in the tension of skin and subcutaneous and other connective tissues that are segmentally related to visceral pathologic processes are referred to as connective tissue zones or reflex 15
46
zones. Somatovisceral pain occurs when a myalgic condition causes functional disturbance of the underlying viscera, such as the trigger points of the abdominal muscles causing diarrhea, vomiting, or excessive burping (Case Example 3-2).
Visceral Sources of Pain Visceral sources of pain include the internal organs and the heart muscle. This source of pain includes all body organs located in the trunk or abdomen, such as those of the respiratory, digestive, urogenital, and endocrine systems, as well as the spleen, the heart, and the great vessels. Visceral pain is not well localized for two reasons: 1. Innervation of the viscera is multisegmental 2. There are few nerve receptors in these structures (see Fig. 3-3). The pain tends to be poorly localized and diffuse. Visceral pain is well known for its ability to produce referred pain (i.e., pain perceived in an area other than the site of the stimuli). Referred pain occurs because visceral fibers synapse at the level of the spinal cord close to fibers supplying specific somatic structures. In other words, visceral pain corresponds to dermatomes from which the organ receives its innervations, which may be the same innervations for somatic structures. For example, the heart is innervated by the C3T4 spinal nerves. Pain of a cardiac source can affect any part of the soma (body) also innervated by these levels. This is one reason why someone having a heart attack can experience jaw, neck, shoulder, mid-back, arm or chest pain and accounts for the many and varied clinical pictures of myocardial infarction (see Fig. 6-9). More specifically, the pericardium (sac around the entire heart) is adjacent to the diaphragm. Pain of cardiac and diaphragmatic origin is often experienced in the shoulder because the C5-6
128
CASE
SECTION I
EXAMPLE
3-2
INTRODUCTION TO THE SCREENING PROCESS
Somatic
Disorder Mimicking
A 61-year-old woman reported left shoulder pain for the last 3 weeks. The pain radiates down the arm in the pattern of an ulnar nerve distribution. She had no known injury, trauma, or repetitive motion to account for the new onset of symptoms. She denied any constitutional symptoms (nausea, vomiting, unexplained sweating, or sweats). There was no reported shortness of breath. Pain was described as "gripping" and occurred most often at night, sometimes waking her up from sleep. Physical activity, motion, and exertion did not bring on, reproduce, or make her symptoms worse. After completing the interview and screening examination, what final question should always be asked every client? • Do you have any other pain or symptoms of any kind anywhere else in your body? Result: In response to this question, the client reported left-sided chest pain that radi-
Visceral
Disease
ated to her nipple and then into her left shoulder and down the arm. Palpation of the chest wall musculature revealed a trigger point (TrP) of the pectoralis major muscle. This trigger point was responsible for the chest and breast pain. Further palpation reproduced a TrP of the left subclavius muscle, which was causing the woman's left arm pain. Releasing the trigger points eliminated all of the woman's symptoms. Should you make a medical referral for this client? Yes, referral should be made to rule out a viscerosomatic reflex causing the TrPs. A clinical breast exam (CBE) and mammography may be appropriate depending on client's history and when she had her last CBE and mammogram. The client saw a cardiologist. Her echocardiogram and stress tests were negative. She was diagnosed with pseudocardiac disease secondary to a myofascial pain disorder.
From Murphy DR: Myofascial pain and pseudocardiac disease, Posted on-line April 22, 2004 [www.chiroweb.coml.
spinal segment (innervation for the shoulder) also supplies the heart and the diaphragm. Other examples of organ innervations and their corresponding sensory overlap are as follows: • Sensory fibers to the heart and lungs enter the spinal cord from Tl to T4 (this may extend to T6). • Sensory fibers to the gallbladder, bile ducts, and stomach enter the spinal cord at the level of the T7-8 dorsal roots (i.e., the greater splanchnic nerve). • The peritoneal covering of the gallbladder and/or the central zone of the diaphragm are innervated by the phrenic nerve originating from the C3-5 (phrenic nerve) levels of the spinal cord. • The phrenic nerve (C3-5) also innervates portions of the pericardium. • Sensory fibers to the duodenum enter the cord at the T9-10 levels. • Sensory fibers to the appendix enter the cord at the T10 level (i.e., the lesser splanchnic nerve). • Sensory fibers to the renal/ureter system enter the cord at the L l - 2 level (i.e., the splanchnic nerve). 2
As mentioned earlier, diseases of internal organs can be accompanied by cutaneous hypersensitivity to touch, pressure, and temperature. This viscerocutaneous reflex occurs during the acute phase of the disease and disappears with its recovery. The skin areas affected are innervated by the same cord segments as for the involved viscera; they are referred to as Head's zones. Anytime a client presents with somatic symptoms also innervated by any of these levels, we must consider the possibility of a visceral origin. Keep in mind that when it comes to visceral pain, the viscera have few nerve endings. The visceral pleura are insensitive to pain. It is not until the organ capsule (deep somatic structure) is stretched (e.g., by a tumor or inflammation) that pain is perceived and possibly localized. This is why changes can occur within the organs without painful symptoms to warn the person. It is not until the organ is inflamed or distended enough from infection or obstruction to impinge nearby structures or the lining of the chest or abdominal cavity that pain is felt. The neurology of visceral pain is not well understood. There is not a known central processing 46
CHAPTER 3
system unique to visceral pain. Scientists are currently using various theories without proven facts. For example, exact nerve fibers and specific nociceptors have not been identified in organs. It is known that the afferent supply to internal organs follows a path similar to that of the sympathetic nervous system, often in close proximity to blood vessels. The origins of embryology explain far more of the visceral pain patterns than anything else (see discussion, this chapter). In the early stage of visceral disease, sympathetic reflexes arising from afferent impulses of the internal viscera can be expressed first as sensory, motor, and/or trophic changes in the skin, subcutaneous tissues, and/or muscles. As mentioned earlier, this may present as itching, dysesthesia, skin temperature changes, or dry skin. The viscera do not perceive pain, but the sensory side is trying to get the message out that something is wrong by creating sympathetic sudomotor changes. It appears that there is no specific group of spinal neurons that respond only to visceral inputs. Since messages from the soma and viscera come into the cord at the same level (and sometimes visceral afferents converge over several segments of the spinal cord), the nervous system has trouble deciding: Is it somatic or visceral? It sends efferent information back out to the plexus for change or reaction, but the input results in an unclear impulse at the cord level. The body may get skin or somatic responses such as muscle pain or aching periosteum or it may tell a viscus innervated at the same level to do something it can do (e.g., the stomach increases its acid content). This also explains how sympathetic signals from the liver to the spinal cord can result in itching or other sudomotor responses in the area embryologically related to the liver. This somatization of visceral pain is why we must know the visceral pain patterns and the spinal versus visceral innervations. We examine one (somatic) while screening for the other (viscera). Because the somatic and visceral afferent messages enter at the same level, it is possible to get somatic-somatic reflex responses (e.g., a bruise on the leg causes knee pain), somato-visceral reflex responses (e.g., a biomechanical dysfunction of the 10th rib can cause gallbladder changes), or viscero-somatic reflex responses (e.g., gallbladder impairment can result in a sore 10th rib; pelvic floor dysfunction can lead to incontinence; heart attack causes arm or jaw pain). These are actually all referred pain patterns originating in the soma or viscera. 2
2
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PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
A more in-depth discussion of the visceralsomatic response is available. A visceral-somatic response can occur when biochemical changes associated with visceral disease affect somatic structures innervated by the same spinal nerves. Prior to her death, Dr. Janet Travell was researching how often people with anginal pain are really experiencing residual pectoralis major trigger points (TrPs) caused by previous episodes of angina or myocardial infarction. This is another example of the viscero-somatic response mentioned. A viscero-viscero reflex occurs when pain or dysfunction in one organ causes symptoms in another organ. For example, the client presents with chest pain and has an extensive cardiac workup with normal findings. The client may be told "it's not in your heart, so don't worry about it." The problem may really be the gallbladder. Because the gallbladder originates from the same tissue embryologically as the heart, gallbladder impairment can cause cardiac changes in addition to shoulder pain from its contact with the diaphragm. This presentation is then confused with cardiac pathology. On the other hand, the doctor may do a gallbladder workup and find nothing. The chest pain could be coming from arthritic changes in the cervical spine. This occurs because the cervical spine and heart share common sensory pathways from C3 to the spinal cord. Information from the cardiac plexus and brachial plexus enter the cord at the same level. The nervous system is not able to identify who sent the message, just what level it came from. It responds as best it can, based on the information present, sometimes resulting in the wrong symptoms for the problem at hand. Pain and symptoms of a visceral source are usually accompanied by an autonomic nervous system (ANS) response such as change in vital signs, unexplained perspiration (diaphoresis), and/or skin pallor. Signs and symptoms associated with the involved organ system may also be present. We call these associated signs and symptoms. They are red flags in the screening process. 47
47
2
Neuropathic Pain Neuropathic or neurogenic pain results from damage to or pathophysiologic changes of the peripheral or central nervous system. Neuropathic pain can occur as a result of injury or destruction to the peripheral nerves, pathways in the spinal cord, or neurons located in the brain. 48
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SECTION |
INTRODUCTION TO THE SCREENING PROCESS
Neuropathic pain can be acute or chronic depending on the timeframe. This type of pain is not elicited by the stimulation of nociceptors or kinesthetic pathways as a result of tissue damage, but rather by malfunction of the nervous system itself. Disruptions in the transmission of afferent and efferent impulses in the periphery, spinal cord, and brain can give rise to alterations in sensory modalities (e.g., touch, pressure, temperature), and sometimes motor dysfunction. It can be drug-induced, metabolic based, or brought on by trauma to the sensory neurons or pathways in either the peripheral or central nervous system. It appears to be idiosyncratic; not all individuals with the same lesion will have pain. Some examples are listed in Table 3-4. It is usually described as sharp, shooting, burning, tingling, or producing an electric shock sensation. The pain is steady or evoked by some stimulus that is not normally considered noxious (e.g., light touch, cold). Some affected individuals report aching pain. There is no muscle spasm in neurogenic pain. Neuropathic pain is not alleviated by opiates or narcotics, although local anesthesia can provide temporary relief. Medications used to treat neuropathic pain include antidepressants, anticonvulsants, antispasmodics, adrenergics, and anesthetics. Many clients have a combination of neuropathic and somatic pain making it more difficult to identify the underlying pathology. 46
49
46
TABLE
3-4
Central
Causes
neuropathic
Referred Pain By definition, referred pain is felt in an area far from the site of the lesion, but supplied by the same or adjacent neural segments. Referred pain occurs by way of shared central pathways for afferent neurons and can originate from any cutaneous, somatic, or visceral source. Referred pain can occur alone or with accompanying deep somatic or visceral pain. When caused by an underlying visceral or systemic disease, visceral pain usually precedes the development of referred musculoskeletal pain. However, the client may not remember or mention this previous pain pattern . . . and the therapist has not asked about the presence of any other symptoms. Referred pain is usually well localized (i.e., the person can point directly to the area that hurts), but it does not have sharply defined borders. It can spread or radiate from its point of origin. Local tenderness is present in the tissue of the referred pain area, but there is no objective sensory deficit. Referred pain is often accompanied by muscle hypertonus over the referred area of pain. Visceral disorders can refer pain to somatic tissue (see Table 3-7). On the other hand, as mentioned in the last topic on visceral sources of pain, some somatic impairments can refer pain to visceral locations or mimic known visceral pain patterns. Finding the original source of referred pain can be quite a challenge (Case Example 3-3). Always ask one or both of these two questions in your pain interview as part of the screening process:
of N e u ropathic Pain pain
Multiple sclerosis Headache (migraine) Stroke Traumatic brain injury (TBI) Parkinson's disease Spinal cord injury (incomplete)
Peripheral
neuropathic
pain
Trigeminal neuralgia (Tic douloureux) Poorly controlled diabetes mellitus (metabolic induced) Vincristine (Oncovin) (drug-induced; used in cancer treatment) Isoniazid (INH) (drug-induced; used to treat tuberculosis) Amputation (trauma) Crush injury/brachial avulsion (trauma) Herpes Zoster (Shingles, postherpetic neuralgia) Complex regional pain syndrome (CRPS2, causalgia) Nerve compression syndromes (e.g., carpel tunnel syndrome, thoracic outlet syndrome) Paraneoplastic neuropathy (cancer-induced) Cancer (tumor infiltration/compression of the nerve) Liver or biliary impairment (e.g., liver cancer, cirrhosis, primary biliary cirrhosis) Leprosy Congenital neuropathy (e.g., porphyria) Guillain-Barre Syndrome
CHAPTER 3
CASE EXAMPLE 3 - 3
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
T y p e of P a i n a n d P o s s i b l e
A 44-year-old woman has come to physical therapy with reports of neck, jaw, and chest pain when using her arms overhead. She describes the pain as sharp and "hurting." It is not always consistent. Sometimes she has it; sometimes she does not. Her job as the owner of a window coverings business requires frequent, long periods of time with her arms overhead. A) Would you classify this as cutaneous, somatic, visceral, neuropathic, or referred pain? B) What are some possible causes and how can you differentiate neuromusculoskeletal from systemic? A) The client has not mentioned the skin hurting or pointed to a specific area to suggest a cutaneous source of pain. It could be referred pain, but we do not know yet if it is referred from the neuromusculoskeletal system (neck, ribs, shoulder) or from the viscera (given the description, most likely cardiac). Without further information, we can say it is somatic or referred visceral pain. We can describe it as radiating since it starts in the neck and affects a wide area above and below that. No defined dermatomes have been identified to suggest a neuropathic cause, so this must be evaluated more carefully. B) This could be a pain pattern associated with thoracic outlet syndrome (TOS) because the lower cervical plexus can innervate as far down as the nipple line. This can be differentiated when performing tests and measures for TOS.
Follow-Up
Questions
• Are you having any pain anywhere else in your body? • Are you having symptoms of any other kind that may or may not be related to your main problem?
Differentiating Sources of Pain
2
How do we differentiate somatic sources of pain from visceral sources? It can be very difficult to make this distinction. That is one reason why clients end up in physical therapy even though there is a viscerogenic source of the pain and/or symptomatic presentation.
131
Cause
Since TOS can impact the neuro- or vascular bundle, it is important to measure blood pressure in both arms and compare them for a possible vascular component. Onset of anginal pain occurs in some people with the use of arms overhead. To discern if this may be a cardiac problem, have the client use the lower extremities to exercise without using the arms (e.g., stairs, stationary bike). Onset of symptoms from a cardiac origin usually has a lag effect. In other words, symptoms do not start until 5 to 10 minutes after the activity has started. It is not immediate as it might be when using impaired muscles. If the symptoms are reproduced 3 to 5 or 10 minutes after the lower extremity activity, consider a cardiac cause. Look for signs and symptoms associated with cardiac impairment. Ask about a personal/family history of heart disease. At age 44, she may be perimenopausal (unless she has had a hysterectomy, which brings on surgical menopause) and still on the young side for cardiac cause of upper quadrant symptoms. Still, it is possible and would have to be ruled out by a physician if you are unable to find a NMS cause of symptoms. Chest pain can have a wide range of causes including trigger points, anabolic steroid or cocaine use, breast disease, premenstrual symptoms, assault or trauma, lactation problems, scar tissue from breast augmentation or reduction, and so on. See further discussion, Chapter 17.
The superficial and deep somatic structures are innervated unilaterally via the spinal nerves, whereas the viscera are innervated bilaterally through the autonomic nervous system via visceral afferents. The quality of superficial somatic pain tends to be sharp and more localized. It is mediated by large myelinated fibers, which have a low threshold for stimulation and a fast conduction time. This is designed to protect the structures by signaling a problem right away. Deep somatic pain is more likely to be a dull or deep aching that responds to rest or a non-weightbearing position. Deep somatic pain is often poorly localized (transmission via small unmyelinated fibers) and can be referred from some other site.
132
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INTRODUCTION TO THE SCREENING PROCESS
Pain of a deep somatic nature increases after movement. Sometimes the client can find a comfortable spot, but after moving the extremity or joint, cannot find that comfortable spot again. This is in contrast to visceral pain, which usually is not reproduced with movement, but rather, tends to hurt all the time or with all movements. Pain from a visceral source can also be dull and aching, but usually does not feel better after rest or recumbency. Keep in mind pathologic processes occurring within somatic structures (e.g., metastasis, primary tumor, infection) may produce localized pain that can be mechanically irritated. This is why movement in general (rather than specific motions) can make it worse. Back pain from metastasis to the spine can become quite severe before any radiologic changes are seen. Visceral diseases of the abdomen and pelvis are more likely to refer pain to the back, whereas intrathoracic disease refers pain to the shoulder(s). Visceral pain rarely occurs without associated signs and symptoms, although the client may not recognize the correlation. Careful questioning will usually elicit a systemic pattern of symptoms. Back or shoulder range of motion is usually full and painless in the presence of visceral pain, especially in the early stages of disease. When the painful stimulus increases or persists over time, muscle splinting and guarding can result in subsequent changes in biomechanical patterns, making it more difficult to recognize the systemic origin of musculoskeletal dysfunction. 2
2
TYPES OF PAIN Although there are five sources of most physiologic pain (from a medical screening perspective), many types of pain exist within these categories (see Table 3-3). When orienting to pain from these main sources, it may be helpful to consider some specific types of pain patterns. Not all pain types can be discussed here, but some of the most commonly encountered are included.
Myofascial Pain Myalgia, or muscle pain, can be a symptom of an underlying systemic disorder. Cancer, renal failure, hepatic disease, and endocrine disorders are only a few possible systemic sources of muscle involvement. For example, muscle weakness, atrophy, myalgia, and fatigue that persist despite rest may be early manifestations of thyroid or parathyroid
disease, acromegaly, diabetes, Cushing's syndrome, or osteomalacia. Myalgia can be present in anxiety and depressive disorders. Muscle weakness and myalgia can occur as a side effect of drugs. Prolonged use of systemic corticosteroids and immunosuppressive drugs has known adverse effects on the musculoskeletal system including degenerative myopathy with muscle wasting and tendon rupture. Infective endocarditis caused by acute bacterial infection can present with myalgias and no other manifestation of endocarditis. The early onset of joint pain and myalgia as the first sign of endocarditis is more likely if the person is older and has had a previously diagnosed heart murmur. Joint pain (arthralgia) often accompanies myalgia and the client is diagnosed with rheumatoid arthritis. Polymyalgia rheumatica (PR; literally "pain in many muscles") is a disorder marked by diffuse pain and stiffness that primarily affects muscles of the shoulder and pelvic girdles. With PR symptoms are vague and difficult to diagnose resulting in delay in medical treatment. The person may wake up one morning with muscle pain and stiffness for no apparent reason or the symptoms may come on gradually over several days or weeks. Adults over age 50 are affected most often (white women have the highest incidence); most cases occur after age 70. Temporal arteritis occurs in 25% of all cases of PR. Watch for headache, visual changes (blurred or double vision), intermittent jaw pain (claudication), and cranial nerve involvement. The temporal artery may be prominent and painful to touch and the temporal pulse absent. From a screening point of view, there are many types of muscle-related pain such as tension, spasm, weakness, trauma, inflammation, infection, neurologic impairment, and trigger points (see Table 3-3). The clinical presentation most common with systemic disease is presented here. 50
51
Muscle
Tension
Muscle tension, or sustained muscle tone, occurs when prolonged muscular contraction or co-contraction results in local ischemia, increased cellular metabolites, and subsequent pain. Ischemia as a factor in muscle pain remains controversial. Interruption of blood flow in a resting extremity does not cause pain unless the muscle contracts during the ischemic condition. Muscle tension also can occur with physical stress and fatigue. Muscle tension and the subsequent ischemia may occur as a result of faulty ergonomics, prolonged work positions (e.g., as with 52
CHAPTER 3
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
computer or telephone operators), or repetitive motion. Take for example the person sitting at a keyboard for hours each day. Constant typing with muscle co-contraction does not allow for the normal contract-relax sequence. Muscle ischemia results in greater release of Substance P, a pain neurotransmitter (neuropeptide). Increased Substance P levels increase pain sensitivity. Increased pain perception results in more muscle spasm as a splinting or protective guarding mechanism. And so the pain-spasm cycle is perpetuated. This is a somatic-somatic response. Muscle tension from a visceral-somatic response can occur when pain from a visceral source results in increased muscle tension and even muscle spasm. For example, the pain from any inflammatory or infectious process affecting the abdomen (e.g., appendicitis, diverticulitis, pelvic inflammatory disease) can cause increased tension in the abdominal muscles. Given enough time and combined with overuse and repetitive use or infectious or inflammatory disease, muscle tension can turn into muscle spasm. When opposing muscles such as the flexors and extensors contract together for long periods of time (called co-contraction), muscle tension and then muscle spasm can occur.
Muscle
Spasm
Muscle spasm is a sudden involuntary contraction of a muscle or group of muscles, usually occurring as a result of overuse or injury of the adjoining neuromusculoskeletal or musculotendinous attachments. A person with a painful musculoskeletal problem may also have a varying degree of reflex muscle spasm to protect the joint(s) involved (a somatic-somatic response). A client with painful visceral disease can have muscle spasm of the overlying musculature (a viscero-somatic response). Spasm pain cannot be attributed to transient increased muscle tension because the intramuscular pressure is insufficiently elevated. Pain with muscle spasm may occur from prolonged contraction under an ischemic situation. An increase in the partial pressure of oxygen has been documented inside the muscle in spasm under these circumstances. 53
Muscle
Trauma
Muscle trauma can occur with acute trauma, burns, crush injuries, or unaccustomed intensity or duration of muscle contraction, especially eccentric contractions. Muscle pain occurs as broken fibers leak potassium into the interstitial fluid. Blood
133
extravasation results from damaged blood vessels, setting off a cascade of chemical reactions within the muscle. When disintegration of muscle tissue occurs with release of their contents (e.g., oxygen-transporting pigment myoglobin) into the blood stream, a potentially fatal muscle toxicity called rhabdomyolysis can occur. Risk factors and clinical signs and symptoms are listed in Table 3-5. Immediate medical attention is required (Case Example 3-4). 52
Muscle
Deficiency
Muscle deficiency (weakness and stiffness) is a common problem as we age. Connective tissue changes may occur as small amounts of fibrinogen (produced in the liver and normally converted to fibrin to serve as a clotting factor) leak from the vasculature into the intracellular spaces, adhering to cellular structures. The resulting microfibrinous adhesions among the cells of muscle and fascia cause increased muscular stiffness. Activity and movement normally break these adhesions; however, with the aging process, production of fewer and less efficient macrophages combined with immobility for any reason result in reduced lysis of these adhesions. Other possible causes of aggravated stiffness include increased collagen fibers from reduced collagen turnover, increased cross-links of aged collagen fibers, changes in the mechanical properties of connective tissues, and structural and functional changes in the collagen protein. Tendons and ligaments also have less water content, resulting in increased stiffness. When muscular stiffness occurs as a result of aging, increased physical activity and movement can reduce associated muscular pain. As part of the diagnostic evaluation, consider a general conditioning program for the older adult reporting generalized muscle pain. Even ten minutes a day on a stationary bike, treadmill or in an aquatics program can bring dramatic and fast relief of painful symptoms when caused by muscle deficiency. Proximal muscle weakness accompanied by change in one or more deep tendon reflexes is a red flag sign of cancer or neurologic impairment. In the presence of a past medical history of cancer, further screening is advised with possible medical referral required depending on the outcome of the examination/ evaluation. 54
55
Trigger
Points
Trigger points (TrPs; as myofascial trigger
sometimes referred to points or MTrPs) are
SECTION I
134
TABLE 3-5
INTRODUCTION TO THE SCREENING PROCESS
Risk Factors for Rhabdomyolysis Examples
Signs and symptoms
Trauma
Crush injury Electric shock Severe burns Extended mobility
Profound muscle weakness Pain Swelling Stiffness and cramping Associated Signs and Symptoms: • Reddish-brown urine (myoglobin) • Decreased urine output • Malaise • Fever • Sinus tachycardia • Nausea, vomiting • Agitation, confusion
Extreme Muscular Activity
Strenuous exercise Status epilepticus Severe dystonia
Toxic Effects
Ethanol Ethylene glycol Isopropanol Methanol Heroin Barbiturates Methadone Cocaine Amphetamines Ecstasy (street drug) Carbon monoxide Snake venom Tetanus
Metabolic Abnormalities
Hypothyroidism Hyperthyroidism Diabetic ketoacidosis
Medication-induced
Inadvertent intravenous (IV) infiltration (e.g., amphotericin B, azathioprine, cyclosporine) Cholesterol-lowering statins (e.g., Zocor, Lipitor, Crestor)
Risk factors for rhabdomyolysis
Data from Fort CW: How to combat 3 deadly trauma complications, Nursing2003 33(5):58-64, 2003.
hyperirritable spots within a taut band of skeletal muscle or in the fascia. There is often a history of immobility (e.g., cast immobilization after fracture or injury), prolonged or vigorous activity such as bending or lifting, or forceful abdominal breathing such as occurs with marathon running. TrPs are reproduced with palpation or resisted motions. When pressing on the TrP you may elicit a "jump sign." Some people say the jump sign is a local twitch response of muscle fibers to trigger point stimulation, but this is an erroneous use of the term. 47
The jump sign is a general pain response as the client physically withdraws from the pressure on the point and may even cry out or wince in pain. The local twitch response is the visible contraction of tense muscle fibers in response to stimulation. When trigger points are compressed, local tenderness with possible referred pain results. In other words, pain that arises from the trigger point is felt at a distance, often remote from its source. The referred pain pattern is characteristic and specific for every muscle. Knowing the trigger point
CHAPTER 3
CASE EXAMPLE
3-4
PAIN TYPES AND VISCEROGENIC PAIN PATTERNS
135
M i l i t a r y R h a b d o my o l y s i s
A 20-year-old soldier reported to the military physical therapy clinic with bilateral shoulder pain and weakness. He was unable to perform his regular duties due to these symptoms. He attributed this to doing many push-ups during physical training 2 days ago. When asked if there were any other symptoms of any kind to report, the client said that he noticed his urine was a dark color yesterday (the day after the push-up exercises). The soldier had shoulder active range of motion to 90 degrees accompanied by an abnormal scapulohumeral rhythm with excessive scapular elevation on both sides. Passive shoulder range of motion was full but painful. Elbow active and passive range of motion were also restricted to 90 degrees of flexion second to pain in the triceps muscles. The client was too painful to handle manual muscle testing with pain on palpation to the pectoral, triceps, and infraspinatus muscles, bilaterally. The rotator cuff tendon appeared to be intact.
What are the red flags in this case? • Bilateral symptoms (pain and weakness) • Age (for cancer, too young [under 25 years old] or too old [over 50] is a red flag sign) • Change in urine color Result: The soldier had actually done hundreds of different types of push-ups including regular, wide-arm, and diamond push-ups. Although the soldier was not in any apparent distress, laboratory studies were ordered. Serum CK level was measured as 9600 U/L (normal range: 55-170 U/L). The results were consistent with acute exertional rhabdomyolysis (AED) and the soldier was hospitalized. Early recognition of a potentially serious problem may have prevented serious complications possible with this condition. Physical therapy intervention for muscle soreness without adequate hydration could have led to acute renal failure. He returned to physical therapy for a recovery program following hospitalization.
Data from Baxter RE, Moore JH: Diagnosis and treatment of acute exertional rhabdomyolysis, J Orthop Sports Phys Ther 33(3):104108, 2003.
locations and their referred pain patterns is helpful. By knowing the pain patterns, you can go to the site of origin and confirm (or rule out) the presence of the TrP. The distribution of referred trigger point pain rarely coincides entirely with the distribution of a peripheral nerve or dermatomal segment. In the screening process, TrPs must be eliminated to rule out systemic pathology as a cause of muscle pain. Beware when your client fails to respond to trigger point therapy. Consider this situation a yellow flag. It is not necessarily a red flag suggesting the need for screening for systemic or other causes of muscle pain. Muscle recovery from trigger points is not always so simple. Muscles with active trigger points fatigue faster and recover more slowly. They show more abnormal neural circuit dysfunction. The pain and spasm of trigger points may not be relieved until the aberrant circuits are corrected. Any compromise of muscle energy metabolism such as occurs with endocrine or cancer-related 47
56
disorders can aggravate and perpetuate trigger points making successful intervention a more challenging and lengthy process. Remember, too, that visceral disease can create tender points. For those who understand the Jones' Strain/Counterstrain concept, some of the Jones' points might happen to fall in the same area as viscerogenic tender point, but the two are not the same points. A careful evaluation is required to differentiate between Jones' points and viscerogenic tender points. Travell's trigger points (TrPs) can also produce visceral symptoms without actual organ impairment or disease. This is an example of a somatovisceral response. For example, the client may have an abdominal muscle TrP, but the history is one of upset stomach or chest (cardiac) pain. It is possible to have both tender points and TrPs when the underlying cause is visceral disease. Pain and dysfunction of myofascial tissues is the subject of several texts to which the reader is referred for more information. ' 47 5758
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INTRODUCTION TO THE SCREENING PROCESS
Joint Pain Noninflammatory joint pain (no redness, no warmth, no swelling) of unknown etiology can be caused by a wide range of pathologic conditions (Box 3-4). Fibromyalgia, leukemia, sexually transmitted infections, artificial sweeteners, " Crohn's disease (also known as regional enteritis), and infectious arthritis are all possible causes of joint pain. Joint pain in the presence of fatigue may be a red flag for anxiety, depression, or cancer. The client history and screening interview may help the therapist find the true cause of joint pain. Look for risk factors for any of the listed conditions and review the client's recent activities. When comparing joint pain associated with systemic versus musculoskeletal causes, one of the major differences is in the area of associated signs and symptoms (Table 3-6). Joint pain of a systemic or visceral origin usually has additional signs or symptoms present. The client may not realize there is a connection, or the condition may not have 59
BOX 3-4
61
Systemic Causes of Joint Pain
Infectious and noninfectious systemic causes of joint pain can include, but are not limited to • Allergic reactions (e.g., medications such as antibiotics) • Side effect of other medications such as statins, prolonged use of corticosteroids, aromatase inhibitors • Delayed reaction to chemicals or environmental factors • Sexually transmitted infections (STIs) (e.g., HIV, syphilis, chlamydia, gonorrhea) • Infectious arthritis • Infective endocarditis • Recent dental surgery • Lyme disease • Rheumatoid arthritis • Other autoimmune disorders (e.g., systemic lupus erythematosus, mixed connective tissue disease, scleroderma, polymyositis) • Leukemia • Tuberculosis • Acute rheumatic fever • Chronic liver disease (hepatic osteodystrophy affecting wrists and ankles; hepatitis causing arthralgias) • Inflammatory bowel disease (e.g., Crohn's disease or regional enteritis) • Anxiety or depression (major depressive disorder) • Fibromyalgia • Artificial sweeteners
progressed enough lor associated signs and symptoms to develop. The therapist also evaluates joint pain over a 24-hour period. Joint pain from a systemic cause is more likely to be constant and present with all movements. Rest may help at first but over time even this relieving factor will not alter the symptoms. This is in comparison to the client with osteoarthritis (OA), who often feels better after rest (though stiffness may remain). Morning joint pain associated with OA is less than joint pain at the end of the day after using the joint(s) all day. On the other hand, muscle pain may be worse in the morning and gradually improves as the client stretches and moves about during the day. The Pain Assessment Record Form (see Fig. 3-6) includes an assessment of these differences across a 24-hour span as part of the "Pattern." The therapist can use the specific screening questions for joint pain to assess any joint pain of unknown cause or with an unusual presentation or history. Joint pain and symptoms that do not fit the expected pattern for injury, overuse, or aging can be screened using a few important questions (Box 3-5).
Drug-Induced Joint pain as an allergic response, sometimes referred to as "serum sickness" can occur up to 6 weeks after taking a prescription drug (especially antibiotics). Joint pain is also a potential side effect of statins (e.g., Lipitor, Zocor). These are cholesterol-lowering agents. Noninflammatory joint pain is typical of a delayed allergic reaction. The client may report fever, skin rash, and fatigue that go away when the drug is stopped.
Chemical
Exposure
Likewise, delayed reactions can occur as a result of occupational or environmental chemical exposure. A work and/or military history may be required for anyone presenting with joint or muscle pain or symptoms of unknown cause. These clients can be mislabeled with a diagnosis of autoimmune disease or fibromyalgia. The alert therapist may recognize and report clues to help the client obtain a more accurate diagnosis.
Inflammatory
Bowel
Disease
(IBD)
Ulcerative colitis (UC) and regional enteritis (Crohn's disease; CD) are accompanied by an arthritic component and skin rash in about 25% of all people affected by this inflammatory bowel condition.
CHAPTER 3
T A B L E 3-6
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
137
loint Pc lin: Systemic or Musculoskeletal?
Clinical Presentation
Systemic
Musculoskeletal
Awakens at night Deep aching, throbbing Reduced by pressure* Constant or waves/spasm
Decreases with rest Sharp Reduced by change in position Reduced or eliminated when stressful action is stopped Restriction of A/PROM Restriction of accessory motions 1 or more movements "catch," reproducing or aggravating pain/symptoms
Cyclical, progressive symptoms
Past Medical History
Recent history of infection: Hepatitis, bacterial infection from staphylococcus or streptococcus (e.g., cellulitis), mononucleosis, measles, URI, UTI, gonorrhea, osteomyelitis, cellulitis History of bone fracture, joint replacement or arthroscopy History of human bite Sore throat, headache with fever in the last 3 weeks or family/household member with recently diagnosed strep throat Skin rash (infection, medications) Recent medications (last 6 weeks); any drug but especially statins (cholesterol lowering) and antibiotics History of injection drug use/abuse History of allergic reactions Presence of extensor surface nodules History of GI symptoms Recent history of enteric or venereal infection or new sexual contact (e.g., Reiter's)
Repetitive motions Arthritis Static postures (prolonged) Trauma (including domestic violence)
Associated Signs and Symptoms
Jaundice Migratory arthralgias Skin rash/lesions Nodules (extensor surfaces) Fatigue Weight loss Low grade fever Proximal muscle weakness Presence of GI symptoms Cyclic, progressive symptoms Suspicious or aberrant lymph nodes
Usually none Check for trigger points Trigger points may be accompanied by some minimal ANS phenomenon (e.g., nausea, sweating)
URI, Upper respiratory infection; UTI, urinary tract infection; GI, gastrointestinal; ANS, autonomic nervous system; AI PROM, active/passive range of motion. * This is actually a cutaneous or somatic response because the pressure provides a counter irritant; it does not really affect the viscera directly.
The person may have a known diagnosis of IBD. but may not know that new onset of joint symptoms can be part of this condition. The client interview should have brought out the personal history of either UC or CD. See the discussion of IBD in Chapter 8.
Peripheral joint disease associated with IBD involves the large joints, most often a single hip or knee. Joint symptoms often occur simultaneously with UC, but less often at the same time as CD. Ankylosing spondylitis (AS) is also possible with either form of IBD.
138
B O X 3-5
SECTION I
INTRODUCTION TO THE SCREENING PROCESS
Screening Questions for Joint Pain
• Please describe the pattern of pain/symptoms from when you wake up in the morning to when you go to sleep at night. • Do you have any symptoms of any kind anywhere else in your body? (You may have to explain these symptoms don't have to relate to the joint pain; if the client has no other symptoms, offer a short list including constitutional symptoms, heart palpitations, unusual fatigue, nail or skin changes, sores or lesions anywhere but especially in the mouth or on the genitals, and so forth.) • Have you ever had Cancer of any kind Leukemia Crohn's disease (regional enteritis) Sexually transmitted infection (you may have to prompt with specific diseases such as chlamydia, genital herpes, genital warts, gonorrhea or "the clap," syphilis, Reiter's Syndrome, HrV) Fibromyalgia Joint replacement or arthroscopic surgery of any kind • Have you recently (last 6 weeks) had any: Fractures Bites (human, animal) Antibiotics or other medications Infections [you may have to prompt with specific infections such as strep throat, mononucleosis, urinary tract, upper respiratory (cold or flu), gastrointestinal, hepatitis] Skin rashes or other skin changes • Do you drink diet soda/pop or use aspartame, Equal, or NutraSweet? (If the client uses these products in any amount, suggest eliminating
As with typical AS, symptoms affect the low back, sacrum, or sacroiliac joint first. The most common symptoms are intermittent low-back pain with decreased low back motion. The course of AS associated with IBD is the same as without the bowel component. Joint problems usually respond to medical treatment of the underlying bowel disease but in some cases require separate management. Interventions for the musculoskeletal involvement follow the usual protocols for each area affected.
them on a trial basis for 30 days; artificial sweetener-induced symptoms may disappear in some people; effects from use of the new product Splenda have not been reported.) To the therapist: You may have to conduct an environmental or work history (occupation, military, exposure to chemicals) to identify a delayed reaction. Quick survey • What kind of work do you do? • Do you think your health problems are related to your work? • Are your symptoms better or worse when you're at home or at work? • Follow up if worse at work: Do others at work have similar problems? • Have you been exposed to dusts, fumes, chemicals, radiation, or loud noise? Follow up: It may be necessary to ask additional questions based on past history, symptoms, and risk factors present. • Do you live near a hazardous waste site or any industrial facilities that give off chemical odors or fumes? • Do you live in a home built more than 40 years ago? Have you done renovations or remodeling? • Do you use pesticides in your home, on your garden, or on your pets? • What is your source of drinking water? • Chronology of jobs (type of industry, type of job, years worked) • How new is the building you are working in? • Exposure survey (protective equipment used, exposure to dust, radiation, chemicals, biologic hazards, physical hazards)
is usually a positive history or other associated signs and symptoms to help the therapist identify the need for medical referral. INFECTIOUS ARTHRITIS Joint pain can be a local response to an infection. This is called infectious, septic, or bacterial arthritis. Invading microorganisms cause inflammation of the synovial membrane with release of cytokines (e.g., tumor necrosis factor, interleukin-1) and proteases. The end result can be cartilage destruction even after eradicating the offending organism. 62
Arthritis Joint pain (either inflammatory or noninflammatory) can be associated with a wide range of systemic causes including bacterial or viral infection, trauma, and sexually transmitted diseases. There
Bacteria can find its way to the joint via the bloodstream (most common) by: • Direct inoculation (e.g., surgery, arthroscopy, intra-articular corticosteroid injection, central line placement, total joint replacement)
CHAPTER 3
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
• Penetrating wound (e.g., human bite or fracture) • Direct extension (e.g., osteomyelitis, cellulitis, diverticulitis, abscess) Staphylococcus aureus, streptococci, and gonococci are the most common infectious causes. A connection between infection and arthritis has been established in Lyme disease. Arthritis can be the first sign of infective endocarditis. Viruses, mycobacteria, fungal agents, and Lyme disease are other causes. Viral infections such as hepatitis B, rubella (after vaccination), and Fifth's (viral) disease can be accompanied by arthralgias and arthritis sometimes called viral arthritis. Joint symptoms appear during the prodromal state of hepatitis (prior to the clinical onset of jaundice). Sexually transmitted (infectious) diseases (STIs/STDs) are often accompanied by joint pain and symptoms called gonococcal arthritis. Joint pain accompanied by skin lesions at the joint or elsewhere may be a sign of sexually transmitted infections. In the case of STI/STDs with joint involvement, skin lesions over or near a joint have a typical appearance with a central black eschar or scab-like appearance surrounded by an area of erythema (Fig. 3-9). Alternately, the skin lesion may have a hemorrhagic base with a pustule in the center. 63
62
139
Fever and arthritic-like symptoms are usually present (Fig. 3-10). Anyone with HIV may develop unusual rheumatologic disorders. Diffuse body aches and pain without joint arthritis are common among clients with HIV. (See further discussion on human immunodeficiency syndrome [HIV], in Chapter 12.) Other forms of arthritis such as systemic lupus erythematosus (SLE), scleroderma, polymyositis, and mixed connective tissue disease may have an infectious-based link but the connection has never been proven definitively. Infectious (septic) arthritis should be suspected in an individual with persistent joint pain and inflammation occurring in the course of an illness of unclear origin or in the course of a well-documented infection such as pneumococcal pneumonia, staphylococcal sepsis, or urosepsis. Major risk factors include age (older than 80 years), diabetes mellitus, intravenous drug use, indwelling catheters, immunocompromised condition, rheumatoid arthritis, or osteoarthritis. Look for a history of preexisting joint damage due to bone trauma (e.g., fracture) or degenerative joint disease. Other predisposing factors are listed in Box 3-6. Infectious arthritis is a rare complication of anterior cruciate ligament (ACL) reconstruction using contaminated bone-tendon-bone allografts. Infections in prosthetic joints can occur years after the implant is inserted. Indwelling catheters and urinary tract infections are major risk factors for seeding to prosthetic joints. 62
64,65
55
Fig. 3 - 9
•
Skin lesions a r e c o m m o n in clients w i t h sexually
transmitted infections. The lesion here o c c u r r e d in a m a n w i t h
Fig.
disseminated gonococcal infection presenting as (gonococcal)
r h a g i c b a s e . T h e t y p i c a l client presents w i t h fever, arthritis, a n d
arthritis in the a n k l e joint. The t y p i c a l central b l a c k e s c h a r a r e a
scattered lesions as show. Cultures f r o m the lesions a r e often
3-10
•
Disseminated gonorrhea.
Pustule on
a
hemor-
surrounded by a base of e r y t h e m a is s h o w n . The skin lesion
n e g a t i v e . The t h e r a p i s t s h o u l d a l w a y s use s t a n d a r d p r e c a u -
persisted f o r 5 to 7 d a y s a n d
t i o n s . M e d i c a l r e f e r r a l i s r e q u i r e d . ( F r o m C a l l e n JP, Poller A S ,
healed quickly with antibiotic
t r e a t m e n t . (From W i l l i a m s RC: Infection a n d a r t h r i t i s : h o w a r e they
G r e e r KE et a l :
related? J Musculoskel Med 1 0 ( 6 ) : 3 8 - 5 1 ,
WB Saunders; Fig. 6 - 5 , p 148.)
1 9 9 3 ; Fig.
1A, p 39.)
Color atlas of dermatology, ed 2, P h i l a d e l p h i a , 2 0 0 0 ,
SECTION I
140
B O X 3-6
•
• • • • • • • • •
INTRODUCTION TO THE SCREENING PROCESS
Risk Factors for Infectious Arthritis
History of: • Previous surgery, especially arthroscopy for joint repair or replacement • Human bite, tick bite (Lyme's disease), fracture, central line placement • Direct, penetrating trauma • Infection of any kind (e.g., osteomyelitis, cellulitis, diverticulitis, abscess (located anywhere), hepatitis A or B, Staphylococcus aureus, streptococcus pneumoniae, gonococci, urinary tract, or respiratory tract infection) • Rheumatoid arthritis, systemic lupus erythematosus, scleroderma, or mixed connective tissue disease • Diabetes mellitus • Sarcoidosis (inflammatory pulmonary condition can affect knees, PIP joints, wrists, elbows) Sexually active, young adult Injection drug user Chronic joint damage (e.g., rheumatoid arthritis, gout) Previous infection of joint prosthesis Recent immunization Increasing age Indwelling catheter (especially in the client with a prosthetic joint) Malnutrition, skin breakdown Immunosuppression or immunocompromise (e.g., renal failure, steroid treatment, organ transplantation, chemotherapy)
Watch for joint symptoms in the presence of skin rash, low-grade fever, and lymphadenopathy. The rash may appear and disappear before the joint symptoms. Joints may be mildly to severely involved. Fingers, knees, shoulders, and ankles are affected most often (bilaterally). Inflammation is nonerosive, suggestive of rheumatoid arthritis. Often one joint is involved (knee or hip), but sometimes two or more are also symptomatic depending on the underlying pathologic mechanism. Symptoms can range from mild to severe. Joint destruction can be rapid so immediate medical referral is required. Once treated (antibiotics, joint aspiration), the postinfectious inflammation may last for weeks. With infectious arthritis, the client may be unable to bear weight on the joint. Usually, there is an acute arthritic presentation and the client has a fever (often low-grade in older adults or in anyone who is immunosuppressed). Medical referral is important for the client with joint pain with no known cause and a recent 50
66
history of infection of any kind. Ask about a recen (last 6 weeks) skin lesions or rashes of any kini anywhere on the body, urinary tract infection, o respiratory infection. Take the client's temperature and ask abou recent episodes of fever, sweats, or other constitu tional symptoms. Palpate for residual lym phadenopathy. Early diagnosis and interventioi are essential to limit joint destruction and preserve function. Diagnosis can be difficult. The physiciai must differentiate infectious/septic arthritis fror reactive arthritis (Case Example 3-5). Clinical Signs and Symptoms of Infectious
Arthritis
•
Fever (low-grade or high), chills, malaise
• • • •
Recurrent sore throat Lymphadenopathy Persistent joint pain Single painful swollen joint (knee, hip, ankle, elbow, shoulder)* Multiple joint involvement (often migratory)* Pain on weight bearing Back pain (infective endocarditis) Skin lesions (characteristic of the specific underlying infection) Conjunctivitis, uveitis Other musculoskeletal symptoms depending on the specific underlying infection • Myalgias • Tenosynovitis (especially wrist and ankle extensor tendon sheaths) Elevated C-reactive protein and sedimentation rate
• • • • • •
•
• The particular joint or joints involved and associated signs and symptoms will vary from client to client and are dependent upon the underlying infectious cause. For example, joint involvement with Lyme disease presents differently from Reiter's syndrome or Hepatitis B.
REACTIVE ARTHRITIS
Reactive arthritis is sometimes used synonymously with Reiter's syndrome, a triad of nongonococcal urethritis, conjunctivitis, and multiple joint involvement of inflammatory arthritis (oligoarthropathy). However, joint symptoms can occur 1 to 4 weeks after either a gastrointestinal (GI) or genitourinary (GU) infection. The most common GI infections associated with reactive arthritis include Salmonella, Shigella, and Campylobacter, which occur in men and women equally. Reactive arthritis from sexually acquired urethritis is caused by Chlamydia or Ureaplasma and affects only men.
CHAPTER 3
CASE EXAMPLE 3 - 5
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
141
Septic Arthritis
A 62-year-old man presented in physical therapy with left wrist pain. There was no redness, warmth, or swelling. Active motion was mildly limited by pain. Passive motion could not be tested because of pain. All other clinical tests were negative. Neuro screen was negative. Past medical history includes hypertension and non-insulindependent diabetes mellitus controlled by diet and exercise. The client denied any history of fever, skin rashes, or other lesions. He reported a recent trip to Haiti (his native country) 3 weeks ago. How do you screen this client for systemic-induced joint pain? • Review Box 3-6 (Risk Factors for Infectious Arthritis). Besides diabetes, what other risk factors are present? Ask the client about any that apply. Compile a list to review during the Review of Systems. • Ask the client: Are there any other symptoms of any kind anywhere else in your body? • Use the client's answer while reviewing Clinical Signs and Symptoms of Infectious Arthritis for any signs and symptoms of infectious arthritis. • Review Box 3-5 (Screening Questions for Joint Pain). Are there any further questions from this list appropriate for the screening process? • Assess the joints above and below (e.g., elbow, shoulder, neck). Assess for trigger points. Using the information obtained from these steps, look at past medical history, clinical pres-
The joint is not septic (infected), but rather, aseptic (without infection). Affected joints are often at a site remote from the primary infection. Often only one joint is involved (knee, ankle, foot, distal interphalangeal joint), but two or more can be affected. Reactive arthritis often causes inflammation along tendons or where tendons attach to the bone resulting in persistent pain from plantar fasciitis and sacroiliitis. Nail bed changes can include onycholysis (fingers or toes). Anyone with joint pain of unknown cause who presents with a skin rash, lesions on the genitals, or recent history of infection (especially GI or GU;
entation, and associated signs and symptoms. What are the red flags? Review the Clues To Screening for Viscerogenic Pain Patterns and Guidelines for Physician Referral in this chapter. Based on your findings, decide whether to treat and re-evaluate or make a medical referral now. Result: In this case the therapist did not find enough red flags or suspicious findings to warrant immediate referral. Treatment intervention was initiated. The client missed three appointments because of the "flu." When he returned, his wrist pain was completely gone, but he was reporting left knee pain. There was mild effusion and warmth on both sides of the knee joint. The client stated that he still had some occasional diarrhea from his bout with the flu. The therapist recognized some additional red flags including ongoing gastrointestinal (GI) symptoms attributed by the client to the flu and new onset of inflammatory joint pain. The therapist decided to take the client's vital signs and found he was febrile (100° F). Given his recent travel history, migratory noninflammatory and inflammatory arthralgias, and ongoing constitutional symptoms, the client was referred to his medical doctor. Lab tests resulted in a physician's diagnosis of joint sepsis with hematogenous seeding to the wrist and knee; possible osteomyelitis. Probable cause: Exposure to pathogens in contaminated water or soil during his stay in Haiti.
usually within the last 1 to 3 weeks) must be referred to a health care clinic or medical doctor for further evaluation.
Radicular Pain Radicular pain results from direct irritation of axons of a spinal nerve or neurons in the dorsal root ganglion and is experienced in the musculoskeletal system in a dermatome, sclerotome, or myotome. Radicular, radiating, and referred pain are not the same things, although a client can have radicular pain that radiates. Radiating means the pain spreads or fans out from the originating point of pain.
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Whereas radicular pain is caused by nerve root compression, referred pain results from activation of nociceptive free nerve endings (nociceptors) of the nervous system in somatic or visceral tissue. The physiologic basis for referred pain is convergence of afferent neurons onto common neurons within the central nervous system. As mentioned previously, the central nervous system may not be able to distinguish which part of the body is responsible for the input into these common neurons so, for example, ischemia of the heart results in shoulder pain, one of several somatic areas innervated by the same neural segments as the heart. Differentiating between radicular (pain from the peripheral nervous system) and referred pain from the autonomic nervous system can be difficult. Both can start at one point and radiate outwards. Both can cause pain distal to the site of pathology. Referred pain occurs most often far away from the site of pathologic origin of symptoms, whereas radicular pain does not skip myotomes, dermatomes, or sclerotomes associated with the affected peripheral nerves. For example, cardiac pain may be described as beginning retrosternally (behind the sternum) and radiating to the left shoulder and down the inner side of the left arm. This radiating referred pain is generated via the pathways of the ANS but follows the somatic pattern of ulnar nerve distribution. It is not radicular pain from direct irritation of a spinal nerve of the peripheral nervous system but rather referred pain from shared pathways in the spinal cord. Ischemic cardiac pain does not cause arm pain, hand pain, or pain in somatic areas other than those innervated at the C3 to T4 spinal levels of the autonomic nervous system. Similarly, gallbladder pain may be felt to originate in the right upper abdomen and to radiate to the angle of the scapula. These are the somatic areas innervated by the same level of the autonomic nervous system as the involved viscera mentioned. Physical disease can localize pain in dermatomal or myotomal patterns. More often the therapist sees a client who describes pain that does not match a dermatomal or myotomal pattern. This is neither referred visceral pain from ANS involvement nor irritation of a spinal nerve. For example, the client who describes whole leg pain or whole leg numbness may be experiencing inappropriate illness behavior. Inappropriate illness behavior is recognized clinically as illness behavior that is out of proportion to the underlying physical disease and is 67
related more to associated psychologic disturbances than to actual physical disease. This behavioral component to pain is discussed in the section on Screening For Systemic Versus Psychogenic Symptoms. 68
Arterial, Pleural, and Tracheal Pain Pain arising from arteries, as with arteritis (inflammation of an artery), migraine, and vascular headaches, increases with systolic impulse so that any process associated with increased systolic pressure, such as exercise, fever, alcohol consumption, or bending over, may intensify the already throbbing pain. Pain from the pleura, as well as from the trachea, correlates with respiratory movements. Look for associated signs and symptoms of the cardiac or pulmonary systems. Listen for a description of pain that is "throbbing" (vascular) or sharp and increased with respiratory movements such as breathing, laughing, or coughing. Palpation and resisted movements will not reproduce the symptoms, which may get worse with recumbency, especially at night or while sleeping.
Gastrointestinal Pain Pain arising from the gastrointestinal tract tends to increase with peristaltic activity, particularly if there is any obstruction to forward progress of the food bolus. The pain increases with ingestion and may lessen with fasting or after emptying the involved segment (vomiting or bowel movement). On the other hand, pain may occur secondary to the effect of gastric acid on the esophagus, stomach, or duodenum. This pain is relieved by the presence of food or by other neutralizing material in the stomach, and the pain is intensified when the stomach is empty and secreting acid. In these cases it is important to ask the client about the effect of eating on musculoskeletal pain. Does the pain increase, decrease, or stay the same immediately after eating and 1 to 3 hours later? When hollow viscera, such as the liver, kidneys, spleen, and pancreas, are distended, body positions or movements that increase intraabdominal pressure may intensify the pain, whereas positions that reduce pressure or support the structure may ease the pain. For example, the client with an acutely distended gallbladder may slightly flex the trunk. With pain arising from a tense, swollen kidney (or distended renal pelvis), the client flexes the trunk and tilts toward the involved side; with pancreatic
CHAPTER 3
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
pain, the client may sit up and lean forward or lie down with the knees drawn up to the chest.
Pain at Rest Pain at rest may arise from ischemia in a wide variety of tissue (e.g., vascular disease or tumor growth). The acute onset of severe unilateral extremity involvement accompanied by the "five Ps"—pain, pallor, pulselessness, paresthesia, and paralysis—signifies acute arterial occlusion (peripheral vascular disease [PVD]). Pain in this situation is usually described by the client as burning or shooting and may be accompanied by paresthesia. Pain related to ischemia of the skin and subcutaneous tissues is characterized by the client as burning and boring. All these occlusive causes of pain are usually worse at night and are relieved to some degree by dangling the affected leg over the side of the bed and by frequent massaging of the extremity. Pain at rest secondary to neoplasm occurs usually at night. Although neoplasms are highly vascularized (a process called angiogenesis), the host organ's vascular supply and nutrients may be compromised simultaneously, causing ischemia of the local tissue. The pain awakens the client from sleep and prevents the person from going back to sleep, despite all efforts to do so. See the next section on Night Pain. The client may describe pain noted on weightbearing or bone pain that may be mild and intermittent in the initial stages, becoming progressively more severe and more constant. A series of questions to identify the underlying cause of night pain is presented later in this chapter.
Night Pain Whenever you take a pain history, an evaluation of night pain is important (Box 3-7). As therapists, we are always gauging pain responses to identify where the client might be on the continuum from acute to subacute to chronic. This information helps guide our treatment plan and intervention. For example, the client who cannot even lie on the involved side is probably fairly acute. Pain modulation is the first order of business. Modalities and cryotherapy may be most effective here. On the other hand, the client who can roll onto the involved side and stay there for 30 minutes to an hour may be more in the subacute phase. A combination of modalities, hands-on treatment, and exercise may be warranted. The client who can lie on the involved side for up to two hours is more likely in the chronic phase
B O X 3-7
143
Screening Questions for N i g h t Pain
When screening someone with night pain for the possibility of a systemic or cancerous condition, some possible questions are: • Tell me about the pattern of your symptoms at night (open-ended question). • Can you lie on that side? For how long? • (Alternate question): Does it wake you up when you roll onto that side? • How are you feeling in general when you wake up? • Follow-up question: Do you have any other symptoms when the pain wakes you up? Give the client time to answer before prompting with choices such as coughing, wheezing, shortness of breath, nausea, need to go to the bathroom, night sweats. Always ask the client reporting night pain of any kind (not just bone pain) the following screening questions: • What makes it better/worse? • What happens to your pain when you sit up? [Upright posture reduces venous return to the heart; decreased pain when sitting up may indicate a cardiopulmonary cause]. How does taking aspirin affect your pain/symptoms? (Disproportionate pain relief can occur using aspirin in the presence of bone cancer.) • How does eating or drinking affect your pain/symptoms (for shoulder, neck, back, hip, pelvic pain/symptoms; GI system)? • Does taking an antacid such as Turns change your pain/symptoms? (Some women with pain of a cardiac nature experience pain relief much like men do with nitroglycerin; remember this would be a woman who is postmenopausal, possibly with a personal and/or family history of heart disease—check vital signs!)
of the musculoskeletal condition. Tissue ischemia brings on painful symptoms after prolonged static positioning. A more aggressive approach can usually be taken in these cases. These comments all apply to pain of a neuromusculoskeletal (NMS) origin.
Night Pain
and
Cancer
Pain at night is a classic red flag symptom of cancer, but it does not mean that all pain at night is caused by cancer. For example, the person who lies down at night and has not even fallen asleep who reports increased pain may just be experiencing the first moment in the day without
144
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INTRODUCTION TO THE SCREENING PROCESS
distractions. Suddenly, his or her focus is on nothing but the pain, so the client may report the pain is much worse at night. Bone pain at night is the most highly suspicious symptom, especially in the presence of a previous history of cancer. Neoplasms are highly vascularized at the expense of the host. This produces local ischemia and pain. In the case of bone pain (deep pain; pain on weight bearing), perform a heel strike test. This is done by applying a percussive vertical force with the heel of your hand through the heel of the client's foot in a non-weightbearing (supine) position. Reproduction of painful symptoms is positive and highly suspicious of a bone fracture or stress reaction. Keep in mind for the older adult that pain on weight bearing may be a symptom of a hip fracture. It is not uncommon for an older adult to fall, have hip pain, and the X-rays are initially negative. If the pain persists, new X-rays or additional imaging may be needed. MRIs are extremely sensitive for a femoral neck fracture very early after the fracture. MRI may miss a pubic rami fracture, requiring Single Photon Emission Computerized Tomography (SPECT) bone scan to rule out an occult fracture in a client who has fallen and is still having hip pain. In a physically capable client, clear the hip, knee, and ankle by asking the client to assume a full squat position. You may also ask him or her to hop on the involved side. These tests are used to screen for pubic ramus or hip stress fractures (reactions). Stress reactions or stress fractures are discussed in Chapter 16. 69
Pain w i t h Activity Pain with activity is common with neuromusculoskeletal pathology. Mechanical and postural factors are common. Pain with activity from a systemic or disease process is most often caused by vascular compromise. In this context activity pain of the upper quadrant is known as angina when the heart muscle is compromised and intermittent vascular claudication in the case of peripheral vascular compromise (lower quadrant). Pain from an ischemic muscle (including heart muscle) builds up with the use of the muscle and subsides with rest. Thus there is a direct relationship between the degree of circulatory insufficiency and muscle work. In other words, the interval between the beginning of muscle contraction and the onset of pain depends on how long it takes for hypoxic products of muscle metabolism to accumulate and exceed
the threshold of receptor response. This means with vascular-induced pain there is usually a delay or lag time between the beginning of activity and the onset of symptoms. The client complains that a certain distance walked, a certain level of increased physical activity, or a fixed amount of usage of the extremity brings on the pain. When a vascular pathologic condition causes ischemic muscular pain, the location of the pain depends on the location of the vascular pathologic source. This is discussed in greater detail later in this text (see the section on Arterial Disease in Chapter 6). The timing of symptom onset offers the therapist valuable screening clues when determining when symptoms are caused by musculoskeletal impairment or by vascular compromise. Look for immediate pain or symptoms (especially when these can be reproduced with palpation, resistance to movement, and/or a change in position) versus symptoms 5 to 10 minutes after activity begins. Further investigate for the presence of other signs and symptoms associated with cardiac impairment, appropriate risk factors, and positive personal and/or family history.
Diffuse Pain Diffuse pain that characterizes some diseases of the nervous system and viscera may be difficult to distinguish from the equally diffuse pain so often caused by lesions of the moving parts. Most clients in this category are those with obscure pain in the trunk, especially when the symptoms are felt only anteriorly. The distinction between visceral pain and pain caused by lesions of the vertebral column may be difficult to make and will require a medical diagnosis. 70
Chronic Pain Chronic pain persists past the expected physiologic time of healing. This may be less than 1 month or, more often, longer than 6 months. An underlying pathology is no longer identifiable and may never have been present. The International Association for the Study of Pain has fixed 3 months as the most convenient point of division between acute and chronic pain. There are some who suggest 6 weeks is a better cut-off point in terms of clinical progress. Any longer than that and the client is at increased risk for chronic pain and behavioral consequences of that pain. Chronic pain syndrome is characterized by a constellation of life changes that produce altered 71
72
73
74
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PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
behavior in the individual and persist even after the cause of the pain has been eradicated. This syndrome is a complex multidimensional phenomenon that requires a focus toward maximizing functional abilities rather than treatment of pain. With chronic pain, the approach is to assess how the pain has affected the person. Physical therapy intervention can be directed toward decreasing the client's emotional response to pain or developing skills to cope with stress and other changes that impair quality of life. In acute pain the pain is proportional and appropriate to the problem and is treated as a symptom. In the chronic pain syndrome uncontrolled and prolonged pain alters both the peripheral and central nervous systems through processes of neural plasticity and central sensitization and thus pain becomes a disease itself. Each person may have a unique response to pain called a neuromatrix or neurosignature. The neuromatrix is initially determined through genetics and early sensory development. Later, life experiences related to pain and coping shape the neural patterns. Each person develops individual perceptual and behavioral responses to pain that are unique to that person. The person's description of chronic pain often is not well denned and is poorly localized; objective findings are not identified. The person's verbal description of the pain may contain words associated with emotional overlay (see Table 3-1). This is in contrast to the predominance of sensory descriptors associated with acute pain. It may be helpful to ask the client or caregiver to maintain a pain log (see Figs. 3-7 and 3-8). This should include entries for pain intensity and its relationship to activities or intervention. Clients can be reevaluated regularly for improvement, deterioration, or complications, using the same scales that were used for the initial evaluation. Always keep in mind that painful symptoms out of proportion to the injury or that are not consistent with the objective findings may be a red flag indicating systemic disease. Pain can be triggered by bodily malfunction or severe illness. In some cases of chronic pain, a diagnosis is finally made (e.g., spinal stenosis or thyroiditis) and the intervention is specific, not merely pain management. More often, identifying the cause of chronic pain is unsuccessful. Research evidence has implicated psychologic factors as a key factor in chronic pain. Cognitive processes such as thoughts, beliefs, and expectations are important in understanding chronic pain, 75
76
71
145
adaptation to chronic pain, response to intervention, and disability. The therapist should be aware that chronic pain can be associated with physical and/or sexual abuse in both men and women. (See discussion of Assault in Chapter 2.) The abuse may be part of the childhood history and/or a continuing part of the adult experience. 77
Fear-Avoidance
Behavior
Fear-avoidance behavior can also be a part of disability from chronic pain. The Fear-Avoidance Model of Exaggerated Pain Perception (FAMEPP) was first introduced in the early 1980s. The concept is based on studies that show a person's fear of pain (not physical impairments) is the most important factor in how he or she responds to low back pain. Fear of pain commonly leads to avoiding physical or social activities. Screening for fear-avoidance behavior can be done using the Fear Avoidance Beliefs Questionnaire (Table 3-7). Elevated fearavoidance beliefs are not indicative of a red flag for serious medical pathology. They are indicative of someone who has a poorer prognosis for rehabilitation. They are more accurately labeled a "yellow flag" indicating psychosocial involvement and provide insight into the prognosis. Such a yellow flag signals the need to modify intervention and consider the need for referral to a psychologist or behavioral counselor. When the client shows signs of fear-avoidance beliefs, then the therapist's management approach should include education that addresses the client's fear and avoidance behavior, and should consider a graded approach to therapeutic exercise. The therapist can teach clients about the difference between pain and tissue injury. Chronic ongoing pain does not mean continued tissue injury is taking place. This common misconception can result in movement avoidance behaviors. There are no known "cut-off scores for referral to a specialist. ' Some researchers categorize FABQ scores into "high" and "low" based on the physical activity scale (score range 0-24). Less than 15 is a "low" score (low risk for elevated fear-avoidance beliefs) and more than 15 is "high." Higher numbers indicate increased levels of fear-avoidance beliefs. The distinction between these two categories is minor and arbitrary. It may be best to consider the scores as a continuum rather than dividing them into low or high. ' A cut-off score for the work scale indicative of having a decreased chance of returning to work has been 78,79
80
81
82
81 82
81
82
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TABLE 3-7
SECTION I
Fear-Avoidance
INTRODUCTION TO THE SCREENING PROCESS
Beliefs Q u e s t i o n n a i r e (FABQ)
Here are some of the things other patients have told us about their pain. For each statement please circle any number from 0 to 6 to say how much physical activities such as bending, walking , or driving affect or would affect your back pain. Unsure
Completely
Completely
disagree
1. 2. 3. 4.
My pain was caused by physical activity Physical activity makes my pain worse Physical activity might harm my back I should not do physical activities which (might) make my pain worse 5. I cannot do physical activities which (might) make my pain worse
agree
0 0 0
1 1 1
2 2 2
3 3 3
4 4 4
5 5 5
6 6 6
0
1
2
3
4
5
6
0
1
2
3
4
5
6
The following statements are about how your normal work affects or would affect your back pain. Completely
Unsure
Completely agree
disagree
6. My pain was caused by my work or by an accident at work 7. My work aggravated my pain 8. I have a claim for compensation for my pain 9. My work is too heavy for me 10. My work makes or would make my pain worse 11. My work might harm my back 12. I should not do my normal work with my present pain 13. I cannot do my normal work with my present pain 14. I cannot do my normal work until my pain is treated 15. I do not think I will be back to my normal work 16. I do not think that I will ever be able to go back to that work
0 0 0 0 0 0
1 1 1 1 1 1
2 2 2 2 2 2
3 3 3 3 3 3
4 4 4 4 4 4
5 5 5 5 5 5
6 6 6 6 6 6
0 0 0 0
1 1 1 1
2 2 2 2
3 3 3 3
4 4 4 4
5 5 5 5
6 6 6 6
0
1
2
3
4
5
6
The Fear-Avoidance Beliefs Questionnaire (FABQ) is used to quantify the level of fear of pain and beliefs clients with low back pain have about the need to avoid movements or activities that might cause pain. The FABQ has 16 items, each scored from 0 to 6, with higher numbers indicating increased levels of fear avoidance beliefs. There are 2 subscales: a 7-item work subscale (Sum of items 6, 7, 9, 10, 11, 12, and 15; score range = 0-42) and a 4-item physical activity subscale (Sum of items 2, 3, 4, and 5; score range = 0-24). The FABQ work subscale is associated with current and future disability and work loss in patients with acute and chronic LBP. From Waddell G, Somerville D, Henderson I, et al: Fear-avoidance beliefs questionnaire (FABQ) and the role of fear avoidance beliefs in chronic low back pain and disability, Pain 52:157-158, 1993.
proposed. The work subscale of the Fear-Avoidance Beliefs Questionnaire is the strongest predictor of work status. There is a greater likelihood of returnto-work for scores less than 30 and less likelihood of return-to-work or increased risk of prolonged work restrictions for scores greater than 34. Examination of fear-avoidance beliefs may serve as a useful screening tool for identifying clients who are at risk for prolonged work restrictions. Caution is advised when interpreting and applying the results of the FABQ work subscale to individual clients. This screening tool may be a better predictor of low risk for prolonged work restrictions. The work subscale may be less effective in identifying clients at high risk for prolonged work 83
™ o + ™ „ « ~ v ^ 83
Differentiating Chronic Systemic Disease
Pain
from
Sometimes a chronic pain syndrome can be differentiated from a systemic disease by the nature and description of the pain. Chronic pain is usually dull and persistent. The chronic pain syndrome is characterized by multiple complaints, excessive preoccupation with pain, and, frequently, excessive drug use. With chronic pain, there is usually a history of some precipitating injury or event. Systemic disease is more acute with a recent onset. It is often described as sharp, colicky, knifelike, and/or deep. Look for concomitant constitutional symptoms, any red flags in the personal or family history, and/or any known risk factors. Ask about the presence of associated signs and symp-
CHAPTER 3
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
toms characteristic of a particular organ or body system (e.g., GI, GU, respiratory, gynecologic). Because pain has an affective component, chronic pain can cause anxiety, depression, and anger. The amount of pain behaviors and the intensity of pain perceived can change with alterations in environmental reinforcers (e.g., increasing as the time to return to work draws near, decreasing when no one is watching). For more information and assessment tools, see the discussions related to anxiety and depression in this chapter. Secondary gain may be a factor in perpetuating the problem. This may be primarily financial, but social and family benefits, such as increased attention or avoidance of unpleasant activities or work situations, may be factors (see later discussion of behavior responses to injury/illness).
Aging
and
Chronic
B O X 3-8
• • • •
•
Pain
Chronic pain in older adults is very common. One in five older Americans is taking analgesic medications regularly. Many take prescription pain medications for more than 6 months. Older adults are more likely to suffer from arthritis, bone and joint disorders, back problems, and other chronic conditions. Pain is the single most common problem for which aging adults seek medical care. At the same time older adults have been observed to present with unusually painless manifestations of common illnesses such as myocardial infarction, acute abdomen, and infections. " To address the special needs of older adults, the American Geriatrics Society (AGS) has developed specific recommendations for assessment and management of chronic pain (Box 3-8). 84
85
87
•
88
COMPARISON OF SYSTEMIC VERSUS MUSCULOSKELETAL PAIN PATTERNS Table 3-2 provides a comparison of the clinical signs and symptoms of systemic pain versus musculoskeletal pain using the typical categories described earlier. The therapist must be very familiar with the information contained within this table. Even with these guidelines to follow, the therapist's job is a challenging one. In the orthopedic setting, physical therapists are very aware that pain can be referred above and below a joint. So, for example, when examining a shoulder problem, the therapist always considers the neck and elbow as potential NMS sources of shoulder pain and dysfunction.
•
147
A G S Recommendations for C h r o n i c Pain Assessment in the Geriatric Population
All older clients should be assessed for signs of chronic pain. Use alternate words for pain when screening older clients (e.g., burning, discomfort, aching, sore, heavy, tight) Contact caregiver for pain assessment in adults with cognitive or language impairments Clients with cognitive or language impairments should be observed for nonverbal pain behaviors, recent changes in function, and vocalizations to suggest pain (e.g., irritability, agitation, withdrawal, gait changes, tone changes, nonverbal but vocal utterances such as groaning, crying, or moaning) Follow AGS guidelines for comprehensive pain assessment including Medical history Medication history including current and previously used prescription and over-thecounter drugs as well as any nutraceuticals (natural products, "remedies") Physical examination Review pertinent laboratory results and diagnostic tests (look for clues to the sequence of events leading to present pain complaint) Assess characteristics of pain (frequency, intensity, duration, pattern, description, aggravating and relieving factors); use a standard pain scale such as the visual analogue scale (see Fig. 3-6) Observe neuromusculoskeletal system for: Neurologic impairments Weakness Hyperalgesia; hyperpathia (exaggerated response to pain stimulus) Allodynia (skin pain to non-noxious stimulus) Numbness, paresthesia Tenderness, trigger points Inflammation Deformity Pain that affects function or quality of life should be included in the medical problem list
Data from American Geriatrics Society (AGS) Panel on Chronic Pain in Older Persons. Clinical practice guidelines, JAGS 46:635-651, 1998.
Table 3-8 reflects what is known about referred pain patterns for the musculoskeletal system. Sites for referred pain from a visceral pain mechanism are listed. Lower cervical and upper thoracic impairment can refer pain to the interscapular and posterior shoulder areas.
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TABLE 3-8 Pain
INTRODUCTION TO THE SCREENING PROCESS
C o m m o n Patterns of Pain Referral
mechanism
Lesion
Referral
site
site
Somatic
C7, Tl-5 vertebrae Shoulder LI, L2 vertebrae Hip joint Pharynx TMJ
Interscapular area, posterior shoulder Neck, upper back Sacroiliac joint and hip SI and knee Ipsilateral ear Head, neck, heart
Visceral
Diaphragmatic irritation Heart Urothelial tract Pancreas, Liver, Spleen, Gallbladder Peritoneal or abdominal cavity (inflammatory or infectious process)
Shoulder, lumbar spine Shoulder, neck, upper back, TMJ Back, inguinal region, anterior thigh, and genitalia Shoulder, midthoracic or low back Hip pain from abscess of psoas or obturator muscle
Neuropathic
Nerve or plexus Nerve root Central nervous system
Anywhere in distribution of a peripheral nerve Anywhere in corresponding dermatome Anywhere in region of body innervated by damaged structure
Likewise, shoulder impairment can refer pain to the neck and upper back, while any condition affecting the upper lumbar spine can refer pain and symptoms to the sacroiliac (SI) joint and hip. When examining the hip region, the therapist always considers the possibility of an underlying SI or knee joint impairment and so on. If the client presents with the typical or primary referred pain pattern, he or she will likely end up in a physician's office. A secondary or referred pain pattern can be very deceiving. The therapist may not be able to identify the underlying pathology (in fact, it is not required), but it is imperative to recognize when the clinical presentation does not fit the expected pattern for NMS impairment. A few additional comments about systemic versus musculoskeletal pain patterns are important. First, it is unlikely that the client with back, hip, SI, or shoulder pain that has been present for the last 5 to 10 years is demonstrating a viscerogenic cause of symptoms. In such a case, systemic origins are suspected only if there is a sudden or recent change in the clinical presentation and/or the client develops constitutional symptoms or signs and symptoms commonly associated with an organ system. Secondly, note the word descriptors used with pain of a systemic nature: knifelike, boring, deep, throbbing. Pay attention any time someone uses these particular words to describe the symptoms. Third, observe the client's reaction to the information you provide. Often, someone with a NMS
problem gains immediate and intense pain relief just from the examination provided and evaluation offered. The reason? A reduction in the anxiety level. Many people have a need for high control. Pain throws us in a state of fear and anxiety and a perceived loss of control. Knowing what the problem is and having a plan of action can reduce the amplification of symptoms for someone with soft tissue involvement when there is an underlying psychologic component such as anxiety. On the other hand, someone with cancer pain, viscerogenic origin of symptoms or systemic illness of some kind will not obtain relief from or reduction of pain with reassurance. Signs and symptoms of anxiety are presented later in this chapter. Fourth, aggravating and relieving factors associated with NMS impairment often have to do with change in position or a change (increased or decreased) in activity levels. There is usually some way the therapist can alter, provoke, alleviate, eliminate, or aggravate symptoms of a NMS origin. Pain with activity is immediate when there is involvement of the NMS system. There may be a delayed increase in symptoms after the initiation of activity with a systemic (vascular) cause. For the orthopedic or manual therapist, be aware that an upslip of the innominate that does not reduce may be a visceral-somatic reflex. It could be a visceral ligamentous problem. If the
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problem can be corrected with muscle energy techniques or other manual therapy intervention, but by the end of the treatment session or by the next day, the correction is gone and the upslip is back, then look for a possible visceral source as the cause. If you can reduce the upslip, but it does not hold during the treatment session, then look for the source of the problem at a lower level. It can even be a crossover pattern from the pelvis on the other side. Aggravating and relieving factors associated with systemic pain are organ dependent and based on visceral function. For example, chest pain, neck pain or upper back pain from a problem with the esophagus will likely get worse when the client is swallowing or eating. Back, shoulder, pelvic, or sacral pain that is made better or worse by eating, passing gas, or having a bowel movement is a red flag. Painful symptoms that start 3 to 5 minutes after initiating an activity and go away when the client stops the activity suggest pain of a vascular nature. This is especially true when the client uses the word "throbbing," which is a descriptor of a vascular origin. Clients presenting with vascular-induced musculoskeletal complaints are not likely to come to the therapist with a report of cardiac-related chest pain. Rather, the therapist must be alert for the man over age 50 or postmenopausal woman with a significant family history of heart disease, who is borderline hypertensive. New onset or reproduction of back, neck, TMJ, shoulder, or arm pain brought on by exertion with arms raised overhead or by starting a new exercise program is a red flag. Leaning forward or assuming a hands and knees position sometimes lessens gallbladder pain. This position moves the distended or inflamed gallbladder out away from its position under the liver. Leaning or side bending toward the painful side sometimes ameliorates kidney pain. Again, for some people, this may move the kidney enough to take the pressure off during early onset of an infectious or inflammatory process. Finally, notice the long list of potential signs and symptoms associated with systemic conditions (see Table 3-2; see Box 4-18). At the same time, note the lack of associated signs and symptoms listed on the musculoskeletal side of the table. Except for the possibility of some autonomic nervous system responses with the stimulation of trigger points, there are no comparable constitutional or systemic signs and symptoms associated with the NMS system. 2
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CHARACTERISTICS OF VISCEROGENIC PAIN There are some characteristics of viscerogenic pain that can occur regardless of which organ system is involved. Any of these by itself is cause for suspicion and careful listening and watching. They often occur together in clusters of two or three. Watch for any of the following components of the pain pattern.
Gradual, Progressive, and Cyclical Pain Patterns Gradual, progressive, and cyclical pain patterns are characteristic of viscerogenic disease. The one time this pain pattern occurs in an orthopedic situation is with the client who has low back pain of a discogenic origin. The client is given the appropriate intervention and begins to do his/her exercise program. The symptoms improve and the client completes a full weekend of gardening, 18 holes of golf, or other excessive activity. The activity aggravates the condition and the symptoms return worse than before. The client returns to the clinic, gets firm reminders by the therapist regarding guidelines for physical activity, and is sent out once again with the appropriate exercise program. The "cooperate—get better— then overdo" cycle may recur until the client completes the rehabilitation process and obtains relief from symptoms and return of function. This pattern can mimic the gradual, progressive, and cyclical pain pattern normally associated with underlying organic pathology. The difference between a NMS pattern of pain and symptoms and a visceral pattern is the NMS problem gradually improves over time whereas the systemic condition gets worse. Of course, beware of the client with discogenic back and leg pain who suddenly returns to the clinic completely symptom free. There is always the risk of disc herniation and sequestration when the nucleus detaches and becomes a loose body that may enter the spinal canal. In the case of a "miraculous cure" from disc herniation, be sure to ask about the onset of any new symptoms, especially changes in bowel and bladder function.
Constant Pain Pain that is constant and intense should raise a red flag. There is a logical and important first question to ask anyone who says the pain is "constant." Can you think what this question might be?
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INTRODUCTION TO THE SCREENING PROCESS
Questions
• Do you have that pain right now? It is surprising how often the client will answer 'No' to this question. While it is true that pain of a NMS origin can be constant, it is also true there is usually some way to modulate it up or down. The client often has one or two positions that make it better (or worse). Constant, intense pain in a client with a previous personal history of cancer and/or in the presence of other associated signs and symptoms raises a red flag. You may want to use the McGill Home Recording Card to assess the presence of true constant pain (see Fig. 3-7). It is not necessary to have the client complete an entire week's pain log to assess constant pain. A 24- to 48-hour time period is sufficient. Use the recording scale on the right indicating pain intensity and medications taken (prescription and overthe-counter). Under item number 3, include sexual activity. The particulars are not necessary, just some indication that the client was sexually active. The client defines "sexually active" for him or herself, whether this just touching and holding or complete coitus. This is another useful indicator of pain levels and functional activity. Remember to offer clients a clear explanation for any questions asked concerning sexual activity, sexual function, or sexual history. There is no way to know when someone will be offended or claim sexual harassment. It is in your own interest to behave in the most professional manner possible. There should be no hint of sexual innuendo or humor injected into any of your conversations with clients at any time. The line of sexual impropriety lies where the complainant draws it and includes appearances of misbehavior. This perception differs broadly from client to client. Finally, the number of hours slept is helpful information. Someone who reports sleepless nights may not actually be awake, but rather, may be experiencing a sleep disturbance. Cancer pain wakes the client up from a sound sleep. An actual record of being awake and up for hours at night or awakened repeatedly is significant (Case example 3-6). See the discussion on Night Pain earlier in this chapter. 2
Physical Therapy Intervention "Fails" If a client does not get better with physical therapy intervention, do not immediately doubt yourself.
The lack of progression in treatment could very well be a red flag symptom. If the client reports improvement in the early intervention phase, but later takes a turn for the worse, it may be a red flag. Take the time to step back, reevaluate the client and your intervention, and screen if you have not already done so (or screen again if you have). If painful, tender, or sore points (e.g., Trigger points, Jones' points, acupuncture/acupressure points/Shiatsu) are eliminated with intervention then return quickly (by the end of the individual session), suspect visceral pathology. If a tender point comes back later (several days or weeks), you may not be holding it long enough. 2
Bone Pain and Aspirin There is one odd clinical situation you should be familiar with; not because you are likely to see it, but because the physicians may use this scenario to test your screening knowledge. Before the advent of non-aspirin pain relievers, a major red flag was always the disproportionate relief of bone pain from cancer with a simple aspirin. The client who reported such a phenomenon was suspected of having osteoid osteoma and a medical work-up would be ordered. The mechanism behind this is explained by the fact that salicylates in the aspirin inhibit the pain-inducing prostaglandins produced by the bone tumor. When conversing with a physician, it is not necessary for the therapist to identify the specific underlying pathology as a bone tumor. Such a conclusion is outside the scope of a physical therapist's practice. However, recognizing a sign of something that does not fit the expected mechanical or NMS pattern is within the scope of our practice and that is what the therapist can emphasize when communicating with medical doctors. Understanding this concept and being able to explain it in medical terms can enhance communication with the physician.
Pain Does Not Fit the Expected Pattern In a primary care practice or under direct access, the therapist may see a client reporting back, hip, or sacroiliac pain of systemic or visceral origin early on in its development. In these cases, during early screening, the client often presents with full and pain free range of motion. Only after pain has been present long enough to cause splinting and guarding, does the client exhibit biomechanical changes (Box 3-9).
CHAPTER 3
CASE
EXAMPLE
3-6
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
Constant Night Pain
A 33-year-old man with left shoulder pain reports "constant pain at night." After asking all the appropriate screening questions related to night pain and constant pain, you see the following pattern: Shoulder pain that is made worse by lying down whether it is at night or during the day. There are no increased pulmonary or breathing problems at night when lying down. Pain is described as a "deep aching." The client cannot find a comfortable position and moves from bed to couch to chair to bed all night long. He injured his arm 6 months ago in a basketball game when he fell and landed on that shoulder. Symptoms have been gradually getting worse and nothing he does makes it go away. He reports a small amount of relief if he puts a rolled towel under his armpit. He is not taking any medication, has no significant personal or family history for cancer, kidney, heart, or stomach disease and has no other symptoms of any kind. Do you need to screen any further for systemic origin of symptoms? Probably not, even though there are what look like red flags: Constant pain Deep aching Symptoms beyond the expected time for physiologic healing No position is comfortable
BOX 3-9
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Range o f M o t i o n Changes with Systemic Disease
Once you complete the objective tests and measures, you will have a better idea if further questions are needed. Although his pain is "constant" and occurs at night, it looks like it may be positional. An injury 6 months ago with continued symptoms falls into the category of "symptoms persist beyond the expected time for physiologic healing." His description of not being able to find a position of comfort is a possible example of "no position is comfortable." Given the mechanism of injury and position of mild improvement (towel roll under the arm), it may be more likely that a soft tissue tear is present and physiologic healing has not been possible. Referral to a physician (or returning the client to the referring physician) may not be necessary just yet. Some clients do not want surgery and opt for a rehabilitation approach. Make sure you have all the information from the primary care physician if there is one involved. Your rehabilitation protocol will depend on a specific diagnosis (e.g., torn rotator cuff, labral tear, impingement syndrome). If the client does not respond to physical therapy intervention, reevaluation (possibly including a screening component) is warranted with physician referral considered at that time.
may also have significant underlying injury. Physical pain and emotional changes are two sides of the same coin. Pain is not just a physical sensation that passes up to consciousness and then produces secondary emotional effects. Rather, the neurophysiology of pain and emotions are closely linked throughout the higher levels of the CNS. Sensory and emotional changes occur simultaneously and influence each other. The sensory discriminative component of pain is primarily physiologic in nature and occurs as a result of nociceptive stimulation in the presence of organic pathology. The motivational-affective dimension of pain is psychologic in nature subject to the underlying principles of emotional behavior. The therapist's practice often includes clients with personality disorders, malingering, or other 89
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• E a r l y s c r e e n i n g : Full and pain free ROM • L a t e s c r e e n i n g : Biomechanical response to pain results in changes associated with splinting and guarding
SCREENING FOR EMOTIONAL AND PSYCHOLOGIC OVERLAY Pain, emotions, and pain behavior are all integral parts of the pain experience. There is no disease, illness, or state of pain without an accompanying psychologic component. This does not mean the client's pain is not real or does not exist on a physical level. In fact, clients with behavioral changes 2
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psychophysiologic disorder. Psychophysiologic disorders (also known as psychosomatic disorders) are any conditions in which the physical symptoms may be caused or made worse by psychologic factors. Recognizing somatic signs of any psychophysiologic disorder is part of the screening process. Behavioral, psychologic, or medical treatment may be indicated. Psychophysiologic disorders are generally characterized by subjective complaints that exceed objective findings, symptom development in the presence of psychosocial stresses, and physical symptoms involving one or more organ systems. It is the last variable that can confuse the therapist when trying to screen for medical disease. It is impossible to discuss the broad range of psychophysiologic disorders that comprise a large portion of the physical therapy caseload in a screening text of this kind. The therapist is strongly encouraged to become familiar with the Diagnostic and Statistical Manual-IV to understand the psychologic factors affecting the successful outcome of rehabilitation. However, recognizing clusters of signs and symptoms characteristic of the psychologic component of illness is very important in the screening process. Likewise, the therapist will want to become familiar with nonorganic signs indicative of psychologic factors. " Three key psychologic components have important significance in the pain response of many people: • Anxiety • Depression • Panic Disorder 42
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Anxiety, Depression, and Panic Disorder Psychologic factors such as emotional stress and conflicts leading to anxiety, depression, and panic disorder play an important role in the client's experience of physical symptoms. In the past, physical symptoms caused or exacerbated by psychologic variables were labeled psychosomatic. Today the interconnections between the mind, the immune system, the hormonal system, the nervous system, and the physical body have led us to view psychosomatic disorders as psychophysiologic disorders. There is considerable overlap, shared symptoms, and interaction between these emotions. They are all part of the normal human response to pain and stress and occur often in clients with serious or chronic health conditions. Intervention is not always needed. However, strong emotions 73
experienced over a long period of time can become harmful if excessive. Depression and anxiety often present with somatic symptoms that may resolve with effective treatment of these disorders. Diagnosis of these conditions is made by a medical doctor or trained mental health professional. The therapist can describe the symptoms and relay that information to the appropriate agency or individual when making a referral.
Anxiety Anyone who feels excessive anxiety may have a generalized anxiety disorder with excessive and unrealistic worry about day-to-day issues that can last months and even longer. Anxiety amplifies physical symptoms. It is like the amplifier ("amp") on a sound system. It does not change the sound; it just increases the power to make it louder. The tendency to amplify a broad range of bodily sensations may be an important factor in experiencing, reporting, and functioning with an acute and relatively mild medical illness. Keep in mind the known effect of anxiety on the intensity of pain of a musculoskeletal versus systemic origin. Defining the problem, offering reassurance, and outlining a plan of action with expected outcomes can reduce painful symptoms amplified by anxiety. It does not ameliorate pain of a systemic nature. Musculoskeletal complaints such as sore muscles, back pain, headache, or fatigue can result from anxiety-caused tension or heightened sensitivity to pain. Anxiety increases muscle tension, thereby reducing blood flow and oxygen to the tissues, resulting in a buildup of cellular metabolites. Somatic symptoms are diagnostic for several anxiety disorders, including panic disorder, agoraphobia (fear of open places, especially fear of being alone or of being in public places) and other phobias (irrational fears), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and generalized anxiety disorders. Anxious persons have a reduced ability to tolerate painful stimulation, noticing it more or interpreting it as more significant than do nonanxious persons. This leads to further complaining about pain and to more disability and pain behavior such as limping, grimacing, or medication seeking. To complicate matters more, persons with an organic illness sometimes develop anxiety known as adjustment disorder with anxious mood. Additionally, the advent of a known organic condition, such as a pulmonary embolus or chronic obstruc94
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tive pulmonary disease (COPD), can cause an agoraphobia-like syndrome in older persons, especially if the client views the condition as unpredictable, variable, and disabling. According to C. Everett Koop, the former U.S. Surgeon General, 80% to 90% of all people seen in a family practice clinic are suffering from illnesses caused by anxiety and stress. Emotional problems amplify physical symptoms such as ulcerative colitis, peptic ulcers, or allergies. Although allergies may be inherited, anxiety amplifies or exaggerates the symptoms. Symptoms may appear as physical, behavioral, cognitive, or psychologic (Table 3-9). The Beck Anxiety Inventory (BAI) quickly assesses the presence and severity of client anxiety in adolescents and adults ages 17 and older. It was designed to reduce the overlap between depression and anxiety scales by measuring anxiety symptoms shared minimally with those of depression. The BAI consists of 21 items, each scored on a four-point scale between 0 and 3, for a total score ranging from 0 to 63. Higher scores indicate higher levels of anxiety. The BAI is reported to have good
TABLE
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Symptoms
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reliability for clients with various psychiatric diagnoses. ' Both physiological and cognitive components of anxiety are addressed in the 21 items describing subjective, somatic, or panic-related symptoms. The BAI differentiates between anxious and nonanxious groups in a variety of clinical settings and is appropriate for all adult mental health populations. 96
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Depression Once defined as a deep and unrelenting sadness lasting 2 weeks or more, depression is no longer viewed in such simplistic terms. As an understanding of this condition has evolved, scientists have come to speak of the depressive illnesses. This term gives a better idea of the breadth of the disorder, encompassing several conditions including depression, dysthymia, bipolar disorder, and seasonal affective disorders (SAD). Although these conditions can differ from individual to individual, each includes some of the symptoms listed. Often the classic signs of depression are not as easy to recognize in people older
of A n x iety
Physical
Increased sighing respirations Increased blood pressure Tachycardia Shortness of breath Dizziness Lump in throat Muscle tension Dry mouth Diarrhea Nausea Clammy hands Profuse sweating Restlessness, pacing, irritability, difficulty concentrating Chest pain* Headache Low back pain Myalgia (muscle pain, tension, or tenderness) Arthralgia (joint pain) Abdominal (stomach) distress Irritable bowel syndrome (IBS)
Behavioral
Cognitive
Psychologic
Hyperalertness Irritability Uncertainty Apprehension Difficulty with memory or concentration Sleep disturbance
Fear of losing mind Fear of losing control
Phobias Obsessive-compulsive behavior
* Chest pain associated with anxiety accounts for more than half of all emergency department admissions for chest pain. The pain is substernal, a dull ache that does not radiate and is not aggravated by respiratory movements but is associated with hyperventilation and claustrophobia. See Chapter 17 for further discussion of chest pain triggered by anxiety.
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than 65, and many people attribute such symptoms simply to "getting older" and ignore them. Anyone can be affected by depression at any time. There are, in fact, many underlying physical and medical causes of depression (Box 3-10), including medications used for Parkinson's disease, arthritis, cancer, hypertension, and heart disease (Box 3-11). The therapist should be familiar with these. For example, anxiety and depressive disorders occur at a higher rate in clients with chronic obstructive pulmonary disease ( C O P D ) . There is also a link between depression and heart risks in women. Depressed, but otherwise healthy, postmenopausal women face a 50% higher risk of dying from heart disease than women who are not depressed. People with chronic pain have three times the average risk of developing depression or anxiety 98
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B O X 3-10
B O X 3-11
• • • • • • • • • •
Drugs C o m m o n l y Associated with Depression
Anti-anxiety medications (e.g., Valium, Xanax) Illegal drugs (e.g., cocaine, crack) Antihypertensive drugs (e.g., beta blockers, anti-adrenergics) Cardiovascular medications (e.g., digitoxin, digoxin) Antineoplastic agents (e.g., vinblastine) Opiate analgesics (e.g., morphine, Demerol, Darvon) Anticonvulsants (e.g., Dilantin, Phenobarbital) Corticosteroids (e.g., Prednisone, cortisone) Alcohol Hormone replacement therapy and oral contraceptives
For a complete list of drugs that can cause depression see: Wolfe, S: List of drugs that cause depression, Public Citizen's Health Research Group, Washington, DC, 2004 http://www.worstpills.org/public/aalist.cfm?aa=73&drug_order=l
Physical Conditions C o m m o n ly Associated with Depression
Cardiovascular Atherosclerosis Hypertension Myocardial infarction Angioplasty or bypass surgery
Pneumonia Influenza Nutritional Folic acid deficiency Vitamin B deficiency Vitamin B deficiency 6
Central Nervous System Parkinson's disease Huntington's disease Cerebral arteriosclerosis Stroke Alzheimer's disease Temporal lobe epilepsy Postconcussion injury Multiple sclerosis Miscellaneous focal lesions Endocrine, Metabolic Hyperthyroidism Hypothyroidism Addison's disease Cushing's disease Hypoglycemia Hyperglycemia Hyperparathyroidism Hyponatremia Diabetes mellitus Pregnancy (post-partum)
12
I m m i in A
Immune
Fibromyalgia Chronic fatigue syndrome Systemic Lupus Erythematosus Sjogren's syndrome Eheumatoid arthritis Immunosuppression (e.g., corticosteroid treatment) Cancer Pancreatic Bronchogenic Renal Ovarian Miscellaneous Pancreatitis Sarcoidosis Syphilis Porphyria Corticosteroid treatment
Viral Acquired immunodeficiency syndrome Hepatitis From Goodman CC. Biopsychosocial-Spiritual Concepts Related to Health Care. In Goodman CC, Boissonnault WG, Fuller K: Pathology: implications for the physical therapist, ed 2, Philadelphia, 2003, WB Saunders; p 54.
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and clients who are depressed have three times the average risk of developing chronic pain. Almost 500 million people are suffering from mental disorders today. One in four families has at least one member with a mental disorder at any point in time. And these numbers are on the increase. Depressive disorders are the fourth leading cause of disease and disability. Public health prognosticators predict that by 2020, clinical depression will be the leading cause of medical disability on earth. Adolescents are increasingly affected by depression. The reasons for the increased incidence are speculative at best. Rapid cultural change around the world, worldwide poverty, and the aging of the world's population (the incidence of depression and dementia increases with age) have been put forth by researchers as possibilities. " 100
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TABLE
3-10
Systemic
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Others suggest better treatment of the symptoms has resulted in fewer suicides. Researchers think that genes may play a role in a person's risk of developing depression. " In earlier times, adults who had this genetic link may have committed suicide before bearing children and passing the gene on. Today, with better treatment and greater longevity, people with major depressive disorders may unwittingly pass the disease on to their children. New insights on depression have led scientists to see clinical depression as a biologic disease possibly originating in the brain with multiple visceral involvements (Table 3-10). One error in medical treatment has been to recognize and treat the client's esophagitis, palpitations, irritable bowel, heart disease, asthma, chronic low back pain without seeing the real underlying impairment of 105
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Effects of Depression
System
Sign
or
symptom
General (multiple system cross over)
Persistent fatigue Insomnia, sleep disturbance See clinical signs and symptoms of depression (text)
Cardiovascular
Chest pain • Associated with myocardial infarction • Can be atypical chest pain that is not associated with coronary artery disease Palpitations Ventricular tachycardia
Gastrointestinal
Irritable bowel syndrome Esophageal dysmotility Nonulcer dyspepsia Functional abdominal pain (heartburn)
Neurologic (often symmetrical and nonanatomic)
Paresthesia Dizziness Difficulty concentrating and making decisions; problems with memory
Musculoskeletal
Weakness Fibromyalgia (or other unexplained rheumatic pain) Myofascial pain syndrome Chronic back pain
Immune
Multiple allergies Chemical hypersensitivity Autoimmune disorders Recurrent or resistant infections
Dysregulation
Autonomic instability • Temperature intolerance • Blood pressure changes Hormonal dysregulation (e.g., amenorrhea)
Other
Migraine and tension headaches Shortness of breath associated with asthma or not clearly explained Anxiety or panic disorder
Data From: Smith NL: The effects of depression and anxiety on medical illness, University of Utah, School of Medicine, Stress Medicine Clinic, Sandy, Utah, 2002.
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the central nervous system (CNS dysregulation: depression) leading to these d y s f u n c t i o n s . A medical diagnosis is necessary because several known physical causes of depression are reversible if treated (e.g., thyroid disorders, vitamin B deficiency, medications [especially sedatives], some hypertensives, and H blockers for stomach problems). About half of clients with panic disorder will have an episode of clinical depression during their lives. Depression is not a normal part of the aging process, but it is a normal response to pain or disability and may influence the client's ability to cope. Whereas anxiety is more apparent in acute pain episodes, depression occurs more often in clients with chronic pain. The therapist may want to screen for psychosocial factors, such as depression that influences physical rehabilitation outcomes, especially when a client demonstrates acute pain that persists for more than 6 to 8 weeks. Screening is also important because depression is an indicator of poor prognosis. In the primary care setting, the physical therapist has a key role in identifying comorbidities that may have an impact on physical therapy intervention. Depression has been clearly identified as a factor that delays recovery for clients with low back pain. The longer depression is undetected, 105110111
i 2
2
TABLE
For 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
3-11
the greater the likelihood of prolonged physical therapy intervention and increased disability Tests such as the Beck Depression Inventory II (BDI-II), - the Zung Depression Scale, or the Geriatric Depression Scale (short form) (Table 311) can be administered by a physical therapist to obtain baseline information that may be useful in determining the need for a medical referral. These tests do not require interpretation that is out of the scope of physical therapist practice. The short form of the BDI, the most widely used instrument for measuring depression, takes five minutes to complete, and is also used to monitor therapeutic progress. The BDI consists of questions that are noninvasive and straightforward in presentation. The Beck Depression Inventory Second Edition (BDI-II) is a 21-item self-report instrument intended to assess the existence and severity of symptoms of depression in adults and adolescents 13 years of age and older as listed in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; 1994). When presented with the BDI-II, a client is asked to consider each statement as it relates to the way they have felt for the past 2 weeks, to more accurately correspond to the DSM-IV criteria. The authors warn against the use of this instrument as 112113
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Geriatric Depression Scale (Short Form)
each question, choose the answer that best describes how you felt over the past week. Are you basically satisfied with your life? Have you dropped many of your activities and interests? Do you feel that your life is empty? Do you often get bored? Are you in good spirits most of the time? Are you afraid that something bad is going to happen to you? Do you feel happy most of the time? Do you often feel helpless? Do you prefer to stay at home, rather than going out and doing new things? Do you feel you have more problems with memory than most people? Do you think it is wonderful to be alive now? Do you feel pretty worthless the way you are now? Do you feel full of energy? Do you feel that your situation is hopeless? Do you think that most people are better off than you are?
Yes/NO YES/No YES/No YES/No Yes/NO YES/No Yes/NO YES/No YES/No YES/No Yes/NO YES/No Yes/NO YES/No YES/No
NOTE: The scale is scored as follows: 1 point for each response in capital letters. A score of 0 to 5 is normal; a score above 5 suggests depression and warrants a follow-up interview; a score above 10 almost always indicates depression. Used with permission from Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version, Clin Gerontol 5:165-173, 1986.
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a sole diagnostic measure, because depressive symptoms may be part of other primary diagnostic disorders (see Box 3-10). In the acute care setting, the therapist may see results of the BDI-II for Medical Patients in the medical record. This seven-item self-report measure of depression in adolescents and adults reflects the cognitive and affective symptoms of depression, while excluding somatic and performance symptoms that might be attributable to other conditions. It is a quick and effective way to assess depression in populations with biological, medical, alcohol, and/or substance abuse problems. The Beck Scales for anxiety, depression, or suicide can help identify clients from ages 13 to 80 with depressive, anxious, or suicidal tendencies even in populations with overlapping physical and/or medical problems. The Beck Scales have been developed and validated to assist health care professionals in making focused and reliable client evaluations. Test results can be the first step in recognizing and appropriately treating an affective disorder. These are copyrighted materials and can be obtained directly from The Psychological Corporation now under the new name of Harcourt Assessment. If the resultant scores for any of these assessment tools suggest clinical depression, psychologic referral is not always necessary. Intervention outcome can be monitored closely and if progress is not made, the therapist may want to review this outcome with the client and discuss the need to communicate this information to the physician. Depression can be treated effectively with a combination of therapies, including exercise, proper nutrition, antidepressants, and psychotherapy.
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signal, and responds with too much of a reaction. Serotonin levels are low and substance P levels are too high when, in fact, these two neurotransmitters are supposed to work together to modulate the GI r e s p o n s e . Other researchers propose that one of the mechanisms underlying chronic disorders associated with depression such as irritable bowel syndrome and fibromyalgia is an increased activation of brain regions concerned with the processing and modulation of visceral and somatic afferent information, particularly in the subregions of the anterior cingulate cortex ( A C C ) . Another red flag for depression is any condition associated with smooth muscle spasm such as asthma, irritable or overactive bladder, Raynaud's disease, and hypertension. Neurologic symptoms with no apparent cause such as paresthesias, dizziness, and weakness may actually be symptoms of depression. This is particularly true if the neurologic symptoms are symmetrical or not anatomic. 120121
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SYMPTOMS OF DEPRESSION
About one-third of the clinically depressed clients treated do not feel sad or blue. Instead, they report somatic symptoms such as fatigue, joint pain, headaches, or chronic back pain (or any chronic, recurrent pain present in multiple places). Eighty to 90% of the most common gastrointestinal disorders (e.g., esophageal motility disorder, nonulcer dyspepsia, irritable bowel syndrome) are associated with depressive or anxiety disorders. " Some scientists think the problem is overresponse of the enteric system to stimuli. The gut senses stimuli too early, receives too much of a 111
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Clinical Signs and Symptoms of D e p r e s s i o n (See Also Table 3-10) • • • • • • • • • • • • • • • • •
Persistent sadness, low mood, or feelings of emptiness Frequent or unexplained crying spells A sense of hopelessness Feelings of guilt or worthlessness Problems in sleeping Loss of interest or pleasure in ordinary activities or loss of libido Fatigue or decreased energy Appetite loss (or overeating) Difficulty in concentrating, remembering, and making decisions Irritability Persistent joint pain Headache Chronic back pain Bilateral neurologic symptoms of unknown cause (e.g., numbness, dizziness, weakness) Thoughts of death or suicide Pacing and fidgeting Chest pain and palpitations
Modified from Hendrix ML: Understanding panic disorder. Washington, DC, U.S. Department of Health and Human Services, National Institutes of Health, January 1993.
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EXAMPLE 3 - 7
Post-Total Knee Replacement
A 71-year-old woman has been referred for home health following a left total knee replacement. Her surgery was 6 weeks ago and she has had severe pain, swelling, and loss of motion. She has had numerous previous surgeries including right shoulder arthroplasty, removal of the right eye (macular degeneration), rotator cuff repair on the left, hysterectomy, two caesarian sections, and several inner ear surgeries. In all, she proudly tells you she has had 21 operations in 21 years. Her family tells you she is taking Percocet prescribed by the orthopedic surgeon and Darvon left over from a previous surgery. They estimate she takes at least 10 to 12 pills everyday. They are concerned because she complains of constant pain and sleeps 18 hours a day. They want you to "do something." What is the appropriate response in this situation? As part of the evaluation process, you will be gathering more information about your client's functional level, functional status, mental status, and assessing her pain more thoroughly. Take some time to listen to the client's pain description and concerns. Find out what her goals are and what would help her to reach those goals. Consider using the McGill Pain Questionnaire to assess for emotional overlay. With a long
DRUGS, DEPRESSION, OR DEMENTIA?
The older adult often presents with such a mixed clinical presentation, it is difficult to know what is a primary musculoskeletal problem and what could be caused by drugs or depression (Case Example 3-7). Family members confuse signs and symptoms of depression with dementia and often ask the therapist for a differentiation. Depression and dementia share some common traits, but there are differences. A medical diagnosis is needed to make the differentiation. The therapist may be able to provide observational clues by noting any of the following : • Mental function: declines more rapidly with depression • Disorientation: present only in dementia • Difficulty concentrating: depression • Difficulty with short-term memory: dementia • Writing, speaking, and motor impairments: dementia 123
history of medical care she may be dependent on the attention she gets for each operation. Addiction to pain relieving drugs can occur, but it is more likely that she has become dependent on them because of a cycle of pain-spasminactivity-pain-spasm, and so on. Physical therapy intervention may help reduce some of this and change around her pain pattern. Depression may be a key factor in this case. Review the possible signs and symptoms of depression with the client. It may not be necessary to tell the client ahead of time that these signs and symptoms are typical of depression. Read the list and ask her to let you know if she is experiencing any of them. See how many she reports at this time. Afterwards, ask her if she may be depressed and see how she responds to the question. Medical referral for review of her medications and possible psychologic evaluation may be in her best interest. You may want to contact the doctor with your concerns and/or suggest the family report their concerns as well. Keep in mind exercise is a key intervention strategy for depression. As the therapist, you may be able to "do something" by including a general conditioning program in addition to her specific knee exercises.
• Memory loss: people with depression notice and comment, people with dementia are indifferent to the changes
Panic
Disorder
Persons with panic disorder have episodes of sudden, unprovoked feelings of terror or impending doom with associated physical symptoms, such as racing or pounding heartbeat, breathlessness, nausea, sweating, and dizziness. During an attack people may fear that they are gravely ill, going to die, or going crazy. The fear of another attack can itself become debilitating so that these individuals avoid situations and places that they believe will trigger the episodes, thus affecting their work, their relationships, and their ability to take care of everyday tasks. Initial panic attacks may occur when people are under considerable stress, for example, an overload
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of work or from loss of a family member or close friend. The attacks may follow surgery, a serious accident, illness, or childbirth. Excessive consumption of caffeine or use of cocaine, other stimulant drugs, or medicines containing caffeine or stimulants used in treating asthma can also trigger panic attacks. The symptoms of a panic attack can mimic those of other medical conditions, such as respiratory or heart problems. Anxiety or panic is a leading cause of chest pain mimicking a heart attack. Residual sore muscles are a consistent finding after the panic attack and can also occur in individuals with social phobias. People suffering from these attacks may be afraid or embarrassed to report their symptoms to the physician. The alert therapist may recognize the need for a medical referral. A combination of antidepressants known as selective serotonin reuptake inhibitors (SSRIs) combined with cognitive behavioral therapy (CBT) has been proven effective in controlling symptoms. Panic disorder is characterized by period of sudden, unprovoked, intense anxiety with associated physical symptoms lasting a few minutes up to a few hours. Dizziness, paresthesias, headaches, and palpitations are common. Pain perception involves a sensory component (pain sensation) and an emotional reaction referred to as the sensory-discriminative and motivational-affective dimensions, respectively. 124
125
Psychoneuroimmunology When it comes to pain assessment, sources of pain, mechanisms of pain, and links between the mind and body, it is impossible to leave out a discussion of a new area of research and study called psychoneuroimmunology (PNI). PNI is the study of the interactions among behavior, neural, endocrine, enteric (digestive), and immune system function. PNI explains the influence of the nervous system on the immune and inflammatory responses, and how the immune system communicates with the neuro-endocrine systems. The immune system can activate sensory nerves and the central nervous system by releasing proinflammatory cytokines, creating an exaggerated pain response. Further, there is a unique integration of the hypothalamic-pituitary-adrenal axis and the neuro-endocrine-enteric axis. This is accomplished on a biologic basis, a discovery first made in the late 1990s. Physiologically adaptive processes occur as a result of these biochemically based mind-body connections and likely impact the perception of pain and memory of pain. Researchers at the National Institute of Health (NIH) made a groundbreaking discovery when the biologic basis for emotions (neuropeptides and their receptors) was identified. This new understanding of the interconnections between the mind and body goes far beyond our former understanding of the psychosomatic response in illness, disease, or injury. Neuropeptides are chemical messengers that move through the blood stream to every cell in the body. These information molecules take messages throughout the body to every cell and organ system. For example, the digestive (enteric) system and the neurologic system communicate with the immune system via these neuropeptides. These three systems can exchange information and influence one another's actions. More than 30 different classes of neuropeptides have been identified. Every one of these messengers is found in the enteric nervous system of the gut. The constant presence of these neurotransmitters and neuromodulators in the bowel suggests that emotional expression of active coping generates a balance in the neuropeptide-receptor network and physiologic healing beginning in the GI system. The identification of biologic carriers of emotions has also led to an understanding of a concept well known to physical therapists but previously unnamed: cellular memories. " Many health 126
127
Clinical Signs and Symptoms of Panic
Disorder
•
Racing or pounding heartbeat
• • • • •
Chest pains a n d / o r palpitations Dizziness, lightheadedness, nausea Headaches Difficulty in breathing Bilateral numbness or tingling in nose, cheeks, lips, fingers, toes Sweats or chills Hand wringing Dreamlike sensations or perceptual distortions Sense of terror Extreme fear of losing control Fear of dying
• • • • • •
Modified from Hendrix ML: Understanding panic disorder. Washington, DC, U.S. Department of Health and Human Services, National Institutes of Health, 1993. For more information, contact the National Institute of Mental Health: 800-64-PANIC.
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128
131
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care professionals have seen the emotional and psychological response of a hands-on approach. Concepts labeled as cranio-sacral, unwinding, myofascial release, and soft tissue mobilization are based (in part) with this in mind. These new discoveries help substantiate the idea that cells containing memories are shuttled through the body and brain via chemical messengers. The biologic basis of emotions and memories helps explain how soft tissues respond to emotions; indeed, the soft tissue structures may even contain emotions by way of neuropeptides. Perhaps this can explain why two people can experience a car accident and whiplash (flexionextension) or other injury. One recovers without any problems, while the other develops chronic pain that is resistant to any intervention. The focus of research on behavioral approaches combined with our hands-on intervention may bring a better understanding of what works and why. Other researchers investigating neuropathic pain see a link between memory and pain. Studies looking at the physical similarities between the way a memory is formed and the way pain becomes persistent and chronic support such a link. Researchers suggest when somatic pain persists beyond the expected time of healing the pain no longer originates in the tissue that was damaged. Pain begins in the central nervous system instead. The experience changes the nervous system. The memory of pain recurs again and again in the CNS. The nervous system transmits pain signals efficiently and small pain signals may be amplified until the sensation of pain is out of proportion to what is expected for the injury. Pain amplification occurs in the spinal cord. Spinal cord cells called glia become activated, releasing a variety of chemical substances that cause pain messages to become amplified. Other researchers have reported the discovery of a protein that allows nerve cells to communicate and thereby enhance perceptions of chronic pain. The results reinforce the notion that the basic process that leads to memory formation may be the same as the process that causes chronic pain. Along these same lines, other researchers have shown a communication network between the immune system and the brain. Pain phenomena are actually modulated by immune function. Proinflammatory cytokines (e.g., tumor necrosis factor [TNF], interleukin-1 [IL-1], interleukin-6 [IL-6]) released by activated immune cells signal the brain 132
132
133
134
by both blood-borne and neural routes, leading to alterations in neural activity. The cytokines in the brain interfere with cognitive function and memory; the cytokines within the spinal cord exaggerate fatigue and pain. By signaling the central nervous system, these proinflammatory cytokines create exaggerated pain as well as an entire constellation of physiologic, hormonal, and behavioral changes referred to as the sickness response. In essence immune processes work well when directed against pathogens or cancer cells. When directed against peripheral nerves, dorsal nerve ganglia, or the dorsal roots in the spinal cord, the immune system attacks the nerves, resulting in extreme pain. Such exaggerated pain states occur with infection, inflammation, or trauma of the skin, peripheral nerves, and central nervous system. The neuro-immune link may help explain the exaggerated pain state associated with conditions such as chronic fatigue syndrome and fibromyalgia. With this new understanding that all peripheral nerves and neurons are affected by immune and glial activation, intervention to modify pain will likely change in the near f u t u r e . 135
136,137
126138
SCREENING FOR SYSTEMIC VERSUS PSYCHOGENIC SYMPTOMS Screening for emotional or psychologic overlay has a place in our examination and evaluation process. Recognizing that this emotion-induced somatic pain response has a scientific basis may help us find better ways to alter or eliminate it. The key in screening for systemic versus psychogenic basis of symptoms is to identify the client with a significant emotional or psychologic component influencing the pain experience. Whether to refer the client for further psychologic evaluation and treatment or just modify the physical therapy plan of care is left up to the therapist's clinical judgment. In all cases of pain, watch for the client who reports any of the following red flag symptoms: • Symptoms are out of proportion to the injury. • Symptoms persist beyond the expected time for physiologic healing. • No position is comfortable. These symptoms reflect both the possibility of an emotional or psychologic overlay as well as the pos-
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sibility of a more serious underlying systemic disorder (including cancer). In this next section, we will look at ways to screen for emotional content, keeping in mind what has already been said about anxiety, depression, and panic disorder.
Three Screening Tools There are three tools that can be used quickly and easily to help screen for emotional overlay in painful symptoms (Box 3-12). The client may or may not be aware that he or she is, in fact, exaggerating pain responses or experiencing pain associated with emotional or psychologic overlay. This discussion does not endorse physical therapists' practicing as psychologists, which is outside the scope of our expertise and experience. It merely recognizes that, in treating the whole client, not only the physical but also the psychologic, emotional, and spiritual needs of that person will be represented in his or her magnitude of symptoms, length of recovery time, response to pain, and responsibility for recovery.
McGill
Pain
Questionnaire
The McGill Pain Questionnaire (MPQ) from McGill University in Canada is a well-known and commonly used tool in assessing chronic pain. The MPQ is designed to measure the subjective pain experience in a quantitative form. It is considered a good baseline for assessing pain and has both high reliability and validity in younger adults. It has not been tested specifically with older adults. The MPQ consists primarily of two major classes of word descriptors, sensory and affective (emotional), and can be used to specify the subjective pain experience. It also contains an intensity scale and other items to determine the properties of pain experience. There is a shorter version, which some clinicians find more practical for routine u s e . It can be used for both assessment and ongoing monitoring for any condition. However, for screening purposes outlined here, the format of the original McGill Questionnaire may work best (Fig. 3-11). 139 1 4 0
B O X 3-12
Screening Tools for Emotional Overlay
• McGill Pain Questionnaire • Symptom Magnification and Illness Behavior • Waddell's Nonorganic Signs
161
The original form of the MPQ with all its affective word descriptors to help clients describe their pain gives results that help the therapist identify the source of the pain: vascular (visceral), neurogenic (somatic), musculoskeletal (somatic), or emotional (psycho-somatic) (see Table 3-1). When administering this portion of the questionnaire, the therapist reads the list of words in each box. The client is to choose the one word that best describes his or her pain. If no word in the box matches, the box is left blank. The words in each box are listed in order of ascending (rank order) intensity. For example, in the first box, the words begin with "flickering" and "quivering" and gradually progress to "beating" and "pounding." Beating and pounding are considered much more intense than flickering and quivering. Word descriptors included in Group 1 reflect characteristics of pain of a vascular disorder. Knowing this information can be very helpful as the therapist continues the examination and evaluation of the client. Groups 2 through 8 are words used to describe pain of a neurogenic origin. Group 9 reflects the musculoskeletal system and groups 10 through 20 are all the words a client might use to describe pain in emotional terms (e.g., torturing, killing, vicious, agonizing). After completing the questionnaire with the client, add up the total number of checks. According to the key, choosing up to eight words to describe the pain is within normal limits. Selecting more than 10 is a red flag for emotional or psychologic overlay, especially when the word selections come from groups 10 through 20.
Illness Behavior Syndrome Symptom Magnification
and
Pain in the absence of an identified source of disease or pathologic condition may elicit a behavioral response from the client that is now labeled illness behavior syndrome. Illness behavior is what people say and do to show they are ill or perceive themselves as sick or in pain. It does not mean there is nothing wrong with the person. Illness behavior expresses and communicates the severity of pain and physical impairment. This syndrome has been identified most often in people with chronic pain. Its expression depends on what and how the client thinks about his or her symptoms/illness. Components of this syndrome include 73
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INTRODUCTION TO THE SCREENING PROCESS
D I R E C T I O N S : T h e r e a r e m a n y w o r d s that d e s c r i b e p a i n . S o m e o f t h e s e w o r d s are g r o u p e d below. C h e c k ( / ) o n e w o r d i n e a c h c a t e g o r y that best d e s c r i b e s y o u r p a i n . A n y c a t e g o r y that d o e s not d e s c r i b e your pain s h o u l d r e m a i n blank.
Fig.
3-11
•
M c G i l l - M e l z a c k Pain Q u e s t i o n n a i r e . The key a n d scoring i n f o r m a t i o n c a n be used to screen for e m o t i o n a l overlay
or to identify a specific somatic or visceral source of p a i n .
I n s t r u c t i o n s a r e p r o v i d e d i n t h e t e x t . (From M e l z a c k R : The M c G i l l p a i n
q u e s t i o n n a i r e : m a j o r p r o p e r t i e s a n d s c o r i n g m e t h o d s , Pain 1 : 2 7 7 - 2 9 9 , 1 9 7 5 . Used w i t h p e r m i s s i o n , I n t e r n a t i o n a l A s s o c i a t i o n for the Study o f Pain.)
• Dramatization of complaints, leading to overtreatment and overmedication • Progressive dysfunction, leading to decreased physical activity and often compounding preexisting musculoskeletal or circulatory dysfunction • Drug misuse
• Progressive dependency on others, including health care professionals, leading to overuse of the health care system • Income disability, in which the person's illness behavior is perpetuated by financial gain Symptom magnification syndrome (SMS) is another term used to describe the phenomenon of 71
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illness behavior; conscious symptom magnification is referred to as malingering, whereas unconscious symptom magnification is labeled illness behavior. The term symptom magnification was first coined by Leonard N. Matheson, PhD* in 1977 to describe clients whose symptoms have reinforced their behavior; that is, the symptoms have become the predominant force in the client's function rather than the physiologic phenomenon of the injury determining the outcome. By definition, SMS is a self-destructive, socially reinforced behavioral response pattern consisting of reports or displays of symptoms that function to control the life of the sufferer. " The symptoms rather than the physiologic phenomenon of the injury determine the outcome/function. The affected person acts as if the future cannot be controlled because of the presence of symptoms. All present limitations are blamed on the symptoms: "My (back) pain won't let me. . . ." The client may exaggerate limitations beyond those that seem reasonable in relation to the injury, apply minimal effort on maximal performance tasks, and overreact to physical loading during objective examination. It is important for physical therapists to recognize that we often contribute to SMS by focusing on the relief of symptoms, especially pain, as the goal of therapy. Reducing pain is an acceptable goal for some types of clients, but for those who experience pain after the injuries have healed, the focus should be restoration, or at least improvement, of function. In these situations, instead of asking whether the client's symptoms are "better, the same, or worse," it may be more appropriate to inquire about functional outcomes; for example, what can the client accomplish at home that she or he was unable to attempt at the beginning of treatment, last week, or even yesterday. Conscious or unconscious? Can a physical therapist determine when a client is consciously or unconsciously symptom magnifying? Is it within the scope of the physical therapist's practice to use the label 'malingerer' without a psychologist or psychiatrist's diagnosis of such first? Some therapists suggest there is a need to keep to what can be measured objectively. Health care professionals have not learned yet how to read someone's mind to determine his/her motivation. 141
163
Keep in mind the goal is to screen for a psychologic or emotional component to the client's clinical presentation. The key to achieving this goal is to use objective test measures whenever possible. In this way, the therapist obtains the guidance needed for referral versus modification of the physical therapy intervention. Compiling a list of nonorganic or behavioral signs and identifying how the client is reacting to pain may be all that is needed. Signs of illness behavior may point the therapist in the direction of more careful management of the psychosocial and behavioral aspects of the client's illness. 89
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* Director, ERIC Human Performance Laboratory, Washington University School of Medicine, St. Louis, Missouri.
Waddell's
Nonorganic
Signs
Waddell et a l identified five nonorganic signs and seven nonanatomic or behavioral descriptions of symptoms (Table 3-12). Each of the nonorganic signs is determined by using one or two of the tests listed. These tests are used to assess a client's pain behavior and detect abnormal illness behavior. The literature supports that these signs may be present in 10% of clients with acute low back pain, but are found most often in people with chronic low back pain. A score of three or more positive signs places the client in the category of nonmovement dysfunction. This person is said to have a clinical pattern of nonmechanical, pain-focused behavior. This type of score is predictive of poor outcome and associated with delayed return-to-work or not working. One or two positive signs is a low Waddell's score and does not classify the client with a nonmovement dysfunction. The value of these nonorganic signs as predictors for return to work for clients with low back pain has been investigated. Less than two is a good prognosticator of return to work. The results of how this study might affect practice are available. A positive finding for nonorganic signs does not suggest an absence of pain but rather a behavioral response to pain (see discussion of symptom magnification syndrome). It does not confirm malingering or illness behavior. Neither do these signs imply the non-existence of physical pathology. Waddell and associates have given us a tool that can help us identify early in the rehabilitation process those who need more than just mechanical or physical treatment intervention. Other evaluation tools are available (e.g., Oswestry Back Pain Disability Questionnaire, Roland-Morris Disability Questionnaire). A psychologic evaluation and possibly behavioral therapy or psychologic counseling may be needed as an adjunct to physical therapy. 145
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148
W a d d ell's N o n o r g a n i c Signs a n d Behavioral Symptoms
Test
or
behavioral
description
of symptoms
Tenderness
Superficial—the client's skin is tender to light pinch over a wide area of lumbar skin; unable to localize to one structure Nonanatomic—deep tenderness felt over a wide area, not localized to one structure
(1) Pain at the tip of the tailbone (2) Whole leg pain from the groin down to below the knee in a stocking pattern (not dermatomal or sclerotomal) [intermittent] (3) Whole leg numbness or whole leg "going dead" [intermittent] (4) Whole leg giving way or collapsing (intermittent; client maintains upright position) (5) Constant pain for years on end without relief (6) Unable to tolerate any treatment; reaction or side effects to every intervention (7) Emergency admission to hospital for back pain without precipitating traumatic event
Simulation tests
Axial loading—light vertical loading over client's skull in the standing position reproduces lumbar (not cervical) spine pain Acetabular rotation—lumbosacral pain from upper trunk rotation; back pain reported when the pelvis and shoulders are passively rotated in the same plane as the client stands; this is considered to be a positive test if pain is reported within the first 30 degrees
Distraction tests
Straight-leg-raise (SLR) discrepancy—marked improvement of SLR when client is distracted as compared with formal testing; different response to SLR in supine (worse) compared to sitting (better) when both tests should have the same result in the presence of organic pathology Double leg raise—when both legs are raised after straight leg raising, the organic response would be a greater degree of double leg raising; clients with a nonorganic component demonstrate less double leg raise as compared with the single leg raise
Regional disturbances
Weakness—cogwheeling or giving way of many muscle groups that cannot be explained on a neurologic basis Sensory disturbance—diminished sensation fitting a "stocking" rather than a dermatomal pattern
Overreaction
Disproportionate verbalization, facial expression, muscle tension, and tremor, collapsing, or sweating. Client may exhibit any of the following behaviors during the physical examination: guarding, bracing, rubbing, sighing, clenching teeth, or grimacing
Adapted from Karas R, Mcintosh G, Hall H, et al: The relationship between nonorganic signs and centralization of symptoms in the prediction of return to work for patients with low back pain, Phys Ther 77(4):354-360, 1997.
INTRODUCTION TO THE SCREENING PROCESS
Nonanatomic
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TABLE 3 - 1 2
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Conversion Symptoms
Motor
Whereas SMS is a behavioral, learned, inappropriate behavior, conversion is a psychodynamic phenomenon and quite rare in the chronically disabled population. Conversion is a physical expression of an unconscious psychologic conflict, such as an event (e.g., loss of a loved one) or a problem in the person's work or personal life. The conversion may provide a solution to the conflict or a way to express "forbidden" feelings. It may be a means of enacting the sick role to avoid responsibilities, or it may be a reflection of behaviors learned in childhood. Diagnosis of a conversion syndrome is difficult and often requires the diagnostic and evaluative input of the physical therapist. Presentation always includes a motor and/or sensory component that cannot be explained by a known medical or neuromusculoskeletal condition. The clinical presentation is often mistaken for an organic disorder such as multiple sclerosis, systemic lupus erythematosus, myasthenia gravis, or idiopathic dystonias. At presentation, when a client has an unusual limp or bizarre gait pattern that cannot be explained by functional anatomy, family members may be interviewed to assess changes in the client's gait and whether this alteration in movement pattern is present consistently. The physical therapist can look for a change in the wear pattern of the client's shoes to decide if this alteration in gait has been long-standing. During manual muscle testing, true weakness results in smooth "giving way" of a muscle group; in hysterical weakness the muscle "breaks" in a series of jerks. Often the results of muscle testing are not consistent with functional abilities observed. For example, the person cannot raise the arm overhead during testing but has no difficulty dressing, or the lower extremity appears flaccid during recumbency but the person can walk on the heels and toes when standing. The physical therapist should carefully evaluate and document all sensory and motor changes. Conversion symptoms are less likely to follow any dermatome, myotome, or sclerotome patterns.
• • • •
•
Sudden, acute onset Lack of concern about the symptoms
•
Unexplainable impairment
motor
or
sensory
Seizures or convulsions Absence of significant laboratory findings Electrodiagnostic testing within normal limits Deep tendon reflexes within normal limits
Besides observing for signs and symptoms of psychophysiologic disorders, the therapist can ask a few screening questions (Box 3-13). The client may be aware of the symptoms, but does not know that these problems can be caused by depression, anxiety, or panic disorder. Medical treatment for physiopsychologic disorders can and should be augmented with exercise. Physical activity and exercise has a known benefit in the management of mild-to-moderate
BOX 3-13
• • • • • •
• function
• • • •
Screening Questions for Psychogenic Source or Symptoms
•
• •
• •
Altered touch or pain sensation (paresthesia or dysesthesia) Visual changes (double vision, blindness, black spots in visual field) Hearing loss (mild to profound deafness) Hallucinations
•
•
Conversion
Impaired coordination or balance a n d / o r bizarre gait pattern Paralysis or localized weakness Loss of voice, difficulty swallowing, or sensation of a lump in the throat Urinary retention
Sensory
11
Clinical Signs and Symptoms of
165
Screening Questions for Psychogenic Source of Symptoms
Do you have trouble sleeping at night? Do you have trouble focusing during the day? Do you worry about finances, work, or life in general? Do you feel a sense of dread or worry without cause? Do you ever feel happy? Do you have a fear of being in groups of people? Fear of flying? Public speaking? Do you have a racing heart, unexplained dizziness, or unexpected tingling in your face or fingers? Do you wake up in the morning with your jaw clenched or feeling sore muscles and joints? Are you irritable or jumpy most of the time?
Data from Davidson J, Dreher H: The anxiety book: developing strength in the face of fear, New York, 2003, Penguin Putnam.
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psychologic disorders, especially depression and anxiety. Aerobic exercise or strength training have both been shown effective in moderating the symptoms of these conditions. " Patience is a vital tool for therapists when working with clients who are having difficulty adjusting to the stress of illness and disability or the client who has a psychologic disorder. The therapist must develop personal coping mechanisms when working with clients who have chronic illnesses or psychologic disturbances. Recognizing clients whose symptoms are the direct result of organic dysfunction helps us in coping with clients who are hostile, ungrateful, noncompliant, negative, or adversarial. Whenever possible, involve a psychiatrist, psychologist, or counselor as part of the management team. This approach will benefit the client as well as the health care staff. 149
•
152
•
•
PHYSICIAN REFERRAL Guidelines for Immediate Physician Referral • Immediate medical attention is required for anyone with risk factors for and clinical signs and symptoms of rhabdomyolysis (see Table 35). • Clients reporting a disproportionate relief of bone pain with a simple aspirin may have bone cancer. This red flag requires immediate medical referral in the presence of a personal history of cancer of any kind. • Joint pain with no known cause and a recent history of infection of any kind. Ask about recent (last 6 weeks) skin lesions or rashes of any kind anywhere on the body, urinary tract infection, or respiratory infection. Take the client's temperature and ask about recent episodes of fever, sweats, or other constitutional symptoms. Palpate for residual lymphadenopathy. Early diagnosis and treatment are essential to limit joint destruction and preserve function. 62
Guidelines for Physician Referral Required • Proximal muscle weakness accompanied by change in one or more deep tendon reflexes in the presence of a previous history of cancer. • The physician should be notified of anyone with joint pain of unknown cause who presents with recent or current skin rash or recent history of infection (hepatitis, mononucleosis, urinary
•
•
tract infection, upper respiratory infection, sexually transmitted infection, streptococcus). A team approach to fibromyalgia requires medical evaluation and management as part of the intervention strategy. Therapists should refer clients suspected with fibromyalgia for further medical follow up. Diffuse pain that characterizes some diseases of the nervous system and viscera may be difficult to distinguish from the equally diffuse pain so often caused by lesions of the moving parts. The distinction between visceral pain and pain caused by lesions of the vertebral column may be difficult to make and may require a medical diagnosis. The therapist may screen for signs and symptoms of anxiety, depression, and panic disorder. These conditions are often present with somatic symptoms that may resolve with effective intervention. The therapist can describe the symptoms and relay that information to the appropriate agency or individual when making a referral. Diagnosis is made by a medical doctor or trained mental health professional. Clients with new onset of back, neck, TMJ, shoulder, or arm pain brought on by a new exercise program or by exertion with the arms raised overhead should be screened for signs and symptoms of cardiovascular impairment. This is especially important if the symptoms are described as "throbbing" and start after a brief time of exercise (3 to 5 up to 10 minutes) and diminish or go away quickly with rest. Look for significant risk factors for cardiovascular involvement. Check vital signs. Refer for medical evaluation if indicated. Persistent pain on weight bearing or bone pain at night especially in the older adult with risk factors such as osteoporosis, postural hypotension leading to falls, or previous history of cancer.
Clues to Screening for Viscerogenic Sources of Pain We know systemic illness and pathologic conditions affecting the viscera can mimic NMS dysfunction. The therapist who knows pain patterns and types of viscerogenic pain can sort through the client's description of pain and recognize when something does not fit the expected pattern for NMS problems. We must keep in mind that pain from a disease process or viscerogenic source is often a late symptom rather than a reliable danger signal. For
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this reason the therapist must remain alert to other signs and symptoms that may be present but unaccounted for. In this chapter pain types possible with viscerogenic conditions have been presented along with three mechanisms by which viscera refer pain to the body (soma). Characteristics of systemic pain compared to musculoskeletal pain are presented, including a closer look at joint pain. Pain with the following features raises a red flag to alert the therapist of the need to take a closer look: • Pain of unknown cause • Pain that persists beyond the expected time for physiologic healing • Pain that is out of proportion to the injury • Pain that is unrelieved by rest or change in position • Pain pattern does not fit the expected clinical presentation for a neuromuscular or musculoskeletal impairment • Pain that cannot be altered, aggravated, provoked, reduced, eliminated, or alleviated • There are some positions of comfort for various organs (e.g., leaning forward for the gallbladder or side bending for the kidney), but with progression of disease the client will obtain less and less relief of symptoms over time • Pain, symptoms, or dysfunction are not improved or altered by physical therapy intervention • Pain that is poorly localized • Pain accompanied by signs and symptoms associated with a specific viscera (e.g., GI, GU, GYN, cardiac, pulmonary, endocrine) • Pain that is constant and intense no matter what position is tried and despite rest, eating or abstaining from food; a previous history of cancer in this client is an even greater red flag necessitating further evaluation • Pain (especially intense bone pain) that is disproportionately relieved by aspirin • Listen to the client's choice of words to describe pain. Systemic or viscerogenic pain can be described as deep, sharp, boring, knifelike, stabbing, throbbing, colicky, or intermittent (comes and goes in waves) • Pain accompanied by full and normal range of motion • Pain that is made worse 3 to 5 minutes after initiating an activity and relieved by rest (possible symptom of vascular impairment) versus pain that goes away with activity (symptom of musculoskeletal involvement); listen for the word
•
• • •
•
•
•
descriptor "throbbing" to describe pain of a vascular nature Pain is a relatively new phenomenon and not a pattern that has been present over several years' time Constitutional symptoms in the presence of pain Pain that is not consistent with emotional or psychologic overlay When in doubt, conduct a screening exam for emotional overlay. Observe the client for signs and symptoms of anxiety, depression, and/or panic disorder. In the absence of systemic illness or disease and/or in the presence of suspicious psychologic symptoms, psychologic evaluation may be needed. Pain in the absence of any positive Waddell's signs (i.e., Waddell's test is negative or insignificant) Manual therapy to correct an upslip is not successful and the problem has returned by the end of the session or by the next day; consider a somato-visceral problem or visceral ligamentous problem. If painful, tender or sore points (e.g., Trigger points, Jones' points, acupuncture/acupressure points/Shiatsu) are eliminated with intervention then return quickly (by the end of the treatment session), suspect visceral pathology. If a tender point comes back later (several days or weeks), the clinician may not be holding it long enough Back, neck, TMJ, shoulder, or arm pain brought on by exertion with the arms raised overhead may be suggestive of a cardiac problem. This is especially true in the postmenopausal woman or man over age 50 with a significant family history of heart disease and/or in the presence of hypertension. Back, shoulder, pelvic, or sacral pain that is made better or worse by eating, passing gas, or having a bowel movement Night pain (especially bone pain) that awakens the client from a sound sleep several hours after falling asleep; this is even more serious if the client is unable to get back to sleep after changing position, taking pain relievers, or eating or drinking something Joint pain preceded or accompanied by skin lesions (e.g., rash or nodules), following antibiotics or statins, or recent infection of any kind (e.g., gastrointestinal, pulmonary, genitourinary); check for signs and symptoms associated with any of these systems based on recent client history 2
•
•
•
•
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• Clients can have more than one problem or pathology present at one time; it is possible to for a client to have both a visceral AND a mechanical problem • Remember Osier's Rule of Age*: Under age 60, most clients' symptoms are related to one problem, but over 60, it is rarely just one problem 2
2
* Physicians often rely on ad hoc rules of thumb, or "heuristics," to guide them. These are often referred to as Osier's Rules. Sir William Osier, MD (1849-1919) promoted the idea that good medical science follows from gathering evidence by directly observing patients.
• A careful general history and physical examination is still the most important screening tool; never assume this was done by the referring physician or other staff from the referring agency 2
• Visceral problems are unlikely to cause muscle weakness, reflex changes, or objective sensory deficits (exceptions include endocrine disease and paraneoplastic syndromes associated with cancer). If pain is referred from the viscera to the soma, challenging the somatic structure by stretching, contracting, or palpating will not reproduce the symptoms. For example, if a muscle is not sore when squeezed or contracted, the muscle is not the source of the pain. 2
KEY POINTS TO REMEMBER / Pain of a visceral origin can be referred to the corresponding somatic areas. The mechanisms of referred visceral pain patterns are not fully known. Information in this chapter is based on proposed models from what is known about the somatic sensory system. / Recognizing pain patterns that are characteristic of systemic disease is a necessary step in the screening process. Understanding how and when diseased organs can refer pain to the neuromusculoskeletal (NMS) system helps the therapist identify suspicious pain patterns. / At least three mechanisms contribute to referred pain patterns of the viscera (embryologic development, multisegmental innervation, direct pressure, and shared pathways). Being familiar with each one may help the therapist quickly identify pain patterns of a visceral source. / The therapist should keep in mind cultural rules and differences in pain perception, intensity, and responses to pain found among various ethnic groups. / Pain patterns of the chest, back, shoulder, scapula, pelvis, hip, groin, and sacroiliac joint are the most common sites of referred pain from a systemic disease process. / Visceral diseases of the abdomen and pelvis are more likely to refer pain to the back, whereas intrathoracic disease refers pain to the shoulder(s). Visceral pain rarely occurs without associated signs and symptoms, although the client may not recognize the correlation. Careful questioning will usually elicit a systemic pattern of symptoms. / A comprehensive pain assessment includes a detailed health history, physical exam, medication history (including nonprescription drug use and complementary
and alternative therapies), assessment of functional status, and consideration of psychosocial-spiritual factors. Assessment tools vary from the very young to the very old. / Careful, sensitive, and thorough questioning regarding the multifaceted experience of pain can elicit essential information necessary when making a decision regarding treatment or referral. The use of pain assessment tools such as Fig. 3-6 and Table 3-2 may facilitate clear and accurate descriptions of this critical symptom. / The client describes the characteristics of pain (location, frequency, intensity, duration, description). It is up to the therapist to recognize sources and types of pain and to know the pain patterns of a viscerogenic origin. / Choose alternative words to "pain" when discussing the client's symptoms in order to get a complete understanding of the clinical presentation. / Specific screening questions for joint pain are used to assess any joint pain of unknown cause, joint pain with an unusual presentation or history, or joint pain which does not fit the expected pattern for injury, overuse, or aging (Box 3-5). / It is important to know how to differentiate psychogenic and psychosomatic origins of painful symptoms from systemic origins, including signs and symptoms of cancer. / Pain described as constant or present at night, awakening the client from sleep must be evaluated thoroughly. W h e n assessing constant a n d / o r night pain, the therapist must know how to differentiate the characteristics of acute versus chronic pain associated with a neuromusculoskeletal problem from a viscerogenic or systemic presentation.
CHAPTER 3
SUBJECTIVE Special
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
EXAMINATION
Questions to Ask
Pain Assessment
Location of pain
Show me exactly where your pain is located. Follow up questions may include: • Do you have any other pain or symptoms anywhere else? • If yes, what causes the pain or symptoms to occur in this other area? Description
of pain
What does it feel like? After giving the client time to reply, offer some additional choices in potential descriptors. You may want to ask: Is your pain/Are your symptoms Knifelike Dull Boring Burning Throbbing Prickly Deep aching Sharp Follow up questions may include: • Has the pain changed in quality since it first began? • Changed in intensity? • Changed in duration (how long it lasts)? Frequency and duration
169
of pain
How long do the symptoms last? Clients who indicate that the pain is constant should be asked: • Do you have this pain right now? • Did you notice these symptoms this morning immediately when you woke up? Pattern of pain
Tell me about the pattern of your pain/symptoms. • Alternate question: When does your back/shoulder (name the involved body part) hurt? • Alternate question: Describe your pain/ symptoms from first waking up in the morning to going to bed at night. (See special sleep-related questions that follow.) Follow up questions may include: • Have you ever experienced anything like this before? • If yes, do these episodes occur more or less often than at first? • How does your pain/symptom(s) change with time? • Are your symptoms worse in the morning or evening?
A g g r a v a t i n g a n d Relieving Factors
• What brings your pain (symptoms) on? • What kinds of things make your pain (symptoms) worse (e.g., eating, exercise, rest, specific positions, excitement, stress)? To assess relieving factors, ask: • What makes the pain better? Follow up questions include: • How does rest affect the pain/symptoms? • Are your symptoms aggravated or relieved by any activities? • If yes, what? • How has this problem affected your daily life at work or at home? • How has this problem affected your ability to care for yourself without assistance (e.g., dress, bathe, cook, drive)? Associated
Symptoms
• What other symptoms have you had that you can associate with this problem? If the client denies any additional symptoms, follow up this question with a series of possibilities such as: Burning Heart Numbness/ Difficulty in palpitations Tingling breathing Hoarseness Problems with Difficulty in Nausea vision swallowing Night sweats Vomiting Dizziness Weakness • Are you having any pain anywhere else in your body? Alternately: Are you having symptoms of any other kind that may or may not be related to your main problem? A n x i e t y / D e p r e s s i o n (See Table 3-11) • Have you been under a lot of stress lately? • Are you having some trouble coping with life in general and/or life's tensions? • Do you feel exhausted or overwhelmed mentally or physically? • Does your mind go blank or do you have trouble concentrating? • Do you have trouble sleeping at night (e.g., difficulty getting to sleep, staying asleep, restless sleep, feel exhausted upon awakening)? Focusing during the day? • Do you worry about finances, work, or life in general? • Do you get any enjoyment in life?
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EXAMINATION —cont'd
• Do you feel keyed up or restless? Irritable and jumpy? On edge most of the time? • Do you have a general sense of dread or unknown fears? • Do you have any of these symptoms: a racing heart, dizziness, tingling, muscle or joint pains?
J o i n t P a i n (See Box 3-5) N i g h t P a i n (See Box 3-7) P s y c h o g e n i c S o u r c e o f S y m p t o m s (See Box
3-13)
For the Asian client:
• Do you feel you are having any imbalance of yin and yang? • Is your chi (internal energy) low? • Do you believe it is your destiny to have this condition or your destiny not to have this condition (fatalism versus well-being approach to illness)?
CASE
STUDY*
REFERRAL
A 44-year old male was referred to physical therapy with a report of right-sided thoracic pain. Past Medical History: The client reported a 20-pack year smoking history (one-pack per day for 20 years) and denied the use of alcohol or drugs. There was no other significant past medical history reported. He had a sedentary job. The client's symptoms began following chiropractic intervention to relieve left-sided lower extremity radiating pain. Within 6 to 8 hours after the chiropractor manipulated the client's thoracic spine, he reported sharp shooting pain on the right side of the upper thoracic spine at T4. The pain radiated laterally under the right axilla into the anterior chest. He also reported tension and tightness along the same thoracic level and moderate discomfort during inspiration. There was no history of thoracic pain prior to the upper thoracic manipulation by the chiropractor.
The client saw his primary care physician who referred him to physical therapy for treatment. No imaging studies were done prior to physical therapy referral. The client rated the pain as a constant 10/10 on the Numeric Rating Scale (NRS) during sitting activities at work. He also reported pain waking him at night. The client was unable to complete a full day at work without onset of thoracic discomfort; pain was aggravated by prolonged sitting. EVALUATION
The client was described as slender in build (ectomorph body type) with forward head and shoulders and kyphotic posturing as observed in the upright and sitting positions. There were no significant signs of inflammation or superficial tissue changes observed or palpated in the thoracic spine region. There was palpable tenderness at approximately the T4 costotransverse joint and along the corresponding rib.
* Leanne Lenker, DPT. This case was part of an internship experience at St. Luke's Outpatient Clinic, Allentown, PA under the supervision of Jeff Bays, MSPT (Clinical Instructor). Dr. Lenker is a graduate of the University of St. Augustine for Health Sciences program in St. Augustine, Florida. Used with permission, 2005.
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CASE STUDY* —cont'd A full orthopedic evaluation was conducted to determine the biomechanical and soft tissue dysfunction that produced the client's signs and symptoms. Active and passive motion and intersegmental mobility were tested. Findings were consistent with a physical therapy diagnosis of hypomobile costotransverse joint at level T4. This was further evidenced by pain at the posterior costovertebral joint with radiating pain laterally into the chest wall. Pain was increased on inspiration. Patient had a smoker's cough, but reported no other associated signs or symptoms of any kind. See the Pain Assessment Record Form that follows. RESULT
The client obtained gradual relief from painful symptoms after 8 treatment sessions of stretches and costotransverse joint mobilization (grade 4, non-thrust progressive oscillations at the end of the available range). Pain was reduced from 10/10 to 3/10 and instances of night pain had decreased. The client could sit at work with only mild discomfort, which he could correct with stretching. The client's thoracic pain returned on the 10th and 11th treatment sessions. He attributed this to increased stressors at work and long work hours. Night
pain and pain with respiratory movements (inhalation) increased again. Red flags in this case included: • Age over 40 • History of smoking (20 pack years) • Symptoms persisting beyond the expected time for physiologic healing • Pain out of proportion to the injury • Recurring symptoms (failure to respond to physical therapy intervention) • Pain is constant and intense; night pain The client was returned to his primary care physician for further diagnostic studies and later diagnosed with metastatic lung cancer. SUMMARY
Working with clients several times a week allows the therapist to monitor their symptoms and the effectiveness of interventions. This case study shows the importance of reassessment and awareness of red flags that would lead a practitioner to suspect the symptoms may be pathologic.
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Pain Assessment Record Form Client's name:
D a t e : 10/05/06
#21022
Medications:
O n s e t o f p a i n (circle o n e ) W a s there a n : Accident
Specific activity
Injury
If y e s , d e s c r i b e : Chiropractor manipulated the thoracic spine; 6-8 hours later the client had shooting pain as shown below Date of injury: 2 weeks ago (09/21106) Characteristics of pain/symptoms: L o c a t i o n (Show me exactly where your pain/symptom is located):
Sharp shooting pain Right side of upper thoracic spine at T4 Pain radiates laterally under the axilla into the anterior chest
Do you have any pain or s y m p t o m s anywhere else? D e s c r i p t i o n (If y e s , w h a t d o e s i t f e e l l i k e ) : Tension and tightness along the same thoracic level Circle any other w o r d s that describe the client's s y m p t o m s : Knifelike
Dull
Aching
Boring
Burning
Throbbing
Heaviness
Discomfort
Stinging
Tinalina
Other (describe):
Intermittent (comes and goes)
F r e q u e n c y (circle o n e ) :
No
I f c o n s t a n t : D o y o u h a v e t h i s p a i n right n o w ? I f i n t e r m i t t e n t : H o w o f t e n i s t h e p a i n p r e s e n t ( c i r c l e all t h a t a p p l y ) : Hourly
Intensity:
Intensity:
Once/daily
Numeric
Rating
Visual Analog
Scale a n d
Scale
Twice/daily
the
Faces
Unpredictable
Pain
Scale
Other(please describe):
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Duration: H o w l o n g d o e s y o u r p a i n ( n a m e t h e s y m p t o m ) l a s t ? all the time; intensity varies but always present A g g r a v a t i n g factors (What makes it worse?)
R e l i e v i n g f a c t o r s (What m a k e s it better?)
Prolonged positions, especially sitting Inhalation
Pattern H a s t h e p a i n c h a n g e d s i n c e i t first b e g a n ?
Yes
If y e s , p l e a s e e x p l a i n :
W h a t i s y o u r p a i n / s y m p t o m like f r o m m o r n i n g ( a m ) t o e v e n i n g ( p m ) ?
Pain is work/position-related and gets worse after sitting at work; better at home in the evening then much worse at night after several hours sleeping
Circle one:
Worse in the morning
Worse midday/afternoon
Circle one:
Gradually getting better
Gradually getting worse
Circle all t h a t a p p l y : Present upon w a k i n g up
K e e p s m e f r o m falling a s l e e p
A s s o c i a t e d s y m p t o m s (What other s y m p t o m s have you had with this problem?)
Burning
Shortness of breath
Cough
Skin r a s h (or o t h e r l e s i o n s )
Change in bowel/bladder
Difficulty s w a l l o w i n g
Painful swallowing
Dizziness
Heart palpitations
Hoarseness
Nausea/vomiting
Diarrhea
Constipation
Bleeding of any kind
Sweats
Numbness
Problems with vision
Tingling
Weakness
Joint p a i n
Weight loss/gain
Other:
Final q u e s t i o n : Are there any other pain or s y m p t o m s of a n y kind a n y w h e r e else in y o u r b o d y that we h a v e not talked a b o u t y e t ?
No
For t h e t h e r a p i s t : Follow up questions can include: Are there a n y positions that m a k e it feel better? W o r s e ? How d o e s rest affect the p a i n / s y m p t o m s ? How d o e s activity affect the p a i n / s y m p t o m s ? H o w h a s t h i s p r o b l e m a f f e c t e d y o u r d a i l y life a t w o r k o r a t h o m e ? Has this p r o b l e m affected y o u r ability to c a r e for yourself w i t h o u t a s s i s t a n c e ( e . g . d r e s s , b a t h e , c o o k , drive)? Has this p r o b l e m a f f e c t e d y o u r s e x u a l f u n c t i o n o r a c t i v i t y ? Therapist's evaluation: Can you reproduce the pain by s q u e e z i n g or palpating the s y m p t o m a t i c a r e a ? Does resisted motion reproduce the p a i n / s y m p t o m s ? I s the c l i e n t t a k i n g N S A I D s ? E x p e r i e n c i n g i n c r e a s e d s y m p t o m s a f t e r t a k i n g N S A I D s ? I f t a k i n g N S A I D s , i s t h e c l i e n t a t risk f o r p e p t i c u l c e r ? C h e c k all t h a t a p p l y : •
A g e > 6 5 years
• History of peptic ulcer d i s e a s e or GI d i s e a s e
•
Smoking, alcohol use
• Oral corticosteroid use
•
Anticoagulation or use of other anticoagulants (even w h e n u s e d for heart patients at a lower d o s e , e.g., 81 to 3 2 5 mg aspirin/day)
•
Renal complications in clients with hypertension or congestive heart failure (CHF) or w h o use diuretics or A C E inhibitors
•
NSAIDs c o m b i n e d with selective serotonin reuptake inhibitors ( S S R I s ; antidepressants s u c h as Prozac, Zoloft, C e l e x a , Paxil)
•
Use of acid suppressants (e.g., H - r e c e p t o r antagonists, antacids) 2
Other areas to c o n s i d e r : • Sleep quality
• Bowel/bladder habits
• Correlation of s y m p t o m s with peak effect of medications ( d o s a g e , time of day) • Evaluation of joint pain (see A p p e n d i x : S c r e e n i n g Q u e s t i o n s for Joint Pain)
• D e p r e s s i o n or a n x i e t y s c r e e n i n g s c o r e • For w o m e n : correlation of s y m p t o m s with menstrual cycle
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PRACTICE QUESTIONS 1. What is the best follow up question for someone who tells you that the pain is constant? a. Can you use one finger to point to the pain location? b. Do you have that pain right now? c. Does the pain wake you up at night after you have fallen asleep? d. Is there anything that makes the pain better or worse? 2. A 52-year old woman with shoulder pain tells you that she has pain at night that awakens her. After asking a series of follow up questions, you are able to determine that she had trouble falling asleep because her pain increases when she goes to bed. Once she falls asleep, she wakes up as soon as she rolls onto that side. What is the most likely explanation for this pain behavior? a. Minimal distractions heighten a person's awareness of musculoskeletal discomfort. b. This is a systemic pattern that is associated with a neoplasm. c. It is impossible to tell. d. This represents a chronic clinical presentation of a musculoskeletal problem. 3. Referred pain patterns associated with impairment of the spleen can produce musculoskeletal symptoms in: a. The left shoulder b. The right shoulder c. The mid- or upper back, scapular, and right shoulder areas d. The thorax, scapulae, right, or left shoulder 4. Associated signs and symptoms are a major red flag for pain of a systemic or visceral origin compared to musculoskeletal pain. a. True b. False 5. Words used to describe neurogenic pain often include: a. Throbbing, pounding, beating b. Crushing, shooting, pricking c. Aching, heavy, sore d. Agonizing, piercing, unbearable 6. Pain (especially intense bone pain) that is disproportionately relieved by aspirin can be a symptom of: a. Neoplasm b. Assault or trauma c. Drug dependence d. Fracture
7. Joint pain can be a reactive, delayed, or allergic response to: a. Medications b. Chemicals c. Infections d. Artificial sweeteners e. All of the above 8. Bone pain associated with neoplasm is characterized by: a. Increases with weight bearing b. Negative heel strike c. Relieved by Turns or other antacid in women d. Goes away after eating 9. Pain of a viscerogenic nature is not relieved by a change in position. a. True b. False 1 0 . Referred pain from the viscera can occur alone, but is usually preceded by visceral pain when an organ is involved. a. True b. False 1 1 . A 48-year old man presented with low back pain of unknown cause. He works as a carpenter and says he is very active, has workrelated mishaps (accidents and falls), and engages in repetitive motions of all kinds using his arms, back, and legs. The pain is intense when he has it, but it seems to come and go. He is not sure if eating makes the pain better or worse. He has lost his appetite because of the pain. After conducting an examination including a screening exam, the clinical presentation does not match the expected pattern for a musculoskeletal or neuromuscular problem. You refer him to a physician for medical testing. You find out later he had pancreatitis. What is the most likely explanation for this pain pattern? a. Toxic waste products from the pancreas are released into the intestines causing irritation of the retroperitoneal space. b. Rupture of the pancreas causes internal bleeding and referred pain called Kehr's sign. c. The pancreas and low back structures are formed from the same embryologic tissue in the mesoderm d. Obstruction, irritation, or inflammation of the body of the pancreas distends the pancreas, thus applying pressure on the central respiratory diaphragm
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49. Tasker RR: Spinal cord injury and central pain. In Aronoff GM, editor: Evaluation and treatment of chronic pain, ed 3, Philadelphia, 1999, Lippincott, Williams & Wilkins; pp 131-146. 50. Pachas WN: Joint pains and associated disorders. In Aronoff GM, editor: Evaluation and treatment of chronic pain, ed 3, Philadelphia, 1999, Lippincott Williams and Wilkins; pp 201-215. 51. Kraus H: Muscle deficiency. In Rachlin ES, editor: Myofascial pain and fibromyalgia, St. Louis, 1994, Mosby. 52. Cailliet R: Low back pain syndrome, ed 5, Philadelphia, 1995, FA Davis. 53. Emre M, Mathies H: Muscle spasms and pain, Park Ridge, Illinois, 1988, Parthenon. 54. Sinnott M: Assessing musculoskeletal changes in the geriatric population, American Physical Therapy Association Combined Sections Meeting, February 3-7, 1993. 55. Potter JF: The older orthopaedic patient. General considerations, Clin Orthop Rel Res 425:44-49, 2004. 56. Headley BJ: When movement hurts: a self-help manual for treating trigger points. Innovative Systems, 1997. (Barbara Headley, MS, PT, EMS, director, and CEO of Headley Systems, Colorado, www.360wd.com/headleysystems/home.html). 57. Kostopoulos D, Rizopoulos K: The manual of trigger point and myofascial therapy, Thorofare, NJ, 2001, Slack. 58. Rachlin ES, Rachlin IS, editors: Myofascial pain and fibromyalgia: trigger point management, ed 2, St. Louis, 2002, Mosby. 59. Blaylock RL: Excitotoxins: the taste that kills, New Mexico, 1996, Health Press. Available on-line: www.directtextbook. com/publisher/health-press-nm or http://www.russellblay lockmd.com/. 60. Roberts HJ: Aspartame disease: the ignored epidemic, West Palm Beach, Fl, 1995, Sunshine Sentinel Press. 61. Roberts HJ: Defense against Alzheimer's disease, West Palm Beach, Fl, 2001, Sunshine Sentinel Press. 62. Issa NC, Thompson RL: Diagnosing and managing septic arthritis: a practical approach, J Musculoskel Med 20(2):70-75, 2003. 63. Sapico FL, Liquete JA, Sarma RJ: Bone and joint infections in patients with infective endocarditis: review of a 4-year experience, Clin Infect Dis 22:783-787, 1996. 64. Lutz B: Septic arthritis following anterior cruciate ligament reconstruction using tendon allografts-Florida and Louisiana, 2000, MMWR 50(48):1081-1083, 2001. 65. Pola E: Onset of Berger disease after Staphylococcus aureus infection: septic arthritis after anterior cruciate ligament reconstruction, Arthroscopy 19(4):E29, 2003. 66. Kumar S, Cowdery JS: Managing acute monarthritis in primary care practice, J Musculoskel Med 21(9):465-472, 2004. 67. Bonica J: The management of pain, ed 2, Vol 1, Philadelphia, 1990, Lea & Febiger. 68. Waddell G, Bircher, M, Finlayson D, et al: Symptoms and signs: physical disease or illness behaviour? BMJ 289:739741, 1984. 69. Ozburn MS, Nichols JW: Pubic ramus and adductor insertion stress fractures in female basic trainees, Mil Med 146(5):332-334, 1981. 70. Cyriax J: Textbook of orthopaedic medicine, ed 8, Vol 1, London, 1982, Bailliere. 71. Management of the individual with pain: Part 1-physiology and evaluation, PT Magazine 4(ll):54-63, 1996. 72. Merskey H, Bogduk N: Classification of chronic pain, ed 2, Seattle, 1994, International Association for the Study of Pain. 73. Waddell G: The back pain revolution, ed 2, Philadelphia, 2004, Churchill Livingstone.
74. Hellsing AL, Linton SJ, Kalvemark M: A prospective study of patients with acute back and neck pain in Sweden, Physical Therapy 74(2):116-128, 1994. 75. Turk DC, Melzack R, editors: Handbook of pain assessment, ed 2, New York, 2001, Guilford Press. 76. Melzack R: From the gate to the neuromatrix, Pain 6(suppl 6):S121-126, 1999. 77. Turk DC: Understanding pain sufferers: the role of cognitive processes, Spine J 4(l):l-7, 2004. 78. Lethem J, Slade PD, Troup JDG, et al: Outline of a fearavoidance model of exaggerated pain perception. I, Behav Res Ther. 21(4):401-408, 1983. 79. Slade PD, Troup JDG, Lethem J, et al: The fear-avoidance model of exaggerated pain perception. II, Behav Res Ther 21(4):409-416, 1983. 80. Waddell G, Somerville D, Henderson I, et al: A fear avoidance beliefs questionnaire (FABQ) and the role of fear avoidance beliefs in chronic low back pain and disability, Pain 52:157-168, 1993. 81. George SZ: Personal communication, May 2004. 82. George SZ, Bialosky JE, Fritz JM: Physical therapist management of a patient with acute low back pain and elevated fear-avoidance beliefs, Physical Therapy 84(6):538-549, 2004. 83. Fritz JM, George SZ: Identifying psychosocial variables in patients with acute work-related low back pain. The importance of fear-avoidance beliefs, Physical Therapy 82(10):973-983, 2002. 84. Cooner E, Amorosi S: The study of pain and older Americans, New York, 1997, Louis Harris and Associates (Harris Opinion Poll). 85. Barsky AJ, Hochstrasser B, Coles NA, et al: Silent myocardial ischemia: Is the person or the event silent? JAMA 364:1132-1135, 1990. 86. Kauvar DR: The geriatric acute abdomen, Clin Geriatr Med 9:547-558, 1993. 87. Norman DC, Toledo SD: Infections in elderly persons: an altered clinical presentation, Clin Geriatr Med 8:713-719, 1992. 88. AGS Panel on Chronic Pain in Older Persons: The management of chronic pain in older persons, J Am Geriatr Soc 46:635-651, 1998. 89. Connelly C: Managing low back pain and psychosocial overlie, J Musculoskel Med 21(8):409-419, 2004. 90. Main CJ, Waddell G: Behavioral responses to examination: a reappraisal of the interpretation of "nonorganic signs," Spine 23(21): 2367-2371, 1998. 91. Scalzitti DA: Screening for psychological factors in patients with low back problems: Waddell's nonorganic signs, Phys Ther 77(3):306-312, 1997. 92. Teasell RW, Shapiro AP: Strategic-behavioral intervention in the treatment of chronic nonorganic motor disorders, Am J Phys Med Rehab 73(l):44-50, 1994. 93. Waddell G: Symptoms and signs: physical disease or illness behavior? BMJ 289:739-741, 1984. 94. Barsky AJ, Goodson JD, Lane RS, et al: The amplification of somatic symptoms, Psychosom Med 50(5):510-519, 1988. 95. Turk DC: Understanding pain sufferers: the role of cognitive processes, Spine J 4:1-7, 2004. 96. Beck AT, Epstein N, Brown G, et al: An inventory for measuring clinical anxiety: psychometric properties, J Consult Clin Psych 56:893-897, 1988. 97. Steer RA, Beck AT: Beck anxiety inventory. In Zalaquett CP, Wood RJ, editors: Evaluating stress: a book of resources, Lanham, MD, 1997, Scarecrow Press. 98. Brenes GA: Anxiety and chronic obstructive pulmonary disease: prevalence, impact, and treatment, Psychosom Med 65(6):963-970, 2003. 99. Wassertheil-Smoller S, Shumaker S, Ockene J, et al: Depression and cardiovascular sequelae in postmenopausal women. The Women's Health Initiative (WHI), Arch Intern Med 164(3):289-298, 2004.
CHAPTER 3
PAIN TYPES A N D VISCEROGENIC PAIN PATTERNS
100. Miller MC: Depression and pain, Harvard Mental Health 21(3):4, 2004. 101. World Health Organization (WHO): 2004. www.who.int [type in Depression in search window]. 102. Andrade L, Caraveo-Anduaga JJ, Berglund P, et al: The epidemiology of major depressive episodes: results from the International Consortium of Psychiatric Epidemiology (ICPE) surveys, International J Methods Psychiatr Research 12(3):165, 2003. 103. Abe T: Increased incidence of depression and its sociocultural background in Japan, Seishin Shinkeigaku Zasshi 105(l):36-42, 2003. 104. Kessler RC: Epidemiology of women and depression, J Affect Disord 74(1):5-13, 2003. 105. Smith NL: The effects of depression and anxiety on medical illness, University of Utah, Stress Medicine Clinic, Sandy, Utah, 2002. 106. Corsico A, McGuffm P: Psychiatric genetics: recent advances and clinical implications, Epidemiol Psychiatr Soc 10(4):253-259, 2001. 107. Lotrich FE, Pollock BG: Meta-analysis of serotonin transporter polymorphisms and affective disorders, Psychiatr Genet 14(3):121-129, 2004. 108. Lee MS, Lee HY, Lee HJ, et al: Serotonin transporter promoter gene polymorphism and long-term outcome of antidepressant treatment, Psychiatr Genet 14(2):111-115, 2004. 109. McGuffin P, Marusic A, Farmer A: What can psychiatric genetics offer suicidology? Crisis 22(2):61-65, 2001. 110. Lesperance F, Jaffe AS: Beyond the blues: understanding the link between coronary artery disease and depression. Retrieved June 15, 2006, from http:/I www.medscape.com I viewarticle 1423461 111. Lydiard RB: Irritable bowel syndrome, anxiety, and depression. What are the links? J Clin Psychiatry 62(Suppl 8):38-45, 2001. 112. Haggman S, Maher CG, Refshauge KM: Screening for symptoms of depression by physical therapists managing low back pain, Physical Therapy 84(12):1157-1166, 2004. 113. Sartorius N, Ustun T, Lecrubier Y, et al: Depression comorbid with anxiety: results from the WHO study on psychological disorders in primary health care, Br J Psychiatry 168:38-40, 1996. 114. Beck AT, Ward CH, Mendelson M, et al: An inventory for measuring depression, Arch Gen Psychiatry 4:561-571, 1961. 115. C de C Williams A, Richardson PH: What does the BDI measure in chronic pain? Pain 55:259-266, 1993. 116. Yesavage JA: The geriatric depression scale, J Psychiatr Res 17(l):37-49, 1983. 117. Zung WWK: A self-rating depression scale, Arch Gen Psychiatry 12:63-70, 1965. 118. Harcourt Assessment (formerly The Psychological Corporation): The Beck scales, San Antonia, 2004. 119. Garakani A, Win T, Virk S, et al: Comorbidity of irritable bowel syndrome in psychiatric patients: a review, Am J Ther 10(l):61-67, 2003. 120. Campo JV, Dahl RE, Williamson DE, et al: Gastrointestinal distress to serotonergic challenge: a risk marker for emotional disorder? J Am Acad Child Adolesc Psychiatry 42(10):1221-1226, 2003. 121. Salt WB: Irritable bowel syndrome and the mindbody I brain-gut connection, Columbus, Ohio, 1997, Parkview. 122. Chang L, Berman S, Mayer EA, et al: Brain responses to visceral and somatic stimuli in patients with irritable bowel syndrome with and without fibromyalgia, Am J Gastroenterol 98(6):1354-1361, 2003. 123. Miller MC: Understanding depression. A special health report from Harvard Medical School, Boston, 2003. 124. Hendrix ML: Understanding panic disorder, Washington, DC, 1993, National Institutes of Health.
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125. Melzack R, Dennis SG: Neurophysiologic foundations of pain. In Sternbach RA, editor: The psychology of pain, New York, 1978, Raven Press; pp 1-26. 126. Wieseler-Frank J, Maier SF, Watkins LR: Glial activation and pathological pain, Neurochem Int 45(2-3):389-395, 2004. 127. Pert C: Molecules of emotion. The science behind mindbody medicine, New York, 1998, Simon and Schuster. 128. Knaster, M: Remembering through the body, Massage Therapy Journal 33(l):46-59, 1994. 129. Pearsall P: The heart's code: new findings about cellular memories and their role in the mind I body I spirit connection, New York, 1998, Broadway Books (Random House). 130. van der Kolk BA: The body keeps the score: memory and the evolving psychobiology of posttraumatic stress, Harvard Review of Psychiatry l(5):253-265, 1994. 131. Van Meeteren NLU, et al: Psychoneuroendocrinology and its relevance for physical therapy [Abstract], Physical Therapy 81(5):A66, 2001. 132. Yang J: UniSci International Science News, posted July 30, 2001 [http://unisci.com/], source: University of Rochester Medical Center, Rochester, NY, 2001. 133. Watkins LR, Milligan ED, Maier SF: Glial proinflammatory cytokines mediate exaggerated pain states: implications for clinical pain, Adv Exp Med Biol 521:1-21, 2003. 134. Wu CM, Lin MW, Cheng JT, et al: Regulated, electroporation-mediated delivery of pro-opiomelanocortin gene suppresses chronic constriction injury-induced neuropathic pain in rats, Gene Ther ll(ll):933-940, 2004. 135. Maier SF, Watkins LR: Immune-to-central nervous system communication and its role in modulating pain and cognition: implications for cancer and cancer treatment, Brain Behav Immun 17(Suppl 1):S125-131, 2003. 136. Watkins LR, Maier SF: The pain of being sick: implications of immune-to-brain communication for understanding pain, Annu Rev Psychol 51:29-57, 2000. 137. Watkins LR, Maier SF: Beyond neurons: evidence that immune and glial cells contribute to pathological pain states, Physiol Rev 82(4):981-1011, 2002. 138. Holguin A, O'Connor KA, Biedenkapp J, et al: HIV1 gpl20 stimulates proinflammatory cytokine-mediated pain facilitation via activation of nitric oxide synthase-I (nNOS), Pain 110(3):517-530, 2004. 139. Melzack R: The short-form McGill Pain Questionnaire, Pain 30:191-197, 1987. 140. Melzack R, Katz J: The McGill Pain Questionnaire: appraisal and current status. In Turk DC, Melzack R, editors: Handbook of pain assessment, ed 2, New York, 2001, Guilford Press; pp 35-52. 141. Matheson LN: Work capacity evaluation: systematic approach to industrial rehabilitation, Anaheim, CA, 1986, Employment and Rehabilitation Institute of California. 142. Matheson LN: Symptom magnification casebook, Anaheim, CA, 1987, Employment and Rehabilitation Institute of California. 143. Matheson LN: Symptom magnification syndrome structured interview: rationale and procedure, J Occup Rehab l(l):43-56, 1991. 144. Olney C: Matter of semantics (letter to the editor), ADVANCE for Physical Therapists & PT Assistants 12(15):5, 2001. 145. Waddell G, McCulloch JA, Kummer E, et al: Nonorganic physical signs in low back pain, Spine 5(2):117-125, 1980. 146. Karas R, Mcintosh G, Hall H, et al: The relationship between nonorganic signs and centralization of symptoms in the prediction of return to work for patients with low back pain, Phys Ther 77(4):354-360, 1997. 147. Rothstein JM, Erhard RE, Nicholson GG, et al: Conference, Phys Ther 77(4):361-369, 1997.
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148. Rothstein JM: Unnecessary adversaries (editorial), Physical Therapy 77(4):352, 1997. 149. Goodwin RD: Association between physical activity and mental disorders among adults in the United States, Preu Med 36:698-703, 2003. 150. Lawlor DA, Hopker SW: The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomized controlled trials, BMJ 322:1-8, 2001.
151. Dunn AL, Trivedi MH, Kampert JB, et al: The DOSE study: a clinical trial to examine efficacy and dose response of exercise as treatment for depression, Control Clin Trials 23:584-603, 2002. 152. Dowd SM, Vickers KS, Krahn D: Exercise for depression: physical activity boosts the power of medications and psychotherapy, Psychiatry Online 3(6): June 2004.
Physical Assessment As A Screening Tool
I
n the medical model, clients are often assessed from head to toe. The doctor, physician assistant, nurse, or nurse practitioner starts with inspection, followed by percussion and palpation, and finally by auscultation. In a screening assessment, the therapist may not need to perform a complete head-to-toe physical assessment. If the initial observations, client history, screening questions, and screening tests are negative, move on to the next step. A thorough examination may not be necessary. In most situations, it is advised to assess one system above and below the area of complaint. When screening for systemic origins of clinical signs and symptoms, the therapist first scans the area(s) that directly relate to the client's history and clinical presentation. For example, a shoulder problem can be caused by a problem in the stomach, heart, liver/biliary, lungs, spleen, kidneys, and ovaries (ectopic pregnancy). Only the physical assessment tests related to these areas would be assessed. And these often can be narrowed down by the client's history, gender, age, presence of risk factors, and associated signs and symptoms linked to a specific system. More specifically, consider the postmenopausal woman with primary family history of heart disease who presents with shoulder pain that occurs three to four minutes after starting an activity and is accompanied by unexplained perspiration. This individual should be assessed for cardiac involvement. Or think about the 45-year old mother of five children who presents with scapular pain that is worse after she eats. A cardiac assessment may not be as important as a scan for signs and symptoms associated with the gallbladder or biliary system. Documentation of physical findings is important. From a legal standpoint, if you did not document it, you did not assess it. Look for changes from the expected norm as well as changes for the client's baseline measurements. Use simple and clear documentation that can be understood and used by others. As much as possible, record both normal and abnormal findings for each client. Keep in mind the client's cultural and educational background, beliefs, values, and previous experiences can influence his or her response to questions. Finally, screening and ongoing physical assessment is often a part of an exercise evaluation, especially for the client with one or more serious health concerns. Listening to the heart and lung sounds before initiating an exercise program may bring to light any contraindications to exercise. A compromised cardiopulmonary system may make it impossible and even dangerous for the client to sustain prescribed exercise levels. 1
GENERAL SURVEY Physical assessment begins the moment you meet the client as you observe body size and type, facial expressions, evaluate self-care, and note anything unusual in appearance or presentation. Keep in mind (as discussed
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in Chapter 2) that cultural factors may dictate how the client presents himself (e.g., avoiding eye contact when answering questions, hiding or exaggerating signs of pain). A few pieces of equipment in a small kit within easy reach can make the screening exam faster and easier (Box 4-1). Using the same pattern in screening each time will help the therapist avoid missing important screening clues. As the therapist makes a general survey of each client, it is also possible to evaluate posture, movement patterns and gait, balance, and coordination. For more involved clients the first impression may be based on level of consciousness, respiratory and vascular function, or nutritional status. In an acute care or trauma setting the therapist may be using vital signs and the ABCDE (airway, breathing, circulation, disability, exposure) method of quick assessment. A common strategy for history taking in the trauma unit is the mnemonic: AMPLE: Allergies, Medications, Past medical history, Last meal, and Events of injury. In any setting, knowing the client's personal health history will also help guide and direct which components of the physical examination to include. We are not just screening for medical disease masquerading as neuromusculoskeletal (NMS) problems. Many physical illnesses, diseases, and medical conditions directly impact the NMS system and must be taken into account. For example inspection of the integument, limb inspection, and screening of the peripheral vascular
B O X 4-1 • • • • • • • • • • • • • • •
Contents of a Screening Examination Kit
Stethoscope Sphygmomanometer Thermometer Pulse oximeter Reflex hammer Penlight Safety pin or sharp object (tongue depressor broken in half gives sharp and dull sides) Cotton-tipped swab or cotton ball 2 test tubes Familiar objects (e.g., paper clip, coin, marble) Tuning fork (128 Hz) Watch with ability to count seconds Gloves for palpation of skin lesions Ruler or plastic tape measure to measure wound dimensions, skin lesions, leg length Goniometer
system is important for someone at risk for lymphedema. Neurologic function, balance, reflexes, and peripheral circulation become important when screening a client with diabetes mellitus. Peripheral neuropathy is common in this population group, often making walking more difficult and increasing risk of other problems developing. Therapists in all settings but especially primary care therapists can use a screening physical assessment to provide education toward primary prevention as well as intervention and management of current dysfunctions and disabilities.
Mental Status Level of consciousness, orientation, and ability to communicate are all part of the assessment of a client's mental status. Orientation refers to the client's ability to answer correctly questions about time, place, and person. A healthy individual with normal mental status will be alert, speak coherently, and be aware of the date, day, and time of day. The therapist must be aware of any factor that can affect a client's current mental status. Shock, head injury, stroke, medications, age, and the use of substances and/or alcohol (see discussion, Chapter 2) can cause impaired consciousness. Other factors affecting mental status may include malnutrition, exposure to chemicals, and hypo- or hyperthermia. Depression and anxiety (see discussion, Chapter 3) also can affect a client's functioning, mood, memory, ability to concentrate, judgment, and thought processes. Educational and socioeconomic background along with communication skills (e.g., English as a second language, aphasia) can affect mental status and function. In a hospital, transition unit, or extended care facility, mental status is often evaluated and documented by the social worker or nursing service. It is always a good idea to review the client's chart or electronic record regarding this information before beginning a physical therapy evaluation. It is not uncommon for older adults to experience a change in mental status or go through a stage of confusion after a general anesthetic. Physicians may refer to this as iatrogenic delirium or anesthesia-induced dementia. The cause of deterioration in mental ability is unknown. In some cases dementia appears to be triggered by the shock to the body of anesthesia and surgery. It may be a passing phase with complete recovery by the client, although this can take weeks to months. Several scales are used to assess level of consciousness, performance, and disability. The 23
CHAPTER 4
TABLE 4-1 Score
Karnofsky in %)
Performance Scale (Rating
TABLE 4-2 Grade
80 70 60 50 40 30 20 10 0
E C O G Performance Status Scale
Level o f activity
Description
Fully active, able to carry on all pre-disease performance without restriction (Karnofsky 90-100%) Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work (Karnofsky 70-80%) Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours (Karnofsky 50-60%) Capable of only limited self-care, confined to bed or chair more than 50% of waking hours (Karnofsky 30-40%) Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair (Karnofsky 10-20%) Dead (Karnofsky 0%)
0 100 90
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Normal, no complaints; no evidence of disease Able to carry on normal activities; minor signs or symptoms of disease Normal activity with effort; some signs or symptoms of disease Cares for self; unable to carry on normal activity or to do active work Requires occasional assistance, but able to care for most of own personal needs Requires considerable assistance and frequent medical care Disabled; requires special care and assistance Severely disabled; hospitalization indicated though death not imminent Very ill; hospitalization required; active supportive treatment necessary Failing rapidly; moribund Dead
Glasgow Outcome Scale ' describes patients/clients on a 5-point scale from good recovery (1) to death (5). Vegetative state, severe disability, and moderate disability are included in the continuum. This and other scales and clinical assessment tools are not part of the screening assessment but are available on-line for use by health care professionals. The Karnofsky Performance Scale (KPS; Table 4-1) is used widely to quantify functional status in a wide variety of individuals, but especially among those with cancer. It can be used to compare effectiveness of intervention and to assess individual prognosis. The lower the Karnofsky score, the worse the prognosis for survival. The most practical performance scale for use in any rehabilitation setting for most clients is the ECOG Performance Status Scale (Table 4-2). Researchers and health care professionals use these scales and criteria to assess how an individual's disease is progressing, assess how the disease affects the daily living abilities of the client, and to determine appropriate treatment and prognosis. Any observed change in level of consciousness, orientation, judgment, communication or speech pattern, or memory should be documented no matter what scale is used. The therapist may be the first to notice increased lethargy, slowed motor responses, or disorientation or confusion. Confusion is not a normal change with aging and must be reported and documented. Confusion 4 5
6
1
2
3
4
5
The Karnofsky Performance Scale allows individuals to be classified according to functional impairment. The lower the score, the worse the prognosis for survival for most serious illnesses. ECOG, Eastern Cooperative Oncology Group. From Oken MM, Creech RH, Tormey DC, et al: Toxicity and response criteria of the Eastern Cooperative Oncology Group, Am J Clin Oncol 5:649-655, 1982. Available at: www.ecog.org/general/perf_stat.html.
is often associated with various systemic conditions (Table 4-3). Increased confusion in a client with any form of dementia can be a symptom of infection (e.g., pneumonia, urinary tract infection), electrolyte imbalance, or delirium. Likewise a sudden change in muscle tone (usually increased tone) in the client with a neurologic disorder (adult or child) can signal an infectious process.
Nutritional Status Nutrition is an important part of growth and development and recovery from infection, illness, wounds, and surgery Clients can exhibit signs of malnutrition or overnutrition (obesity). Clinical Signs and Symptoms of
Undernutrition or Malnutrition •
Muscle wasting
•
Alopecia (hair loss)
•
Dermatitis; dry, flaking skin
•
Chapped lips, lesions at corners of mouth
•
Brittle nails
•
Abdominal distention
•
Decreased
physical
fatigue, lethargy •
Peripheral edema
•
Bruising
activity/energy
level;
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Systemic Conditions Associated with Confusional States
TABLE 4-3 System
Impairment/Condition
Endocrine
Hypothyroidism, hyperthyroidism Perimenopause, menopause
Metabolic
Severe anemia Fluid and/or electrolyte imbalances; dehydration Wilson's disease (copper disorder) Porphyria (inherited disorder)
Immune/Infectious
Acquired Immunodeficiency Syndrome (AIDS) Cerebral amebiasis, toxoplasmosis, or malaria Fungal or tuberculosis meningitis Lyme disease Neurosyphilis
Cardiovascular
Congestive heart failure (CHF)
Cerebrovascular
Cerebral insufficiency (TIA, CVA) Postanoxic encephalopathy
Pulmonary
Chronic obstructive pulmonary disease (COPD) Hypercapnia (T C 0 ) Hypoxemia (I arterial 0 ) 2
2
Renal
Renal failure, uremia Urinary tract infection
Neurologic
Encephalopathy (hepatic, hypertensive) Head trauma Cancer Cerebrovascular accident (CVA; stroke)
Other
Chronic drug and/or alcohol use Medication (e.g., anticonvulsants, antidepressants, antiemetics, antihistamines, antipsychotics, benzodiazepines, narcotics, sedative-hypnotics, Zantac, Tagamet) Postoperative Severe anemia Cancer metastasized to the brain Sarcoidosis Sleep apnea Vasculitis (e.g., SLE) Vitamin deficiencies (B-12, folate, niacin, thiamine) Whipple's disease (severe intestinal disorder)
Modified from Dains JE, Baumann LC, Scheibel P: Advanced health assessment & clinical diagnosis in primary care, ed 2, St. Louis, 2003, Mosby; p 425. TIA, Transient ischemic attack; CVA, cerebrovascular accident; stroke; SLE, systemic lupus erythematosus.
Be aware in the health history of any risk factors for nutritional deficiencies (Box 4-2). Remember that some medications can cause appetite changes and that psychosocial factors such as depression, eating disorders, drug or alcohol addictions, and economic variables can affect nutritional status. It may be necessary to determine the client's ideal body weight by calculating the body mass index (BMI). ' Several websites are available to help anyone make this calculation. There is a separate website for children and teens sponsored by 7
8
the National Center for Chronic Disease Prevention and Health Promotion. Whenever nutritional deficiencies are suspected, notify the physician and/or request a referral to a registered dietitian. 9
Body and Breath Odors Odors may provide some significant clues to overall health status. For example, a fruity (sweet) breath odor (detectable by some, but not by all health care professionals) may be a symptom of diabetic ketoacidosis. Bad breath (halitosis) can be a
CHAPTER 4
BOX 4-2
Risk Factors for Nutritional Deficiency
• Economic status alone • Living Older age (metabolic rate slows in older • adults; altered sense of taste and smell affects • • • • • • • • • • • • • •
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appetite) Depression, anxiety Eating disorders Lactose intolerance (common in Mexican Americans, African Americans, Asians, Native Americans) Alcohol/drug addiction Chronic diarrhea Nausea Gastrointestinal impairment (e.g., bowel resection, gastric bypass, pancreatitis, Crohn's disease, pernicious anemia) Chronic endocrine or metabolic disorders (e.g., diabetes mellitus, celiac sprue) Liver disease Dialysis Medications (e.g., captopril, chemotherapy, steroids, insulin, lithium) including over-thecounter drugs (e.g., laxatives) Chronic disability affecting ADLs (e.g., problems with balance, mobility, food preparation) Burns Difficulty chewing or swallowing (dental problems, stroke or other neurologic impairment)
symptom of dental decay, lung abscess, throat or sinus infection, or gastrointestinal disturbances from food intolerances, H. pylori bacteria, or bowel obstruction. Keep in mind that ethnic foods and alcohol can affect breath and body odor. Clients who are incontinent (bowel or bladder) may smell of urine, ammonia, or feces. It is important to ask the client about any unusual odors. It may be best to offer an introductory explanation with some follow-up questions:
Follow-Up Questions Mrs. Smith, as part of a physical therapy exam we always look at our client's overall health and general physical condition. Do you have any other health concerns besides your shoulder/back (Therapist: name the involved body part)? Are you being treated by anyone for any other problems? [Wait for a response but add prompts as needed: chiropractor? acupuncturist? naturopath?]
[If you suspect urinary incontinence]: Are you having any trouble with leaking urine or making it to the bathroom on time? (Ask appropriate follow-up questions about cause, frequency, severity, triggers, and so on; see Appendix B-5). [If you suspect fecal incontinence]: Do you have trouble getting to the toilet on time for a bowel movement? Do you have trouble wiping yourself clean after a bowel movement? (Ask appropriate follow-up questions about cause, frequency, severity, triggers, and so on). [If you detect breath odor]: I notice an unusual smell on your breath. Do you know what might be causing this? (Ask appropriate follow-up questions depending on the type of smell you perceive; you may have to conduct an alcohol screening survey [see Chapter 2 or Appendices B-l and B-2]).
Vital Signs The need for therapists to assess vital signs, especially pulse and blood pressure is increasing. Without the benefit of laboratory values, physical assessment becomes much more important. Vital signs, observations, and reported associated signs and symptoms are among the best screening tools available to the therapist. Vital sign assessment is an important tool because high blood pressure is a serious concern in the United States. Many people are unaware they have high BP. Often primary orthopedic clients have secondary cardiovascular disease. Physical therapists practicing in a primary care setting will especially need to know when and how to assess vital signs. The Guide to the Physical Therapist Practice recommends that heart rate (pulse) and blood pressure measurements be included in the examination of new clients. Exercise professionals are strongly encouraged to measure blood pressure during each visit. Taking a client's vital signs remains the single easiest, most economical, and fastest way to screen for many systemic illnesses. All the vital signs are important (Box 4-3); temperature and blood pressure have the greatest utility as early screening tools for systemic illness or disease, while pulse, blood pressure, and oxygen saturation level offer valuable information about the cardiovascular/ pulmonary systems. As an aside comment: using vital signs is an easy, yet effective way to document outcomes. In today's evidence-based practice, the therapist can 10
11
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use something as simple as pulse or blood pressure to document changes that occur with intervention. For example, if ambulating with a client morning and afternoon results in no change in ease of ambulation, speed, or distance, consider taking
BOX 4-3
• • • • • • •
Vital Signs
Pulse (heart rate) Blood pressure Core body temperature (oral or ear) Respirations Pulse oximetry ( 0 saturation) Skin temperature—digits (thermister)* Pain (now called the 5th vital sign; see Chapter 3 for assessment) 2
* The thermister is a handheld device used to measure skin temperature (fingertips, hand). Similar tools are available as part of some biofeedback equipment. Using skin temperature is an excellent tool for teaching clients how to modulate the autonomic nervous system, a technique called physiologic quieting.® This tool is commercially available with a guided relaxation tape [www.phoenixpub.com; 1-800-549-8371]. It can be a useful intervention with clients who have chronic fatigue syndrome, fibromyalgia, Raynaud's phenomenon or disease, and peripheral vascular disease. Results can be measured using all the vital signs, but especially by measuring and recording changes in skin temperature.
TABLE 4-4
blood pressure, pulse, and oxygen ( 0 ) saturation levels before and after each session. Improvement in 0 saturation levels or faster return to normal of heart rate after exercise are just two examples of how vital signs can become an important part of outcomes documentation. Assessment of baseline vital signs should be a part of the initial data collected so that correlations and comparisons with future values are available when necessary. The therapist compares measurements taken against normal values and also compares future measurements to the baseline units to identify significant changes (normalizing values or moving toward abnormal findings) for each client. Normal ranges of values for the vital signs are provided for the therapist's convenience. However, these ranges can be exceeded by a client and still represent normal for that person. Keep in mind that many factors can affect vital signs, especially pulse and blood pressure (Table 4-4). It is the unusual vital sign in combination with other signs and symptoms, medications, and medical status that gives clinical meaning to the pulse rate, blood pressure, and temperature. 2
2
Factors Affecting Pulse and Blood Pressure Blood pressure*
Pulse
Age Anemia Autonomic dysfunction (diabetes, spinal cord injury) Caffeine Cardiac muscle dysfunction Conditioned/deconditioned state Dehydration (decreased blood volume increases heart rate) Exercise Fear Fever, heat Hyperthyroidism Infection Medications Antidysrhythmic (slows rate) Atropine (increases rate) Beta blocker (slows rate) Digitalis (slows rate) Sleep disorders or sleep deprivation Stress (emotional or psychologic)
Age Alcohol Anxiety Blood vessel size Blood viscosity Caffeine Cocaine and cocaine derivatives Diet Distended urinary bladder Force of heart contraction Living at higher altitudes Medications Ace inhibitors (lowers pressure) Adrenergic inhibitors (lowers pressure) Beta blockers (lowers pressure) Diuretics (lowers pressure) Narcotic analgesics (lowers pressure) Nicotine Pain Time of recent meal (increases SBP)
* Conditions such as chronic kidney disease, renovascular disorders, primary aldosteronism, and coarctation of the aorta are identifiable causes of elevated blood pressure. Chronic over training in athletes, use of steroids and/or nonsteroidal antiinflammatory drugs (NSAIDs), and large increases in muscle mass can also contribute to hypertension. Treatment for hypertension, dehydration, heart failure, heart attack, arrhythmias, anaphylaxis, shock (from severe infection, stroke, anaphylaxis, major trauma), and advanced diabetes can cause low blood pressure. From Goodman CC, Boissonnault WG, and Fuller K: Pathology: implications for the physical therapist, ed 2, Philadelphia, 2003, WB Saunders. 26
CHAPTER 4
Pulse
PHYSICAL A S S E S S M E N T AS A SCREENING TOOL
Rate
The pulse reveals important information about the client's heart rate and heart rhythm. A resting pulse rate (normal range: 60 to 100 beats/min), taken at the carotid artery or radial artery pulse point, should be available for comparison with the pulse rate taken during treatment or after exercise.
It is recommended that the pulse always be checked in two places in older adults and in anyone with diabetes (Fig. 4-1). Pulse strength (amplitude) can be graded as 0 Absent, not palpable 1+ Pulse diminished, barely palpable 2+ Easily palpable, normal
A
B
C
D
E
F
G Fig. 4-1
185
H • Pulse points. The easiest and most commonly palpated pulses are the (A) carotid pulse and (B) radial pulse. Other
pulse points include: (C) brachial pulse, (D) ulnar pulse, (E) femoral pulse, (F) popliteal pulse (knee slightly flexed), (G) dorsalis pedis, and (H) posterior tibial. The anterior tibial pulse becomes the dorsalis pedis and is palpable where the artery lies close to the skin on the dorsum of the foot. Peripheral pulses are more difficult to palpate in older adults and anyone with peripheral vascular disease. (From Potter PA, Weilitz PB: Pocket guide to health assessment, ed 5, St. Louis, 2003, Mosby.)
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3+ Full pulse, increased strength 4+ Bounding, too strong to obliterate Keep in mind that measuring the pulse is not the same as measuring the heart rate. A true measure of heart rate requires measuring the electrical impulses of the heart. A rate above 100 beats per minute indicates tachycardia; below 60 beats per minute indicates bradycardia. Pulse amplitude (weak or bounding quality of the pulse) gives an indication of the circulating blood volume and the strength of left ventricle ejection. Normally, the pulse increases slightly with inspiration and decreases with expiration. Pulse amplitude that fades with inspiration instead of strengthening and strengthens with expiration instead of fading is paradoxic and should be reported to the physician. Paradoxical pulse occurs most commonly in clients with chronic obstructive pulmonary disease (COPD), but is also observed in clients with constrictive pericarditis. A pulse increase with activity of more than 20 beats per minute lasting for more than 3 minutes after rest or changing position should also be reported. Other pulse abnormalities are listed in Box 4-4. The resting pulse may be higher than normal with fever, anemia, infections, some medications, hyperthyroidism, anxiety, or pain. A low pulse rate (below 60bpm) is not uncommon among trained athletes. Medications, such as beta-blockers and calcium channel blockers, can also prevent the normal rise in pulse rate that usually occurs during exercise. In such cases the therapist must monitor rates of perceived exertion (RPE) instead of pulse rate. When taking the resting pulse or pulse during exercise, some clinicians measure the pulse for 15 14
seconds and multiply by 4 to get the rate per minute. For a quick assessment, measure for 6 seconds and add a zero. A 6-second pulse count can result in an error of 10 beats per minute if a one-beat error is made in counting. For screening purposes, it is always best to palpate the pulse for a full minute. Longer pulse counts give greater accuracy and provide more time for detection of some dysrhythmias (Box 4-5). 13
BOX 4-5
• • • • • • • • • • •
•
• BOX 4-4
• • • • • • • •
Pulse Abnormalities
Weak pulse beats alternating with strong beats Weak, thready pulse Bounding pulse (throbbing pulse followed by sudden collapse or decrease in the force of the pulse) Two quick beats followed by a pause (no pulse) Irregular rhythm (interval between beats is not equal) Pulse amplitude decreases with inspiration/increases with expiration Pulse rate too fast (greater than 100 bpm; tachycardia) Pulse rate too slow (less than 60 bpm; bradycardia)
•
•
Tips on Palpating Pulses
Assess each pulse for strength and equality. Expect to palpate 60 to 90 pulses per minute at all pulse sites. Normal pulse is 2+ and equal bilaterally (see scale in text). Apply gentle pressure; pulses are easily obliterated in some people. Popliteal pulse requires deeper palpation. Normal veins are flat; pulsations are not visible. Flat veins in supine that become distended in sitting may indicate heart disease. Pulses should be the same from side to side and should not change with inspiration, expiration, or change in position. Pulses tend to diminish with age; distal pulses are not palpable in many older adults. If pulses are diminished or absent, listen for a bruit to detect arterial narrowing. Pedal pulses can be congenitally absent; the client may or may not know if absent pulse at this pulse site is normal or a change in pulse pressure. In the case of diminished or absent pulses observe the client for other changes (e.g., skin temperature, texture, color, hair loss, change in toenails); ask about pain in calf or leg with walking that goes away with rest (intermittent claudication; PVD). Carotid pulse: Assess in the seated position; have client turn the head slightly toward the side being palpated. Palpate along the medial edge of the sternocleidomastoid muscle (see Fig. 4-1). Palpate one carotid artery at a time; apply light pressure; deep palpation can stimulate carotid sinus with a sudden drop in heart rate and blood pressure. Femoral pulse: Femoral artery is palpable below the inguinal ligament midway between the anterior superior iliac spine (ASIS) and the symphysis pubis. It can be difficult to assess in the obese client; place fingertips of both hands on either side of the pulse site; femoral pulse should be as strong (if not stronger) than radial pulse. Posterior tibial pulse: Foot must be relaxed with ankle in slight planter flexion (see Fig. 4-1).
PHYSICAL A S S E S S M E N T AS A SCREENING TOOL
CHAPTER 4
Respirations Try to assess the client's breathing without drawing attention to what is being done. This measure can be taken right after counting the pulse while still holding the client's wrist. Count respirations for 1 minute unless respirations are unlabored and regular in which case the count can be taken for 30 seconds and multiplied by 2. The rise and fall of the chest equals 1 cycle. The normal rate is between 12 and 20 breaths per minute. Observe rate, excursion, effort, and pattern. Note any use of accessory muscles and whether breathing is silent or noisy. Watch for puffed cheeks, pursed lips, nasal flaring, or asymmetrical chest expansion. Changes in the rate, depth, effort, or pattern of a client's respirations can be early signs of neurologic, pulmonary, or cardiovascular impairment.
Pulse
Oximetry
Oxygen saturation on hemoglobin ( S a 0 ) and pulse rate can be measured simultaneously using pulse oximetry. This is a noninvasive, photoelectric device with a sensor that can be attached to a finger, the bridge of the nose, toe, or ear lobe. Digital readings are less accurate with clients who are anemic, undergoing chemotherapy, or who use fingernail polish or nail acrylics. In such cases, attach the sensor to one of the other accessible body parts. The sensor probe emits red and infrared light, which is transmitted to the capillaries. When in contact with the skin, the probe measures transmitted light passing through the vascular bed and detects the relative amount of color absorbed by the arterial blood. The S a 0 level is calculated from this information. The normal S a 0 range is 95 to 100 percent. The exception to this normal range is for clients with a history of tobacco use and/or chronic obstructive pulmonary disease (COPD). Many individuals with COPD tend to retain carbon dioxide and can become apneic if the oxygen levels are too high. For this reason, oxygen saturation levels are normally kept lower for this population. Increased C 0 levels trigger the brain to increase the respiratory rate. If the client with COPD is on oxygen and the 0 levels get too high, the respiratory system is depressed. Monitoring respiratory rate, level of oxygen administered by nasal canula, and oxygen saturation levels is very important in this client population. Any condition that restricts blood flow (including cold hands) can result in inaccurate S a 0 readings. Relaxation and physiologic quieting 2
2
2
187
techniques can be used to help restore more normal temperatures in the distal extremities. A handheld device such as the Thermister can be used by the client to improve peripheral circulation. Do not apply a pulse oximetry sensor to an extremity with an automatic blood pressure cuff. S a 0 levels can be affected also by positioning because positioning can impact a person's ability to breathe. Upright sitting in individuals with low muscle tone or kyphosis can cause forward flexion of the thoracic spine compromising oxygen intake. Tilting the person back slightly can open the trunk, ease ventilation, and improve S a 0 levels. Using S a 0 levels may be a good way to document outcomes of positioning programs for clients with impaired ventilation. In addition to oxygen saturation levels, assess other vital signs, skin and nail bed color and tissue perfusion, mental status, breath sounds, and respiratory pattern for all clients using pulse oximetry. If the client cannot talk easily whether at rest or while exercising, oxygen saturation levels are likely to be inadequate. 15
16
2
2
17
2
Blood
Pressure
Blood pressure (BP) is the measurement of pressure in an artery at the peak of systole (contraction of the left ventricle) and during diastole (when the heart is at rest after closure of the aortic valve, which prevents blood from flowing back to the heart chambers). The measurement (in mm Hg) is listed as: Systolic (contraction phase) Diastolic (relaxation phase) Blood pressure depends on many factors; the normal range differs slightly with age and varies greatly among individuals (see Table 4-4). Normal systolic blood pressure (SBP) ranges from 100 to 120mmHg, and diastolic blood pressure (DBP) ranges from 60 to 8 0 m m H g . Highly trained athletes may have much lower values. Target ranges for blood pressure are listed in Table 4-5 and Box 4-6.
2
2
2
A S S E S S I N G BLOOD PRESSURE
The blood pressure should be taken in the same arm and in the same position (supine or sitting) each time it is measured. The baseline BP values can be recorded on the Family/Personal History form (see Fig. 2-2). Cuff size is important and requires the bladder width-to-length be at least 1:2. BP measurements are overestimated with a cuff that is too small.
188
TABLE 4-5
SECTION I
Classification
INTRODUCTION TO THE S C R E E N I N G PROCESS
of Blood Pressure Systolic blood pressure
Diastolic b l o o d p r e s s u r e
160
100
For Adults*
Normal Prehypertension Stage 1 Hypertension Stage 2 Hypertension For Children and Adolescentst
Normal Prehypertension Stage 1 Hypertension Stage 2 Hypertension
65 years History of peptic ulcer disease or GI disease Smoking, alcohol use Oral corticosteroid use Anticoagulation or use of other anticoagulants (even when used for heart patients at a lower dose, e.g., 81 to 325 mg aspirin/day) • Renal complications in clients with hypertension or congestive heart failure (CHF) or who use diuretics or ACE inhibitors • Use of acid suppressants (e.g., H -receptor antagonists, antacids); these agents can mask the warning symptoms of more serious GI complications, leaving the client unaware of ongoing damage • NSAIDs combined with selective serotonin reuptake inhibitors (SSRIs; antidepressants such as Prozac, Zoloft, Celexa, Paxil) The newer COX-2 (cyclooxygenase) inhibitors such as Celebrex have reduced the incidence of GI disturbances, but this does not mean a client taking a COX-2 inhibitor cannot have NSAID-induced GI complaints. The risk of complications with COX-2 inhibitors is increased in the presence of any of the risk factors listed above. 2
386
CASE
S E C T I O N II
EXAMPLE
8-6
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
NSAIDs
Outpatient Orthopedic Client: A 72-yearold client with s/p left T K R x 4 weeks. She did not attain 90-degrees knee flexion and continues to walk with a stiff leg. Her orthopedic surgeon has sent her to PT for rehab. Past Medical History: Client reports generalized osteoarthritis. Previous left shoulder replacement 18 months ago. Very slow recovery and still does not have full shoulder ROM. Longstanding hearing impairmentx 60 years. Lost her left eye to macular degeneration 2 years ago. Medications: Client reports the following drug use—Darvocet for pain 3x/day. Vioxx daily for arthritis. Also takes Feldene when her shoulder bothers her and daily ibuprofen. Walks with a Trendelenburg gait and drags left leg using wheeled walker. Current symptoms include left knee and shoulder pain, intermittent dizziness, sleep disturbance, finger/hand swelling in the afternoons, early morning nausea. How do you assess for NSAID complications? Review risk factors: >65 years old Shoulder pain Ask about tobacco and alcohol use Nausea . . . ask about other GI symptoms and previous history of peptic ulcer disease Take blood pressure Observe for peripheral edema (sacral and pedal) How do you carry out a Review of Systems from a screening perspective and a Systems Review in accordance with the Guide? After gathering all of the subjective and objective data, make a list of all the signs and symptoms. Are there any clusters or groups of signs and symptoms that fall into any particular category? These may or may not be associated with the primary neuromusculoskeletal problem as many clients have one or more other diseases, illnesses, or conditions (referred to as comorbidities) with additional clinical manifestations. Start with general health. She reports: Hearing and vision loss Intermittent dizziness Early morning nausea Finger/hand swelling Sleep disturbance There is not much in the report about her general health. Make a note to consider asking
a few more questions about her past and current general health. Ask how she would describe her overall health in one or two words. Review her medications. She reports: Darvocet 3/day for pain Vioxx daily (COX-2 NSAID) Feldene prn (standard or non-selective NSAID) Ibuprofen daily (standard or non-selective NSAID) Given how many forms of NSAIDs she is taking, ask yourself: Did I ask if there were any other symptoms or problems of any kind anywhere else in the body? The remaining symptoms noted (positive Trendelenburg gait and antalgic gait, left shoulder and knee pain) fall into the musculoskeletal category. No other symptoms are noted. Think now about the Systems Review as outlined by the Guide. Are there isolated groupings or clusters of signs and symptoms that fall into any of the other three diagnostic categories? Neuromuscular C ardiovascular/Pulmonary Integumentary Knowing what we do about the potential for GI and renal complications in some clients taking NSAIDs, make a mental note to do two things: 1) Assess risk factors for NSAID-induced gastropathy (see Box 8-3) and 2) Ask about the presence of previously unreported GI or renal signs and symptoms (see Clinical Signs and Symptoms of NSAID-induced impairment). If appropriate you can go through this list and ask Do you have any nausea? Stomach pain? Indigestion or heartburn? Have you had any skin changes? You may want to prompt with: itching? Rash anywhere on your body? Any ringing in the ears? Headaches? Depression or mood changes? Memory loss or confusion? Have you had any trouble getting up out of a chair or bed? Difficulty with stairs? (muscle weakness) Shortness of breath? Unusual fatigue? Are you urinating more often during the day? Getting up at night to empty your bladder? Do you have any trouble wiping yourself clean after a bowel movement? Any change in the color or smell of your stools? Documentation, communication, and medical referral will be based on the results of your evaluation using a review mechanism like the one we just completed.
CHAPTER 8
SCREENING
Chapter 2 for information on screening for the use of NSAIDs. I S Y O U R C L I E N T A T R I S K FOR N S A I D INDUCED GASTROPATHY?
Therapists also can estimate the risk of GI complications in clients with rheumatoid arthritis. The following tool can be used with clients who are taking NSAIDs of any kind for rheumatoid arthritis. This tool may prove valuable in assessing other patient populations as well. This calculation can be used in one of several ways. First, clinical research is needed to substantiate the number of clients in a physical therapy practice who are at risk for serious NSAID-related gastropathy. Second, charting a client's risk can help in the early identification of problems. Because prednisone use and NSAID dose are modifiable risk factors, early identification and referral to the physician can minimize the detrimental effects of NSAID-induced gastropathy. Clients with one or more risk factors for NSAID-associated GI ulcer should be prescribed preventive strategies such as acid-suppressive drugs and/or COX-2 inhibitors rather than standard NSAIDs. ' 37
38
TABLE 8-4
39
FOR
GASTROINTESTINAL
DISEASE
387
Third, from a fiscal point of view, every GI complication prevented lowers the cost of medical care in this country. Clients over 50 with comorbidities such as heart disease, renal disease, a history of ulcers, or taking prednisone or warfarin must be watched carefully. The scoring system in Table 8-4 allows clinicians to estimate the risk of GI problems in clients with rheumatoid arthritis who are also taking NSAIDs. The formula is based on age, history of NSAID symptoms, NSAID dose, and the American Rheumatism Association's (ARA) Functional Classes (Table 8-5). NSAID dose used in this formulation is the fraction of the manufacturer's highest recommended dose. The manufacturer's highest recommended dose on the package insert is given a value of 1.00. The dose of each client is then normalized to this dose. For example, the value 1.03 indicates the client is taking 103% of the manufacturer's highest recommended dose. Most often, clients are taking the highest dose recommended. They receive a 1.0. Anyone taking less will have a fraction percentage less than 1.0. Anyone taking more than the highest 40
Calculating Your Client's Risk of NSAID-lnduced Gastropathy
Risk is equal to the sum of:
Calculation
Points
Age in years
Multiply x 2 =
History of NSAID symptoms e.g., upper abdominal pain, bloating, nausea, heartburn, loss of appetite, vomiting
If yes, add 50 points
ARA class (see Table 8-5)
Add 0, 10, 20 or 30 based on class 1-4
NSAID dose (fraction of maximum recommended; see text explanation)
NSAID dose x 15
If currently using prednisone
Add 40 points
TOTAL Score *Risk/year = [Total Score - 1 0 0 ] + 40 ARA, American Rheumatism Association. * Higher total scores yield a greater predictive risk. The risk ranges from 0.0 (low risk) to 5.0 (high risk) From Fries JF, et al: Nonsteroidal antiinflammatory drug-associated gastropathy: incidence and risk factor models, Am J Med 91(3):213-222, 1991.
TABLE 8-5
ARA Criteria for Classification of Functional Status in Rheumatoid Arthritis
Class 1
Completely able to perform usual ADLs (self-care, vocational, avocational)
0 points
Normal
Class 2
Able to perform usual self-care and vocational activities, but limited in avocational activities
10 points
Adequate
Class 3
Able to perform usual self-care activities, but limited in vocational and avocational activities
20 points
Limited
Class 4
Limited in ability to perform usual self-care, vocational, and avocational activities
30 points
Unable
ARA, American Rheumatism Association.
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dose recommended will have a fraction percentage greater than 1.0. See formulation in Case Example 8-7. To determine the risk (%) of hospitalization or death caused by GI complications over the next 12 months, subtract 100 from the total score obtained in Table 8-4, Calculating Your Client's Risk of NSAID-induced Gastropathy, and divide the result by 40. Higher Total scores yield a greater predictive risk. The risk ranges from 0.0 (low risk) to 5.0 (high risk) (Case Example 8-7).
Diverticular Disease The terms diverticulosis and diverticulitis are used interchangeably although they have distinct meanings. Diverticulosis is a benign condition in which the mucosa (lining) of the colon balloons out through weakened areas in the wall. Up to 60% of people over age 65 have these sac-like protrusions diagnosed typically when screening for colon cancer or other problems. Diverticulitis describes the infection and inflammation that accompany a microperforation of one of the diverticula. Diverticulosis is very common, whereas complications resulting in diverticulitis occur in only 10% to 25% of people with diverticulosis. The most common cause of major lower intes-
CASE EXAMPLE 8 - 7
41
Clinical Signs and Symptoms of Diverticulitis •
Left lower abdominal pain and tenderness
• •
Left pelvic pain Bloody stools
Appendicitis Appendicitis is an inflammation of the vermiform appendix that occurs most commonly in adolescents and young adults. It is a serious disease
I s Your Client A t R isk f o r NSAID-lnduced G a s t r o p a t h y ?
A 66-year-old woman with a history of rheumatoid arthritis (class 3) has been referred to physical therapy after three MCP-joint replacements. Although her doctor has recommended maximum dosage of ibuprofen (800 mg tid; 2400 mg), she is really only taking 1600/day. She says this is all she needs to control her symptoms. She was taking prednisone before the surgery, but tapered herself off and has not resumed its use. She has been hospitalized 3 times in the past 6 years for GI problems related to NSAID use, but does not have any apparent GI symptoms at this time. Calculating her risk for serious problems with NSAID use, we have Age in years History of NSAID symptoms, e.g., abdominal pain, bloating, nausea
tinal tract bleeding is diverticulosis. A significant number of cases of diverticular bleeding are associated with the use of NSAIDs in combination with diverticulosis. There is some controversy regarding whether diverticulosis is symptomatic, but perforation and subsequent infection causes symptoms of left lower abdominal or pelvic pain and tenderness in diverticulitis. For the therapist performing the iliopsoas and obturator tests, abdominal pain in the left lower quadrant may be caused by diverticular disease and should be reported to the physician. The diagnosis of diverticulitis is confirmed by accompanying fever, bloody stools, and elevated white blood cell count.
66 x 2 = +50 points
132 50
ARA class (see Table 8-5) Daily NSAID dose (fraction of maximum recommended) If currently using prednisone
add 0, 10, 20 or 30 based on class 1-4 1600 mg/2400 mg x 15 (0.67x15) add 40 points
TOTAL Score
20 10
0
212
Risk/year = [Total score - 100] + 40 Risk/year = [212 - 100] + 40 Risk/year = 112 + 40 = 2.80
The scores range from 0.0 (very low risk) to 5.0 (very high risk). A predictive risk of 2.8 is moderately high. This client should be reminded to report GI distress to her doctor immediately. Periodic screening for GI gastropathy is indicated with early referral if warranted.
CHAPTER 8
SCREENING FOR GASTROINTESTINAL DISEASE
usually requiring surgery. When the appendix becomes obstructed, inflamed, and infected, rupture may occur, leading to peritonitis. Diseases that can be mistaken for appendicitis include Crohn's disease (regional enteritis), perforated duodenal ulcer, gallbladder attacks, and kidney infection on the right side, and for women, ruptured ectopic pregnancy, twisted ovarian cyst, or a hemorrhaging ovarian follicle at the middle of the menstrual cycle. Right lower lobe pneumonia sometimes is associated with prominent right lower quadrant pain.
Clinical Signs
and Symptoms
The classic symptoms of appendicitis are pain preceding nausea and vomiting and low-grade fever in adults. Children tend to have higher fevers. Other symptoms may include coated tongue and bad breath. The pain usually begins in the umbilical region and eventually localizes in the right lower quadrant of the abdomen over the site of the appendix. In retrocecal appendicitis, the pain may be referred to the thigh or right testicle (see Figure 8-9). Groin and/or testicular pain may be the only symptoms of appendicitis, especially in young, healthy, male athletes. The pain comes in waves, becomes steady, and is aggravated by movement, causing the client to bend over and tense the abdominal muscles or to lie down and draw the legs up to relieve abdominal muscle tension (Case Example 8-8). Generalized peritonitis, whether caused by appendicitis or some other abdominal or pelvic
CASE
EXAMPLE
8-8
389
inflammatory condition, can result in a "boardlike" abdomen due to the spasm of the rectus abdominis muscles. Lean muscle mass deteriorates with aging, especially evident in the abdominal muscles of the aging population. The very old person may not present with this classic sign of generalized peritonitis because of the lack of toned abdominal muscles. For this reason, the nursing home, skilled care facility, or home health therapist must evaluate the aging client who presents with hip or thigh pain for possible systemic origin (assess for Rebound Tenderness; see also McBurney's point, and specific tests for iliopsoas or obturator abscess). Clinical Signs and Symptoms of Appendicitis • Periumbilical and/or epigastric pain • Right lower quadrant or flank pain • Right thigh, groin, or testicular pain • Abdominal muscular rigidity • Positive McBurney's point • •
• • • • •
Rebound tenderness (peritonitis) Positive hop test (hopping on one leg or jumping on both feet reproduces painful symptoms) Nausea and vomiting Anorexia Dysuria (painful/difficult urination) Low-grade fever Coated tongue and bad breath
Appendicitis
Remember the 32-year-old female university student featured in Fig. 1-6? She had been referred to physical therapy with the provisional diagnosis: Possible right oblique abdominis muscle tear /possible right iliopsoas muscle tear. Her history included the sudden onset of "severe pain" in the right lower quadrant with accompanying nausea and abdominal distention. Aggravating factors included hip flexion, sit-ups, fast walking, and movements such as reaching, turning, and bending. Painful symptoms could be reproduced by resisted hip or trunk flexion, and tenderness/tightness was elicited on palpation of the right iliopsoas muscle compared with the left. A neurologic screen was negative.
Screening questions for general health revealed constitutional symptoms including fatigue, night sweats, nausea, and repeated episodes of severe, progressive pain in the right lower abdominal quadrant. Although she presented with a musculoskeletal pattern of symptoms at the time of her initial evaluation with the physician, by the time she entered the physical therapy clinic her symptoms had taken on a definite systemic pattern. She was returned for further medical follow up, and a diagnosis of appendicitis complicated by peritonitis was established. This client recovered fully from all her symptoms following emergency appendectomy surgery.
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Ascending colon
McBurney's point
F i g . 8-8 • The vermiform appendix and colon can refer pain to the area of sensory distribution for the eleventh thoracic nerve (Tl 1). Primary (dark red) and referred (light red) pain patterns associated with the vermiform appendix are shown here with McBurney's point halfway between the ASIS and the umbilicus, usually on the right side. Gentle palpation of McBurney's point produces pain or exquisite tenderness. Rebound tenderness should also be assessed (see Fig. 8-10).
McBurney's
Appendix
F i g . 8 - 9 • Variations in the location of the vermiform appendix. Negative tests for appendicitis using McBurney's point may occur when the appendix is located somewhere other than at the end of the cecum. In 50% of cases the appendix is retrocecal (behind the cecum) or retrocolic (behind the colon). See Fig. 8-10 for an alternate test.
Point
Parietal pain caused by inflammation of the peritoneum in acute appendicitis or peritonitis (from appendicitis or other inflammatory/infectious causes) may be located at McBurney's point (Fig. 8-8). The vermiform appendix receives its sympathetic supply from the 11th thoracic segment. In some people a branch of the 11th thoracic nerve pierces the rectus abdominis muscle and innervates the skin over McBurney's point. This may explain the hyperalgesia seen at this point in appendicitis. McBurney's point is located by palpation with the client in a fully supine position. Isolate the ASIS and the umbilicus; palpate for tenderness halfway between these two surface anatomic points. This method differs from palpation of the iliopsoas muscle, because the position used to locate the iliopsoas muscle is that of the client in a supine position, with hips and knees flexed in a 90-degree position, whereas McBurney's point is palpated with the client in the fully supine position. The palpation point for the iliopsoas muscle is one third the distance between the ASIS and the umbilicus, whereas McBurney's point is halfway between these two points. Be aware that the location of the vermiform appendix can vary from individual to individual making the predictive value of this test less accurate (Fig. 8-9). Since the appen6
dix develops during the descent of the colon, its final position can be posterior to the cecum or colon. These positions of the appendix are called retrocecal or retrocolic, respectively. In about 50% of cases, the appendix is retrocecal or retrocolic. Both McBurney's point and the iliopsoas muscle are palpated for reproduction of symptoms to rule out appendicitis or iliopsoas abscess associated with appendicitis or peritonitis. One final test may be used to assess for the possibility of hip, pelvic, or flank pain from appendicitis, posterior penetrating ulcer, or peritonitis from any cause. After palpating for McBurney's point, if needed, perform the test for rebound tenderness (Fig. 8-10). 42
Pancreatitis Pancreatitis* is an inflammation of the pancreas that may result in autodigestion of the pancreas by its own enzymes. Pancreatitis can be acute or chronic, but the therapist is most likely to see acute pancreatitis. Acute pancreatitis can arise from a variety of etiologic factors, but in most instances, the specific * The pancreas is both an exocrine gland and an endocrine gland. Its function in digestion is primarily an exocrine activity. This chapter focuses on digestive disorders associated with the pancreas. See Chapter 11 for pancreatic disorders associated with endocrine function.
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391
A B F i g . 8 - 1 0 • Rebound Tenderness or Blumberg's Sign. A, To assess for appendicitis or generalized peritonitis, place your hand on the abdomen in an area away from the suspected area of local inflammation. Palpate deeply and slowly. B, The palpating hand is then quickly removed. Pain induced or increased by quick withdrawal results from rapid movement of inflamed peritoneum and is called rebound tenderness. When rebound tenderness is present, the client will have pain or increased pain on the side of the inflammation when the palpatory pressure is released. Ask the client if it hurts as you are palpating or during the release. Since abdominal pain is increased uncomfortably with this test, save it for last when assessing abdominal pain during the physical examination. (From Jarvis C: Physical examination and health assessment, ed 4, Philadelphia, 2004, WB Saunders; Fig. 21-31, p 585.)
cause is unknown. Chronic alcoholism or toxicity from some other agent, such as glucocorticoids, thiazide diuretics, or acetaminophen, can bring on an acute attack of pancreatitis. A mechanical obstruction of the biliary tract may be present, usually because of gallstones in the bile ducts. Viral infections (e.g., mumps, herpesviruses, hepatitis) also may cause an acute inflammation of the pancreas. Chronic pancreatitis is caused by long-standing alcohol abuse in more than 90% of adult cases. Chronic pancreatitis is characterized by the progressive destruction of the pancreas with accompanying irregular fibrosis and chronic inflammation.
Clinical Signs
and Symptoms
The clinical course of most clients with acute pancreatitis follows a self-limited pattern. Symptoms can vary from mild, nonspecific abdominal pain to profound shock with coma and, ultimately, death. Abdominal pain begins abruptly in the midepigastrium, increases in intensity for several hours, and can last from days to more than a week. The pain has a penetrating quality and radiates to the back. Pain is made worse by walking and lying supine and is relieved by sitting and leaning forward. The client may have a bluish discoloration of the periumbilical area as a physical manifestation of acute pancreatitis. This occurs in cases of severe hemorrhagic pancreatitis. Turner's sign is a
bluish discoloration of the flanks, also present in hemorrhagic pancreatitis. Symptoms associated with chronic pancreatitis include persistent or recurrent episodes of epigastric and left upper quadrant pain with referral to the upper left lumbar region. Pathology of the head of the pancreas is more likely to cause epigastric and midthoracic pain from T5 to T9. Impairment of the tail of the pancreas (located to the left of midline; see Fig. 3-4) can refer pain to the left shoulder. Anorexia, nausea, vomiting, constipation, flatulence, and weight loss are common. Attacks may last only a few hours or as long as 2 weeks; pain may be constant. In clients with alcoholassociated pancreatitis, the pain often begins 12 to 48 hours after an episode of inebriation. Clients with gallstone-associated pancreatitis typically experience pain after a large meal. Nausea and vomiting accompany the pain. Other symptoms include fever, tachycardia, jaundice, and malaise. Clinical Signs and Symptoms of Acute Pancreatitis •
Epigastric pain radiating to the back
• • •
Nausea and vomiting Fever and sweating Tachycardia Continued on p. 392
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• • •
Malaise Weakness Bluish discoloration of abdomen or flanks (severe hemorrhagic acute pancreatitis)
•
Jaundice
Clinical Signs and Symptoms of Pancreatic Carcinoma
Clinical Signs and Symptoms of Chronic Pancreatitis •
light-colored stools, constipation, nausea, vomiting, loss of appetite, weight loss, and weakness.
Epigastric pain radiating to the back
• Upper left lumbar region pain • Nausea and vomiting • Constipation • Flatulence • Weight loss
•
Epigastric/upper abdominal pain radiating to the back • Low back pain may be the only symptom • Jaundice • Anorexia and weight loss • Light-colored stools • Constipation • Nausea and vomiting •
Weakness
Pancreatic Carcinoma
Inflammatory Bowel Disease
Pancreatic carcinoma is the fifth most common cause of death from cancer for women and fourth most common for men. The majority of pancreatic cancers (70%) arise in the head of the gland and only 20% to 30% occur in the body and tail (see Fig. 9-1). The latter usually have grown to a large size by the time the diagnosis is made, due to the absence of symptoms.
Inflammatory bowel disease (IBD) refers to two inflammatory conditions; it is not the same as irritable bowel syndrome (IBS) discussed separately: • Ulcerative colitis (UC) • Crohn's disease (CD) (also referred to as regional enteritis or ileitis) Crohn's disease and ulcerative colitis are disorders of unknown etiology involving genetic and immunologic influences on the GI tract. Ulcerative colitis affects the large intestine (colon). Crohn's disease can affect any portion of the intestine from the mouth to the anus. Both diseases not only cause inflammation inside the intestine, but can also cause significant problems in other parts of the body. These two diseases share many epidemiologic, clinical, and therapeutic features. Both are chronic, medically incurable conditions. Extraintestinal manifestations occur frequently in clients with inflammatory bowel disease and complicate its management. The client may not know these signs and symptoms are associated with Crohn's disease. Manifestations involve the joints most commonly (see previous discussion of Arthralgia). The client with new onset of joint pain should be asked about a previous history of Crohn's disease. Skin lesions may occur as either erythema nodosum (red bumps/purple knots over the ankles and shins) or pyoderma (deep ulcers or canker sores) of the shins, ankles, and calves. Ask about a recent history (last 6 weeks) of skin lesions anywhere on the body. Uveitis may cause red and painful eyes that are sensitive to light, but this condition does not affect the person's vision. Nutritional deficiencies are the most common complications of IBD. Evidence to suggest increased intestinal permeability allowing increased exposure to foreign antigens has been
Clinical Signs
and Symptoms
The clinical features of pancreatic cancer initially are nonspecific and vague, contributing to a delay in diagnosis and high mortality. Symptoms do not usually appear until the tumor obstructs nearby bile ducts or grows large enough to cause abdominal pressure of pain. The most common symptoms of pancreatic cancer are anorexia and weight loss, epigastric/upper abdominal pain with radiation to the back, and jaundice secondary to obstruction of the bile duct. Jaundice is characterized by fatigue and yellowing of the skin and sclera of the eye. The urine may become dark like the color of a cola soft drink. As with any pancreatic impairment, involvement of the head of the pancreas is more likely to cause epigastric and mid-thoracic pain (T5-T9), whereas, impairment of the tail of the pancreas (located to the left of midline; see Fig. 3-4) can refer pain to the left shoulder. Epigastric pain is often vague and diffuse. Radiation of pain into the lumbar region is common and sometimes is the only symptom. The pain may become worse after the person eats or lies down. Sitting up and leaning forward may provide some relief, and this usually indicates that the lesion has spread beyond the pancreas and is inoperable. Other signs and symptoms include
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discovered. Inflammation alone and the decrease in functioning surface area of the small intestine, increases food requirements, causing poor absorption. Nutritional problems associated with the medical treatment of IBD may occur. The use of prednisone decreases vitamin D metabolism, impairs calcium absorption, decreases potassium supplies, and increases the nutritional requirement for protein and calories. Decreased vitamin D metabolism and impaired calcium absorption subsequently result in bone demineralization and osteoporosis. 44,45
Crohn's Disease Crohn's disease (CD) is an inflammatory disease that most commonly attacks the terminal end (or distal portion) of the small intestine (ileum) and the colon. However, it can occur anywhere along the alimentary canal from the mouth to the anus. It occurs more commonly in young adults and adolescents but can appear at any age.
Clinical Signs
and Symptoms
CD may have acute manifestations, but the condition is usually slow and nonaggressive. The client may present with mild intermittent symptoms months before the diagnosis is made. Fever may occur, with acute inflammation, abscesses, or rheumatoid manifestations. Terminal ileum involvement produces pain in the periumbilical region with possible referred pain to the corresponding segment of the low back. Pain of the ileum is intermittent and felt in the lower right quadrant with possible associated iliopsoas abscess causing hip pain (see previous discussion of Psoas abscess). The client may experience relief of discomfort after passing stool or flatus. For this reason, it is important to ask whether low back pain is relieved after passing stool or gas. Twenty-five percent of people with CD may present with arthritis or migratory arthralgias (joint pain). The person may present with monoarthritis (i.e., asymmetric pattern affecting one joint at a time), usually involving an ankle or knee, although elbows and wrists can be included. Polyarthritis (involving more than one joint) or sacroiliitis (arthritis of the lower spine and pelvis) is common and may lead to ankylosing spondylitis in rare cases. Whether monoarthritic or polyarthritic, this condition comes and goes with the disease process and may precede repeat episodes of bowel symptoms by 1 to 2 weeks. With proper
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medical intervention, there is no permanent joint deformity.
Ulcerative Colitis By definition, UC is an inflammation and ulceration of the inner lining of the large intestine (colon) and rectum. When inflammation is confined to the rectum only, the condition is known as ulcerative proctitis. UC is not the same as irritable bowel syndrome (IBS) or spastic colitis (another term for IBS). Cancer of the colon is more common among clients with UC than among the general population. The incidence is greatly increased among those who develop UC before the age of 16 years and those who have had the condition for more than 30 years.
Clinical Signs
and Symptoms
The predominant symptom of UC is rectal bleeding; mainly the left colon is involved; the small intestine is never involved. Clients often experience diarrhea, possibly 20 or more stools per day. Nausea, vomiting, anorexia, weight loss, and decreased serum potassium may occur with severe disease. Fever is present during acute disease. Nocturnal diarrhea is usually present when daytime diarrhea is prominent. The development of anemia depends on the degree of blood loss, severity of the illness, and dietary iron intake. Ankylosing spondylitis, anemia, and clubbing of the fingers are occasional findings. Clubbing (see Figs. 4-34 and 4-35) develops quickly within 7 to 10 days. Medical testing and diagnosis are required to differentiate between these inflammatory conditions. Most often, the therapist is faced with clients presenting complaints of pain located in the shoulder, back, or groin that may have a GI origin and not be true musculoskeletal dysfunction at all. Clinical Signs and Symptoms of Ulcerative Colitis a n d Crohn's Disease •
Diarrhea
• Constipation • Fever • Abdominal pain • Rectal bleeding • Night sweats • Decreased appetite, nausea, weight loss • Skin lesions • Uveitis (inflammation of the eye) • Arthritis • Migratory arthralgias • Hip pain (iliopsoas abscess)
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Irritable Bowel Syndrome Irritable bowel syndrome (IBS) has been called the "common cold of the stomach." It is a functional disorder of motility in the small and large intestines diagnosed according to specific bowel symptom clusters. IBS is classified as a "functional" disorder because the abnormal muscle contraction identified in people with IBS cannot be attributed to any identifiable abnormality of the bowel. A lowered visceral pain threshold is commonly found with complaints of bloating and distention at lower volumes of colonic insufflation than normal controls. In other words, affected individuals perceive unpleasant or inappropriate sensory experiences in the absence of any physiologic or pathophysiologic event. IBS rarely progresses and is never fatal. Other descriptive names for this condition are spastic colon, irritable colon, nervous indigestion, functional dyspepsia, pylorospasm, spastic colitis, intestinal neuroses, and laxative or cathartic colitis. IBS is the most common gastrointestinal disorder in Western society and accounts for 50% of subspecialty referrals. It is often linked with psychosocial factors. In cases where symptoms are severe and refractory to treatment, a history of mental, physical, or sexual abuse is suspected. " IBS is most common in women in early adulthood and there is a well-documented association between IBS and dysmenorrhea. It is unclear whether this correlation represents diagnostic confusion or whether dysmenorrhea and IBS have a common physiologic basis. As mentioned earlier in this chapter, emotional or psychologic responses to stress have a profound effect on brain chemistry, which in turn influences the enteric nervous system. Conversely, messages from the central nervous system are processed in the intestines by an elaborate neural network. Research is ongoing to find the biochemical links between psychosocial factors, physical disease, and somatic illness. 46
47
49
50,51
Clinical Signs
and Symptoms
There is a highly variable complex of intermittent gastrointestinal symptoms, including nausea and vomiting, anorexia, foul breath, sour stomach, flatulence, cramps, abdominal bloating, and constipation and/or diarrhea. The client may report white mucus in the stools. Pain may be steady or intermittent, and there may be a dull deep discomfort with sharp cramps in the morning or after eating. The typical pain
pattern consists of lower left quadrant abdominal pain, constipation, and diarrhea. Symptoms seem to come and go with no apparent cause and effect that can be identified by the affected individual. Abdominal pain or discomfort is relieved by defecation. These primary symptoms occur when the natural motility of the bowel (rhythmic peristalsis) is disrupted by stress, smoking, eating, and drinking alcohol. Rapid alterations in the speed of bowel movement create an obstruction to the natural flow of stool and gas. The resultant pressure build-up in the bowel produces pain and spasm. The therapist should also be alert for the client with a known history of IBS now experiencing unexplained weight loss or persistent, severe diarrhea, possibly signaling disorders such as malignancy, inflammatory bowel disease (IBD), or celiac disease. Symptoms of IBS tend to disappear at night when the client is asleep. Nocturnal diarrhea, awakening the client from a sound sleep, is more often a result of organic disease of the bowel and is less likely to occur in IBS. Sudden return of symptoms after age 50 following prolonged remission must be evaluated medically, especially if there is blood in the stool. 52
Clinical Signs and Symptoms of Irritable Bowel Syndrome •
Painful abdominal cramps
• • • • • •
Constipation Diarrhea Nausea and vomiting Anorexia Flatulence Foul breath
Colorectal Cancer Colorectal cancer is the third most commonly diagnosed cancer and third most common cause of death from malignant disease for both men and women in the Western world. Incidence increases with age, beginning around 40 years of age, and is higher in men than women. More African-American than Caucasian women are affected. Mortality can be significantly reduced by population screening by means of a simple fecal occult blood test (FOBT). Screening is particularly applicable to individuals belonging to high-risk groups, particularly those with a previous history of chronic inflammatory bowel disease (e.g., Crohn's disease, ulcerative colitis); adenomatous polyps; and hereditary nonpolyposis colon cancer. 53
54
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Clinical Signs
and Symptoms
The presentation of colorectal carcinoma is related to the location of the neoplasm within the colon. Individuals are asymptomatic in the early stages, then develop minor changes in their bowel patterns (e.g., increased frequency of morning evacuation, sense of incomplete evacuation), and experience occasional rectal bleeding. When vague cramping pain or an aching pressure sensation occurs, it is usually associated with a palpable abdominal mass, although these symptoms are experienced before the identification of the mass. Acute pain is often indistinguishable from that of cholecystitis or acute appendicitis. Fatigue and shortness of breath may occur secondary to the iron deficiency anemia that develops with chronic blood loss. Mahogany-colored stools may be present when there is blood mixed with the stool.* Bleeding with bright red blood is more common with a carcinoma of the left side of the colon. Pencil-thin stool may be described with cancer of the rectum. When rectal tumors enlarge and invade the perirectal tissue, a sensation of rectal fullness develops and may progress to a dull, aching, perineal or sacral pain that can radiate down the legs when peripheral nerves are involved. Clinical Signs and Symptoms of Colorectal Cancer Early Stages •
Rectal bleeding, hemorrhoids
• Abdominal, pelvic, back, or sacral pain • Back pain that radiates down the legs • Changes in bowel patterns
Advanced Stages • Constipation progressing to obstipation • Diarrhea with copious amounts of mucus • Nausea, vomiting • Abdominal distention • Weight loss • •
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Fatigue and dyspnea Fever (less common)
Acute Colonic Pseudo-obstruction Acute colonic pseudo-obstruction (Ogilvie's syndrome) is a massive dilation of the cecum and proximal colon in the absence of actual mechanical * The reddish-mahogany color associated with bleeding in the lower Gl/colon differs from the melena or dark, tarry stools that occur when blood loss in the upper GI tract is oxidized before being excreted.
causes such as colonic obstruction. This severe dilation of the colon may lead to spontaneous perforation of the colon, which is a life-threatening problem. Ogilvie's syndrome is most commonly detected in surgical patients after trauma, burns, and GI tract surgery, or in medical patients who have severe metabolic, respiratory, and electrolyte disturbances. However, this complication has also been seen after hip arthroplasty. Possible explanations include acetabular trauma and heat generation from bone cement leading to damage to tissues close to the point of contact of the heated cement. Other reported risks for development of this syndrome can be related to increased age, immobility, and use of client-controlled narcotic analgesia. Symptoms include abdominal distention, nausea, vomiting, abdominal pain, and absent bowel movements. Bowel sounds may be absent or decreased and rebound tenderness is not usually present unless colon perforation has occurred and peritonitis is present. 56
57
PHYSICIAN REFERRAL A 67-year-old man is seeing you through home health care for a home program after discharge from the hospital 2 weeks ago for a total hip replacement. His recovery has been slowed by chronic diarrhea. A 25-year-old woman who is diagnosed as having a sacroiliac pain and joint dysfunction asks you what exercises she can do for constipation. A 44-year-old man with biceps tendinitis reports several episodes of fever and chills, diarrhea, and abdominal pain, which he contributes to "the stress of meeting deadlines on the job." These are common examples of symptoms of a GI nature that are described by clients and are unrelated to current physical therapy treatment. These people may be seeking the therapist's advice as the only medical person with whom they have contact. Knowing the pain patterns associated with GI involvement and which follow-up questions to ask can assist the therapist in deciding when to suggest that the client return to a physician for a medical examination and treatment. The client may not associate GI symptoms or already diagnosed GI disease with his or her musculoskeletal pain, which makes it necessary for the therapist to initiate questions to determine the presence of such GI involvement. Taking the client's temperature and vital signs during the initial evaluation is recommended for
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any person who has musculoskeletal pain of unknown origin. Fever, low-grade fever over a long period (even if cyclic), or sweats is indicative of systemic disease. When appendicitis or peritonitis from any cause is suspected because of the client's symptoms, a physician should be notified immediately. The client should lie down and remain as quiet as possible. It is best to give her or him nothing by mouth because of the danger of aggravating the condition, possibly causing rupture of the appendix, or in case surgery is needed. Applications of heat are contraindicated for the same reason. On the other hand, the therapist may be evaluating a client, who presents with shoulder, back, or groin pain and limitations that are not caused by true musculoskeletal lesions but rather the result of GI involvement. The presence of associated GI symptoms in the absence of conclusive musculoskeletal findings will alert the therapist to the possible need for medical referral. Correlate the history with pain patterns and any unusual findings that may indicate systemic disease.
Guidelines f o r Immediate Medical Attention • Anytime appendicitis or iliopsoas/obturator abscess is suspected (positive McBurney's test, positive iliopsoas/obturator test, positive test for rebound tenderness) • Anytime the therapist suspects retroperitoneal bleeding from an injured, damaged or ruptured spleen; ectopic pregnancy or (history of trauma; missed menses; positive Kehr's sign)
Guidelines f o r Physician Referral • Clients who chronically rely on laxatives should be encouraged to discuss bowel management without drugs with their physician. • Joint involvement accompanied by skin or eye lesions may be reflective of inflammatory bowel disease and should be reported to the physician if the physician is unaware of these extraintestinal manifestations. • Anyone with a history of NSAID use presenting with back or shoulder pain, especially when accompanied by any of the associated signs and symptoms listed for peptic ulcer must be evaluated by a physician. • Back pain associated with meals or relieved by a bowel movement (especially if accompanied by rectal bleeding) or with back pain and abdomi-
nal pain at the same level requires medical evaluation. • Back pain of unknown cause that does not fit a musculoskeletal pattern, especially in a person with a previous history of cancer.
Clues to Screening for Gastrointestinal These clues will help the therapist in the decision making process. • Age over 45 • Previous history of NSAID-induced GI bleeding; NSAID use, especially chronic or multiple prescriptions and over-the-counter NSAIDs taken simultaneously • Symptoms increase within 2 hours after taking NSAIDs or other medication • Symptoms are affected (increased or decreased) by food anywhere from immediately up to 2 to 4 hours later • Presence of abdominal or GI symptoms occurring within 4 to 6 weeks of musculoskeletal symptoms, especially recurring or cyclical symptoms (systemic pattern) • Back pain and abdominal pain at the same level, simultaneously or alternately, especially when accompanied by constitutional symptoms • Shoulder, back, pelvic, or sacral pain: • Of unknown origin, especially with a past history of cancer • Affected by food, milk, antacids, or vomiting • Accompanied by constitutional symptoms • Back, pelvic, or sacral pain that is relieved or reduced by a bowel movement or accompanied by rectal bleeding • Shoulder pain within 24 to 48 hours of laparoscopy, ruptured ectopic pregnancy, or traumatic blow or injury to the left side (Kehr's sign; see Chapter 18) • Positive iliopsoas or obturator sign; positive McBurney's point; right (or left) lower quadrant abdominal or pelvic pain produced when palpating the iliopsoas muscle or tapping the heel of the involved side • Joint pain or arthralgias preceded by skin rash, especially in the presence of a history of Crohn's disease • When evaluated during early onset of referred pain, there is usually full and painless range of motion but, as time goes on, muscle splinting and guarding secondary to pain will produce altered movements as well
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ESOPHAGEAL PAIN (Fig 8-11)
Fig. 8 - 1 1 • Nerve distribution of the esophagus is through T5 to T6 with primary pain around the xiphoid. Esophageal pain may be projected around the chest at any level corresponding to the esophageal lesion. Only two of the possible bands of pain around the chest are shown here. Similar symptoms can occur anywhere a lesion appears along the length of the esophagus.
Location:
Referral:
Description: Intensity: Duration: Associated signs and symptoms: Possible etiology:
Substernal discomfort at the level of the lesion Lesion of upper esophagus: pain in the (anterior) neck Lesion of lower esophagus: pain originating from the xiphoid process, radiating around the thorax Severe esophageal pain: pain referred to the middle of the back Back pain may be the only symptom or may be the earliest symptom of esophageal cancer Sharp, sticking, knifelike, stabbing Strong burning pain (esophagitis) Varies from mild discomfort to severe pain May be constant; associated with meals Dysphagia, odynophagia, melena Obstruction Esophageal Esophageal Achalasia Esophagitis Esophageal
of the esophagus (neoplasm) stricture secondary to acid reflux (peptic esophagitis) stricture of unknown cause or esophageal spasm varices (usually asymptomatic except bleeding)
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T STOMACH AND DUODENAL PAIN (Fig 8-12)
F i g . 8 - 1 2 • Stomach or duodenal pain (dark red) may occur anteriorly in the midline of the epigastrium or upper abdomen just below the xiphoid process. There is a tendency for the stomach and duodenum to refer pain posteriorly. Referred pain (light red) to the back occurs at the anatomic level of the abdominal lesion [16 to T10). Other patterns of referred pain [light red) may include the right shoulder and upper trapezius or the lateral border of the right scapula.
Location:
Referral:
Description: Intensity: Duration: Associated signs and symptoms: Possible etiology:
Pain in the midline of the epigastrium Upper abdomen just below the xiphoid process One to two inches above and to the right of the umbilicus Common referral pattern to the back at the level of the lesion (T6 to T10) Right shoulder/upper trapezius Lateral border of the right scapula Aching, burning ("heartburn"), gnawing, cramp-like pain (true visceral pain) Can be mild or severe Comes in waves Early satiety Melena Symptoms may be associated with meals Peptic ulcers: gastric, pyloric, duodenal (history of NSAIDs) Stomach carcinoma Kaposi's sarcoma (most common malignancy associated with acquired immunodeficiency syndrome [AIDS]).
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399
SMALL INTESTINE PAIN (Fig. 8-13)
F i g . 8 - 1 3 • Midabdominal pain (dark red) caused by disturbances of the small intestine is centered around the umbilicus (T9 to Tl 1 nerve distribution) and may be referred (light red) to the low back area at the same anatomic level. Keep in mind the umbilicus is at the same level as the L3-L4 disc space in the average adult who is not obese or who has a protruding abdomen.
Location: Referral: Description: Intensity: Duration: Associated signs and symptoms: Possible etiology:
Midabdominal pain (about the umbilicus) Pain referred to the back if the stimulus is sufficiently intense or if the individual's pain threshold is low Cramping pain Moderate to severe Intermittent (pain comes and goes) Nausea, fever, diarrhea Pain relief may not occur after passing stool or gas Obstruction (neoplasm) Increased bowel motility Crohn's disease (regional enteritis)
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LARGE INTESTINE AND COLON PAIN (Fig 8 14)
F i g . 8 - 1 4 • Pain associated with the large intestine and colon (dark red) may occur in the lower abdomen across either or both abdominal quadrants. Pain may be referred to the sacrum (light red) when the rectum is stimulated. The pattern of nerve supply varies depending on the segment: vermiform appendix, cecum, and ascending colon are supplied by the Tl 0-T12 sympathetic fibers. Nerve distribution to the transverse colon is Tl 2-L1 and the descending colon is supplied by L1-L2.
Location: Referral: Description: Intensity: Duration: Associated signs and symptoms:
Possible etiology:
Lower midabdomen (across either or both quadrants) Poorly localized Pain may be referred to the sacrum when the rectum is stimulated Cramping Dull Steady Bloody diarrhea, urgency Constipation Rectal pain; pain during defecation Pain relief may occur after defecation or passing gas Ulcerative colitis Crohn's disease (regional enteritis) Carcinoma of the colon Long-term use of antibiotics Irritable bowel syndrome (IBS)
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401
PANCREATIC PAIN (Fig 8 15)
F i g . 8 - 1 5 • Pancreatic pain (dark red) occurs in the midline or left of the epigastrium, just below the xiphoid process, but may be referred (light red) to the left shoulder or to the mid-thoracic spine. Posterior pain may radiate or lateralize from the spine away from the midline. Sensory nerve distribution is from T5 to T9.
Location: Referral:
Description: Intensity: Duration: Associated signs and symptoms:
Aggravating factors: Relieving factors: Possible etiology:
Midline or to the left of the epigastrium, just below the xiphoid process Referred pain in the middle or lower back is typical with pancreatic disease; more rarely, pain may be referred to the upper back, midscapular region. Somatic pain felt in the left shoulder may result from activation of pain fibers in the left diaphragm by an adjacent inflammatory process in the tail of the pancreas. Burning, or gnawing abdominal pain Severe Constant pain, sudden onset Sudden weight loss Constipation Jaundice Flatulence Nausea and vomiting Tachycardia Light-colored stools(carcinoma) Symptoms may be unrelated to digestive activities (carcinoma) Weakness Symptoms may be related to digestive activities (pancreatitis) Fever Malaise Walking and lying supine (pancreatitis) Alcohol, large meals Sitting and leaning forward (pancreatitis, pancreatic carcinoma) Pancreatitis Pancreatic carcinoma (primarily disease of men, occurs during the 6th and 7th decade)
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APPENDICEAL PAIN (See Fig 8 8) Location: Referral: Description: Intensity: Duration: Associated signs and symptoms:
Right lower quadrant pain Well localized; first referred to epigastric or periumbilical area Referred pain pattern to the right hip and/or right testicle Aching, comes in waves Moderate to severe Steadily progresses over time (usually 12 hours with acute appendicitis) Positive McBurney's point for tenderness Iliopsoas abscess may occur; positive iliopsoas muscle test or positive obturator test Anorexia, nausea, vomiting, low-grade fever Coated tongue and bad breath Dysuria (painful/difficult urination)
K E Y P O I N T S T O REMEMBER / Gastrointestinal disorders can refer pain to the sternum, neck, shoulder, scapula, low back, sacrum, groin, and hip. / When evaluated during early onset of referred pain, there is usually full and painless range of motion, but as time goes on, muscle splinting and guarding secondary to pain or as a component of motor nerve involvement will produce altered movements as well. / The membrane that envelops organs (visceral peritoneum) is insensitive to pain so that, except in the presence of inflammation/ischemia, it is possible to have extensive disease without pain. / Clients may not relate known GI disorders to current (or new) musculoskeletal symptoms. / Sudden and unaccountable changes in bowel habits, blood in the stool, or vomiting red blood or coffee-
/ /
/
/
/
ground vomitus are red flag symptoms requiring medical follow-up. Antibiotics and NSAIDs are the drugs that most commonly induce GI symptoms. Kehr's sign (left shoulder pain) occurs as a result of free air or blood in the abdominal cavity causing distention (e.g., trauma, ruptured spleen, laparoscopy, ectopic pregnancy). Epigastric pain radiating to the upper back or upper back pain alone can be the primary symptom of peptic ulcer, pancreatitis, or pancreatic carcinoma. Appendicitis and diseases of the intestines such as Crohn's disease and ulcerative colitis can cause abscess of the iliopsoas muscle, resulting in hip, thigh, or groin pain. Arthritis and migratory arthralgias occur in 25% of Crohn's disease cases.
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403
Figs. 8-16 and 8-17 provide a summary of all the GI pain patterns described that can mimic the pain and dysfunction usually associated with musculoskeletal lesions.
Fig. 8-17 • Full-figure referred pain patterns: (1) liver/gallbladder/common bile duct; (2) appendix; (3) pancreas; (4) pancreas; (5) small intestine; (6) colon; (7) esophagus; (8) stomach/duodenum; (9) liver/gallbladder/common bile duct; and (10) stomach/duodenum.
Fig. 8-16 • Full-figure primary pain pattern: (1) stomach/ duodenum; (2) liver/gallbladder/common bile duct; (3) small intestine; (4) appendix; (5) esophagus; (6) pancreas; and (7) large intestine/colon.
SUBJECTIVE
EXAMINATION
Special Q u e s t i o n s t o A s k After completing the initial intake interview, if there is cause to suspect GI involvement, include any of the following additional questions that seem pertinent. It may be helpful to let the client know you will be asking some questions about overall health issues that may seem unrelated to their current symptoms but that are nevertheless important. When asking questions about medications, look for long-term use of antibiotics, corticosteroids such as prednisone, or other hepatotoxic drugs. See Table 8-1 for a list of medications that can cause constipation. Past Medical History • (For the client with left shoulder pain): Have you sustained any injuries in the last week during a sports activity, fall, or automobile accident? Were you pushed down or pushed against something hard (assault)? (Ruptured spleen: positive Kehr's sign)
• Have you experienced any abdominal or intestinal problems, nausea, vomiting, episodes of night sweats or fever? • If yes, have you seen a physician about these problems or reported them to your physician? • For further follow-up questions related to this area, see Associated Signs and Symptoms below. • Have you ever had an upset stomach or heartburn while taking your (NSAID) pain relievers like ibuprofen, naproxen (name the specific drug)? • Have you ever been treated for an ulcer or internal bleeding while taking these (NSAID) pain relievers? • If so, when? • Do you still have any pain from your ulcer? Please describe. • Have you ever had a colonoscopy, proctoscopy, or endoscopy? If yes, why and how long ago? • Have you ever been diagnosed with cancer of any kind? If yes, what, when, and has there been any follow-up?
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SUBJECTIVE
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
EXAMINATION —cont'd
• Have you ever had radiation treatment? (Rectal bleeding is a sign of radiation proctitis) • Have you ever had abdominal or spine (anterior retroperitoneal approach) surgery? • If yes, when and what type was it? • Do you have hemorrhoids? • If yes, have you had surgery for your hemorrhoids? (Most common cause of bright red blood coating stools) Associated Signs and Symptoms: Effects of eating/drinking • Do you have any problems chewing or swallowing food? Do you have any pain when swallowing food or liquids? (Dysphagia, odynophagia) • Have you been vomiting? (Esophageal varices, ulcers) • If so, how often? • Is your vomitus ever dark brown or black or look like it has coffee grounds in it? (Blood) • Have you ever vomited, coughed up, or spit up blood? • Have you experienced any loss of appetite or sudden weight loss in the last few weeks? (i.e., 10 to 15 pounds in 2 weeks without trying) • Does eating relieve your symptoms? (Duodenal or pyloric ulcer) • If yes, how soon after eating? • Does eating aggravate your symptoms? (Gastric ulcer, gallbladder inflammation) • Does your pain occur 1 to 3 hours after eating or between meals? (Duodenal or pyloric ulcers, gallstones, pancreatitis) • Have you ever had gallstones? • Have you noticed any change in your symptoms after drinking alcohol? (Alcohol-associated pancreatitis) • Have you ever awakened at night with pain? (Duodenal ulcer, cancer) • Approximately what time does this occur? (12 midnight to 3:00 a.m.: ulcer) • Can you relieve the pain in any way and get back to sleep. If yes, how? (Ulcer: eating and antacids relieve/Cancer: nothing relieves) • Do you have a feeling of fullness after only one or two bites of food? (Early satiety: esophagus, stomach and duodenum, or gallbladder)
Associated Signs and Symptoms: Change in bowel habits • Have you had any changes in your bowel movements (Normal frequency varies from three times a day to once every 3 or more days)? (Constipation/bowel obstruction) • If yes to constipation (see Table 8-1), do you use laxative or stool softeners? How often? • Do you have diarrhea? (Ulcerative colitis, Crohn's disease, long-term use of antibiotics, colonic obstruction, amebic colitis, angiodysplasia, creatine supplementation) • Do you have more than two loose stools a day? If so, do you take medication for this problem? What kind of medication do you use? • Have you traveled outside of the United States within the last 6 months to 1 year? (Amebic colitis associated with bloody diarrhea) • Do you have a sense of urgency so that you have to find a bathroom immediately without waiting? • Do you ever have any blood in your stool, reddish Mahogany-colored stools, or dark, tarry stools that are hard to wipe clean? (Bleeding ulcer, esophageal varices, colon or rectal cancer, hemorrhoids or rectal fissures; rectal lesions with bleeding can be caused by homosexual activity [men] or anal intercourse [women]) • If yes, how often? • For the therapist: If yes, assess NSAID use and risk factors for NSAID-induced gastropathy. • Is the blood mixed in with the stool or does it coat the surface? (Distal colon or rectum versus melena) • Do you ever have white mucus around or in your stools? (Irritable bowel syndrome) • Do you ever have gray-colored stools? (Lack of bile or caused by biliary obstruction such as hepatitis, gallstones, cirrhosis, pancreatic carcinoma, hepatotoxic drugs) • Are your stools ever pencil thin? (Indicates bowel obstruction such as tumor or rectocele [prolapsed rectum] in women after childbirth) • Is your pain relieved after passing stool or gas? (Yes: large intestine and colon; No: small intestine)
CHAPTER 8
CASE
STUDY:
SCREENING FOR GASTROINTESTINAL DISEASE
405
CROHN'S
REFERRAL
Gastrointestinal
A 21-year-old woman comes to you with complaints of pain on hip flexion when she lifts her right foot off the brake in the car. There are no other aggravating factors, and she is unaware of any way to relieve the pain when she is driving her car. Before the onset of symptoms, she jogged 5 to 6 miles/day, but could not recall any injury or trauma that might contribute to this pain. The Family/Personal History form indicates no personal illness but shows a complex, positive family history for heart disease, diabetes, ulcerative colitis, stomach ulcers, stomach cancer, and alcoholism.
• • • •
PHYSICAL THERAPY INTERVIEW
It is suggested that the therapist use the physical therapy interview to assess the client's complaints today and follow up with appropriate additional questions, such as those noted here.
Nausea Diarrhea Loss of appetite Feeling of fullness after only one or two bites of a meal • Unexpected weight gain or loss (10 to 15 pounds without trying) • Vomiting • Constipation • Blood in your stool (If yes to any of these, follow-up with Special Questions to Ask from this chapter.) Have you noticed any association between when you eat and your symptoms? (After allowing the client to respond, you may want to prompt her by asking whether eating relieves the pain or aggravates the pain.) Is your pain relieved or aggravated during or after you have a bowel movement?
Introduction to Client
From your family history form, I notice that a number of your family members have reportedly been diagnosed with various diseases. • Do you have any other medical or health-related problems? • Have you sustained any injuries to the lower back, side, or abdomen in the last week—for example, during a sports activity, fall, or automobile accident? Were you pushed, kicked, or shoved against something? Although the symptoms that you have described appear to be a musculoskeletal problem, I would like to check out the possibility of a urologic, abdominal, or gynecologic source of this irritation. I will ask you some additional questions that may seem to be unrelated to the problem with your hip, but which will help me put together the whole picture of the history, symptoms, and actual physical results from my examination today. General Systemic
What other symptoms have you had with this problem? (After allowing the client to answer, you may prompt her by asking: For example, have you had any . . .) • Numbness • Fatigue • Legs giving out from under you • Burning, tingling sensation • Weakness
Gynecologic
Since your hip/groin/thigh symptoms started, have you been examined by a gynecologist to rule out any gynecologic causes of this problem? If no: • Have you ever been told that you have ovarian cysts, uterine fibroids, retroverted uterus, endometriosis, an ectopic pregnancy, or any other gynecologic problem? • Are you pregnant or have you recently terminated a pregnancy either by miscarriage or abortion? • Are you using an intrauterine contraceptive device (IUD)? • Are you having any unusual vaginal discharge? (If yes to any of these questions, see the followup questions for women in Appendix B-32.) Urologic
Have you had any problems with your kidneys or bladder? If yes, please describe. Have you noticed any changes in your ability to urinate since your pain or symptoms started? (If no, it may be necessary to provide examples of what changes you are referring to; for example, difficulty in starting or continuing the flow of urine, numbness or tingling in the groin or pelvis, painful urination, urinary incontinence, blood in the urine.) Have you had burning with urination during the last 1 to 3 weeks?
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STUDY:
VISCEROGENIC CAUSES OF PAIN A N D D Y S F U N C T I O N
CROHN'S—
cont'd
Objective Examination
RESULTS
Your objective examination reveals tenderness or palpation over the right anterior upper thigh muscles into the groin, with reproduction of the pain on resisted trunk flexion only. This woman attends daily ballet classes, stretches daily, and seems to be very active physically. All tests for flexibility were negative for tightness, including the Thomas' test for tight hip flexors. Other special tests for hip and a neurologic screen had negative results. The client's temperature was normal when it was taken today during the intake screen of vital signs, but during the physical therapy interview, when specifically asked about fevers and night sweats, she indicated several recurrent episodes of night sweats during the last 3 months.
Although the client's complaints are primarily musculoskeletal, the absence of trauma, positive family history for systemic disease, limited musculoskeletal findings, and the client's remark concerning the presence of night sweats will alert the physical therapist to the need for a medical referral to rule out the possibility of a systemic origin of symptoms. The client's condition gradually worsened during a 3-week period and reexamination by the physician led to an eventual diagnosis of Crohn's disease (regional gastroenteritis). The client was treated with medications that reduce abdominal inflammation and eliminated subjective reports of pain on active hip flexion. Performing the special tests for iliopsoas abscess may have provided valuable information and earlier medical referral if assessed during the initial evaluation.
PRACTICE QUESTIONS 1. Bleeding in the GI tract can be manifested as: a. Dysphagia b. Melena c. Psoas abscess d. Tenderness over McBurney's point 2. What is the significance of Kehr's sign? a. Gas, air, or blood in the abdominal cavity b. Infection of the peritoneum (peritonitis, appendicitis) c. Esophageal cancer d. Thoracic disc herniation masquerading as chest or anterior neck pain 3. What areas of the body can gastrointestinal (GI) disorders refer pain to? a. Sternum, shoulder, scapula b. Anterior neck, mid-back, lower back c. Hip, pelvis, sacrum d. All of the above
4. A 56-year old client was referred to PT for pelvic floor rehab. His primary symptoms are obstructed defecation and puborectalis muscle spasm. He wakes nightly with left flank pain. The pattern is low thoracic, laterally, but superior to iliac crest. Sometimes he has buttock pain on the same side. He doesn't have any daytime pain but is up for several hours at night. Advil and light activity do not help much. The pain is relieved or decreased with passing gas. He has very tight hamstrings and rectus femoris. Change in symptoms with gas or defecation is possible with: a. Thoracic disc disease b. Obturator nerve compression c. Small intestine disease d. Large intestine and colon dysfunction
CHAPTER 8
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PRACTICE QUESTIONS—cont'd 5. Name two of the most common medications taken by clients seen in a physical therapy practice likely to induce GI bleeding. a. Corticosteroids b. Antibiotics and antiinflammatories c. Statins d. None of the above 6. What is the significance of the psoas sign? 7. Which of the following are clues to the possible involvement of the GI system? a. Abdominal pain alternating with TMJ pain within a 2-week period b. Abdominal pain at the same level as back pain, occurring either simultaneously or alternately c. Shoulder pain alleviated by a bowel movement d. All of the above 8. A 65-year old client is taking OxyContin for a "sore shoulder." She also reports aching pain of the sacrum that radiates. The sacral pain can be caused by: a. Psoas abscess caused by vertebral osteomyelitis b. GI bleed causing hemorrhoids and rectal fissures c. Crohn's disease manifested as sacroiliitis d. Pressure on sacral nerves from stored fecal content in the constipated client taking narcotics
9. A 64-year old woman with chronic rheumatoid arthritis fell and broke her hip. Six months after her total hip replacement, she is still using a walker and complains of continued loss of strength and function. Her family practice physician has referred her to physical therapy for a home program to "improve gait and increase strength." The client reports frequent episodes of lightheadedness when her legs feel rubbery and weak. She is taking a prescription NSAID along with an OTC NSAID 3 times each day and has been taking NSAIDs 3 years continuously. There are no reported GI complaints or associated signs and symptoms, but after completing the intake interview and objective examination, you think there may be weakness associated with blood loss and anemia secondary to chronic NSAID use. How would you handle a case like this? 10. Body temperature should be taken as part of vital sign assessment: a. For every client evaluated b. For any client who has musculoskeletal pain of unknown origin c. For any client reporting the presence of constitutional symptoms, especially fever or night sweats d. (b) and (c)
REFERENCES 1. Pert CB, Dreher HE, RuffMR: The psychosomatic network: foundations of mind-body medicine, Altern Ther Health Med 4(4):30-41, 1998. 2. Pert C: Paradigms from neuroscience: when shift happens, Mol Interv 3(7):361-366. 3. Mayer EA: Gut feelings: what turns them on? Gastroenterology 108(3):927-931, 1995. 4. Groh V and Spies T: Recognition of stress-induced MHC molecules by intestinal epithelial gamma delta T cells, Science 279:1737-1740, 1998. 5. Wu J, et al: T-cell antigen receptor engagement and specificity in the recognition of stress-inducible MHC class Irelated chains by human epithelial gamma delta T cells, J Immunol 169(3):1236-1240, 2002. 6. Rex L: evaluation and treatment of somatovisceral dysfunction of the gastrointestinal system, Edmonds, Washington, 2004, URSA Foundation. 7. Rose SJ, Rothstein JM: Muscle mutability: general concepts and adaptations to altered patterns of use, Physical Therapy 62:1773, 1982. 8. Ledlie J, Renfro M: Balloon kyphoplasty: one-year outcomes in vertebral body height restoration, chronic
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pain, and activity levels, J Neurosurg (Spine I) 98:36-42, 2003. Travell JG, Simons DG: Myofascial pain and dysfunction: the trigger point manual, Vol 2, Baltimore, 1992, Williams and Wilkins. Oberpenning F, Roth S, Leusmann DB, et al: The Alcock syndrome: temporary penile insensitivity due to compression of the pudendal nerve within the Alcock canal, J Urol 151(2):423-425, 1994. Weiss BD: Clinical syndromes associated with bicycle seats, Clin Sports Med 13(1): 175-186, 1994 McQuaid K: Alimentary tract: antibiotic-associated colitis. In Tierney L, McPhee S, Papadakis M, editors: Current medical diagnosis and treatment, ed 43, New York, 2004, Lange; pp 596-597. Smith J, Dahm DL: Creatine use among select population of high school athletes, Mayo Clin Proc 75(12):1257-1263, 2000. Graham AS, Hatton RC: Creatine: a review of efficacy and safety, J Am Pharm Assoc 39(6):803-810, 1999. Hellman D, Sone J: Arthritis and musculoskeletal disorders, reactive arthritis. In Tierney L, McPhee S, Papadakis M, editors: Current medical diagnosis and treatment, ed 43, New York, 2004, Lange; pp 821-822.
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16. Palm 0, et al: Prevalence of ankylosing spondylitis and other spondyloarthropathies among patients with inflammatory bowel disease: a population study (the IBSEN study), Journal of Rheumatology 29(3):511-515, 2002. 17. Inman RD: Arthritis and enteritis—an interface of protean manifestations, Journal of Rheumatology 14:406-410, 1987. 18. Gran JT, Husby G: Joint manifestations in gastrointestinal diseases, Digestive Diseases 10:295-312, 1992. 19. Baeten D, et al: Influence of the gut and cytokine patterns in spondyloarthropathy, Clin Exp Rheumatol 20(6 Suppl 28):S38-S42, 2002. 20. Sieper J et al: Diagnosing reactive arthritis: role of clinical setting in the value of serologic and microbiologic assays, Arthritis Rheum 46:319, 2002. 21. Mustafa K, Khan MA: Recognizing and managing reactive arthritis, J Musculoskeletal Med 13(6):28-41, 1996. 22. Burger EL: Lumbar disk replacement: restoring mobility, Orthopedics 27(4):386-288, 2004. 23. Tay B et al: Spinal infections, J Amer Acad Orthop Surg 10(3): 188-197, 2002. 24. Goodman CC: The gastrointestinal system. In Goodman CC et al, editors: Pathology: implications for the physical therapist, ed 2, Philadelphia, 2003, WB Saunders; pp 628-666. 25. Rayhorn N, Argel N, Demchak K: Understanding gastroesophageal reflux disease, Nursing2003 33(10):37-41, 2003. 26. Sabesin SM, Fass R, Fisher R: Not all heartburn patients are equal: strategies for coping with gastroesophageal reflux disease (GERD), Medscape Continuing Medical Education. 27. Asthma in older women, Harvard Women's Health Watch 11(3):5, 2003. 28. Margolis S: Getting the right cure for ulcers, Johns Hopkins Medical Letter 10(1): 1-2, 1998. 29. Miwa, H, Sakaki N, Sugano K, et al. Recurrent peptic ulcers in patients following successful Helicobacter pylori eradication: a multicenter study of 4940 patients, Helicobacter 9(1):9-16, 2004. 30. Chan FKL, Graham DY: Prevention of non-steroidal antiinflammatory drug gastrointestinal complications—review and recommendations based on risk assessment, Medscape Continuing Medical Education. 31. Lanas A, Garcia-Rodriquez LA, Arroyo MT, et al: Risk of upper gastrointestinal ulcer bleeding associated with selective COX-2 inhibitors, traditional non-aspirin NSAIDs, aspirin, and combinations, Gut May 10, 2006 (Epub ahead of print). 32. McQuaid K: Alimentary tract: peptic ulcer disease. In Tierney L, McPhee S, Papadakis M, editors: Current medical diagnosis and treatment, ed 43, New York, 2004, Lange; pp 564-570. 33. Chan FK: Celecoxib versus diclofenac and omeprazole in reducing the risk of recurrent ulcer bleeding in patients with arthritis, NEJM 347(26):2104-2110, 2002. 34. Goldstein JL, et al: Incidence of outpatient physician claims for upper gastrointestinal symptoms among new users of celecoxib, ibuprofen, and naproxen in an insured population in the United States, Am J Gastroenterol 98(12):26272634, 1998. 35. Lefkowith JB: Cyclooxygenase-2 specificity and its clinical implications, Am J Med 106:43S-50S, 1999.
36. Chan F: Preventing recurrent upper gastrointestinal bleeding in patients with Helicobacter pylori infection who are taking low-dose aspirin or naproxen, N Engl J Med 344:967, 2001. 37. Peloso PM: NSAIDs: a Faustian bargain, American Journal of Nursing 100(6):34-43, 2000. 38. Sturkenboom MC, Burke TA, Dieleman JP, et al.: Underutilization of preventive strategies in patients receiving NSAIDs, Rheumatology (Oxford) 42(Suppl 3):iii23-31, 2003. 39. Goldstein JL: Challenges in managing NSAID-associated gastrointestinal tract injury, Digestion 69(Suppl l):25-33, 2004. 40. Fries JF, et al: Nonsteroidal antiinflammatory drug-associated gastropathy: incidence and risk factor models, Am J Med 91(3):213-222, 1991. 41. Enns R: Acute lower gastrointestinal bleeding, Parts 1 and 2, Can J Gastroenterology 15:509-517, 2001. 42. Sadler TW: Longman's medical embryology, ed 9, Philadelphia, 2004, Lippincott, Williams & Wilkins. 43. Rayhorn N: Inflammatory bowel disease (IBD), Nursing2003 33(ll):54-55, 2003. 44. Ma TY: Intestinal epithelial barrier dysfunction in Crohn's disease, Proc Soc Exp Biol Med 214(4):318-327, 1997. 45. Ma TY, Iwamoto GK, Hoa NT, et al: TNF-alpha-induced increase in intestinal epithelial tight junction permeability requires NF-kappa B activation, Am J Physiol Gastrointest Liver Physiol 286(3):G367-376, 2004. 46. Older K: Diagnosis of irritable bowel syndrome, Gastroenterology 122:1701, 2002. 47. McQuaid K: Alimentary tract: irritable bowel syndrome. In Tierney L, McPhee S, Papadakis M, editors: Current medical diagnosis and treatment, ed 43, New York, 2004, Lange; pp 592-596. 48. van Zanten SV: Diagnosing irritable bowel syndrome, Rev Gastroenterol Disord 3(Suppl 2):S12-17, 2003. 49. Salmon P, Skaife K, Rhodes J: Abuse, dissociation, and somatization in irritable bowel syndrome: towards an explanatory model, J Behav Med 26(1):1-18, 2003. 50. Crowell MD, Dubin NH, Robinson JC, et al: Functional bowel disorders in women with dysmenorrhea, Am J Gastroenterol 89:1973, 1994. 51. NIH: Irritable bowel syndrome, NIH Publication No. 03693, April, 2003. 52. Lucak S: Diagnosing irritable bowel syndrome: what's too much, what's enough? Medscape Medical Continuing Education on line, posted 3/12/04 on www.medscape. com/viewarticle 465760 53. Jemal A, Tiwari RC, Murray T, et al: Cancer statistics 2004, CA Cancer J Clin 54(l):8-29, 2004. 54. Sargent C, Murphy D: What you need to know about colorectal cancer, Nursing2003 33(2):37-41, 2003. 55. Smith R, et al: American Cancer Society guidelines for early detection of cancer, CA Cancer J Clin 52(l):8-22, 2002. 56. Schermer CR, et al: Ogilvie's syndrome in the surgical patient, a new therapeutic modality, J. Gastroenterol Surg 3(2):173, 1999. 57. el Maraghy A, et al: Ogilvie's syndrome after lower extremity arthroplasty, Can J Surg 42(2):133, 1999.
Screening for Hepatic and Biliary Disease
A
s with many of the organ systems in the human body, the hepatic and biliary organs (liver, gallbladder, and common bile duct) (Fig. 9-1) can develop diseases that mimic primary musculoskeletal lesions. The musculoskeletal symptoms associated with hepatic and biliary pathologic conditions are generally confined to the mid-back, scapular, and right shoulder regions. These musculoskeletal symptoms can occur alone (as the only presenting symptom) or in combination with other systemic signs and symptoms discussed in this chapter.
HEPATIC AND BILIARY SIGNS AND SYMPTOMS The major causes of acute hepatocellular injury include hepatitis, druginduced hepatitis, and ingestion of hepatotoxins. The physical therapist is most likely to encounter liver or gallbladder diseases manifested by a variety of signs and symptoms outlined in this section. Taking a careful history and making close observations of the client's physical condition and appearance can detect telltale signs of hepatic disease. Most of the liver is contained underneath the rib cage and is largely inaccessible (Fig. 9-2). An enlarged liver that is palpable may be a red flag (see Fig. 4-48). Medical diagnosis of liver or gallbladder disease is made by x-ray examination or ultrasonic scanning of the gallbladder and computed tomography (CT) scanning of the abdomen, including the liver. Other tests such as a cholescintigraphy may be used to track the flow of radioactivity into and out of the gallbladder to confirm gallstones. Blood tests may be used to look for signs of infection, obstruction, or jaundice. Laboratory tests useful in the diagnosis and treatment of liver and biliary tract disease are listed inside the back cover.
Skin and Nail Bed Changes Skin changes associated with impairment of the hepatic system include jaundice, pallor, and orange or green skin. In some situations jaundice may be the first and only manifestation of disease. It is first noticeable in the sclera of the eye as a yellow hue when bilirubin reaches levels of 2 to 3 mg/dl. When the bilirubin level reaches 5 to 6mg/dl, the skin becomes yellow. Normally bilirubin, excreted in bile and carried to the small intestines, is reduced to a form that causes the stool to assume a brown color. Lightcolored (almost white) stools and urine the color of tea or cola indicate an inability of the liver or biliary system to excrete bilirubin properly. Gallbladder disease, hepatotoxic medications, or pancreatic cancer blocking the bile duct may cause light stools. Other skin changes may include pruritus (itching), bruising, spider angiomas (Fig. 9-3), and palmar erythema (see Fig. 9-5). Spider angiomas (arterial spider, spider telangiectasis, vascular spider), branched dilations 409
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S E C T I O N II
Gallbladder. Cystic duct.
Common bile duct Portal vein • Celiac artery )
Tail of pancreas Accessory pancreatic duct Ampulla of Vater
Fig. 9-1 • Anatomy of the liver, gallbladder, common bile duct, and pancreas. The pear-shaped gallbladder is tucked up under the right side of the liver. The pancreas is located behind the stomach anterior to the LI to L3 vertebral bodies. It is about 6 inches long, wide at one end (the head), then tapered through the body to the narrow end called the tail.
Duodenum Head of pancreas Pancreatic duct
Liver
Gall bladder
Diaphragm
Fig. 9-2 • Location of the liver and gallbladder. The liver is located just below the respiratory diaphragm, predominately on the right side, but with a portion crossing the midline to the left side. It is a large organ and spans many vertebral levels. The most superior part is the dome of the right lobe. The "peak" of the dome lies at about T8 or T9 during expiration. The inferior border of the left lobe is located just below the level of the left nipple and inclines downwards to the right at the tip of the 8th costal margin. The right lobe angles downward to the 9th and 10th costal margins. Posteriorly, the liver is located from approximately T9 to LI at the midline. This varies from person to person and with inhalation (moves up a level or two) and exhalation (moves down). The fundus (base) of the gallbladder usually appears below the edge of the liver in contact with the anterior abdominal wall at the tip of the 9th right costal cartilage.
Fig. 9-3 • Spider Angioma. Permanently enlarged and dilated capillaries visible on the surface of the skin caused by vascular dilation are called spider angiomas. These capillary radiations can be flat (not shown) or raised in the center (as shown here). They present on the upper half of the body, primarily on the face, neck, chest, or abdomen and occur as a normal development or in association with pregnancy, chronic liver disease, or estrogen therapy. They do not go away when the underlying condition is treated; laser therapy is available to remove them for cosmetic reasons. (From Callen JP, Jorizzo JL, eds: Dermatological signs of internal disease, Philadelphia, 1988, WB Saunders.)
CHAPTER 9
SCREENING FOR HEPATIC A N D BILIARY DISEASE
Fig. 9-4 • Arterial Spider. Schematic diagram of an arterial spider formed by a coiled arteriole that spirals up to a central point and then branches out into thin-walled vessels that merge with normal capillaries resembling a spider in appearance. Exposure to heat (e.g., hot tubs, warm shower) will cause temporary vasodilation. The skin lesion will appear larger until vasoconstriction occurs.
of the superficial capillaries resembling a spider in appearance (Fig. 9-4) may be vascular manifestations of increased estrogen levels (hyperestrogenism). Spider angiomas and palmar erythema both occur in the presence of liver impairment as a result of increased estrogen levels normally detoxified by the liver. Palmar erythema (warm redness of the skin over the palms, also called liver palms) caused by an extensive collection of arteriovenous anastomoses especially affects the hypothenar and thenar eminences and pulps of the finger (Fig. 9-5). The soles of the feet may be similarly affected. The person may complain of throbbing, tingling palms. Various forms of nail disease have been described in cases of liver impairment, such as the white nails of Terry (Fig. 9-6). Other nail bed changes such as white bands across the nail plate (leukonychia), clubbed nails (see Fig. 4-34), or koilonychia (see Fig. 4-30) can occur but these are not specific to liver impairment and can develop in the presence of other diseases as well.
Musculoskeletal Pain Musculoskeletal pain associated with the hepatic and biliary systems includes thoracic pain between the scapulae, right shoulder, right upper trapezius,
41 1
Fig. 9-5 • Palmer erythema caused by liver impairment presents as a warm redness of the skin over the palms and soles of the feet in the Caucasian population. Darker skin tones may change from a tan color to a gray appearance. Look for other signs of liver disease such as nail bed changes, spider angiomas, liver flap, and bilateral carpal or tarsal tunnel syndrome. Palmer erythema can occur in healthy individuals and in association with nonhepatic diseases. (From Barrison I, ed: Gastroenterology in practice, St. Louis, 1992, Mosby.)
Fig. 9-6 • Nails of Terry. Opaque white nails of Terry in a patient with cirrhosis. Various forms of nail disease have been described in patients with cirrhosis. This is an example of the classic white nails of Terry characterized by an opaque nail plate with a narrow line of pink at the distal end instead of the more normal pink nail plate in the Caucasian. (From Callen JP, Jorizzo JL, eds: Dermatological signs of internal disease, Philadelphia, 1988, WB Saunders.)
right interscapular, or right subscapular areas (see Fig. 9-10 and Table 9-1). Referred shoulder pain may be the only presenting symptom of hepatic or biliary disease. Pain from the superior ligaments of the liver and the superior portion of the liver capsule is transmitted by the phrenic nerves. Sympathetic fibers from the biliary system are connected through the celiac (abdominal) and splanchnic (visceral) plexuses to
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TABLE 9-1
S E C T I O N II
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
Referred Pain Patterns: Liver, Gallbladder, Common Bile Duct
Systemic causes
Location (see Figure 9-10)
Liver disease (abscess, cirrhosis, tumors, hepatitis) Gallbladder
Thoracic spine (T7-T10; midline to the right) Right upper trapezius and shoulder Right upper trapezius and shoulder Right interscapular area (T4 or T5-T8) Right subscapular area
terol-lowering) drugs such as Zocor, Lipitor, or Crestor. Rhabdomyolysis is the most severe form of muscle disorder associated with statin use. Statinassociated myopathy is more likely characterized by muscle aches, cramps, soreness, and weakness. It may be accompanied by other symptoms of liver or renal involvement. Laboratory testing will show a creatine kinase (CK) level more than 10 times the upper limit of normal. Although the literature reports the incidence of this severe myopathy with statin use as about 0.1% to 2.0% in clinical trials, therapists report seeing cases more often than the low percentage would suggest. Statin-associated myopathy appears to occur more often in people with complex medical problems and/or taking other drugs, especially agents that share common metabolic pathways. Other risk factors that increase the chances of this condition include excessive alcohol use, advancing age (over 80 years), recent history of surgery, and small physical stature. 2
3
4
the hepatic fibers in the region of the dorsal spine (see Fig. 3-3). The celiac and splanchnic connections account for the intercostal and radiating interscapular pain that accompanies gallbladder disease. Although the innervation is bilateral, most of the biliary fibers reach the cord through the right splanchnic nerves, synapsing with adjacent phrenic nerve fibers innervating the diaphragm and producing pain in the right shoulder (see Fig. 3-4). Hepatic osteodystrophy, abnormal development of bone, can occur in all forms of cholestasis (bile flow suppression) and hepatocellular disease, especially in the alcoholic person. Either osteomalacia or, more often, osteoporosis frequently accompanies bone pain from this condition. Vertebral wedging, vertebral crush fractures, and kyphosis can be severe; decalcification of the ribcage and pseudofractures occur frequently.* Osteoporosis associated with primary biliary cirrhosis and primary sclerosing cholangitis parallels the severity of liver disease rather than its duration. Painful osteoarthropathy may develop in the wrists and ankles as a nonspecific complication of chronic liver disease. Rhabdomyolysis can occur as a result of acute trauma, overexertion, or in the case of liver impairment, from the use of cholesterol-lowering drugs called statins (e.g., Zocor, Lipitor, Crestor). Rhabdomyolysis, a potentially fatal condition involving the breakdown of muscle tissue, has been reported as a potential complication of all statin (choles1
* Pseudofractures, or Looser's zones, are narrow lines of radiolucency (areas of darkness on x-ray film) usually oriented perpendicular to the bone surface. This may represent a stress fracture that is repaired by laying down inadequately mineralized osteoid, or these sites may occur as a result of mechanical erosion caused by arterial pulsations since arteries frequently overlie sites of pseudofractures.
5
2
Neurologic Symptoms Neurologic symptoms such as confusion, sleep disturbances, muscle tremors, hyperreactive reflexes, and asterixis may occur. When liver dysfunction results in increased serum ammonia and urea levels, peripheral nerve function can be impaired. Ammonia from the intestine (produced by protein breakdown) is normally transformed by the liver to urea, glutamine, and asparagine, which are then excreted by the renal system. When the liver does not detoxify ammonia, ammonia is transported to the brain, where it reacts with glutamate (excitatory neurotransmitter), producing glutamine. The reduction of brain glutamate impairs neurotransmission, leading to altered central nervous system metabolism and function. Asterixis and numbness/tingling (misinterpreted as carpal tunnel syndrome) can occur as a result of this ammonia abnormality, causing an intrinsic nerve pathologic condition (Case Example 9-1). There are many potential causes of carpal tunnel syndrome, both musculoskeletal and systemic (see Table 11-2). Careful evaluation is required (Box 9-1).
Pathophysiology Asterixis (also called flapping tremors or liver flap) is a motor disturbance, specifically, the inability to maintain wrist extension with forward flexion of the upper extremities. Asterixis can be tested for by asking the client to dorsiflex the hand with the
CHAPTER 9
CASE
EXAMPLE
9-1
Carpal Tunnel Syndrome
A 45-year-old truck driver was diagnosed by a hand surgeon as having bilateral carpal tunnel syndrome (CTS) and referred to physical therapy. A screening examination was not performed during the evaluation. During the course of treatment, the client commented that he was seeing an acupuncturist, who told him that liver disease was the cause of his bilateral CTS. The therapist suspected a history of alcohol abuse, which is a risk factor for liver disease.
B O X 9-1
413
SCREENING FOR HEPATIC AND BILIARY DISEASE
from
Liver
Impairment
Further questioning at that time indicated the lack of any other associated symptoms to suggest liver or hepatic involvement. However, because his symptoms were bilateral and there is a known correlation between liver disease and CTS, the referring physician was notified of these findings. The client was referred for evaluation, and a diagnosis of liver cancer was confirmed. Physical therapy for CTS was appropriately discontinued.
Evaluating Carpal Tunnel Syndrome Associated with Liver Impairment
For any client presenting with bilateral carpal tunnel syndrome • Ask about the presence of similar symptoms in the feet • Ask about a personal history of liver or hepatic disease (e.g., cirrhosis, cancer, hepatitis) • Look for a history of hepatotoxic drugs (see Box 9-3) • Look for a history of alcoholism • Ask about current or previous use of statins (cholesterol-lowering drugs such as Crestor, Lipitor, or Zocor) • Look for other signs and symptoms associated with liver impairment (see Clinical Signs and Symptoms of Liver Disease) • Test for signs of liver disease Skin color changes Spider angiomas Palmer erythema (liver palms) Nail bed changes (e.g., white nails of Terry, white bands, clubbing) Asterixis (liver flap)
Fig. 9-7 • To test for asterixis or liver flap, have the client extend the arms, spread the fingers, extend the wrist, and observe for the abnormal "flapping" tremor at the wrist. If a tremor is not readily apparent, ask the client to keep the arms straight while gently hyperextending the client's wrist. There is an alternate method of testing for this phenomenon: have the client relax the legs in the supine position with the knees bent. The feet are flat on the table. As the legs fall to the sides, watch for a flapping or tremoring of the legs at the hip. The knees appear to come back towards the midline repeatedly. 6
rest of the arm supported on a firm surface or with the arms held out in front of the body (Fig. 9 - 7 ) . Observe for quick, irregular extensions and flexions of the wrist and fingers. Altered neurotransmission, specifically, impaired inflow of joint and other afferent information to the brainstem reticular formation, results in this movement dysfunction. Asterixis may be observed during blood pressure readings. Observe for flapping when the cuff is released. Watch for lack of concentration, fatigue, and other symptoms of encephalopathy (see Table 9 - 5 ) . 6
A careful history and close observation of the client are important in determining whether a person may need a medical referral for possible liver disease. Jaundice in the postoperative client is not uncommon, but it can be a potentially serious complication of surgery and anesthesia. Clues to screening for hepatic disease (see Clues to Screening for Hepatic Disease at the end of this chapter) should be taken into consideration when evaluating the clinical history and observations.
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Clinical Signs and Symptoms of
Liver Disease • • •
Sense of fullness of the abdomen Anorexia, nausea, and vomiting Skin changes and nail bed changes • Jaundice • Bruising • Spider angioma • Palmar erythema • White nails of Terry, other nail bed changes may be present • Dark urine and light-colored or clay-colored feces • •
Ascites (Fig. 9-8) Edema and oliguria (reduced urine secretion in relation to fluid intake)
•
Right upper quadrant (RUQ) abdominal pain • Musculoskeletal pain, especially right shoulder pain • Myopathy (rhabdomyolysis in severe cases) •
Neurologic symptoms • Confusion • Sleep disturbances • Muscle tremors • Hyperactive reflexes • Asterixis (motor disturbance resembling body or extremity flapping) • Bilateral carpal/tarsal tunnel • Pallor (often linked to cirrhosis or carcinoma) • Gynecomastia (enlargement of breast tissue in men)
HEPATIC AND BILIARY PATHOPHYSIOLOGY Liver Diseases Hepatitis Hepatitis is an acute or chronic inflammation of the liver. It can be caused by a virus, a chemical, a drug reaction, or alcohol abuse. In addition, hepatitis can be secondary to disease conditions, such as an infection with other viruses (e.g., EpsteinBarr virus or cytomegalovirus). VIRAL HEPATITIS
Viral hepatitis is an acute infectious inflammation of the liver caused by one of the following identified viruses: A, B, C, D, E, and G (Table 9-2). Hepatitis is a major uncontrolled public health problem for several reasons: not all the causative agents have been identified, there are limited specific drugs for its treatment, its incidence has increased in relation to illicit drug use, and it can be communicated before the appearance of observable clinical symptoms. Viral hepatitis is spread easily to others and usually results in an extended period of convalescence with loss of time from school or work. It is estimated that 60% to 90% of viral hepatitis cases are unreported because many cases are subclinical or involve mild symptoms. Hepatitis A and E are transmitted primarily by the fecal-oral route. Common source outbreaks result from contaminated food or water. As people and foods, including produce, extend across the globe, the possibility of infection with these viruses increases. Hepatitis A (HAV) must also be considered a potential problem in situations where fecaloral communication along with food handling and/or unsanitary conditions occur. Some examples of potential sources of contact with HAV might include restaurants, day care centers, correctional institutions, sewage plants, and countries where these viruses are endemic. Hepatitis viruses B, C, D, and G are primarily blood borne pathogens that can be transmitted from percutaneous or mucosal exposures to blood or other body fluids from an infected person. Hepatitis B virus (HBV) is usually transmitted by inoculation of infected blood or blood products or by sexual contact and is also found in body fluids (e.g., spinal, peritoneal, pleural) saliva, semen, and vaginal secretions. Hepatitis D virus must have Hepatitis B virus present to coinfect. Groups at risk include homosexuals and intravenous drug users; health care workers in any area where 7
Clinical Signs and Symptoms of
Gallbladder Disease • Right upper abdominal pain • Jaundice (result of blockage of the common bile duct) • Low-grade fever, chills • Indigestion, nausea, feeling of fullness • Excessive belching, flatulence (intestinal gas) • • •
Intolerance of fatty foods Persistent pruritus (skin itching) Sudden, excruciating pain in the mid-epigastrium with referral to the back and right shoulder (acute cholecystitis) • Anterior rib pain (tip of 10th rib; can also affect ribs 11 and 12)
8
TABLE 9-2 • Comparison of Major Types of Viral Hepatitis Factor
Hepatitis C
Hepatitis D (delta agent)
Hepatitis E
Incidence
Endemic in areas of of poor sanitation; common in fall and early winter
Worldwide, especially in drug addicts, homosexuals, people exposed to blood products; occurs all year
Posttransfusion; those working around blood and blood products; occurs all year
Parts of Asia, Africa, and Mexico, where sanitation is poor
Incubation period Risk factors
2-6 weeks Close personal contact or by handling fecescontaminated food or water
6-7 weeks Similar to hepatitis B; healthcare workers in contact with blood and body fluids; blood transfusion recipients
Transmission
Infected feces, fecaloral route*; may be airborne (if copious secretions); shellfish from contaminated water; also rarely parenteral; no carrier state Mortality low; rarely causes fulminating hepatic failure
6 weeks-6 months Health care workers in contact with body secretions, blood, and blood products; hemodialysis and posttransfusion clients; homosexually active males and drug abusers; morticians; those receiving tattoos; workers, residents of correctional settings Parenteral, sexual contact, and fecal-oral route; carrier state
Causes hepatitis only in association with hepatitis B and only presence of HbsAg; endemic in Mediterranean area Same as hepatitis B Same as hepatitis B
Contact with blood and body fluids; source of infection uncertain in many clients; carrier state
Coinfects with hepatitis B, close personal contact; carrier state
Fecal-oral route, foodborne or waterborne; no carrier state
More serious; may be fatal; mortality rate is up to 60%
Can lead to chronic hepatitis
Hygiene; avoidance of risk factors; immune globulin (passive); hepatitis B vaccine (active); treatment with adefovir dipivoxil (Hepsera)
Hygiene; immune globulin (passive); treatment with Interferon alfacon-1 (Infergen) or pegylated interferons (peginterferon alpha2a) and Ribavirin (viral inhibitor)
Similar to hepatitis B; more severe if occurs with chronic active hepatitis B Hygiene; hepatitis B vaccine (active)
Illness self-limiting; mortality rate in pregnant women is 10% to 20% Hygiene; sanitation; no immunity
Severity
Prophylaxis and active or passive immunity
Hygiene; vaccine available; immune globulin
2-9 weeks Traveling or living in areas where incidence is high
415
* The oral-fecal route of transmission is primarily from poor or improper handwashing and personal hygiene, particularly after using the bathroom and then handling food for public consumption. This route of transmission may also occur through shared use of razors and oral utensils such as straws, silverware, and toothbrushes.
SCREENING FOR HEPATIC AND BILIARY DISEASE
Hepatitis B
CHAPTER 9
Hepatitis A
S E C T I O N II
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VISCEROGENIC CAUSES OF PAIN A N D DYSFUNCTION
contact with blood, blood products, or body fluids are likely; and residents and workers in correctional settings. Hepatitis C is transmitted similarly to HBV and HDV. Risk factors are also very similar with the addition of people who have received blood transfusions or organ transplants, including anterior cruciate ligament (ACL) reconstruction allograft. There has been growing concern worldwide about the risk of occupational transmission of HCV. New findings, however, suggest that the transmission rate for health care workers is about 0.5% rather than the earlier reported 1.8%. Hepatitis G (HGV) designation has been applied to a virus that is percutaneously transmitted and associated with blood borne viral presence lasting approximately 10 years. HGV has been detected primarily in IV drug users, clients on hemodialysis, clients with hemophilia, and in a small percentage of blood donors. It does not appear to cause important liver disease or affect the response rate of those with chronic HBV or HCV to antiviral therapy. Hepatitis affects people in three stages: the initial or preicteric stage, the icteric or jaundiced stage, and the recovery period (Table 9-3). During 9
1011
12
13
TABLE 9-3
Stages of Hepatitis
Initial/preicteric (1-3 weeks) Dark urine Light stools Vague GI symptoms Constitutional symptoms Fatigue Malaise Weight loss Anorexia Nausea/vomiting Diarrhea Aversion to food, alcohol, cigarette smoke Enlarged and tender liver Intermittent pruritus (itching) Arthralgias
Icteric (2-4 weeks)
Recovery (3-4 months)
Jaundice GI symptoms subside Liver decreases in size and tenderness Enlarged spleen Enlarged post cervical lymph nodes
Easily fatigued
Modified from Goodman CC, Boissonnault WG: Pathology: implication for the physical therapist, Philadelphia, 2003, WB Saunders, p 676.
the initial or preicteric stage, which lasts for 1 to 3 weeks, the person experiences vague gastrointestinal (GI) and general body symptoms. Fatigue, malaise, lassitude, weight loss, and anorexia are common. Many people develop an aversion to food, alcohol, and cigarette smoke. Nausea, vomiting, diarrhea, arthralgias,* and influenza-like symptoms may occur. The liver becomes enlarged and tender (see Fig. 4-48), and intermittent itching (pruritus) may develop. From 1 to 14 days before the icteric stage, the urine darkens and the stool lightens as less bilirubin is conjugated and excreted. The icteric stage is characterized by the appearance of jaundice, which peaks in 1 to 2 weeks and persists for 6 to 8 weeks. During this stage the acuteness of the inflammation subsides. The GI symptoms begin to disappear, and after 1 to 2 weeks of jaundice the liver decreases in size and becomes less tender. During the icteric stage the post-cervical lymph nodes and spleen are enlarged (see Fig. 4-50). Persons who have been treated with human immune serum globulin (ISG) may not develop jaundice. The recovery stage lasts for 3 to 4 months, during which time the person generally feels well but fatigues easily. People with mild-to-moderate acute hepatitis rarely require hospitalization. The emphasis is on preventing the spread of infectious agents and avoiding further liver damage when the underlying cause is drug-induced or toxic hepatitis. People with fulminant (severe, sudden intensity, sometimes fatal) hepatitis require special management because of the rapid progression of their disease and the potential need for urgent liver transplantation. An entire spectrum of rheumatic diseases can occur concomitantly with hepatitis B and hepatitis C, including transient arthralgias, vasculitis, polyarteritis nodosa, rheumatoid arthritis (RA), fibromyalgia, lymphoma, Sjogren's syndrome, and persistent synovitis. Some conditions, such as RA and fibromyalgia, occur only in association with HCV, whereas others, such as polyarteritis nodosa, are observed in association with both forms of hepatitis. Rheumatic manifestations of hepatitis are varied early in the course of disease and can be 1415
* There is a strong association between arthralgia and age with increasing incidence of joint involvement with increased age; arthralgia in children is much less common.
CHAPTER 9
SCREENING FOR HEPATIC A N D BILIARY DISEASE
indistinguishable from mild RA. The therapist should be suspicious of anyone with risk factors for hepatitis, including injection drug use; previous blood transfusion, especially before 1991; hemodialysis; or other exposure to blood products/body fluids, such as a health care worker (Box 9-2) or a past history of hepatitis that currently appears with arthralgias. (Case Example 9-2) Other red flag symptoms include joint or muscle pain that is disproportionate to the physical findings and the presence of palmar tendinitis in someone with RA and positive risk factors for hepatitis.
BOX 9-2
Risk Factors for Hepatitis
Injection drug use Acupuncture Tattoo inscription or removal Ear or body piercing Recent operative procedure Liver transplant recipient Blood or plasma transfusion before 1991 Hemodialysis Health care worker exposed to blood products or body fluids Exposure to certain chemicals or medications Unprotected homosexual/bisexual activity Severe alcoholism Travel to high risk areas Consumption of raw shellfish
CASE
EXAMPLE
9-2
417
Clinical Signs and Symptoms of
Hepatitis A Hepatitis A is often acquired in childhood as a mild infection with symptoms similar to the "flu" and may be misdiagnosed or ignored. It does not usually cause lasting damage to the liver, although the following symptoms may persist for weeks: • Extreme fatigue • Anorexia • Fever • Arthralgias and myalgias (generalized aching) • Right upper abdominal pain • Clay-colored stools • Dark urine • Icterus (jaundice) • Headache • Pharyngitis • Alterations in the senses of taste and smell • Loss of desire to smoke cigarettes or drink alcohol • Low-grade fever • Indigestion (varying degrees of nausea, heartburn, flatulence)
Clinical Signs and Symptoms of
Hepatitis B Hepatitis B may be asymptomatic but can include • Jaundice (changes in skin and eye color) • Arthralgias Continued on p. 418
Hepatitis C
A 43-year-old man, 1 year following traumatic injury to the right forearm, underwent surgery to transplant his great toe to function as a thumb. The surgery took place in another state, and the man, who had been a client in our facility before surgery, returned for postoperative rehabilitation. Complaints of hives of the involved forearm, fatigue, depression, and increased perspiration were documented but attributed by his physician to recovery from the traumatic injury and the multiple operations. Medical records from the hospital consisted of therapy notes only. Eventually, the client developed a yellowing of the sclerae (white outer coat of the eyeballs). Medical referral was requested, and the client
was evaluated by an internal medicine specialist. Hepatitis C was diagnosed, and full medical records then obtained revealed that although the man had donated his own blood in advance for the surgery, he was short by one unit of blood, which he received through a blood bank. The blood donation was attributed as the probable source of contamination. Continued physical therapy intervention was modified to accommodate liver impairment with particular attention paid to activity level. The therapist also observed the client carefully for signs of fluid shift, such as weight gain and orthostasis; dehydration; pneumonia; and vascular problems.
S E C T I O N II
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•
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
Rash (over entire body)
• Dark urine • Anorexia, nausea • Painful abdominal bloating • Fever
k n o w n side effects associated w i t h classical i n t e r feron t r e a t m e n t (e.g., fatigue, headache, myalgia, fever, anxiety, i r r i t a b i l i t y , G I u p s e t ) . 18
Clinical Signs and Symptoms of
C H R O N I C HEPATITIS Chronic hepatitis is the t e r m u s e d to describe an i l l n e s s associated w i t h prolonged i n f l a m m a t i o n o f the l i v e r after u n r e s o l v e d v i r a l h e p a t i t i s o r associated w i t h chronic active hepatitis ( C A H ) of u n k n o w n cause. Chronic is defined as i n f l a m m a t i o n of the l i v e r for 6 m o n t h s or more. T h e s y m p t o m s and biochemical a b n o r m a l i t i e s may continue for m o n t h s o r y e a r s . I t i s divided i n t o C A H and chronic persistent hepatitis ( C P H ) by findings on l i v e r biopsy. Chronic Active Hepatitis T h i s type of hepat i t i s r e f e r s t o s e r i o u s l y destructive l i v e r disease t h a t can r e s u l t i n c i r r h o s i s . C A H i s often a r e s u l t o f v i r a l infection ( H B V , H C V , and H D V ) , b u t i t can also be secondary to d r u g s e n s i t i v i t y (e.g., m e t h y l dopa [Aldomet], an a n t i h y p e r t e n s i v e medication, and i s o n i a z i d [ I N H ] , a n a n t i t u b e r c u l a r d r u g ) . S t e r o i d therapy i s s o m e t i m e s recommended for c l i e n t s w i t h evidence o f aggressive l i v e r i n f l a m m a t i o n and necrosis (identified by l i v e r biopsy) as a r e s u l t o f these d r u g s . I f C A H i s l e f t untreated, i t s course is unpredictable and may range f r o m prog r e s s i v e deterioration of l i v e r f u n c t i o n to spontaneous r e m i s s i o n s and exacerbations. S t e r o i d s m a y be used to t r e a t C A H . T h e y are u s u a l l y prescribed for a period of 3 to 5 y e a r s . In addition, recombinant interferon-alpha-2b inject i o n s in low doses over a 6 - m o n t h period have been s h o w n t o improve hepatic function i n p e r s o n s w i t h C A H . T r e a t m e n t o f h e p a t i t i s C i s r e l a t i v e l y new and c o n s i s t s of the use of i n t e r f e r o n s ( I F N s ) , a p r o t e i n n a t u r a l l y occurring i n the h e a l t h y body i n response to infection such as the h e p a t i t i s v i r u s . Conventional i n t e r f e r o n ( I F N s ) h a s been used for m a n y y e a r s i n the t r e a t m e n t o f chronic hepatit i s C i n c l i e n t s who p e r s i s t e n t l y m a i n t a i n H C V / R N A blood l e v e l s . C o m b i n i n g i n t e r f e r o n s w i t h the d r u g r i b a v i r i n h a s r e s u l t e d i n better control o f chronic H C V i n some i n d i v i d u a l s b u t the t r e a t m e n t is not w e l l tolerated because of side effects f r o m the r i b a v i r i n . 1 6 1 7
Pegylated i n t e r f e r o n s such as Pegasys (pegint e r f e r o n alpha-2a) are new, improved f o r m s of i n t e r f e r o n s t h a t allow a decrease in dosage and offer improved efficacy. P e g i n t e r f e r o n s ( P E G s ) i n combination w i t h r i b a v i r i n are now considered the s t a n d a r d t r e a t m e n t for chronic H C V infection. T h e s e new P E G i n t e r f e r o n s d o not e l i m i n a t e the
Chronic Active Hepatitis The clinical signs and symptoms of chronic active hepatitis may range from asymptomatic to the person who is bedridden with cirrhosis and advanced hepatocellular failure. In the latter the prominent signs and symptoms may reflect multisystem involvement, including • Fatigue • Jaundice • Abdominal pain • Anorexia • Arthralgia • Fever • Splenomegaly and hepatomegaly • Weakness • Ascites (see Fig. 9-8) • Hepatic encephalopathy
Clinical Signs and Symptoms of
Chronic P e r s i s t e n t Hepatitis •
Right upper quadrant pain
•
Anorexia
• Mild fatigue • Malaise
Metabolic Disease T h e m o s t common metabolic diseases t h a t can cause chronic hepatitis and are of i n t e r e s t to a physical t h e r a p i s t are W i l s o n ' s disease and hematochromatosis, also termed hemochromatosis. B o t h these diseases are dealt w i t h in greater detail as metabolic d i s o r d e r s in Chapter 11. Wilson's disease is an autosomal recessive disorder i n w h i c h b i l i a r y excretion o f copper i s impaired, and, as a consequence, total body copper is prog r e s s i v e l y increased. T h e r e may be mild-to-severe neurologic d y s f u n c t i o n , depending on the rate of hepatocyte i n j u r y . Hemochromatosis is the m o s t common genetic disorder (autosomal recessive defect in i r o n absorpt i o n ) causing l i v e r f a i l u r e . E x c e s s i v e i r o n i s stored i n v a r i o u s parenchymal organs w i t h subsequent development of fibrosis. A r t h r a l g i a s and arthropat h y may develop and are often confused w i t h RA or o s t e o a r t h r i t i s . T h e second and t h i r d metacarpophalangeal j o i n t s are u s u a l l y involved first.
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Knees, hips, shoulders, and lower back may be affected. Acute synovitis with pseudogout of the knees has been observed. N O N V I R A L HEPATITIS
Nonviral hepatitis is considered to be a toxic or drug-induced form of liver inflammation. This type of hepatitis occurs secondary to exposure to alcohol, certain chemicals, or drugs such as antiinflammatories, anticonvulsants, antibiotics, cytotoxic drugs for the treatment of cancer, antituberculars, radiographic contrast agents for diagnostic testing, antipsychotics, and antidepressants (Box 9-3). Acetaminophen, the popular OTC pain reliever has been found to be the leading cause of sudden liver failure in adults in the United States. The drug is safe when taken properly, but even a small overdose in some people can trigger sudden liver failure. The use of this drug becomes even more dangerous with taken by individuals with an already impaired liver. The mechanism by which these agents induce overt injury may be dose-related and predictable or idiosyncratic and unpredictable, with the latter caused by an unusual susceptibility of the individual. Some drugs (e.g., oral contraceptives) may impair liver function and produce jaundice without causing necrosis, fatty infiltration of liver cells, or a hypersensitivity reaction. 19
Clinical Signs and Symptoms of
Toxic and Drug-Induced Hepatitis These vary with the severity of liver damage and the causative agent. In most individuals symptoms resemble those of acute viral hepatitis: • Anorexia, nausea, vomiting •
Fatigue and malaise
• • • •
Jaundice Dark urine Clay-colored stools Headache, dizziness, drowsiness (carbon tetrachloride poisoning) • Fever, rash, arthralgias, epigastric or right upper quadrant pain (halothane anesthetic)
B O X 9-3
419
Common Hepatotoxic Agents
Analgesics
Cardiovascular
Acetaminophen Aspirin Diclofenac
Quinidine sulfate Amiodarone Methyldopa
Anesthetics
Hormonal
Halothane Enflurane Methoxyflurane Chloroform
Oral contraceptives Anabolic steroids Oral hypoglycemics
Anticonvulsants
Alcohol Cocaine Ecstasy
Valproic acid Phenytoin Carbamazepine Lamotrigine Antidepressants/ antipsychotics
Monamine oxidase (MAO) inhibitors Chlorpromazine and other phenothiazines Antineoplastics
Methotrexate (related to cumulative dose) Mercaptopurine L-asparaginase Carmustine, lomustine Streptozocin
Recreational Drugs
Vitamins
Vitamin A (large doses) Niacin (large doses) Other
Carbon tetrachloride Poisonous mushrooms Heavy metals Phosphorus Tannic acid Propylthiouracil Diagnostic contrast agents
Antimicrobials
Chloramphenicol Isoniazid (antitubercular) Oxacillin Erythromycin estolate Novobiocin Ketoconazole (antifungal) Nitrofurantoin Sulfonamides (class) Minocycline Tetracyclines (class) Efavirenz (antiviral) Nevirapine (antiviral) Ritonavir (antiviral)
Cirrhosis Cirrhosis is a chronic hepatic disease characterized by the destruction of liver cells and by the replacement of connective tissue by fibrous bands. As the liver becomes more and more scarred (fibrosed), blood and lymph flow become impaired, causing hepatic insufficiency and increased clinical manifestations. The causes of cirrhosis can be varied,
although alcohol abuse is the most common cause of liver disease in the United States. In addition, about 25% of Americans have a problem called nonalcoholic fatty liver disease (NAFLD), defined as fatty infiltration of the liver
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exceeding 5% to 10% by weight. NAFLD is an illness closely associated with diabetes and obesity and may make liver damage caused by other agents (e.g., alcohol, industrial toxins, hepatatrophic viruses) worse. Ten to 20% of people with NAFLD will develop liver inflammation leading to liver scarring and cirrhosis. Prevention and treatment of both diabetes and obesity, and protection of the liver from toxins can help to limit the course of this disease. The activity level of the client with damage from chronic liver impairment is determined by the symptoms. Because hepatic blood flow diminishes with moderate exercise, rest periods are advised and are adjusted according to the level of fatigue experienced by the client both during the exercise and afterward at home. The person may return to work with medical approval but is advised to avoid straining, such as lifting heavy objects if portal hypertension and esophageal varices are a problem. Because stress decreases hepatic blood flow, any reduction of stress at home, at work, or during treatment is therapeutic. 20
21
Clinical Signs and Symptoms of
Cirrhosis •
Mild right upper quadrant pain (progressive)
•
GI symptoms • Anorexia • Indigestion • Weight loss • Nausea and vomiting • Diarrhea or constipation Dull abdominal ache Ease of fatigue (with mild exertion) Weakness Fever
• • • •
PROGRESSION OF CIRRHOSIS
As the cirrhosis progresses and hepatic insufficiency develops, a series of conditions emerges, including portal hypertension, ascites, and esophageal varices. Late symptoms affecting the entire body develop (Table 9-4). Portal hypertension is elevated pressure in the portal vein (through which blood passes from the GI tract and spleen to the liver), occurring as portal blood meets increased resistance to flow in the fibrotic liver. The blood then backs up into esophageal, stomach, and splenic structures and bypasses the liver through collateral vessels.
Clinical Signs and Symptoms of
Portal Hypertension • Ascites (see Fig. 9-8) •
Dilated collateral veins • Esophageal varices (upper Gl) • Hemorrhoids (lower Gl) • Splenomegaly (enlargement of the spleen) • Thrombocytopenia (decreased number of blood platelets for clotting)
Ascites is an abnormal accumulation of fluid containing large amounts of protein and electrolytes in the peritoneal cavity as a result of portal backup and loss of proteins (Fig. 9-8). For the physical therapist, abdominal hernias and lumbar lordosis observed in clients with ascites may present symptoms that mimic musculoskeletal involvement, such as groin or low-back pain (Case Example 9-3). Esophageal varices are dilated veins of the lower esophagus that occur as a result of portal vein blood backup. These varices are thin-walled and can rupture, causing severe hemorrhage and sometimes death. Clinical Signs and Symptoms of
H e m o r r h a g e Associated w i t h Esophageal Varices • • • • •
Restlessness Pallor Tachycardia Cooling of the skin Hypotension
Hepatic Encephalopathy (Hepatic Coma) Hepatic coma is a neurologic disorder resulting from the inability of the liver to detoxify ammonia (produced from protein breakdown) in the intestine. Increased serum levels of ammonia are directly toxic to central and peripheral nervous system function, causing an array of neurologic symptoms. Flapping tremors (asterixis) and numbness/tingling (misinterpreted as carpal/tarsal tunnel syndrome) are common symptoms of this ammonia abnormality. CLINICAL S I G N S A N D S Y M P T O M S
Clinical manifestations of hepatic encephalopathy vary, depending on the severity of neurologic involvement, and develop in four stages as the ammonia level increases in the serum. The accompanying clinical features are presented in Table 9-5.
CHAPTER 9
TABLE 9-4
SCREENING FOR HEPATIC A N D BILIARY DISEASE
421
Clinical Manifestations of Cirrhosis
Body system
Clinical manifestations
Respiratory
Limited thoracic expansion (caused by ascites) Hypoxia Dyspnea Cyanosis Clubbing
Central nervous system (progressive to hepatic coma)
Subtle changes in mental acuity (progressive) Mild memory loss Poor reasoning ability Irritability Paranoia and hallucinations Slurred speech Asterixis (tremor of outstretched hands) Peripheral neuritis Peripheral muscle atrophy
Hematologic
Impaired coagulation/bleeding tendencies Nosebleeds Easy bruising Bleeding gums Anemia (usually caused by Gl blood loss from esophageal varices)
Endocrine (caused by liver's inability to metabolize hormones)
Testicular atrophy Menstrual irregularities Gynecomastia (excessive development of breasts in men) Loss of chest and axillary hair
Integument (cutaneous and skin)
Severe pruritus (itching) Extreme dryness Poor tissue turgor Abnormal pigmentation Prominent spider angiomas Palmar erythema
Hepatic
Hepatomegaly (enlargement of the liver) Ascites Edema of the legs Hepatic encephalopathy (see Table 9-5)
Gastrointestinal (Gl)
Anorexia Nausea Vomiting Diarrhea
For the physical therapist, the inpatient with impending hepatic coma has difficulty in ambulating and is unsteady. Protection from falling and seizure precautions must be taken. Skin breakdown in a client who is malnourished because of liver disease, immobile, jaundiced, and edematous can occur in less than 24 hours. Careful attention to skin care, passive exercise, and frequent changes in position are required.
Newborn
Jaundice
Jaundice affects approximately 60% of newborn infants because liver function is somewhat slow to
develop in the first few days of life. In a small percentage of infants, extreme jaundice can occur and if left untreated for too long can result in brain damage from toxic levels of bilirubin in the blood. It is critically important for all newborns to be screened for the development of this condition. Development of any color change in newborns needs immediate referral and testing for abnormal bilirubin levels. 23
Liver
Abscess
A liver abscess occurs when bacteria or protozoa destroy hepatic tissue and produce a cavity that
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Fig. 9-8 • Ascites is an abnormal accumulation of serous (edematous) fluid in the peritoneal cavity associated with liver impairment, especially the portal and hepatic venous hypertension that accompanies cirrhosis of the liver. This condition also may be associated with other disorders such as advanced congestive heart failure, constrictive pericarditis, and hyperaldosteronism. Any condition affecting the peritoneum by producing increased permeability of the peritoneal capillaries and electrolyte disturbances can result in ascites. (From Swartz M: Textbook of physical diagnosis: health and examination, Philadelphia, 1989, WB Saunders.)
fills with infectious organisms, liquefied liver cells, and leukocytes. Necrotic tissue then isolates the cavity from the rest of the liver. Even though liver abscess is relatively uncommon, it carries a mortality of 30% to 50%. This rate rises to more than 80% with multiple abscesses or other complications. Clinical Signs and Symptoms of
Liver Abscess Clinical signs and symptoms of liver abscess depend on the degree of involvement; some people are acutely ill, others are asymptomatic. Depending on the type of abscess, the onset may be sudden or insidious. The most common signs include • • • • • • •
Right abdominal pain Right shoulder pain Weight loss Fever, chills Diaphoresis Nausea and vomiting Anemia
Liver Cancer Metastatic tumors to the liver occur 20 times more often than primary liver tumors. The liver filters blood coming from the gastrointestinal tract,
making it a primary metastatic site for tumors of the stomach, colorectum, and pancreas. It is also a common site for metastases from other primary cancers such as esophagus, lung, and breast. Primary liver tumors (hepatocellular carcinoma [HCC]) are often associated with cirrhosis but can be linked to other predisposing factors, such as fungal infection (common in moldy foods of Africa), viral hepatitis, excessive use of anabolic steroids, trauma, nutritional deficiencies, and exposure to hepatotoxins. Cholangiocarcinoma (CCC), a serious and often fatal form of liver cancer, is the second most common form of hepatic malignancy. CCC originates from the epithelium of the bile ducts and has many of the same risk factors as HCC, but preexisting biliary disease is the primary risk factor. Several types of benign and malignant hepatic neoplasms can result from the administration of chemical agents. For example, adenoma (a benign tumor) can occur in recipients of oral contraceptives. Regression of the tumor occurs after withdrawal of the drug. In most instances interference with liver function does not occur until approximately 80% to 90% of the liver is replaced by metastatic carcinoma or primary carcinoma. Signs of liver impairment are often late in the presentation making early detection and successful treatment less likely. The alert physical therapist may be the first to identify liver involvement when the neuromuscular or musculoskeletal systems are affected. 24
Clinical Signs and Symptoms of
Liver N e o p l a s m If clinical signs and symptoms of liver neoplasm do occur (whether of primary or metastatic origin), these may include: • • • • • • •
Jaundice (icterus) Progressive failure of health Anorexia and weight loss Overall muscular weakness Epigastric fullness and pain or discomfort Constant ache in the epigastrium or mid-back Early satiety (cystic tumors)
GALLBLADDER AND DUCT DISEASES Cholelithiasis Gallstones are stonelike masses called calculi (singular: calculus) that form in the gallbladder possibly as a result of changes in the normal components of bile. Although there are two types
CASE
EXAMPLE
9-3
Ascites
A 69-year-old man was seen at the Veteran's Administration (VA) Hospital outpatient physical therapy department following a left total hip replacement (THR) 2 weeks ago. The surgery was performed at a civilian hospital, but all his follow up care is through the VA. He had a long history of alcohol and tobacco use and medical intervention for heart disease, hypertension, and peripheral vascular disease. The medical problem list (established by the physician) included Liver cirrhosis secondary to alcoholism Ascites secondary to portal hypertension Coronary artery disease with hypertension Peripheral vascular disease (arterial) Mild vision loss secondary to macular degeneration The client was referred to physical therapy for rehabilitation following his THR. During the examination the client reported various other musculoskeletal aches and pains including chronic low back pain present off and on for the last 6 months and new onset of groin pain on the left side (just since the THR). Ascites can be a cause of low back and/or groin pain. How do you screen this client for a medical (vascular, liver) cause of the groin pain? Past Medical History Past history of cancer of any kind Past history of abdominal or inguinal hernia Clinical
Presentation
Ask additional questions about pain pattern as discussed in Chapter 3 What do you think is causing your groin pain? Watch for red flag for possible vascular involvement: client describes pain as "throbbing" Pain is worse 5 to 10 minutes after the start of activity involving the lower extremities and relieved by rest (intermittent claudication) Visual inspection and palpation including observing for postural components (e.g., lumbar lordosis associated with ascites) as a contributing factor, abdominal or inguinal hernia, liver palpation, and lymph node palpation Perform stretching and resistive movements to eliminate, reproduce, or aggravate symptoms; you may be limited in this assessment area because of THR precautions Red flag: pain is not altered by stretching or resistive movement; pain cannot be reproduced with palpation
Assess for trigger points (e.g., adductor magnus) keeping in mind that common systemic perpetuating factors with myofascial pain include anemia and hypothyroidism as well as vitamin deficiency common with chronic alcohol use. Further screening may require assessing for risk factors and associated signs and symptoms for each of these conditions Associated Signs and Symptoms Ask the client about any other symptoms of any kind that may have developed just before or around the time of the onset of groin pain; offer some suggestions from the Overview section that appears later in this chapter. As mentioned above, the therapist may have to ask about the presence of signs and symptoms associated with anemia and endocrine disease. Should you send this client back to the doctor before continuing with physical therapy intervention? It is very likely that this client will require referral to his physician. Your referral decision will be dependent on your findings, of course. For example, the presence of trigger points may warrant treatment first and reassessment for change in clinical presentation before making a final decision. Given the movement precautions this soon after a THR may prevent you from using positional release or stretch positions for trigger points. You may have to use alternate methods of trigger point release. Remember true hip pain is often felt in the groin or deep buttock. There could be a problem with the hip implant (e.g., fracture, infection, loosening) causing the groin pain. There will be pain with active or passive motion of the hip joint. The pain increases with weight bearing. If the physician does not know about this new groin pain, medical referral to reevaluate the implant is needed before continuing with a THR rehab protocol. By continuing the screening process, the therapist can provide the physician with additional information to describe the problem. Communication is an important key element in the referral process. Provide the physician with a brief summary of your findings including a list of any unusual findings (see further discussion regarding physician in Chapter 1). 22
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TABLE 9-5
S E C T I O N II
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
Hepatic Encephalopathy Stages of Hepatic Encephalopathy Stage II (impending stage)
Stage III (stuporous stage)
Stage IV (comatose stage)
Subtle symptoms may be overlooked
Tremor progresses to asterixis (liver flap)
Client can still be aroused
Client cannot be aroused; responds only to painful stimuli
Slight personality changes: Disorientation Confusion Euphoria or depression Forgetfulness Slurred speech
Resistance to passive movement (increased muscle tone) Lethargy Aberrant behavior Apraxia* Ataxia Facial grimacing and blinking
Hyperventilation Marked confusion Abusive and violent Noisy, incoherent speech Asterixis (liver flap) Muscle rigidity Positive Babinskit reflex Hyperactive deep tendon reflexes
No asterixis Positive Babinski reflex Hepatic fetor (musty, sweet odor to the breath caused by the liver's inability to metabolize the amino acid methionine)
Stage 1 (prodromal stage)
* This type of motor apraxia can be best observed by keeping a record of the client's handwriting and drawings of simple shapes, such as a circle, square, triangle, rectangle. Check for progressive deterioration. t A reflex action of the toes that is normal during infancy but abnormal after 12 to 18 months. It is elicited by a firm stimulus (usually scraping with the handle of a reflex hammer) on the sole of the foot from the heel along the lateral border of the sole to the little toe, across the ball of the foot to the big toe. Normally such a stimulus causes all the toes to flex downward. A positive Babinski reflex occurs when the great toe flexes upward and the smaller toes fan outward.
of stones, pigment and cholesterol stones, most types of gallstone disease in the United States, Europe, and Africa are associated with cholesterol stones. Cholelithiasis, the presence or formation of gallstones, can be asymptomatic, detected incidentally during medical imaging. Problems arise if a stone leaves the gallbladder and causes obstruction somewhere else in the biliary system, presenting as biliary colic, cholecystitis, or cholangitis.
B O X 9-4
• • •
Cholelithiasis is the fifth leading cause of hospitalization among adults and accounts for 90% of all gallbladder and duct diseases. The incidence of gallstones increases with age, occurring in more than 40% of people older than 70. See Box 9-4 for risk factors to watch for in a client's history that correlate with the incidence of gallstones.
• • • • • • •
Clients with gallstones may be asymptomatic or may have symptoms of a gallbladder attack described in the next section. The prognosis is usually good with medical treatment, depending on the severity of disease, presence of infection, and response to antibiotics.
•
Risk Factors for Gallstones
Age: Incidence increases with age Sex: Women are affected more than men before age 60 Elevated estrogen levels Pregnancy Oral contraceptives Hormone therapy Multiparity (woman who has had two or more pregnancies resulting in viable offspring) Obesity Diet: High cholesterol, low fiber Diabetes mellitus Liver disease Rapid weight loss or fasting Taking cholesterol-lowering drugs (statins) Ethnicity (Stronger genetic predisposition in Native Americans, Mexican Americans) Genetics (family history of gallstones)
CHAPTER 9
Biliary
SCREENING FOR HEPATIC A N D BILIARY DISEASE
Colic
With biliary colic, the stone gets lodged in the neck of the gallbladder (cystic duct). Pain results as the gallbladder contracts and tries to push the stone through. The classic symptom of this problem is right upper abdominal pain that comes and goes in waves. The pain builds to a peak and then fades away. Obstructions of the gallbladder can result in biliary stasis, delayed gallbladder emptying, and subsequent mixed stone formation. Stasis and delayed gallbladder emptying can occur with any pathologic conditions of the liver, hormonal influences, and pregnancy (usually third trimester when the developing fetus compresses the mother's gallbladder up against the liver). Cholecystitis Cholecystitis, blockage, or impaction of gallstones in the cystic duct (Fig. 9-9) leads to infection or inflammation of the gallbladder. This condition may be acute or chronic, causing painful distension of the gallbladder. The affected individual may feel
steady, severe pain that increases rapidly, lasting several minutes to several hours. Nausea, vomiting, and fever may be present. Other causes of acute cholecystitis may be typhoid fever or a malignant tumor obstructing the biliary tract. Whatever the cause of the obstruction, the normal flow of bile is interrupted and the gallbladder becomes distended and ischemic. Gallstones may also cause chronic cholecystitis (persistent gallbladder inflammation), in which the gallbladder atrophies and becomes fibrotic, adhering to adjacent organs. It is not unusual for affected clients to have repeated episodes before seeking medical attention.
Cholangitis Gallstones lodged further down in the system in the common bile duct can cause cholangitis. Blocking the flow of bile at this point in the biliary tree can lead to jaundice. Infection can develop here and travel up to the liver, becoming a potentially life-threatening situation.
Clinical Signs
and Symptoms
The typical pain of gallbladder disease has been described as colicky pain that occurs in the right upper quadrant of the abdomen after the person has eaten a meal that is high in fat (although food that provokes an attack of pain does not need to be "fatty"). However, the pain is not necessarily limited to the right upper quadrant, and more likely than not, it is constant, not colicky. Like the stomach, pylorus, and duodenum, the liver and gallbladder can cause spasm of the rectus abdominis muscles above the umbilicus. This occurs when disturbances within the hepatic and biliary systems as part of the overall gastrointestinal system affect motor reflexes. These disturbances can be reflected in muscular contractions of the spinal, abdominal, and other muscles supplied by the motor nerves from the anterior horn of the segment innervating the affected viscera. It looks just like a musculoskeletal problem, but the pain pattern is the result of viscero-somatic reflexes as discussed in Chapter 3 (Case Example 9 - 4 ) . Ask about the timing of symptoms in relation to eating or drinking. Watch for symptoms that are worse immediately after eating (gallbladder inflammation) or pain and nausea 1 to 3 hours after eating (gallstones). Muscle guarding and tenderness of the spinal musculature in the presence of constitutional symptoms (e.g., fever, sweats, chills, nausea) is another red flag. Ask about a previous history of 25
F i g . 9-9 • The gallbladder and its divisions: fundus, body, infundibulum, and neck. A, Cholelithiasis, the presence or formation of gallstones, can be asymptomatic, detected incidentally during medical imaging. Problems arise if a stone leaves the gallbladder and causes obstruction somewhere else in the biliary system. B, If a gallstone enters the cystic duct and becomes lodged there, it can lead to cholecystitis (inflammation of the gallbladder). C, Obstruction of either the hepatic or common bile duct by stone or spasm blocks the exit of bile from the liver where it is formed. Jaundice is often the first symptom. If an infection develops and backs up into the liver, a condition called cholangitis can occur, a potentially lifethreatening problem.
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CASE
S E C T I O N II
EXAMPLE
9-4
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
Gallbladder Pain
A 48-year-old schoolteacher was admitted to the hospital following an episode of intense, sharp pain that started in the epigastric region and radiated around her thorax to the interscapular area. Her gallbladder had been removed 2 years ago, but she remarked that her current symptoms were "exactly like a gallbladder attack." The client was referred to physical therapy for "back care/education" on the day of discharge. On examination, the client was in acute distress, unable to tolerate a full examination. She had not been able to transfer or ambulate independently. She was instructed in relaxation and breathing techniques to reduce her extreme level of anxiety associated with pain and given supportive reassurance. Instruction and assistance were provided in all transfers to minimize pain and maximize independent function. Given
GI, liver, or gallbladder problems and review client's risk factors for hepatic involvement. In the case of gallbladder disease, it is also possible to get tender points in the soma corresponding to visceral innervation. A gallbladder problem can result in a sore 10th rib tip (right side anteriorly) when messages from the viscera entering the spinal cord at the same level as the innervation of the rib are misinterpreted as a somatic problem. The gallbladder has most of its innervation from the right side of the cervical ganglia to the splanchnic nerves, which explains the predominance of right-sided somatic symptoms. When visceral and cutaneous fibers enter the spinal cord at the same level, the nervous system may respond with sudomotor changes such as pruritus (itching of the skin) or a sore rib, instead of gallbladder symptoms. The clinical presentation appears as a biomechanical problem such as a rib dysfunction instead of nausea and food intolerances normally associated with gallbladder dysfunction. Likewise, from our understanding of viscerogenic pain patterns based on embryologic development, we know that the visceral pericardium of the heart (see Fig. 6-5) is derived from the same embryologic tissue as the gallbladder. A gallbladder problem can also cause referred pain to the heart and must be ruled out by the physician as a possible cause of chest pain.
her discharge status, outpatient physical therapy was recommended for follow up intervention. She returned to physical therapy as planned and was provided with a back care program. She was also treated locally for scar tissue adhesion at the site of the gallbladder removal. Symptomatic relief was obtained in the first two sessions without recurrence of symptoms. This case example is included to demonstrate how scar tissue associated with organ removal can reproduce visceral symptoms that are actually of musculoskeletal origin—the opposite concept of what is presented in this text. This may be more of an example of cellular memories sustaining a viscero-somatic reflex via the action of neuropeptides at the cellular level (see discussion of Psychoneuroimmunology in Chapter 3 ) .
Clinical Signs and Symptoms of
Acute Cholecystitis • Chills, low-grade fever • Jaundice • • • • • •
GI symptoms Nausea Anorexia Vomiting Tenderness over the gallbladder Tenderness on the tip of the 10th rib (right side anteriorly); called a "hot rib;" can also affect 11 th and 12th ribs (right anterior) • Severe pain in the right upper quadrant and epigastrium (increases on inspiration and movement) • Pain radiating into the right shoulder and between the scapulae
Clinical Signs and Symptoms of
Chronic Cholecystitis These may be vague or a sense of indigestion and abdominal discomfort after eating, unless a stone leaves the gallbladder and causes obstruction of the common duct (called choledocholithiasis), causing • Biliary colic: severe, steady pain for 3 to 4 hours in the right upper quadrant
CHAPTER 9
SCREENING FOR HEPATIC A N D BILIARY DISEASE
•
Pain: may radiate to the mid-back between the scapulae (caused by splanchnic fibers synapsing with phrenic nerve fibers) • Nausea (intolerance of fatty foods; decreased bile production results in decreased fat digestion) • Abdominal fullness • Heartburn • Excessive belching • Constipation and diarrhea
427
Gallbladder Cancer Gallbladder cancer is closely associated with gallstone disease, is usually late in diagnosis, and often has a very poor outcome. The primary associated risk factors include cholelithiasis (especially symptomatic, untreated), obesity, reproductive abnormalities, chronic gallbladder infections, and exposure to radon and certain industrial exposures including cellulose acetate fiber manufacturing. Testing and treatment of symptomatic gallstones is the only preventative measure identified at this time for gallbladder cancer. 26
Primary Biliary Cirrhosis Primary biliary cirrhosis (PBC) is a chronic, progressive, inflammatory disease of the liver that involves primarily the intrahepatic bile ducts and results in impairment of bile secretion. The disease, which often affects middle-aged women, begins with pruritus or biochemical evidence of cholestasis and progresses at a variable rate to jaundice, portal hypertension, and liver failure. The cause of PBC is unknown, although various factors are being investigated. Many clients have associated autoimmune features, particularly Sjogren's syndrome, autoimmune thyroiditis, and renal tubular acidosis. In more rare cases, clients may exhibit sensory peripheral neuropathies of the hands and feet. The most significant clinical problem for clients with PBC is bone disease characterized by impaired osteoblastic activity and accelerated osteoclastic activity. Calcium and vitamin D should be carefully monitored and appropriate replacement instituted. Physical activity following an osteoporosis protocol should be encouraged. No specific treatment has been established yet for PBC other than liver transplantation or supportive measures for the clinical symptoms described. Clinical Signs and Symptoms of
Primary Biliary Cirrhosis • • • • •
Pruritus Jaundice GI bleeding Ascites (see Fig. 9-8) Fatigue
• Right upper quadrant pain (posterior) • Sensory neuropathy of hands/feet (rare) • • • •
Osteoporosis (decreased bone mass) Osteomalacia (softening of the bones Burning, pins and needles, prickling of the eyes Muscle cramping
PHYSICIAN REFERRAL A careful history and close observation of the client are important in determining whether a person may need a medical referral for possible hepatic or biliary involvement. Any client with mid-back, scapular, or right shoulder pain (see Table 9-1) without a history of trauma (e.g., forceful movement of the spine, repetitive movements of the shoulder or back, or easy lifting) should be screened for possible systemic origin of symptoms. For the physical therapist treating the inpatient population, jaundice in the postoperative individual is not uncommon, but can be a potentially serious complication of surgery and anesthesia. Clinical management of jaundice is complicated by anything capable of damaging the liver, including physical stress associated with physical therapy intervention. Hypoxemia, blood loss, infection, and administration of multiple drugs can add additional physical stress. When making the referral, it is important to report to the physician the results of your objective findings, especially when there is a lack of physical evidence to support a musculoskeletal lesion. The Special Questions to Ask may assist in assessing the client's overall health status.
Guidelines to Immediate Physician Referral • New onset of myopathy in any client, but especially the older adult, with a history of statin use (cholesterol-lowering drugs); look for other risk factors and other signs and symptoms of liver or renal impairment.
Guidelines to Physician Referral • Obvious signs of hepatic disease, especially with a history of previous cancer or risk factors for hepatitis (see Box 9-2)
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VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
• Development of arthralgias of unknown cause in anyone with a previous history of hepatitis or risk factors for hepatitis • Presence of bilateral carpal tunnel syndrome accompanied by bilateral tarsal tunnel syndrome unknown to the physician, asterixis, or other associated hepatic signs and symptoms • Presence of sensory neuropathy of unknown cause accompanied by signs and symptoms associated with hepatic system impairment
Clues to Screening for Hepatic Disease • Right shoulder/scapular and/or upper mid-back pain of unknown cause (see also Clues to Screening Shoulder Pain, Chapter 18) • Shoulder motion is not limited by painful symptoms; client is unable to localize or pinpoint pain or tenderness • Presence of GI symptoms, especially if there is any correlation between eating and painful symptoms • Bilateral carpal/tarsal tunnel syndrome, especially of unknown origin; check for other signs of liver impairment such as liver flap, liver palms, and skin or nail bed changes (see Box 9-1)
• Personal history of cancer, liver, or gallbladder disease • Personal history of hepatitis, especially with joint pain associated with rheumatoid arthritis or fibromyalgia accompanied by palmar tendinitis • Recent history of statin use (cholesterollowering drugs such as Zocor, Lipitor, Crestor) or other hepatotoxic drugs • Recent operative procedure (possible postoperative jaundice) • Recent (within last 6 months) injection drug use, tattoo (receiving or removal), acupuncture, ear or body piercing, dialysis, blood or plasma transfusion, active homosexual activity, heterosexual sexual activity with homosexuals, consumption of raw shellfish (hepatitis) • Changes in skin (yellow hue, spider angiomas, palmar erythema) or eye color (jaundice) • Employment or lifestyle involving alcohol consumption (jaundice) • Contact with jaundiced persons (health care worker handling blood or body fluids, dialysis clients, injection drug users, active homosexual sexual activity, heterosexual sexual activity with homosexuals)
LIVER PAIN (Fig. 9-10) Gallbladder
Liver
Fig. 9-10 • The primary pain pattern from the liver, gallbladder, and common bile duct (dark red) presents typically in the midepigastrium or right upper quadrant of the abdomen. Innervation of the liver and biliary system is through the autonomic nervous system from T5 to Tl 1 (see Fig. 3-3). Liver impairment is primarily reflected through the 9th thoracic distribution. Referred pain (light red) from the liver occurs in the thoracic spine from approximately 17 to T10 and/or to the right of midline, possibly affecting the right shoulder (right phrenic nerve). Referred pain from the gallbladder can affect the right shoulder by the same mechanism. The gallbladder can also refer pain to the right interscapular (T4 or T5 to T8) or right subscapular area.
CHAPTER 9
Location: Referral:
Description: Intensity: Duration: Associated signs and symptoms:
Possible etiology:
SCREENING FOR HEPATIC A N D BILIARY DISEASE
Pain in the midepigastrium or right upper quadrant (RUQ) of abdomen Pain over the liver, especially after exercise (hepatitis) RUQ pain may be associated with right shoulder pain Both RUQ and epigastrium pain may be associated with back pain between the scapulae Pain may be referred to the right side of the midline in the interscapular or subscapular area (T7-T10) Dull abdominal aching Sense of fullness of the abdomen or epigastrium Mild at first, then increases steadily Constant Nausea, anorexia (viral hepatitis) Early satiety (cystic tumors) Aversion to smoking for smokers (viral hepatitis) Aversion to alcohol (hepatitis) Arthralgias and myalgias (hepatitis A, B, or C) Headaches (hepatitis A, drug-induced hepatitis) Dizziness/drowsiness (drug-induced hepatitis) Low-grade fever (hepatitis A) Pharyngitis (hepatitis A) Extreme fatigue (hepatitis A, cirrhosis) Alterations in the sense of taste and smell (hepatitis A) Rash (hepatitis B) Dark urine, light- or clay-colored stools Ascites (see Fig. 9-8) Edema and oliguria Neurologic symptoms (hepatic encephalopathy) Confusion, forgetfulness Muscle tremors Asterixis (Liver flap) Slurred speech Impaired handwriting Skin and nail bed changes Skin pallor (often linked with cirrhosis or carcinoma) Jaundice (skin and sclerae changes) Spider angiomas Palmar erythema (liver palms) Nail beds of Terry; leukonychia; digital clubbing; koilonychia Bleeding disorders Purpura Ecchymosis Diaphoresis (liver abscess) Overall muscular weakness (cirrhosis, liver carcinoma) Peripheral neuropathy (chronic liver disease) Any liver disease Hepatitis Cirrhosis Metastatic tumors Pancreatic carcinoma Liver abscess Medications: Use of hepatotoxic drugs
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S E C T I O N II
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
GALLBLADDER PAIN (see Fig. 9-10) Location: Referral:
Description:
Intensity: Duration: Aggravating factors:
Associated signs and symptoms:
Possible etiology:
Pain in the midepigastrium (may be perceived as heartburn) RUQ of abdomen RUQ pain may be associated with right shoulder pain Both may be associated with back pain between the scapulae; back pain can occur alone as the primary symptom Pain may be referred to the right side of the midline in the interscapular or subscapular area Anterior rib pain (soreness or tender) at the tip of the 10th rib (less often, can also affect ribs 11 and 12) Dull aching Deep visceral pain (gallbladder suddenly distends) Biliary carcinoma is more persistent and boring Mild at first, then increases steadily to become severe 2 to 3 hours Respiratory inspiration Eating Upper body movement Lying down Dark urine, light stools Jaundice Skin: Green hue (prolonged biliary obstruction) Persistent pruritus (cholestatic jaundice) Pain and nausea occur 1 to 3 hours after eating (gallstones) Pain immediately after eating (gallbladder inflammation) Intolerance of fatty foods or heavy meals Indigestion, nausea Excessive belching Flatulence (excessive intestinal gas) Anorexia Weight loss (gallbladder cancer) Bleeding from skin and mucous membranes (late sign of gallbladder cancer) Vomiting Feeling of fullness Low-grade fever, chills Gallstones (cholelithiasis) Gallbladder inflammation (cholecystitis) Neoplasm Medications: Use of hepatotoxic drugs
COMMON BILE DUCT PAIN (see Fig 9-10) Location: Referral:
Pain in midepigastrium or RUQ of abdomen Epigastrium: Heartburn (choledocholithiasis) RUQ pain may be associated with right shoulder pain Both may be associated with back pain between the scapulae Pain may be referred to the right side of the midline in the interscapular or subscapular area
CHAPTER 9
Description:
Intensity: Duration: Associated signs and symptoms:
Possible etiology:
SCREENING FOR HEPATIC A N D BILIARY DISEASE
431
Dull aching Vague discomfort (pressure within common bile duct increasing) Severe, steady pain in RUQ (choledocholithiasis) Biliary carcinoma is more persistent and boring Mild at first, increases steadily Constant 3 to 4 hours (choledocholithiasis) Dark urine, light stools Jaundice Nausea after eating Intolerance of fatty foods or heavy meals Feeling of abdominal fullness Skin: Green hue (prolonged biliary obstruction); pruritus (skin itching) Low-grade fever, chills Excessive belching (choledocholithiasis) Constipation and diarrhea (choledocholithiasis) Sensory neuropathy (primary biliary cirrhosis) Osteomalacia (primary biliary cirrhosis) Osteoporosis (primary biliary cirrhosis) Common duct stones Common duct stricture (previous gallbladder surgery) Pancreatic carcinoma (blocking the bile duct) Medications: Use of hepatotoxic drugs Neoplasm Primary biliary cirrhosis Choledocholithiasis (obstruction of common duct)
KEY POINTS TO REMEMBER / Primary signs and symptoms of liver diseases vary and can include GI symptoms, edema/ascites, dark urine, light-colored or clay-colored feces, and right upper abdominal pain. / Neurologic symptoms, such as confusion, muscle tremors, and asterixis may occur. / Skin changes associated with the hepatic system include pruritus, jaundice, pallor, orange or green skin, bruising, spider angiomas, and palmar erythema. / Active, intense exercise should be avoided when the liver is compromised (jaundice or other active disease). / Antiinflammatory and minor analgesic agents can cause drug-induced hepatitis. Nonviral hepatitis may occur postoperatively.
/ When liver dysfunction results in increased serum ammonia and urea levels, peripheral nerve function is impaired. Flapping tremors (asterixis) and numbness/tingling (misinterpreted as carpal/tarsal tunnel syndrome) can occur. / Musculoskeletal locations of pain associated with the hepatic and biliary systems include thoracic spine between scapulae, right shoulder, right upper trapezius, right interscapular, or right subscapular areas. / Referred shoulder pain may be the only presenting symptom of hepatic or biliary disease. / Gallbladder impairment can present as a rib dysfunction with tenderness anteriorly over the tip of the 1 Oth rib (occasionally ribs 11 and 12 are also involved)
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S E C T I O N II
SUBJECTIVE
VISCEROGENIC CAUSES OF PAIN A N D DYSFUNCTION
EXAMINATION
Special Q u e s t i o n s t o A s k Past Medical H i s t o r y • Have you ever had an ulcer, gallbladder disease, your spleen removed, or hepatitis/jaundice? • If yes to hepatitis or jaundice: When was this diagnosed? How did you get this? • Has anyone in your family ever been diagnosed with Wilson's disease (excessive copper retention) or hemochromatosis (excessive iron absorption)? (Hereditary) • Do you work in a clinical laboratory, operating room, or with dialysis clients? (Hepatitis) • Have you been out of the United States in the last 6 to 12 months? (parasitic infection, country where hepatitis is endemic) • Have you worked in any setting that might be high risk for disease transmission such as a day care, correctional setting, or institutional setting? (Hepatitis) • Have you had any recent contact with hepatitis or with a jaundiced person? • Have you eaten any raw shellfish recently? (Viral hepatitis) • Have you had any recent blood or plasma transfusion, blood tests, acupuncture, ear or body piercing, tattoos (including removal), or dental work done? (Viral hepatitis) • Have you had a recent ACL reconstruction with an allograft? (Hepatitis) • Have you had any kind of injury or trauma to your abdomen? (Possible liver damage) For women: Are you currently using oral contraceptives? (Hepatitis, adenoma) For the therapist: • When asking about drug history, keep in mind that oral contraceptives may cause cholestasis (suppression of bile flow) or liver tumors. Some common over-the-counter drugs (e.g., acetaminophen) and some antibiotics, antitubercular drugs, anticonvulsants, cytotoxic drugs for cancer, antipsychotics, and antidepressants may have hepatotoxic effects. Ask about the use of cholesterol-lowering statins.
• Use questions from Chapter 2 to determine possible consumption of alcohol as a hepatotoxin. Associated Signs and Symptoms • Have you noticed a recent tendency to bruise or bleed easily? (Liver disease) • Have you noticed any change in the color of your stools or urine? (Dark urine, the color of cola and light- or clay-colored stools associated with jaundice) • Has your weight fluctuated 10 or 15 pounds or more recently without a change in diet? (Cancer, cirrhosis, ascites, but also congestive heart failure) • If no, have you noticed your clothes fitting tighter around the waist from abdominal swelling or bloating? (Ascites) • Do you have a feeling of fullness after only one or two bites of food? (Early satiety: stomach and duodenum, cystic tumors, or gallbladder) • Does your stomach feel swollen or bloated after eating? (Abdominal fullness) • Do you have any abdominal pain? (Abdominal pain may be visceral from an internal organ [dull, general, poorly localized], parietal from inflammation of overlying peritoneum [sharp, precisely localized, aggravated by movement], or referred from a disorder in another site.) • How does eating affect your pain? (When eating aggravates symptoms: gastric ulcer, gallbladder inflammation) • Are there any particular foods you have noticed that aggravate your symptoms? • If yes, which ones? (Gallbladder: intolerance to fatty foods) • Have you noticed any unusual aversion to odors, food, alcohol, or (for people who smoke) smoking? (Jaundice) • For clients with only shoulder or back pain: Have you noticed any association between when you eat and when your symptoms increase or decrease?
CHAPTER 9
CASE
STUDY
SCREENING FOR HEPATIC AND BILIARY DISEASE
433
HEPATITIS
REFERRAL
A 29-year-old male law student has come to you (self-referral) with headaches that developed after a motor vehicle accident 12 weeks ago. He was evaluated and treated in the emergency department of the local hospital and is not under the care of a primary care physician. The headaches occur two to three times each week, starting at the base of the occiput and progressing up the back of his head to localize in the forehead bilaterally. The client has a sedentary lifestyle with no regular exercise, and he describes his stress level as being 6 on a scale from 0 to 10. The Family/Personal History form (see Fig. 2-2) indicates that he was diagnosed with hepatitis at the time of the accident. PHYSICAL THERAPY INTERVIEW
What follow-up questions will you ask this client related to the hepatitis? • I see from your History form that you have hepatitis. • What type of hepatitis do you have? Give the client a chance to respond, but you may need to prompt with "type A," "type B," or "types C or D." Remember that hepatitis A is communicable before the appearance of any observable clinical symptoms. If he has been diagnosed, he is probably past this stage. • Do you know how you initially came in contact with hepatitis? (Depending on the answer to the previous question, you may not need to ask this question). Considerations requiring further questioning may include • Illicit or recreational drug use • Inadequate hygiene and poor handwashing in close quarters with travel companion • Ingestion of contaminated food, water, milk, or seafood • Recent blood transfusion or contact with blood/blood products • For type B: Modes of sexual transmission Remember the three stages when trying to determine whether this person may still be contagious. Hepatitis B can persist in body fluids indefinitely, requiring necessary precautions by you. Hepatitis caused by medications or toxins is non-infectious hepatitis and is not communicable.
Transmissible hepatitis requires handwashing and hygiene precautions, including avoidance of any body fluids on your part through the use of protective gloves. This is especially true when treating a person with diabetes requiring fingerstick blood testing, when performing needle electromyograms, or providing open wound care, especially with debridement. MEDICAL TREATMENT
• Did you receive any medical treatment? (immune globulin) Immune serum globulin (ISG) is considered most effective in producing passive immunity for 3 to 4 months when administered as soon as possible after exposure to the hepatitis virus, but within 2 weeks after the onset of jaundice. Persons who have been treated with ISG may not develop jaundice, but those who have not received the gamma globulin usually develop jaundice. • Are you currently receiving follow-up care for your hepatitis through a local physician? This information will assist you in determining the appropriate medical source for further information if you need it and, in a case like this, assist you in choosing further follow up questions that may help you determine whether this person requires additional medical follow up. Keep in mind that headaches can be persistent symptoms of hepatitis A. If the client is receiving no further medical follow up (especially if no serum globulin was administered initially), consider these follow up questions: ASSOCIATED SYMPTOMS
• What symptoms did you have with hepatitis? • Do you have any of those symptoms now? • Are you experiencing any unusual fatigue or muscle or joint aches and pains? • Have you noticed any unusual aversion to foods, alcohol, or cigarettes/smoke that you did not have before? • Have you had any problems with diarrhea, vomiting, or nausea? • Have you noticed any change in the color of your stools or urine? (1 to 4 days before the icteric stage, the urine darkens and the stool lightens) • Have you noticed any unusual skin rash developing recently? • When did you notice the headaches developing?
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PRACTICE QUESTIONS 1. Referred pain patterns associated with hepatic and biliary pathologic conditions produce musculoskeletal symptoms in the a. Left shoulder b. Right shoulder c. Mid-back or upper back, scapular, and right shoulder areas d. Thorax, scapulae, right or left shoulder 2. What is the mechanism for referred right shoulder pain from hepatic or biliary disease? 3. Why does someone with liver dysfunction develop numbness and tingling that is sometimes labeled carpal tunnel syndrome? 4. When a client with bilateral carpal tunnel syndrome is being evaluated, how do you screen for the possibility of a pathologic condition of the liver? 5. What is the first most common sign associated with liver disease? 6. You are treating a 53-year-old woman who has had an extensive medical history that includes bilateral kidney disease with kidney removal on one side and transplantation on the other. The client is 10 years post-transplant and has now developed multiple problems as a result of the long-term use of immunosuppressants (cyclosporine to prevent organ rejection) and corticosteroids (prednisone). For example, she is extremely osteoporotic and has been diagnosed with cytomegalovirus and corticosteroidinduced myopathy. The client has fallen and broken her vertebra, ankle, and wrist on separate occasions. You are seeing her at home to implement a strengthening program and to instruct her in a falling prevention program, including home modifications. You notice the sclerae of her eyes are yellow-tinged. How do you tactfully ask her about this? 7. Clients with significant elevations in serum bilirubin levels caused by biliary obstruction will have which of the following associated signs?
REFERENCES 1. Key L, Bell NH: Osteomalacia and disorders of vitamin D metabolism. In Stein JH, editor: Internal medicine, ed 5, St Louis, 1998, Mosby. 2. Lenfant C: ACC/AHA/NHLBI Clinical advisory on the use and safety of statins, Cardiology Review 20(4Suppl):9-ll, 2003.
a. Dark urine, clay-colored stools, jaundice b. Yellow-tinged sclera c. Decreased serum ammonia levels d. a and b only 8. Preventing falls and trauma to soft tissues would be of utmost importance in the client with liver failure. Which of the following laboratory parameters would give you the most information about potential tissue injury? a. Decrease in serum albumin levels b. Elevated liver enzyme levels c. Prolonged coagulation times d. Elevated serum bilirubin levels 9. Decreased level of consciousness, impaired function of peripheral nerves, and asterixis (flapping tremor) would probably indicate an increase in the level of a. AST (aspartate aminotransferase) b. Alkaline phosphatase c. Serum bilirubin d. Serum ammonia 1 0 . An inpatient who has had a total hip replacement with a significant history of alcohol use/abuse has a positive test for asterixis. This may signify a. Renal failure b. Hepatic encephalopathy c. Diabetes d. Gallstones obstructing the common bile duct 1 1 . A decrease in serum albumin is common with a pathologic condition of the liver because albumin is produced in the liver. The reduction in serum albumin results in some easily identifiable signs. Which of the following signs might alert the therapist to the condition of decreased albumin? a. Increased blood pressure b. Peripheral edema and ascites c. Decreased level of consciousness d. Exertional dyspnea
3. Newman CB, Palmer G, Silbershatz H, et al: Safety of atorvastatin derived from analysis of 44 completed trials in 9,416 patients, Am J Cardiol 92(6):670-676, 2003. 4. Based on author's personal experience and communication with therapists in clinical practice across the country, 2004. 5. Ballantyne CM, Corsini A, Davidson MH, et al: Risk for myopathy with statin therapy in high-risk patients, Arch Intern Med 163(5):553-564, 2003.
CHAPTER 9
SCREENING FOR HEPATIC AND BILIARY DISEASE
6. Parnes A: Asterixis, Trinity Student Medical Journal 1:58, 2000. Available at: http://www.tcd.ie/tsmj. 7. Blumberg D, Low CM: Prevention of hepatitis A in a global community, www.medscape.com/vicuprogram 12004. 8. Grande P, Cronquist A: Public health dispatch, multistate outbreak of hepatitis A among young adult concert attendees, United States, 2003, MMWR CDC 52(35), 844-845, 2003. (www.cdc.gov/mmwr/preview/mmwr/ html I mm5235a5. htm) 9. Weinbaum C, Lyerla C: Prevention and control of infections with hepatitis viruses in correctional settings, www.cdc. gov/mmwr/preview/mmwr/html/rr5201al.htm; 1-33, Jan 24, 2003. 10. Parini S: Hepatitis C, Nursing2003 33(4):57, 2003. 11. Spencer KY, Chang MD: Anterior cruciate ligament reconstruction: allograft vs. autograft, J of Arthroscopic and Related Surgery 19(5):453, 2003. 12. Perry J, Jagger J: Statistically your risk of HCV infection has dropped, Nursing2003 33(6):82, 2003. 13. Friedman L: Liver, biliary tract and pancreas, diseases of the liver. In Tierney L, McPhee S, Papadakis M, editors: Current medical diagnosis and treatment, ed 43, New York, 2004, Lange; pp 629. 14. Lovy MR, Wener MH: Rheumatic disease: when is hepatitis C the culprit? J Musculoskel Med 13(4):27-35, 1996. 15. Rull M, Zonay L, Schumacher HR: Hepatitis C and rheumatic diseases, J Musculoskel Med 15(ll):38-44, 1998.
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16. Foster GR: Past, present, and future hepatitis C treatments, Semin Liver Disease Suppl 2:97-104, 2004. 17. Pearlman BL: Hepatitis C treatment update, Am J Med 117(5):344-352, 2004. 18. Pullen L: Hep-Hazard, Hemaware 9(2):54-56, 2004. 19. Liver function: two new threats, The John Hopkins Medical Letter, Health After 50 15(3):2-7, 2003. www.hopkinsafter50. com. 20. Salt WB: Nonalcoholic fatty liver disease (NAFLD): a comprehensive review, J Insur Med 36(1):27-41, 2004. 21. Younossi ZM, McCullough AJ, Ong JP, et al: Obesity and non-alcoholic fatty liver disease in chronic hepatitis C, J Clin Gastroenterol 38(8):705-709, 2004. 22. Kimbel DL: Hip pain in a 50-year-old woman with RA, Journal of Musculoskeletal Medicine 16(ll):651-652, 1999. 23. Neonatal jaundice, unwelcome return for kernicterus. Nursing2003 33(11):35, 2003., www.aap.org. 24. Bisceglie A: Medscape gastroenterology conference coverage: hepatocellular carcinoma and cholangiocarcinoma, 12-8-2001. www.medscape.com/Medscape/CNO/2007AASCD? pal-AASLD.html, 12-8-2001. 25. Rex L: Evaluation and treatment of somatovisceral dysfunction of the gastrointestinal system, Edmonds, Washington, 2004, URSA Foundation. 26. Lazcano-Ponce EC, Miquel JF: Epidemiology and molecular pathology of gallbladder cancer. CA Cancer J Clin 51(6):349, 2001.
Screening for Urogenital Disease
A
40-year-old athletic man comes to your clinic for an evaluation of back pain that he attributes to a very hard fall on his back while he was alpine skiing 3 days ago. His chief complaint is a dull, aching costovertebral pain on the left side, which is unrelieved by a change in position or by treatment with ice, heat, or aspirin. He stated that "even the skin on my back hurts." He has no previous history of any medical problems. After further questioning, the client reveals that inspiratory movements do not aggravate the pain, and he has not noticed any change in color, odor, or volume of urine output. However, percussion of the costovertebral angle (see Fig. 4-51) results in the reproduction of the symptoms. This type of symptom complex may suggest renal involvement even without obvious changes in urine. Whether secondary to trauma or of insidious onset, a client's complaints of flank pain, low back pain, or pelvic pain may be of renal or urologic origin and should be screened carefully through the subjective and objective examinations. Medical referral may be necessary. SIGNS AND SYMPTOMS OF RENAL AND UROLOGICAL DISORDERS
This chapter is intended to guide the physical therapist in understanding the origins and relationships of renal, ureteral, bladder, and urethral symptoms. The urinary tract, consisting of kidneys, ureters, bladder, and urethra (Fig. 10-1), is an integral component of human functioning that disposes of the body's toxic waste products and unnecessary fluid and expertly regulates extremely complicated metabolic processes. The ureters, bladder, and urethra function primarily as transport vehicles for urine formed in the kidneys. The lower urinary tract is the last area through which urine is passed in its final form for excretion. Formation and excretion of urine is the primary function of the renal nephron (the functional unit of the kidney) (Fig. 10-2). Through this process the kidney is able to maintain a homeostatic environment in the body. Besides the excretory function of the kidney, which includes the removal of wastes and excessive fluid, the kidney plays an integral role in the balance of various essential body functions, including the following: • Acid base balance • Electrolyte balance • Control of blood pressure with renin • Formation of red blood cells (RBCs) • Activation of vitamin D and calcium balance The failure of the kidney to perform any of these functions results in severe alteration and disruption in homeostasis and signs and symptoms resulting from these dysfunctions (Box 10-1). 1
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S C R E E N I N G FOR UROGENITAL DISEASE
BOX 10-1
437
S i g n s and Symptoms of Genitourinary Disease
Constitutional Symptoms Hilum Renal pelvis
Kidney Ureter
Bladder Symphysis pubis Urethra Fig. 10-1
•
Rib cage Upper urinary tract
Lower • urinary tract
• Urinary tract structures. The upper urinary tract
Fatigue, malaise
•
Anorexia, weight loss
Musculoskeletal •
Unilateral costovertebral tenderness
•
L o w b a c k , flank, inner thigh, or leg pain
•
Ipsilateral shoulder pain
Urinary Problems •
Dysuria (painful burning or discomfort with urination)
•
is composed of the kidneys and ureters while the lower urinary tract is made up of the bladder and urethra. The upper portion
Fever, chills
•
Nocturia (getting up more than once at night to urinate)
•
Feeling that bladder has not emptied
of each kidney is protected by the rib cage, and the bladder
completely but unable to urinate more;
is partially protected by the symphysis pubis.
straining to start a s t r e a m of urine or to empty bladder completely •
H e m a t u r i a (blood in urine; pink or red-tinged urine)
•
Dribbling at the e n d of urination
•
Frequency (need to urinate or e m p t y bladder more than every 2 hours)
•
Hesitancy (weak or interrupted urine stream)
•
Proteinuria (protein in urine; urine is foamy)
Other •
Skin hypersensitivity (T10-L1)
•
Infertility
Women •
Abnormal vaginal bleeding
•
Painful menstruation (dysmenorrhea)
•
C h a n g e s in m e n s t r u a l pattern
•
Pelvic m a s s e s or lesions
•
Vaginal itching or d i s c h a r g e
•
Pain during intercourse (dyspareunia)
Men Fig. 10-2 • Components of the nephron. The afferent arte-
•
D i f f i c u l t y s t a r t i n g or c o n t i n u i n g a s t r e a m of urine
riole carries blood to the glomerulus for filtration through Bowman's capsule and the renal tubular system. (From Foster
•
Discharge from penis
RL, Hunsberger MM, Anderson JJ: Family-centered nursing
•
Penile lesions
care of children, Philadelphia, 1989, WB Saunders.)
•
T e s t i c u l a r or p e n i s p a i n
•
E n l a r g e m e n t of scrotal contents
•
Swelling or m a s s in groin
•
Sexual dysfunction
THE URINARY TRACT The upper urinary tract consists of the kidneys and ureters. The kidneys are located in the posterior upper abdominal cavity in a space behind the peritoneum (retroperitoneal space) (see Fig. 4-47). Their anatomic position is in front of and on both
sides of the vertebral column at the level of T i l to L3. The right kidney is usually lower than the left. The upper portion of the kidney is in contact with the diaphragm and moves with respiration. The kidneys are protected anteriorly by the rib 2
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VISCEROGENIC CAUSES OF PAIN A N D DYSFUNCTION
cage and abdominal organs (see Fig. 4-46) and posteriorly by the large back muscles and ribs. The lower portions of the kidneys and the ureters extend below the ribs and are separated from the abdominal cavity by the peritoneal membrane. The lower urinary tract consists of the bladder and urethra. From the renal pelvis, urine is moved by peristalsis to the ureters and into the bladder. The bladder, which is a muscular, membranous sac, is located directly behind the symphysis pubis and is used for storage and excretion of urine. The urethra is connected to the bladder and serves as a channel through which urine is passed from the bladder to the outside of the body. Voluntary control of urinary excretion is based on learned inhibition of reflex pathways from the walls of the bladder. Release of urine from the bladder occurs under voluntary control of the urethral sphincter. The male genital or reproductive system is made up of the testes, epididymis, vas deferens, seminal vesicles, prostate gland, and penis (Fig. 10-3).
A.
B.
Fig. 10-3 • A, The prostate is located at the base of the bladder, surrounding a part of the urethra. It is innervated by Tl 1 -LI and S2-S4 and can refer pain to the sacrum, low back, and testes (see Fig. 10-10). As the prostate enlarges, the urethra can become obstructed, interfering with the normal flow of urine. B, The prostate is composed of three zones. The transitional zone surrounds the urethra as it passes through the prostate. This is a common site for benign prostatic hyperplasia (BPH). The central zone is a cone-shaped section that sits behind the transitional zone. The peripheral zone is the largest portion of the gland and borders the other two zones. This is the most common site for cancer development. Most early tumors do not produce any symptoms because the urethra is not in the peripheral zone. It is not until the tumor grows large enough to obstruct the bladder outlet that symptoms develop. Tumors in the transitional zone, which houses the urethra, may cause symptoms sooner than tumors in other zones.
These structures are susceptible to inflammatory disorders, neoplasms, and structural defects. In males the posterior portion of the urethra is surrounded by the prostate gland, a gland approximately 3.5 cm long by 3 cm wide (about the size of two almonds). Located just below the bladder, this gland can cause severe urethral obstruction when enlarged from a growth or inflammation resulting in difficulty starting a flow of urine, continuing a flow of urine, frequency, and/or nocturia. The prostate gland is commonly divided into five lobes and three zones. Prostate carcinoma usually affects the posterior lobe of the gland; the middle and lateral lobes typically are associated with the nonmalignant process called benign prostatic hyperplasia (BPH). RENAL A N D UROLOGICAL PAIN U p p e r U r i n a r y Tract ( R e n a l / U r e t e r a l ) The kidneys and ureters are innervated by both sympathetic and parasympathetic fibers. The kidneys receive sympathetic innervation from the lesser splanchnic nerves through the renal plexus, which is located next to the renal arteries. Renal vasoconstriction and increased renin release are associated with sympathetic stimulation. Parasympathetic innervation is derived from the vagus nerve, and the function of this innervation is not known. Renal sensory innervation is not completely understood, even though the capsule (covering of the kidney) and the lower portions of the collecting system seem to cause pain with stretching (distention) or puncture. Information transmitted by renal and ureteral pain receptors is relayed by sympathetic nerves that enter the spinal cord at T10 to LI (see Fig. 3-3). Because visceral and cutaneous sensory fibers enter the spinal cord in close proximity and actually converge on some of the same neurons, when visceral pain fibers are stimulated, concurrent stimulation of cutaneous fibers also occurs. The visceral pain is then felt as though it is skin pain (hyperesthesia), similar to the condition of the alpine skier who stated that "even the skin on my back hurts." Renal and ureteral pain can be felt throughout the T10 to LI dermatomes. Renal pain (see Fig. 10-7) is typically felt in the posterior subcostal and costovertebral regions. To assess the kidney, the test for costovertebral angle tenderness can be included in the objective examination (see Fig. 4-51). Ureteral pain is felt in the groin and genital area (see Fig. 10-8). With either renal pain or ureteral
CHAPTER 10
pain, radiation forward around the flank into the lower abdominal quadrant and abdominal muscle spasm with rebound tenderness can occur on the same side as the source of pain. The pain can also be generalized throughout the abdomen. Nausea, vomiting, and impaired intestinal motility (progressing to intestinal paralysis) can occur with severe, acute pain. Nerve fibers from the renal plexus are also in direct communication with the spermatic plexus, and because of this close relationship, testicular pain may also accompany renal pain. Neither renal nor urethral pain is altered by a change in body position. The typical renal pain sensation is aching and dull in nature but can occasionally be a severe, boring type of pain. The constant dull and aching pain usually accompanies distention or stretching of the renal capsule, pelvis, or collecting system. This stretching can result from intrarenal fluid accumulation, such as inflammatory edema, inflamed or bleeding cysts, and bleeding or neoplastic growths. Whenever the renal capsule is punctured, a dull pain can also be felt by the client. Ischemia of renal tissue caused by blockage of blood flow to the kidneys results in a constant dull or a constant sharp pain. Ureteral obstruction (e.g., from a urinary calculus or "stone" consisting of mineral salts) results in distention of the ureter and causes spasm that produces intermittent or constant severe colicky pain until the stone is passed. Pain of this origin usually starts in the CVA and radiates to the ipsilateral lower abdomen, upper thigh, testis, or labium (see Fig. 10-8). Movement of a stone down a ureter can cause renal colic, an excruciating pain that radiates to the region just described and usually increases in intensity in waves of colic or spasm. Chronic ureteral pain and renal pain tend to be vague, poorly localized, and easily confused with many other problems of abdominal or pelvic origin. There are also areas of referred pain related to renal or ureteral lesions. For example, if the diaphragm becomes irritated because of pressure from a renal lesion, shoulder pain may be felt (see Figs. 3-4 and 3-5). If a lesion of the ureter occurs outside the ureter, pain may occur on movement of the adjacent iliopsoas muscle (see Fig. 8-3). Abdominal rebound tenderness results when the adjacent peritoneum becomes inflamed. Active trigger points along the upper rim of the pubis and the lateral half of the inguinal ligament may lie in the lower internal oblique muscle and possibly in the lower rectus abdominis. These trigger points can cause increased irritation and spasm of the
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SCREENING FOR UROGENITAL DISEASE
detrusor and urinary sphincter muscles, producing urinary frequency, retention of urine, and groin pain. 3
Pseudorenal Pain Pseudorenal pain may occur secondary to radiculitis or irritation of the costal nerves caused by mechanical derangements of the costovertebral or costotransverse joints. Disorders of this sort are common in the cervical and thoracic areas, but the most common sites are T10 and T12. Irritation of these nerves causes costovertebral pain that can radiate into the ipsilateral lower abdominal quadrant. The onset is usually acute with some type of traumatic history, such as lifting a heavy object, sustaining a blow to the costovertebral area, or falling from a height onto the buttocks. The pain is affected by body position, and although the client may be awakened at night when assuming a certain position (e.g., sidelying on the affected side), the pain is usually absent on awakening and increases gradually during the day. It is also aggravated by prolonged periods of sitting, especially when driving on rough roads in the car. It may be relieved by changing to another position (Table 10-1). Radiculitis may mimic ureteral colic or renal pain, but true renal pain is seldom affected by movements of the spine. Exerting pressure over the costovertebral angle (CVA) with the thumb may elicit local tenderness of the involved peripheral nerve at its point of emergence, whereas gentle percussion over the angle may be necessary 4
TABLE 10-1
Assessment for Pseudorenal Pain
History
T r a u m a (fall, assault, blow, lifting) H i s t o r y of straining, lifting, accident or other m e c h a n i c a l injury to thoracic spine
Pain Pattern
•
B a c k and/or flank pain occur at the s a m e level as the k i d n e y
•
Affected by c h a n g e in position •
Lying on the i n v o l v e d side increases pain
•
P r o l o n g e d sitting increases pain
•
S y m p t o m s are r e p r o d u c e d with m o v e m e n t s o f the spine
•
Costovertebral angle t e n d e r n e s s present on palpation
A s s o c i a t e d Signs and S y m p t o m s
None M u r p h y ' s percussion test is n e g a t i v e R e p o r t of b o w e l and b l a d d e r c h a n g e s unlikely
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S E C T I O N II
VISCEROGENIC CAUSES OF PAIN A N D D Y S F U N C T I O N
to elicit renal pain, indicating a deeper, more visceral sensation. Fig. 4-51 illustrates percussion over the CVA (Murphy's percussion). L o w e r U r i n a r y Tract ( B l a d d e r / U r e t h r a ) Bladder innervation occurs through sympathetic, parasympathetic, and sensory nerve pathways. Sympathetic bladder innervation assists in the closure of the bladder neck during seminal emission. Afferent sympathetic fibers also assist in providing awareness of bladder distention, pain, and abdominal distention caused by bladder distention. This input reaches the cord at T9 or higher. Parasympathetic bladder innervation is at S2, S3, and S4 and provides motor coordination for the act of voiding. Afferent parasympathetic fibers assist in sensation of the desire to void, proprioception (position sensation), and perception of pain. Sensory receptors are present in the mucosa of the bladder and in the muscular bladder walls. These fibers are more plentiful near the bladder neck and the junctional area between the ureters and bladder. Urethral innervation, also at the S2, S3, and S4 level, occurs through the pudendal nerve. This is a mixed innervation of both sensory and motor nerve fibers. This innervation controls the opening of the external urethral sphincter (motor) and an awareness of the imminence of voiding and heat (thermal) sensation in the urethra. Bladder or urethral pain is felt above the pubis (suprapubic) or low in the abdomen (see Fig. 10-9). The sensation is usually characterized as one of urinary urgency, a sensation to void, and dysuria (painful urination). Irritation of the neck of the bladder or of the urethra can result in a burning sensation localized to these areas, probably caused by the urethral thermal receptors. See Box 10-2 for
BOX 10-2
Extraurologic Conditions Causing U r i n a r y Tract Symptoms
A c u t e or chronic conditions affecting other viscera outside the urologic system can refer pain and symptoms to the upper or lower urinary tract. T h e s e can include •
Perforated viscus (any large internal organ)
•
Intestinal obstruction
•
Cholecystitis (inflammation of the gallbladder)
•
Pelvic inflammatory disease
•
Tubo-ovarian abscess
•
Ruptured ectopic pregnancy
•
Twisted ovarian cyst
•
T u m o r (benign or m a l i g n a n t )
causes of pain outside the urogenital system that present like upper or lower urinary tract pain of either an acute or chronic nature. RENAL AND URINARY TRACT PROBLEMS Pathologic conditions of the upper and lower urinary tracts can be categorized according to primary causative factors. Inflammatory/infectious and obstructive disorders are presented in this section along with renal failure and cancers of the urinary tract. When screening for any conditions affecting the kidney and urinary tract system, keep in mind factors that put people at increased risk for these problems (Case Example 10-1). Early screening and detection is recommended based on the presence of these risk factors. • Age over 60 • Personal or family history of diabetes or hypertension • Personal or family history of kidney disease, heart attack, or stroke • Personal history of kidney stones, urinary tract infections, lower urinary tract obstruction, or autoimmune disease • African, Hispanic, Pacific Island, or Native American descent • Exposure to chemicals (e.g., paint, glue, degreasing solvents, cleaning solvents), drugs, or environmental conditions • Low birth weight 5
Inflammatory/Infectious Disorders Inflammatory disorders of the kidney and urinary tract can be caused by bacterial infection, by changes in immune response, and by toxic agents such as drugs and radiation. Common infections of the urinary tract develop in either the upper or lower urinary tract (Table 10-2). Upper urinary tract infections include kidney or ureteral infections. Lower urinary tract infections include cystitis (bladder infection) or urethritis (urethral infection). Symptoms of urinary tract infection (UTI) depend on the location of the infection in either the upper or lower urinary tract (although, rarely, infection could occur in both simultaneously). Inflammatory/Infectious Disorders of the Upper Urinary Tract Inflammations or infections of the upper urinary tract (kidney and ureters) are considered to be
CHAPTER 10
CASE EXAMPLE 1 0 - 1
Disease
A 66-year-old African American woman with a personal history of systemic lupus erythematosus (SLE) lost her balance and fell off the deck at her home. She sustained vertebral and rib fractures at T10 and T i l . She is a retired paint factory worker. She reported daily exposure to paint and paint solvents during her 15 years of employment. She was seen as a walk-in at the local medical clinic where she is a regular patient. She did not see the rheumatologist who was managing her SLE. The attending physician told her the injuries were "probably from the long-term use of prednisone for her lupus." She was referred to physical therapy by the attending physician for postural exercises. During the interview, when asked, "Are you having any symptoms of any kind anywhere else in your body?" the client admitted to a pink color to her urine and some burning on urination. These symptoms have been present since the day after the fall 3 weeks ago. There were no other signs or symptoms reported. Blood pressure measured 175/95 on three separate occasions. The client reported her blood pressure was elevated at the time of her visit to the doctor, but she thought it was caused by the stress of the fall. Question: As you step back and conduct a Review of Systems, what are the red flags to suggest medical referral is needed? To whom do you refer this client?
TABLE 10-2 T Urinary Tract Infections
Renal infections, such as pyelonephritis (renal p a r e n c h y m a , i.e., kidney tissue) Acute or chronic glomerulonephritis (glomeruli) Renal papillary necrosis Renal tuberculosis
441
S c r e e n i n g in t h e P r e s e n c e o f R i s k F a c t o r s f o r Kidney
Upper urinary tract infection
SCREENING FOR UROGENITAL DISEASE
Lower urinary tract infection Cystitis (bladder infection) Urethritis (urethra infection)
Red flags: • Age over 40 (age over 60 is a risk factor for kidney disease) • African American descent (at risk for diabetes, kidney disease) • Long-term use of NSAIDs (synergistic nephrotoxin in combination with certain chemicals such as paint and paint solvents) • Elevated blood pressure • Change in color and pattern of urination The therapist may not recognize specific factors present that put the client at increased risk for kidney disease, but the obvious changes in urine color and pattern along with changes in blood pressure require medical referral. Without the medical records, it is impossible to know what (if any) testing was done related to kidney function (e.g., urinalysis, blood test) at the time of the initial injury. A phone call to the referring physician is probably the best place to start. Documentation of the recent events and current red flag symptoms should be sent to the referring physician, the primary care physician, and the rheumatologist (if different from the primary care doctor). Physical therapy intervention is still appropriate given her musculoskeletal injuries. Further medical assessment is warranted based on the development of symptoms unknown to the referring physician.
more serious because these lesions can be a direct threat to renal tissue itself. The more common conditions include pyelonephritis (inflammation of the renal parenchyma) and acute and chronic glomerulonephritis (inflammation of the glomeruli of both kidneys). Less common conditions include renal papillary necrosis and renal tuberculosis. Symptoms of upper urinary tract inflammations and infections are shown in Table 10-3. If the diaphragm is irritated, ipsilateral shoulder pain may occur. Signs and symptoms of renal impairment are also shown in Table 10-4 and, if present,
442
TABLE 10-3
S E C T I O N II
VISCEROGENIC C A U S E S OF PAIN A N D D Y S F U N C T I O N
Clinical Symptoms of Infectious/Inflammatory U r i n a r y Tract Problems
Upper urinary tract (kidney or ureteral infection)
Lower urinary tract (cystitis or urethritis)
Unilateral costovertebral t e n d e r n e s s
U r i n a r y frequency
F l a n k pain
Urinary urgency
Ipsilateral shoulder pain
L o w b a c k pain
F e v e r and chills
Pelvic/lower a b d o m i n a l pain
Skin hypersensitivity (hyperesthesia of d e r m a t o m e s )
D y s u r i a (discomfort, such as pain or b u r n i n g during urination)
H e m a t u r i a (blood [ R B C s ] in u r i n e )
Hematuria
P y u r i a (pus or w h i t e b l o o d cells in u r i n e )
Pyuria
Bacteriuria (bacteria in u r i n e )
Bacteriuria
N o c t u r i a ( u n u s u a l or increased n i g h t t i m e need to urinate)
D y s p a r e u n i a (painful intercourse)
are significant symptoms of impending kidney failure. Inflammatory/Infectious Disorders of the Lower Urinary Tract Both the bladder and urine have a number of defenses against bacterial invasion. These defenses are mechanisms such as voiding, urine acidity, osmolality, and the bladder mucosa itself, which is thought to have antibacterial properties. Urine in the bladder and kidney is normally sterile, but urine itself is a good medium for bacterial growth. Interferences in the defense mechanisms of the bladder, such as the presence of residual or stagnant urine, changes in urinary pH or concentration, or obstruction of urinary excretion can promote bacterial growth. Routes of entry of bacteria into the urinary tract can be ascending (most commonly up the urethra into the bladder and then into the ureters and kidney), blood borne (bacterial invasion through the bloodstream), or lymphatic (bacterial invasion through the lymph system, the least common route). A lower UTI occurs most commonly in women because of the short female urethra and the proximity of the urethra to the vagina and rectum. The rate of occurrence increases with age and sexual activity since intercourse can spread bacteria from the genital area to the urethra. Chronic health problems, such as diabetes mellitus, gout, hypertension, obstructive urinary tract problems, and medical procedures requiring urinary catheterization, are also predisposing risk factors for the development of these infections. Individuals with diabetes are prone to complications associated with urinary tract infections. Staphylococcus infection of the urinary tract may be a source of osteomyelitis, an infection of a vertebral body resulting from hematogenous spread or 6
local spread from an abscess into the vertebra. The infected vertebral body may gradually undergo degeneration and destruction, with collapse and formation of a segmental scoliosis. This condition is suspected from the onset of nonspecific low back pain, unrelated to any specific motion. Local tenderness can be elicited, but the initial x-ray finding is negative. Usually, a lowgrade fever is present but undetected, or it develops as the infection progresses. This is why anyone with low back pain of unknown origin should have his or her temperature taken, even in a physical therapy setting. Cystitis (inflammation with infection of the bladder), interstitial cystitis (inflammation without infection), and urethritis (inflammation and infection of the urethra) appear with a similar symptom progression (Case Example 10-2). Interstitial cystitis (IC), chronic inflammation of the bladder, affects more than 700,000 individuals each year in the United States. As many as 90% of those affected are women. Several other disorders are associated with IC including allergies, inflammatory bowel syndrome, fibromyalgia, and vulvitis. Bladder pain associated with IC can vary from woman to woman and even within the same individual and may be dull, achy, or acute and stabbing. Discomfort while urinating also varies from mild stinging to intense burning. Sexual intercourse may ignite pain that lasts for days. Clients with any of the symptoms listed for the lower urinary tract in Table 10-3 at presentation should be referred promptly to a physician for further diagnostic work-up and possible treatment. Infections of the lower urinary tract are potentially very dangerous because of the possibility of upward spread and resultant damage to renal tissue. Some individuals, however, are asymptomatic, and routine urine culture and microscopic 7
8
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CHAPTER 10
CASE EXAMPLE 1 0 - 2
SCREENING FOR UROGENITAL DISEASE
443
Bladder Infection
A 55-year-old woman came to the clinic with back pain associated with paraspinal muscle spasms. Pain was of unknown cause (insidious onset), and the client reported that she was "just getting out of bed" when the pain started. The pain was described as a dull aching that was aggravated by movement and relieved by rest (musculoskeletal pattern). No numbness, tingling, or saddle anesthesia was reported, and the neurologic screening examination was negative. Sacroiliac (SI) testing was negative. Spinal movements were slow and guarded, with muscle spasms noted throughout movement and at rest. Because of her age and the insidious onset of symptoms, further questions were initiated to screen for medical disease. This client was midmenopausal and was not taking any hormone replacement therapy (HRT). She had a bladder infection a month ago that was treated with antibiotics; tests for this were negative when she was evaluated and referred by her physician for back pain. Two weeks ago she had an upper respiratory infec-
examination are the most reliable methods of detection and diagnosis. Older adults (both men and women) are at increased risk for UTI. They may present with nonspecific symptoms, such as loss of appetite, nausea and vomiting abdominal pain, or change in mental status (e.g., onset of confusion, increased confusion). Watch for predisposing conditions that can put the older client at risk for UTI. These may include diabetes mellitus or other chronic diseases, immobility, reduced fluid intake, catheterization, and previous history of UTI or kidney stones. Obstructive Disorders Urinary tract obstruction can occur at any point in the urinary tract and can be the result of primary urinary tract obstructions (obstructions occurring within the urinary tract) or secondary urinary tract obstructions (obstructions resulting from disease processes outside the urinary tract). A primary obstruction might include problems such as acquired or congenital malformations, strictures, renal or ureteral calculi (stones), polycystic kidney disease, or neoplasms of the urinary tract (e.g., bladder, kidney).
tion (a "cold") and had been "coughing a lot." There was no previous history of cancer. Local treatment to reduce paraspinal muscle spasms was initiated, but the client did not respond as expected over the course of five treatment sessions. Because of her recent history of upper respiratory and bladder infections, questions were repeated related to the presence of constitutional symptoms and changes in bladder function/urine color, force of stream, burning on urination, and so on. Occasional "sweats" (present sometimes during the day, sometimes at night) was the only red flag present. The combination of recent infection, failure to respond to treatment, and the presence of sweats suggested referral to the physician for early reevaluation. The client did not return to the clinic for further treatment, and a follow up telephone call indicated that she did indeed have a recurrent bladder infection that was treated successfully with a different antibiotic. Her back pain and muscle spasm were eliminated after only 24 hours of taking this new antibiotic.
Secondary obstructions produce pressure on the urinary tract from outside and might be related to conditions such as prostatic enlargement (benign or malignant); abdominal aortic aneurysm; gynecologic conditions such as pregnancy, pelvic inflammatory disease, and endometriosis; or neoplasms of the pelvic or abdominal structures. Obstruction of any portion of the urinary tract results in a backup or collection of urine behind the obstruction. The result is dilation or stretching of the urinary tract structures that are positioned behind the point of blockage. Muscles near the affected area contract in an attempt to push urine around the obstruction. Pressure accumulates above the point of obstruction and can eventually result in severe dilation of the renal collecting system (hydronephrosis) and renal failure. The greater the intensity and duration of the pressure, the greater is the destruction of renal tissue. Because urine flow is decreased with obstruction, urinary stagnation and infection or stone formation can result. Stones are formed because urine stasis permits clumping or precipitation of organic matter and minerals.
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VISCEROGENIC CAUSES OF PAIN A N D D Y S F U N C T I O N
Lower urinary tract obstruction can also result in constant bladder distention, hypertrophy of bladder muscle fibers, and formation of herniated sacs of bladder mucosa. These herniated sacs result in a large, flaccid bladder that cannot empty completely. In addition, these sacs retain stagnant urine, which causes infection and stone formation. Obstructive Disorders Urinary Tract
of the
Upper
Obstruction of the upper urinary tract may be sudden (acute) or slow in development. Tumors of the kidney or ureters may develop slowly enough that symptoms are totally absent or very mild initially, with eventual progression to pain and signs of impairment. Acute ureteral or renal blockage by a stone (calculus consisting of mineral salts), for example, may result in excruciating, spasmodic, and radiating pain accompanied by severe nausea and vomiting. Calculi form primarily in the kidney. This process is called nephrolithiasis. The stones can remain in the kidney (renal pelvis) or travel down the urinary tract and lodge at any point in the tract. Strictly speaking, the term kidney stone refers to stones that are in the kidney. Once they move into the ureter, they become ureteral stones. Ureteral stones are the ones that cause the most pain. If a stone becomes wedged in the ureter, urine backs up distending the ureter and causing severe pain. If a stone blocks the flow of urine, urine pressure may build up in the ureter and kidney causing the kidney to swell (hydronephrosis). Unrecognized hydronephrosis can sometimes cause permanent kidney damage. The most characteristic symptom of renal or ureteral stones is sudden, sharp, severe pain. If the pain originates deep in the lumbar area and radiates around the side and down toward the testicle in the male and the bladder in the female, it is termed renal colic. Ureteral colic occurs if the stone becomes trapped in the ureter. Ureteral colic is characterized by radiation of painful symptoms toward the genitalia and thighs (see Fig. 10-8). Since the testicles and ovaries form in utero in the location of the kidneys and then migrate at full term following the pathways of the ureters, kidney stones moving down the pathway of the ureters cause pain in the flank. This pain radiates to the scrotum in males and the labia in females. For the same reason ovarian or testicular cancer can refer pain to the back at the level of the kidneys. Renal tumors may also be detected as a flank mass combined with unexplained weight loss, 9
fever, pain, and hematuria. The presence of any amount of blood in the urine always requires referral to a physician for further diagnostic evaluation because this is a primary symptom of urinary tract neoplasm. Clinical Signs and Symptoms of Obstruction of the U p p e r U r i n a r y Tract •
Pain (depends on the rapidity of onset and on the location) • • •
• • • • • • • •
Acute, spasmodic, radiating Mild and dull flank pain Lumbar discomfort with some renal diseases or renal back pain with ureteral obstruction Hyperesthesia of dermatomes (Tl 0 through L I ) Nausea and vomiting Palpable flank mass Hematuria Fever and chills Urge to urinate frequently
Abdominal muscle spasms Renal impairment indicators (see inside front cover: Renal Blood Studies; see also Table
10-4)
Obstructive Disorders Urinary Tract
of the
Lower
Common conditions of (mechanical) obstruction of the lower urinary tract are bladder tumors (bladder cancer is the most common site of urinary tract cancer) and prostatic enlargement, either benign (benign prostatic hyperplasia [BPH]) or malignant (cancer of the prostate). An enlarged prostate gland can occlude the urethra partially or completely. Mechanical problems of the urinary tract result in difficulty emptying urine from the bladder. Improper emptying of the bladder results in urinary retention and impairment of voluntary bladder control (incontinence). Several possible causes of mechanical bladder dysfunction include pelvic floor dysfunction, UTIs, partial urethral obstruction, trauma, and removal of the prostate gland. The nerves that carry pain sensation from the prostate do not localize the source of pain very precisely, and therefore it may be difficult for the man to describe exactly where the pain is coming from. Discomfort can be localized in the suprapubic region, in the penis and testicles, or it can be centered in the perineum or rectum (see Fig. 10-10).
CHAPTER 10
SCREENING FOR UROGENITAL DISEASE
Rectum
Anus
Fig. 10-4 • Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) can have a serious impact on a man's quality of life as a result of voiding problems, chronic pelvic pain and discomfort, and sexual dysfunction with painful ejaculation, cramping or discomfort after ejaculation, and infertility.
445
Bladder
Prostate
Fig. 10-5 • Digital rectal examination performed by a medical doctor or trained health care professional such as a nurse practitioner or physician's assistant puts pressure on the inflamed prostate reproducing painful symptoms associated with prostatitis.
PROSTATITIS
Prostatitis is a relatively common inflammation of the prostate causing prostate enlargement. This condition affects up to 10% of the adult male population accounting for the 2 million or more men who seek treatment annually in the United States. It is often disabling, affecting men at any age, but typically found in men ages 40 to 70 years. Acute bacterial prostatitis occurs most often in men under age 35. The NIH consensus classification of prostatitis includes four categories: • Type I Acute bacterial prostatitis • Type II Chronic bacterial prostatitis • Type III Chronic prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) A. Inflammatory B. Noninflammatory • Type IV Asymptomatic inflammatory prostatitis Chronic (Type III, nonbacterial) prostatitis can be associated with pelvic pain syndrome, a chronic condition characterized primarily by pelvic pain. The symptoms of CP/CPPS appear to occur as a result of interplay between psychologic factors and dysfunction in the immune, neurologic, and endocrine systems. Studies show a major impact on quality of life, urinary function, and sexual function along with chronic pain and discomfort (Fig. 10-4). The pain of prostatitis can be exacerbated by sexual activity, and some men describe pain upon ejaculation. A digital rectal examination by the physician will reproduce painful symptoms 10,11
12
1314
when the prostate is inflamed or infected (Fig. 10-5). In men with chronic prostatitis, voiding complaints similar to those caused by BPH are the predominant symptoms. These complaints include urgency, frequency, and nocturia (getting up at nighttime more than once); less frequently, men may complain of difficulty starting the urinary stream or a slow stream. These symptoms typically differ from symptoms of BPH in that they are associated with some degree of discomfort before, during, or after voiding. Physical or emotional stress and/or irritative components of the diet (e.g., caffeine in coffee, soft drinks) commonly exacerbate chronic prostatitis symptoms. The causes of prostatitis are unclear. Although it can be the result of a bacterial infection, many men have nonbacterial prostatitis of unknown cause. Risk factors for bacterial prostatitis include some sexually transmitted diseases (e.g., gonorrhea) from unprotected anal and vaginal intercourse, which can allow bacteria to enter the urethra and travel to the prostate. Other risk factors include bladder outlet obstruction (e.g., stone, tumor, benign prostatic hyperplasia), diabetes mellitus, immunosuppression, and urethral catheterization. Neither prostatitis nor prostate enlargement is known to cause cancer, but men with prostatitis or BPH can develop prostate cancer as well. The National Institutes of Health Prostatitis Symptom Index (NIH-CPSI) provides a valid
446
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VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
outcome measure for men with chronic prostatitis. The index may be useful in clinical practice as well as research protocols. A less complete list of questions for screening purposes are most appropriate for men with low back pain and any of the risk factors or symptoms listed for prostatitis and may include the following. 15
Follow-Up Questions
• Do you ever have burning pain or discomfort during or right after urination? • Does it feel like your bladder is not empty when you finish urinating? • Do you have to go to the bathroom every 2 hours (or more often)? • Do you ever have pain or discomfort in your testicles, penis, or the area between your rectum and your testicles (perineum)? • Do you ever have pain in your pubic or bladder area? • Do you have any discomfort during or after sexual climax (ejaculation)? The therapist is reminded in asking these questions to offer clients a clear explanation for any questions asked concerning sexual activity, sexual function, or sexual history. There is no way to know when someone will be offended or claim sexual harassment. It is in your own interest to conduct the interview in the most professional manner possible. There should be no hint of sexual innuendo or humor injected into any of your conversations with clients at any time. The line of sexual impropriety lies where the complainant draws it and includes appearances of misbehavior. This perception differs broadly from client to client. Prostatitis cannot always be cured but can be managed. Correct diagnosis is the key to the management of prostatitis. Screening men with red flag symptoms, history, and risk factors can result in early detection and medical referral. Physical therapy has been shown to have some potential in helping men with chronic prostatitis. Physical therapy for this problem is more common in the European countries but is gaining support in the U.S. Intervention is directed toward reducing pelvic floor muscle tone and improving urinary function using electrostimulation, transrectal microwave hyperthermia, biofeedback, myofascial release, and transrectal mobilization of the pelvic ligaments. " 16
17
20
Clinical Signs and Symptoms of Prostatitis • . • • • •
Sudden moderate-to-high fever Chills Low back, inner thigh, and perineal pain Testicular or penis pain Urinary frequency and urgency Nocturia/(unusual voiding during the night)/ sleep disturbance • Dysuria (painful or difficult urination) • Weak or interrupted urine stream (hesitancy) • Unable to completely empty bladder • Sexual dysfunction (e.g., painful ejaculation, cramping/discomfort after ejaculation, infertility) . General malaise • Arthralgia • Myalgia
B E N I G N PROSTATIC HYPERPLASIA
Benign prostatic hyperplasia (BPH; enlarged prostate) is a common occurrence in men older than 50. Like all cells in the body, cells in the prostate constantly die and are replaced by new cells. As men age, the ratio of new prostate cells to old prostate cells shifts in favor of lower cell death. With a lower cell turnover, there are more "old" cells than "new" ones and the prostate enlarges, squeezing the urethra and interfering with urination and sexual function. It is unclear why cell replacement is diminished, but it may be related to hormone changes associated with aging. Prostate enlargement affects about half of all men between ages 60 and 69 and close to 80% of men between ages 70 and 90. Severity of signs and symptoms varies and only about half of men with prostate enlargement have problems noticeable enough to seek treatment. Because of the prostate's position around the urethra (see Fig. 10-3), enlargement of the prostate quickly interferes with the normal passage of urine from the bladder. Sexual function is not usually affected unless prostate surgery is required and sexual dysfunction occurs as a complication. If the prostate is greatly enlarged, chronic constipation may result. Urination becomes increasingly difficult, and the bladder never feels completely empty. Straining to empty the bladder can stretch the bladder, making it less elastic. The detrusor becomes less efficient and urine collecting in the bladder can foster urinary tract infections. If left untreated, loss of bladder tone and damage to the detrusor may not be reversible. 21
CHAPTER 10
Continued enlargement of the prostate eventually obstructs the bladder completely, and emergency measures become necessary to empty the bladder. Like prostatitis, BPH cannot be cured but symptoms can be managed with medical treatment. Anyone with undiagnosed symptoms of BPH should seek medical evaluation as soon as possible. Screening questions for an enlarged prostate can include the following. F o l l o w - U p Questions
• Does it feel like your bladder is not empty when you finish urinating? • Do you have to urinate again less than 2 hours after the last time you emptied your bladder? • Do you have a weak stream of urine or find you have to start and stop urinating several times when you go to the bathroom? • Do you have to push or strain to start urinating or to keep the urine flowing? • Do you have any leaking or dribbling of urine from the penis? • Do you get up more than once at night to urinate? Clinical Signs and Symptoms of Obstruction o f the L o w e r U r i n a r y Tract (Benign Prostatic H y p e r p l a s i a / P r o s t a t e Cancer) Lower urinary tract symptoms of blockage are most commonly related to bladder or urethral pressure (e.g., prostate enlargement). This pressure results in bladder distention and subsequent pain. Common symptoms of lower urinary tract (LUT) obstruction include • Bladder palpable above the symphysis pubis • Urinary problems • Hesitancy: difficulty in initiating urination or an interrupted flow of urine • Small amounts of urine with voiding (weak urine stream) • Dribbling at the end of urination • Frequency: need to urinate often (more than every 2 hours) • Nocturia (unusual voiding during the nighfj/sleep disturbance • Lower abdominal discomfort with a feeling of the need to void • Low back and/or hip, upper thigh pain or stiffness • Suprapubic or pelvic pain • Difficulty having an erection • Blood in urine or semen
SCREENING FOR UROGENITAL DISEASE
447
PROSTATE C A N C E R
Prostate cancer is a slow growing form of cancer causing microscopic changes in the prostate in one third of all men by age 50. Carcinoma in situ is present in 50% to 75% of American men by age 75. Most of these changes are latent, meaning they produce no signs or symptoms or they are so slow growing (indolent) that they never cause a health threat. Even so, prostate cancer is the second most common type of cancer and second leading cause of death among men in this country. Of all the men who are diagnosed with cancer each year, about one third have prostate cancer. The number of new diagnosed cases of prostate cancer has dramatically increased over the last two decades (peaking in 1992), probably due to mass screening using a blood test to measure the prostate-specific antigen (PSA). PSA rises in men who have any changes in the prostate (e.g., tumor, infection, enlargement). Despite the many controversies over "normal" levels of PSA, this test has shifted the detection of the majority of prostate cancer cases from late-stage to early-stage disease. Because more men are living longer and the incidence of prostate cancer increases with age, prostate cancer is becoming a significant health issue. Risk factors include advancing age, family history, ethnicity, and diet. Most men with prostate cancer are older than 65; the disease is rare in men younger than 45. A man's risk of prostate cancer is higher than average if his brother or father had the disease. In fact, the more first-degree family members affected, the greater the person's risk of prostate cancer. It is more common in African American men compared to white or Hispanic men. It is less common in Asian and American Indian men. Some studies suggest a diet high in animal fat or meat may be a risk factor. Other risk factors may include low levels of vitamins or selenium, multiple sex partners, viruses, and occupational exposure to chemicals (including farmers exposed to herbicides and pesticides), cadmium, and other metals. Early prostate cancer often does not cause symptoms. But prostate cancer can cause any of the signs and symptoms listed in the box, Clinical Signs and Symptoms of Obstruction of the Lower Urinary Tract. It is often diagnosed when the man seeks medical assistance because of symptoms of lower urinary tract obstruction or low back, hip, or leg 22
23
23
24
22
22
448
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
S E C T I O N II
pain or stiffness (Case Example 10-3). There are four stages of prostate cancer : • Stage I or Stage A—The cancer cannot be felt during a rectal exam. It may be found when surgery is done for another reason, usually for BPH. There is no evidence that the cancer has spread outside the prostate. • Stage II or Stage B—The tumor is large enough that it can be palpated during a rectal exam or found with a biopsy. There is no evidence that the cancer has spread outside the prostate. • Stage III or Stage C—The cancer has spread outside the prostate to nearby tissues. • Stage IV or Stage D—The cancer has spread to lymph nodes or to other parts of the body Back pain and sciatica can be caused by cancer metastasis via the bloodstream of the lymphatic system to the bones of the pelvis, spine, or femur. Lumbar pain is predominant but the thoracolumbar pain can be painful as well depending on the location of the metastases. Prostate cancer is unique in that bone is often the only clinically detectable site of metastases. The resulting tumors tend to be osteoblastic (bone forming causing sclerosis), rather than osteolytic (bone lysing) (Fig. 106; see also Fig. 13-7). Symptoms of metastatic disease include bone pain, anemia, weight loss, lymphedema of the lower extremities and scrotum, and neurologic changes associated with spinal cord compression when spinal involvement occurs. 22
25
Incontinence Urinary incontinence (UI) is the involuntary leakage of urine. According to the U.S. Department of Health and Human Services, incontinence is a vastly underdiagnosed and underreported problem
CASE EXAMPLE 1 0 - 3
affecting millions of Americans each year. The incidence of incontinence is expected to grow dramatically as the U.S. population continues to age. Urinary incontinence is not a disease, but rather a symptom of other underlying health conditions including trauma (e.g., childbirth, incest), diabetes, multiple sclerosis, Parkinson's disease, spinal injury, spina bifida, surgery, hormonal changes, medications, stroke dysfunction, urinary tract infections, neuromuscular conditions, constipation, or even dietary issues including caffeine intake. Incontinent people may restrict their activities for fear of urine loss and concerns about odors in public. This reduction in social activity and impact on lifestyle can have profound effects on psychological well being and health including depression, skin breakdown, urinary tract infections, and urosepsis. The therapist can have an important role in the successful treatment of incontinence; therefore screening for this symptom is vital and should be a routine part of the health assessment for all adult clients, especially in a primary care setting. There are four primary types of UI recognized in adults. These are based on the underlying anatomic or physiologic impairment and include: stress, urge, mixed (combination of urge and stress), and overflow. Stress incontinence occurs when the support for the bladder or urethra is weak or damaged, but the bladder itself is normal. With stress incontinence, pressure applied to the bladder from coughing, sneezing, laughing, lifting, exercising, or other physical exertion increases abdominal pressure, and the pelvic floor musculature cannot counteract the urethral/bladder pressure. This type of 26
P r o s t a t e Cancer
A 66-year-old man with low back pain was evaluated by a female physical therapist but treated by a male physical therapy aide. By the end of the third session, the client reported some improvement in his painful symptoms. During the second week there was no improvement and even a possible slight setback. During the treatment session he commented to the aide that he is impotent. Given this man's age, inconsistent response to therapy, and report of impotency, a medical referral was necessary. A brief note was sent to
the physician relating this information and requesting medical follow-up. (The therapist was careful to use the word follow up rather than medical reevaluation since the impotency was present at the time of the initial medical evaluation.) Result: A medical diagnosis of testicular cancer was established, and appropriate treatment was initiated. Physical therapy was discontinued until medical treatment was completed and systemic origin of the back pain could be ruled out.
SCREENING FOR UROGENITAL DISEASE
CHAPTER 10
449
A
B Fig. 10-6 • Widespread osteoblastic skeletal metastases in prostate adenocarcinoma. A, Anteroposterior radiograph of pelvis shows multiple sclerotic foci. B, Radioisotopic bone scan shows multiple foci of increased uptake in pelvis from the same patient. (From Dorfman HD, Czerniak B: Bone tumors, St. Louis, 1998, Mosby.)
incontinence causes 75% of all cases of urinary incontinence in women and is primarily related to urethral sphincter weakness, pelvic floor weakness, and ligamentous and fascial laxity. Urge incontinence, now more commonly called overactive bladder, is the involuntary contraction of the detrusor muscle (smooth muscle of the bladder wall) with a strong desire to void (urgency) and loss of urine as soon as the urge is felt. The bladder involuntarily contracts or is unstable, or there may be involuntary sphincter relaxation. Urge incontinence is often idiopathic but can be caused by medications, alcohol, bladder infections, bladder tumor, neurogenic bladder, or bladder outlet obstruction. Overflow incontinence is overdistention of the bladder and the bladder cannot empty completely. Urine leaks or dribbles out so the client does not have any sensation of fullness or emptying. 27
It may be caused by an acontractile or deficient detrusor muscle, a hypotonic or underactive detrusor muscle secondary to drugs, fecal impaction, diabetes, lower spinal cord injury, or disruption of the motor innervation of the detrusor muscle (e.g., multiple sclerosis). In men, overflow incontinence is most often secondary to obstruction caused by prostatic hyperplasia, prostatic carcinoma, or urethral stricture. In women, this type of incontinence occurs as a result of obstruction caused by severe genital prolapse or surgical overcorrection of urethral detachment. The client with incontinence from overflow will report a feeling that the bladder does not empty completely with an urge to void frequently including at night. Small amounts of urine are lost involuntarily throughout the day and night. There may be a weak stream or flow sometimes described as "dribbling."
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VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
The term functional incontinence describes another type of UI that occurs when the bladder is normal but the mind and body are not working together. Functional incontinence occurs from mobility and access deficits, such as being confined to a wheelchair or needing a walker to ambulate. Deficits in dexterity, such as weakness from a stroke or neuropathy and loss of motion from arthritis may keep the individual from getting pants unfastened or panties pulled down in time to avoid an accident. Altered mentation from dementia or Alzheimer's can also contribute to untimely urination without a urologic structural problem. Causes of incontinence can range from urologic/gynecologic to neurologic, psychologic, pharmaceutical, or environmental. Anything that can interfere with neurologic function or produce obstruction can contribute to UI. There is a high prevalence of stress and urge incontinence in female elite athletes. The frequency of UI is significantly higher in eating disordered athletes. Risk factors for developing UI are listed in Box 10-3. Chronic constipation at any time, but especially during pregnancy, can lead to increased abdominal pressure, which can cause UI. Any condition leading to an enlarged abdomen (e.g., ascites, weight gain, pregnancy) with increased pressure on the bladder can contribute to incontinence. Chemotherapy, radiation, surgery, and medications can cause disruptions in the cycle of micturition (urination) for many different physiologic reasons. For example, chemotherapy can increase fat deposits and decrease muscle mass, which increase the risk of bowel and bladder dysfunction. Radiation alters tissue viability in the surrounding area, which can affect circulation to the organs and support from muscle, fascia, ligaments, and tendons. Radiation can cause fibrotic contracted bladder tissue and damaged sphincter contributing to UI. Acute radiation prostatocystitis due to external beam radiation can cause frequency, nocturia, urgency, or urge incontinence as well as hematuria or transient urine retention. Surgery to remove tumors, lymph nodes, or the prostate can affect bladder control through alterations of blood and lymphatic circulation, innervation, and fascial support. Edema secondary to lymphatic system compromise can increase bladder (and bowel) dysfunction. Brain, spinal cord, or pelvic surgery can affect nervous control of the bowel and bladder. Urge incontinence can occur as a result of bladder denervation from surgical injury. Postprostatectomy UI (when incontinence is defined as any leak) occurs in up to 70% 28
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31
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BOX 10-3
Risk Factors for Urinary Incontinence
Advancing age Overweight/obese Chronic cough Chronic constipation History of urinary tract infections E n l a r g e d a b d o m e n (e.g., a s c i t e s , p r e g n a n c y , obesity, t u m o r ) Diabetes mellitus Neurologic disorders Medications Sedatives Diuretics Anticholinergics Alpha-adrenergic blockers Calcium channel blockers Antipsychotics Antidepressants Antiparkinsonian drugs Opioids Vincristine Angiotensin-converting enzyme (ACE) inhibitors Caffeine, alcohol F e m a l e g e n d e r (see below)
Specific to Women Pregnancy (multiparity) Vaginal or cesarean* birth Previous bladder or pelvic surgery Pelvic t r a u m a or radiation Bladder or bowel prolapse M e n o p a u s e (natural or surgically induced; estrogen deficiency)t Tobacco use
Specific to Men Enlarged prostate gland Prostate or pelvic surgery Radiation (acute and late complications) especially w h e n combined with brachytherapy
3 2
* Although the abdominal muscles are disrupted with a cesarean section and limit how much the woman can bear down on the bladder, abdominal tone and function are essential for pelvic muscle function, t Urinary incontinence in middle-aged women may be more closely associated with mechanical factors such as childbearing, history of urinary tract infections, gynecologic surgery, chronic constipation, obesity, and exertion than with menopausal transition. 30
of all cases but the rate of urine leak decreases as a result of time, medical treatment, and physical therapy intervention. UI is two times more common after prostatectomy than after radiation; surgical clients are three times more likely to use pads. Recovery occurs in most cases between 6 and 12 months after surgery. Incontinence is not a 32
CHAPTER 10
normal part of the aging process. When confronted with urinary incontinence in an older adult, consider some of the following causes of this disorder: infection, endocrine disorders, atrophic urethritis or vaginitis, restricted mobility, stool impaction (especially in smokers), alcohol or caffeine intake, and medications. Smoking contributes to constipation and is often accompanied by chronic cough, which stresses the bladder. Some medications can lead to UI or aggravate already existing UI. Medications commonly involved with alterations in urinary continence include anticholinergic agents, calcium channel blockers, diuretics, sedatives, (3-antagonists, and pjagonists. With any kind of incontinence, the onset of cervical spine pain at the same time that urinary incontinence develops is a red flag. These two findings would suggest there is a protrusion pressing on the spinal cord. If a medical diagnosis for cervical disk protrusion has been established, referral would not be necessary. However, if incontinence is a new development from the time of the medical evaluation, the physician should be made aware of this information. Cervical spinal manipulation is considered contraindicated. Many people are embarrassed about having an incontinence problem. It may help to introduce the subject by making a general statement such as "Many men and women have problems with bladder control. This is an area physical therapists can often help clients with so we routinely ask a few questions about bladder function." 33
F o l l o w - U p Questions
Screening questions include
for incontinence
can
General:
Do you have any problems holding urine or emptying your bladder? Do you ever leak urine or have accidents? Do you wear pads to protect against urine leaking? Follow-up: How many do you use in a 24-hour period and how wet are they? Are your activities limited because of urine leaking? If the client answers "yes" to any of these questions, you may want to screen further with the following questions. For stress incontinence:
Do you ever lose urine or wet your pants when you cough, sneeze, or laugh?
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451
Do you lose urine or wet your pants when getting out of a chair, lifting, or exercising? For overactive bladder (urge incontinence):
Do you have frequent, strong, or sudden urges to urinate and cannot get to the bathroom in time? For example: When arriving home and getting out of the car? When using a key to open the door? When you hear water running? Or when you run water over your hands? When you go out into cold weather or put your hands in the freezer? Do you get to the toilet and lose urine as you are pulling down your panties/shorts? Do you urinate more than eight times a day? Do you get up to go more than twice a night? For overflow incontinence:
Do you dribble urine during the day and/or at night? Can you urinate with a strong stream or does the urine dribble out slowly? Does it feel like your bladder is empty when you are done urinating? For functional incontinence:
Can you get to the toilet easily? Do you have trouble getting to the bathroom on time? Do you have trouble finding the bathroom or toilet? Do you have accidents in the bathroom because you cannot get your pants unfastened or pulled down? Renal Failure A person is unlikely to seek treatment for renal problems from the physical therapist. However, patients/clients with renal failure may receive treatment for primary musculoskeletal lesions in both inpatient and outpatient clinics. Renal failure exists when the kidneys can no longer maintain the homeostatic balances within the body that are necessary for life. Renal failure is classified as acute or chronic in origin and progression. Acute renal failure refers to the abrupt cessation of kidney activity, usually occurring over a period of hours to a few days. Acute renal failure is often reversible, with return of kidney function in 3 to 12 months. Chronic renal failure, or irreversible renal failure (also known as end-stage renal disease or ESRD), is defined as a state of progressive decrease
452
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in the ability of the kidney to filter fluids, metabolites, and electrolytes from the body, resulting in eventual permanent loss of kidney function. It can develop slowly over a period of years or can result from an episode of acute renal failure that does not resolve. ESRD is a complex condition with multiple systemic complications. Diabetic nephropathy is the primary cause of ESRD, accounting for approximately 40% of newly diagnosed cases of ESRD. Individuals with diabetes and ESRD have higher morbidity and mortality rates than individuals with ESRD only. Risk factors for ESRD include age, diabetes mellitus, hypertension, chronic urinary tract obstruction and infection, and kidney transplantation. Hereditary defects of the kidneys, polycystic kidneys, and glomerular disorders such as glomerulonephritis can also lead to renal failure. Chronic intake of certain medications and overthe-counter (OTC) drugs is also a factor in the development of renal disease. The increasing availability of OTC drugs has led to consumers treating themselves when they may lack the knowledge to do so safely. Age-related decline in renal function 34
TABLE 10-4
combined with multiple medication use in the aging adult population increases the risk of hepatotoxicity. Excessive consumption of acetaminophen and nonsteroidal antiinflammatory drugs, especially when combined with caffeine and/or codeine, are toxic to the kidneys. ' 35
36 37
Clinical Signs and Symptoms Failure of the filtering and regulating mechanisms of the kidney can be either acute (sudden in onset and potentially reversible) or chronic (called uremia, which develops gradually and is usually irreversible). Individuals with either type of renal failure develop signs and symptoms characteristic of impaired fluid and waste excretion and altered renal regulation of other body metabolic processes, such as pH regulation, RBC production, and calcium-phosphorus balance. Signs of renal impairment are shown in Table 10-4. The signs of actual renal failure are the same but more pronounced. In most cases of renal failure, urine volume is significantly decreased or absent. Edema becomes severe and can result in heart failure. Renal anemia is usually associated
Systemic Manifestations of Renal Failure
System
Manifestation
General
Fatigue, malaise
S k i n and nail b e d s
Pallor, e c c h y m o s i s , pruritus, dry skin a n d m u c o u s m e m b r a n e s , thin/brittle nail beds, urine odor on
Skeletal
O s t e o m a l a c i a , osteoporosis,* b o n e p a i n , myopathy, t e n d o n rupture, fracture, j o i n t pain, dependent
skin, u r e m i c frost (white u r e a crystals) on the face and u p p e r trunk, poor w o u n d healing edema Neurologic
CNS: R e c e n t m e m o r y loss, d e c r e a s e d alertness, difficulty concentrating, irritability, lethargy/sleep disturbance, coma, impaired judgment PNS: M u s c l e w e a k n e s s , t r e m o r s , a n d c r a m p i n g ; restless leg s y n d r o m e , carpal tunnel s y n d r o m e , paresthesias
E y e , ear, n o s e , t h r o a t
Metallic taste in m o u t h , n o s e b l e e d s , u r e m i c (urine-smelling) breath, pale conjunctiva, visual blurring
Cardiovascular
H y p e r t e n s i o n , friction r u b , congestive h e a r t failure, pericarditis, cardiomyopathy, arrhythmia, Raynaud's phenomenon
Pulmonary
D y s p n e a , p u l m o n a r y e d e m a , crackles (rales), pleural effusion
Gastrointestinal
A n o r e x i a , n a u s e a , v o m i t i n g , h i c c u p s , gastrointestinal b l e e d i n g
Genitourinary
D e c r e a s e d urine o u t p u t and other c h a n g e s in pattern of urination (e.g., nocturia)
Metabolic/endocrine
D e h y d r a t i o n , h y p e r k a l e m i a , m e t a b o l i c acidosis, h y p o c a l c e m i a , h y p e r p h o s p h a t e m i a , fertility and sexual dysfunction (e.g., i m p o t e n c e , loss of libido, a m e n o r r h e a ) , h y p e r p a r a t h y r o i d i s m
Hematologic
Anemia Thrombocytopenia
* Bone demineralization leads to a condition called renal osteodystrophy. CNS, Central nervous system; PNS, peripheral nervous system. From Goodman CC, Boissonnault WG, Fuller K: Pathology: implications for the physical therapist, ed. 2. Philadelphia, 2003, WB Saunders.
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with extreme fatigue and intolerance to normal daily activities as well as a marked decrease in exercise capacity. In addition, the continuous presence of toxic waste products in the bloodstream (urea, creatinine, uric acid) results in damage to many other body systems, including the central nervous system, peripheral nervous system, eyes, gastrointestinal tract, integumentary system, endocrine system, and cardiopulmonary system. Treatment of renal failure involves several elements designed to replace the lost excretory and metabolic functions of this organ. Treatment options include dialysis, dietary changes, and medications to regulate blood pressure and assist in replacement of lost metabolic functions, such as calcium balance and RBC production. The choice of treatment options, such as dialysis, transplantation, or no treatment, depends on many factors, including the person's age, underlying physical problems, and availability of compatible organs for transplantation. Untreated or chronic renal failure eventually results in death. From a screening perspective, the therapist must be alert to the many complications associated with chronic renal failure and dialysis. Watch for signs and symptoms of fluid and electrolyte imbalances (see Chapter 11), dehydration (see Chapter 11), cardiac arrhythmias (see Chapter 6), and depression (see Chapter 3). 38
39
Clinical Signs and Symptoms of Renal I m p a i r m e n t Symptoms of upper urinary tract infection, particularly renal infection, can be categorized according to urinary tract manifestations or systemic manifestations caused by renal impairment (see Table 10-4). Clinical signs and symptoms of urinary tract involvement can include • Unilateral costovertebral tenderness • Flank pain • Ipsilateral shoulder pain • Fever and chills • Skin hypersensitivity • Hematuria (blood in urine) • Pyuria (pus in urine) • Bacteriuria (presence of bacteria in urine) • Hypertension • Decreased urinary output • Dependent edema • Weakness • Anorexia (loss of appetite) • Dyspnea • Mild headache
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•
Proteinuria (protein in urine, urine may be foamy) • Abnormal blood serum level, such as elevated blood urea nitrogen (BUN) and creatinine • Anemia
Cancers o f t h e U r i n a r y Tract Bladder Cancer Bladder cancer is a common, major public health concern and it is strongly linked to cigarette smoking. It is the fourth most common cancer in men and the tenth most common in women. Bladder cancer is nearly three times more common in men than in women, thus it is typically diagnosed later in women and often at a more advanced stage. The exact cause of bladder cancer is not known, but certain risk factors have been identified which increase chances of developing this type of cancer. • Age (over 40) • Tobacco use (cigarette, pipe, and cigar smokers) • Occupation (work place carcinogens such as rubber, chemical, leather industries; hairdressers, machinists, metal workers, printers, painters, textile workers, truck drivers) • Infections (parasitic, usually in tropical areas of the world) • Treatment with cyclophosphamide or arsenic (for other cancers) • Race (whites highest; Asians lowest) • Gender (men 2 to 3 times more likely than women) • Previous personal history of bladder cancer • Family history (some association but not clearly defined) Common symptoms of bladder cancer include blood in the urine, pain during urination, and urinary urgency or the feeling of urinary urgency without resulting urination. These symptoms are not sure signs of bladder cancer, but anyone with these symptoms should be referred to a physician for further follow up studies. Measures that have been shown to reduce the risk of developing bladder cancer include cessation of smoking, adequate intake of fluids, intake of cruciferous vegetables, limiting exposure to workplace chemicals, and prompt treatment of bladder infections. 40
41
4243
Renal Cancer Cancer of the kidney (renal cancer) develops most often in people over the age of forty and has some associated risk factors. The following risk factors for renal cancer include
S E C T I O N II
454
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
• • • • •
Smoking (two times the risk as nonsmokers) Obesity Hypertension Long-term dialysis Van Hippel-Lindau (VHL) syndrome (genetic, familial syndrome) • Occupation (coke oven workers in the iron and steel industry; asbestos and cadmium exposure) • Gender (men twice more likely than women) Common symptoms of renal cancer are very similar to those of bladder cancer and require immediate referral for follow up. These symptoms can include blood in the urine, pain in the side that does not go away, a lump or mass in the side or abdomen, weight loss, fever, and general fatigue or feeling of poor health. 44
Clinical Signs and Symptoms of B l a d d e r a n d Renal Cancer Bladder Cancer •
Blood in the urine
• •
Pain during urination Urinary urgency
Renal Cancer • • • •
Blood in the urine Pain during urination Urinary urgency Flank or side pain
The cause of testicular cancer and even the risk factors remain unknown. Risk is higher than average for boys born with an undescended testicle (cryptorchidism). The cancer risk for boys with this condition is increased even if surgery is done to move the testicle into the scrotum. In the case of unilateral cryptorchidism, the risk of testicular cancer is increased in the normal testicle as well. This fact suggests testicular cancer is due to whatever caused the undescended testicle. Having a brother or father with testicular cancer also increases an individual's risk. Other risk factors may include occupation (e.g., miners, oil and gas workers, leather workers, food and beverage processing workers, janitors, firefighters, utility workers) and HIV infection. The risk of testicular cancer among white American men is about 5 to 10 times that of African American men and more than twice that of Asian American men. The risk for Hispanics is between that of Asians and non-Hispanic whites. The reason for this difference is unknown. The testicular cancer rate has more than doubled among white Americans in the past 40 years but has not changed for African Americans. Worldwide, the risk of developing this disease is highest among men living in the United States and Europe and lowest among African and Asian men. CLINICAL S I G N S A N D S Y M P T O M S
• Lump or mass in the side or abdomen • Weight loss • Fever • General fatigue; feeling of poor health
T e s t i c u l a r Cancer The testicles (also called testes or gonads) are the male sex glands. They are located behind the penis in a pouch of skin called the scrotum (see Fig. 10-3). The testicles produce and store sperm and serve as the body's main source of male hormones. These hormones control the development of the reproductive organs and other male characteristics, such as body and facial hair, low voice, wide shoulders, and sexual function. Testicular cancer is relatively rare and occurs most often in young men between the ages of 15 and 35 years old, although any male can be affected at any time (including infants). According to the National Cancer Institute's Surveillance, about 8000 men are diagnosed with testicular cancer each year (390 deaths annually). The incidence of testicular cancer around the world has doubled in the past 30 to 40 years. 45
23
Testicular cancer can be completely asymptomatic. The most common sign is a hard, painless lump in the testicle about the size of a pea. There may be a dull ache in the scrotum and the man may be aware of tender, larger breasts. Other symptoms are listed in the box Clinical Signs and Symptoms of Testicular Cancer. There are three stages of testicular cancer: • Stage I—The cancer is confined to the testicle. • Stage II—The cancer has spread to the retroperitoneal lymph nodes, located in the posterior abdominal cavity below the diaphragm and between the kidneys. • Stage III—The cancer has spread beyond the lymph nodes to remote sites in the body, including the lungs, brain, liver, and bones. If found early testicular cancer is almost always curable. The American Cancer Society recommends monthly self-exam of the testicles for adolescents and men, starting at age 15. Testicular self-examination is an effective way of getting to know this area of the body and thus detecting testicular cancer at a very early, curable stage. The self-exam is best performed once each month during or after a warm bath or shower when 23
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the heat has relaxed the scrotum (see Appendix D-8). Men who have been treated for cancer in one testicle have about a 3% to 4% chance of developing cancer in the remaining testicle. If cancer does arise in the second testicle, it is nearly always a new disease rather than metastasis from the first tumor. Metastases occur via the blood or lymph system. The most common place for the disease spread is to the lymph nodes in the posterior part of the abdomen. Therefore, lower back pain is a frequent symptom of later stage testicular cancer (Case Example 10-4). If the cancer has spread to the lungs, persistent cough, chest pain, and/or shortness of breath can occur. Hemoptysis (sputum with blood) may also develop.
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455
Survivors of testicular cancer should be checked regularly by their doctors and should continue to perform monthly testicular self-examinations. Any unusual symptoms should be reported to the doctor immediately. Outcome even after a secondary testicular cancer is still excellent with early detection and treatment. Clinical Signs and Symptoms Testicular Cancer • A lump in either testicle • Any enlargement, swelling, or hardness of a testicle • Significant loss of size in one of the testicles • Feeling of heaviness in the scrotum and/or lower abdomen Continued on p. 456
CASE EXAMPLE 1 0 - 4
T e s t i c u l a r Cancer
A 20-year-old track star and college football player developed back, buttock, and posterior thigh pain after a football injury. He was sent to physical therapy by the team physician with a diagnosis of "Sciatica; L4-5 radiculopathy. Please treat using McKenzie exercise program." During the physical therapy interview, the client reported left low back pain and left buttock pain present for the last 2 weeks after being tackled from the right side in a football game. Symptoms developed approximately 12 hours after the injury. Pain was always present but was worse after sitting and better after standing. On examination the client presented with major losses of lumbar spine range of motion in all planes. There was no observable lateral shift and lumbar lordosis was not excessive or reduced. Overall postural assessment was unremarkable. He was able to lie flat in the prone position and perform a small prone press up without increasing any of his symptoms but he described feeling a "hard knot in my stomach" while in this position. When asked if he had any symptoms of any kind anywhere else in his body, the client replied that right after the injury, his left testicle swelled up but seemed better now. He denied any blood in the urine or difficulty urinating. Vital signs were within normal limits. Even though the therapist thought the clinical findings supported a diagnosis of a derange-
ment syndrome according to the McKenzie classification, there were enough red flags to warrant further investigation. The client was given an appropriate selftreatment program to perform throughout the day with instructions for self-assessment of his condition. In the meantime, the therapist contacted the physician with the following concerns: • Palpable (non pulsatile) abdominal mass in the left upper abdominal quadrant (anterior) • Reported left testicular swelling • Age • No imaging studies were done to confirm a discogenic lesion as the underlying cause of the symptoms Result: Physician referral was made after a telephone discussion outlining the additional findings listed above. An abdominal CT scan showed a 20 cm (5 inch) abdominal mass pressing on the spinal nerves as the cause of the back pain. Further diagnostic testing revealed testicular cancer as the primary diagnosis with metastases to the abdomen causing the abdominal mass. Surgery was performed to remove the testicle. The back pain was relieved within 3 days of starting chemotherapy. Physical therapy was discontinued for back pain but a new plan of care was established for exercise during cancer treatment.
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S E C T I O N II
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
• Dull ache in the lower abdomen or in the groin • Sudden collection of fluid in the scrotum • Pain or discomfort in a testicle or in the scrotum • Enlargement or tenderness of the breasts • Unexplained fatigue or malaise • Infertility • Low back pain (metastases to retroperitoneal lymph nodes)
PHYSICIAN
REFERRAL
The proximity of the kidneys, ureters, bladder, and urethra to the ribs, vertebrae, diaphragm, and accompanying muscles and tendinous insertions often can make it difficult to identify the client's problems accurately. Pain related to a urinary tract problem can be similar to pain felt from an injury to the back, flank, abdomen, or upper thigh. The physical therapist is advised to question the client further whenever any of the signs and symptoms listed in Table 10-3 are reported or observed. Further diagnostic testing and medical examination must be performed by the physician to differentiate urinary tract conditions from musculoskeletal problems. The physical therapist must be able to recognize the systemic origin of urinary tract symptoms that mimic musculoskeletal pain. Many conditions that produce urinary tract pain also include an elevation in temperature, abnormal urinary constituents, and changes in color, odor, or amount of urine. These types of changes would not be observed or reported with a musculoskeletal condition, and the client may not mention them, thinking these symptoms do not have anything to do with the back, flank, or thigh pain present. The therapist must ask a few screening questions to bring this kind of information to the forefront. When the physical therapist conducts a review of systems, any signs and symptoms associated with renal or urologic impairment should be correlated with the findings of the objective examination and combined with the medical history to provide a comprehensive report at the time of referral to the physician or other health care provider. Diagnostic T e s t i n g Screening of the composition of the urine is called urinalysis (UA), and UA is the commonly used method of determining various properties of urine. This analysis is actually a series of several tests of urinary components and is a valuable aid in the diagnosis of urinary tract or metabolic disorders.
Normal urinary constituents are shown (see inside front cover: Urine Analysis). Urine cultures are also very important studies in the diagnosis of UTIs. Anyone at risk for chronic kidney disease should be tested for markers of kidney damage. This is done by urinalysis for albumin (protein in the urine) and by blood serum for creatinine (waste product of muscle metabolism). Various blood studies can be done to assess renal function (see inside front cover: Renal Blood Studies). These studies examine both the serum and cellular components of the blood for specific changes characteristic of renal performance. Substances that must be examined in the serum are those that are a direct reflection of renal function, such as creatinine, and others that are more indirect in renal evaluation, such as BUN, pHrelated substances, uric acid, various ions, electrolytes, and cellular components (RBCs). (For a more in-depth discussion of laboratory values the reader is referred to a more specific source of information. ) " 46
48
Guidelines f o r Immediate Medical A t t e n t i o n • The presence of any amount of blood in the urine always requires a referral to a physician. However, the presence of abnormalities in the urine may not be obvious, and a thorough diagnostic analysis of the urine may be needed. Careful questioning of the client regarding urinary tract history, urinary patterns, urinary characteristics, and pain patterns may elicit valuable information relating to potential urinary tract symptoms. • Presence of cervical spine pain at the same time that urinary incontinence develops. If a diagnosis of cervical disk prolapse has been made, the physician should be notified of these findings; referral may not be necessary, but communication with the physician to confirm this is necessary. • Client with bowel/bladder incontinence and/or saddle anesthesia secondary to cauda equina lesion. Guidelines f o r Physician Referral Although immediate (emergency) medical attention is not required, medical referral is needed under the following circumstances: • When the client has any combination of systemic signs and symptoms presented in this chapter. Damage to the urinary tract structures can occur with accident, injury, assault, or other trauma to the musculoskeletal structures
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surrounding the kidney and urinary tract and may require medical evaluation if the clinical presentation or response to physical therapy treatment suggests it. For example, the alpine skier discussed at the beginning of the chapter had a dull, aching costovertebral pain on the left side that was unrelieved by a change of position or by ice, heat, or aspirin. His pain is related directly to a traumatic episode, and musculoskeletal injury is a definite possibility in his case. He has no medical history of urinary tract problems and denies any changes in urine or pattern of urination. Because the pain is constant and unrelieved by usual measures and the location of the pain is approximate to renal structures, a medical follow up and urinalysis would be recommended. • Back or shoulder pain accompanied by abnormal urinary constituents (e.g., change in color, odor, amount, flow of urine). • Positive Murphy's percussion test, especially with a recent history of renal or urologic infection. Clues S u g g e s t i n g P a i n o f Renal/Urological Origin • Men 45 years old or older • In men, back pain accompanied by burning on urination, difficulty in urination, or fever may be
SCREENING FOR UROGENITAL DISEASE
• •
• •
•
• • • •
457
associated with prostatitis; usually in such a case there is no limitation of back motion and no muscle spasm (until symptoms progress, causing muscle guarding and splinting) Blood in urine Change in urinary pattern such as increased or decreased frequency, change in flow of urine stream (weak or dribbling), and increased nocturia Presence of constitutional symptoms, especially fever and chills; pain is constant (may be dull or sharp, depending on the cause) Pain is unchanged by altering body position; side bending to the involved side and pressure at that level is "more comfortable" (may reduce pain but does not eliminate it) Neither renal nor urethral pain is altered by a change in body position; pseudorenal pain from a mechanical cause can be relieved by a change in position True renal pain is seldom affected by movements of the spine Straight leg-raising test is negative with renal colic appearing as back pain Back pain at the level of the kidneys in a woman with previous breast or uterine cancer (ovarian cancer) Assessment for pseudorenal pain is negative (see Table 10-1)
KIDNEY (Fig. 10-7)
Fig. 10-7 • Renal pain is typically felt in the posterior subcostal and costovertebral region (dark red). It can radiate across the low back (light red) and/or forward around the flank into the lower abdominal quadrant. Ipsilateral groin and testicular pain may also accompany renal pain. Pressure from the kidney on the diaphragm may cause ipsilateral shoulder pain.
458
S E C T I O N II
Location: Referral:
Description: Intensity: Duration: Associated signs and symptoms:
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
Posterior subcostal and costovertebral region Usually unilateral Radiates forward, around the flank or the side into the lower abdominal quadrant (Til to T12), along the pelvic crest and into the groin Pressure from the kidney on the diaphragm may cause ipsilateral shoulder pain Dull, aching, boring Acute: Severe, intense Chronic: Vague and poorly localized Constant Fever, chills Increased urinary frequency Blood in urine Hyperesthesia of associated dermatomes (T9 and T10) Ipsilateral or generalized abdominal pain Spasm of abdominal muscles Nausea and vomiting when severely acute Testicular pain may occur in men Unrelieved by a change in position
URETER (Fig. 10-8)
Fig. 10-8 • Ureteral pain may begin posteriorly in the costovertebral angle. It may then radiate anteriorly to the ipsilateral lower abdomen, upper thigh, testes, or labium.
Location: Referral: Description: Intensity:
Costovertebral angle Unilateral or bilateral Radiates to the lower abdomen, upper thigh, testis, or labium on the same side (groin and genital area) Described as crescendo waves of colic Excruciating, severe (Ureteral pain is commonly acute and caused by a kidney stone. Lesions outside the ureter are usually painless until advanced progression of the disease occurs.)
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Duration: Associated signs and symptoms:
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459
Ureteral pain caused by calculus is intermittent or constant without relief until treated or until the stone is passed Rectal tenesmus (painful spasm of anal sphincter with urgent desire to evacuate the bowel/bladder; involuntary straining with little passage of urine or feces) Nausea, abdominal distention, vomiting Hyperesthesia of associated dermatomes (T10 to LI) Tenderness over the kidney or ureter Unrelieved by a change in position Movement of iliopsoas may aggravate symptoms associated with a lesion outside the ureter (see Fig. 8-3)
BLADDER/URETHRA (Fig 10 9)
Fig. 10-9 • Left, Bladder or urethral pain is usually felt suprapubically or ipsilaterally in the lower abdomen. This is the same pattern for gas pain from the lower Gl tract for some people. Right, Bladder or urethral pain may also be perceived in the low back area [dark red: primary pain center; light red: referred pain). Low back pain may occur as the first and only symptom associated with bladder/urethral pain, or it may occur along with suprapubic or abdominal pain or both.
Location: Referral: Description: Intensity: Duration: Associated signs and symptoms:
Suprapubic or low abdomen, low back Pelvis Can be confused with gas Sharp, localized Moderate-to-severe Intermittent; may be relieved by emptying the bladder Great urinary urgency Tenesmus Dysuria Hot or burning sensation during urination
460
S E C T I O N II
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PROSTATE (Fig. 10-10)
Fig. 10-10 • The prostate is segmentally innervated from Tl 1 - L I , S 2 - S 4 . Prostate problems can be painless. When pain occurs, the primary pain pattern is in the lower abdomen, suprapubic region (dark red), and perineum (between the rectum and testes; not pictured). Pain can be referred to the low back, sacrum, testes, and inner thighs (light red).
Symptoms of prostate involvement vary depending on the underlying cause (e.g., prostatitis vs. BPH vs. prostate cancer). May be pain free; lower abdomen, suprapubic region Location: Low back, pelvis, sacrum, perineum, inner thighs, testes; thoracolumbar spine Referral: with metastases (the latter is not pictured) Description: Persistent aching pain; pain is reproduced with digital rectal exam Intensity: Mild to severe; varies from person to person and can fluctuate for each individual on any given day Duration: Varies according to underlying cause Associated signs and Chills and fever (prostatitis) symptoms: Frequent and/or painful urination Urgency, hesitancy Nocturia Incomplete emptying of bladder Painful ejaculation Hematuria Arthralgia, myalgia
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S C R E E N I N G FOR UROGENITAL DISEASE
461
KEY POINTS TO REMEMBER / Renal and urologic pain can be referred to the shoulder or low back. / Lesions outside the ureter can cause pain on movement of the adjacent iliopsoas muscle. / Radiculitis can mimic ureteral colic or renal pain, but true renal pain is seldom affected by movements of the spine. / Inflammatory pain may be relieved by a change in position. Renal colic remains unchanged by a change in position. / Low back, pelvic, or femur pain can be the first symptom of prostate cancer. / Urinary incontinence is not a normal part of aging and should be evaluated carefully. / With any kind of incontinence, the onset of cervical spine pain at the same time that urinary incontinence develops is a red flag and contraindicates the use of cervical spinal manipulation. / Lower thoracic disc herniation can cause groin pain and/or leg pain, mimicking renal pain. The presence of neurologic changes such as bladder dysfunction can cause confusion when trying to differentiate a systemic
SUBJECTIVE
from neuromusculoskeletal cause of symptoms. True renal pain is seldom affected by movements of the spine. Compare results of palpation and percussion tests. / Testicular cancer with metastasis to the lymph system or bone can cause low back pain from pressure on the spinal nerves. Always watch for red flags even when an injury occurs; this is especially true in the young adult or athlete. / Anyone with hypertension and/or diabetes (and/or other significant risk factors for renal disease) should be monitored carefully and consistently for any systemic signs and symptoms of renal impairment. / People with diabetes are prone to complications associated with urinary tract infections. The sudden onset of nonspecific low back pain, unrelated to any specific motion may be an indication of osteomyelitis from spread of infection to the spine. Take the client's body temperature and ask him/her to monitor temperature for a few days to uncover the possibility of a lowgrade fever associated with osteomyelitis. All the possible pain patterns discussed in this chapter are presented as follows:
EXAMINATION
Special Q u e s t i o n s T o A s k
Clients may be reluctant to answer the physical therapist's questions concerning bladder and urinary function. The physical therapist is advised to explain the need to rule out possible causes of pain related to the kidneys and bladder and to give the client time to respond if answers seem to be
uncertain. For example, the physical therapist may ask the client to observe urinary function over the next 2 days. These questions should be reviewed again at the next appointment. Past Medical H i s t o r y
• Have you had any problems with your prostate (for men), kidneys, or bladder? If so, describe.
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S E C T I O N II
SUBJECTIVE
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
EXAMINATION —cont'd
• Have you ever had kidney or bladder stones? If so, when? How were these stones treated? • Have you had an injury to your bladder or kidneys? If so, when? How was this treated? (Be aware of unreported domestic abuse/ assault.) • Have you had any kidney or bladder infections in the past 6 months? How were these infections treated? Were they related to any specific circumstances (e.g., pregnancy, intercourse, after strep throat or strep skin infections)? • Have you ever had surgery on your bladder or kidneys? If so, when and what? • Have you had any hernias? If yes, when and how was this treated? • Have you ever had cancer of any kind? • Have you ever had testicular, kidney, bladder, or prostate cancer? • Have you ever been treated with radiation or chemotherapy?
For Overactive Bladder (urge incontinence):
Special Questions To A s k : Bladder Control/Incontinence
• Do you dribble urine during the day and/or at night? • Can you urinate with a strong stream or does the urine dribble out slowly? • Does it feel like your bladder is empty when you are done urinating?
Begin with a lead-in introduction to these questions such as: Many people are embarrassed about having an incontinence problem. It may help to introduce the subject by making a general statement such as: "Many men and women have problems with bladder control. This is an area physical therapists can often help clients with so we routinely ask a few questions about bladder function." General:
• Do you have any problems holding urine or emptying your bladder? • Do you ever leak urine or have accidents? • Do you wear pads to protect against urine leaking? Follow-up: How many do you use in a 24-hour period? How wet are they? • Are your activities limited because of urine leaking? If the male client answers "yes" to any of these questions, you may want to screen further with the following questions. See also Appendix B-27. For Stress Incontinence:
• Do you ever lose urine or wet your pants when you cough, sneeze, or laugh? • Do you lose urine or wet your pants when getting out of a chair, lifting, or exercising?
• Do you have frequent, strong, or sudden urges to urinate and cannot get to the bathroom in time? For example: • When arriving home and getting out of the car? • When using a key to open the door? • When you hear water running? • Or when you run water over your hands? • When you go out into cold weather or put your hands in the freezer? • Do you get to the toilet and lose urine as you are pulling down your panties/shorts? • Do you urinate more than every 2 hours in the daytime? • Do you get up to go to the bathroom more than once a night? If yes, does this happen every night? Is it because you drink a large amount of fluids before bedtime? For O v e r f l o w Incontinence:
For Functional Incontinence:
• Can you get to the toilet easily? • Do you have trouble getting to the bathroom on time? • Do you have trouble finding the bathroom or toilet? • Do you have accidents in the bathroom because you cannot get your pants unfastened or pulled down? Special Questions to Ask: U r i n a r y Tract Infection
• Have you had any side (flank) pain (kidney or ureter) or pain just above the pubic area (suprapubic: bladder or urethra, prostate)? • If so, what relieves this pain? Does a change in position affect it? (Inflammatory pain may be relieved by a change in position. Renal colic remains unchanged by a change in position.) • During the last 2 to 3 weeks have you noticed a change in the amount or number of times that you urinate? (Infection)
CHAPTER 10
SUBJECTIVE
SCREENING FOR UROGENITAL DISEASE
463
EXAMINATION —cont'd
• Do you ever have pain or a burning sensation when you urinate? (Lower urinary tract irritation; prostatitis; venereal disease) • Does your urine look brown, red, or black? (Changes in urine color may be normal with some medications and foods such as beets or rhubarb.) • Is your urine clear or cloudy? If not clear, describe. How often does this happen? (Could indicate upper or lower urinary tract infection.) • Have you noticed an unusual or foul odor coming from your urine? (Infection, secondary to medication; may be normal after eating asparagus.) For Women:
• When you urinate, do you have trouble starting or continuing the flow of urine? (Urethral obstruction) • Have you noticed any unusual vaginal discharge during the time that you had pain (pubic, flank, thigh, back, labia)? (Infection) • Have you noticed any changes in your sexual activity/function caused by your symptoms? For Men:
• Have you noticed any unusual discharge from your penis during the time that you had pain (especially pain above the pubic area)? (Infection) • Have you noticed any changes in your sexual activity/function caused by your symptoms? Screening Questions to Ask: Prostatitis or Enlarged Prostate
• Have you ever had any problems with your prostate in the past? Prostatitis
• Do you ever have burning pain or discomfort during urination?
• Does it feel like your bladder is not empty when you finish urinating? • Do you have to go to the bathroom every 2 hours (or more often)? • Do you ever have pain or discomfort in your testicles, penis, or the area between your rectum and your testicles (perineum)? • Do you ever have pain in your pubic or bladder area? • Do you have any discomfort during or after sexual climax (ejaculation)? Enlarged prostate
• Does it feel like your bladder is not empty when you finish urinating? • Do you have to urinate again less than 2 hours after you finished going to the bathroom last? • Do you have a weak stream of urine or find you have to start and stop urinating several times when you go to the bathroom? • Do you have an urge to go to the bathroom but very little urine comes out? • Do you have to push or strain to start urinating or to keep the urine flowing? • Do you have any leaking or dribbling of urine from the penis? • How often do you get up to urinate at night? The American Urologic Association recommends using the following scale when asking most of these screening questions. Some questions such as "How often do you get up at night?" requires a single number response. A total score of seven or more suggests the need for medical evaluation: 0
T
2
3
4
5
N o t at
Less than
Less t h a n
About
More
Almost
all
one t i m e
h a l f the
half
than half
always
in five
time
the
the time
time
464
CASE
S E C T I O N II
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
STUDY
REFERRAL
RESULT
The client is self-referred and states that he has been to your hospital-based outpatient clinic in the past. He has a very extensive chart containing his entire medical history for the last 20 years.
After 3 days of treatment over the course of 1 week, the client has had no subjective improvement in symptoms. Objectively, the scoliotic shift has not changed. A second opinion is sought from two other staff members, and the consensus is to refer the client to his physician. The physician performs a rectal examination and confirms a positive diagnosis of prostatitis based on the results of laboratory tests. These test were consistent with the client's physical findings and previous history of prostate problems 1 year ago. The client was reluctant to discuss bowel or bladder function with the female therapist but readily suggested to his physician that his current symptoms mimicked an earlier episode of prostatitis. It is not always possible to elicit thorough responses from clients concerning matters of genitourinary function. If the client hesitates or is unable to answer questions satisfactorily, it may be necessary to present the questions again at a later time (e.g., next treatment session), to ask a colleague of the client's sex to confer with the client, or to refer the client to his or her physician for further evaluation. Occasionally, the client will answer negatively to any questions regarding observed changes in urinary function and will then report back at the next session that there was some pathologic condition that was not noted earlier. In this case a close review of the extensive medical records may have alerted the physical therapist to the client's previous treatment for the same problem, which he was reluctant to discuss.
BACKGROUND INFORMATION
He is a 44-year-old man who describes his current occupation as "errand boy/gopher," which requires minimal lifting, bending, or strenuous physical activity. His chief complaint today is pain in the lower back, which comes and goes and seems to be aggravated by sitting. The pain is poorly described, and the client is unable to specify any kind of descriptive words for the type of pain, intensity, or duration. SPECIAL QUESTIONS TO ASK
See Chapter 12 for Special Questions to Ask about the back. The client's answer to any questions related to bowel and bladder functions is either "I don't know" or "Well, you know," which makes a complete interview impossible. SUBJECTIVE/OBJECTIVE FINDINGS
There are radiating symptoms of numbness down the left leg to the foot. The client denies any saddle anesthesia. Deep tendon reflexes are intact bilaterally, and the client stands with an obvious scoliotic list to one side. He is unable to tell you whether his symptoms are relieved or alleviated on performing a lateral shift to correct the curve. There are no other positive neuromuscular findings or associated systemic symptoms.
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465
PRACTICE QUESTIONS 1. Percussion of the costovertebral angle that results in the reproduction of symptoms: a. Signifies radiculitis b. Signifies pseudorenal pain c. Has no significance d. Requires medical referral 2. Renal pain is aggravated by: a. Spinal movement b. Palpatory pressure over the costovertebral angle c. Lying on the involved side d. All of the above e. None of the above 3. Important functions of the kidney include all the following except: a. Formation and excretion of urine b. Acid-base and electrolyte balance c. Stimulation of red blood cell production d. Production of glucose
REFERENCES 1. Cannon J: Recognizing chronic renal failure, the sooner, the better, Nursing2004 34(l):50-53, 2004. 2. Netter FH: Atlas of human anatomy, ed 2, Teterboro, New Jersey, 1997, Icon Learning Systems. 3. Simons DG, Travell JG, Simons LS: Travell & Simons' myofascial pain and dysfunction: the trigger point manual, ed 2, vol 1, Baltimore, 1999, Williams & Wilkins. 4. Smith DR, Raney FL, Jr: Radiculitis distress as a mimic of renal pain, J Urol 116:269, 1976. 5. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Available at: http://www. kidney.org/professionals/doqi/kdoqi/p4_class_g3.htm. Accessed February 1, 2005. 6. Banishing urinary tract infections, Harvard Women's Health Watch 10(4):4-5, 2002. 7. Cailliet R: Low back pain syndrome, ed 5, Philadelphia, 1995, FA Davis. 8. Diagnosing and treating interstitial cystitis, Harvard Women's Health Watch 10(12):3, 2003. 9. Medical conditions, coping with kidney stones, Harvard Women's Health Watch 9(4):4-5, 2001. 10. Gurunadha Rao Tunuguntla HS, Evans CP: Management of prostatitis, Prostate Cancer Prostatic Dis 5(3):172-179, 2002. 11. Alexander RB: Treatment of chronic prostatitis, Nat Clin Pract Urol l(l):2-3, 2004. Available on line: http://www. medscape.com/viewarticle/494378. Posted December 8, 2004. 12. Pontari MA, Ruggieri MR: Mechanisms in prostatitis/ chronic pelvic pain syndrome, J Urol 172(3):839-845, 2004. 13. Tripp DA, Curtis NJ, Landis JR, et al: Predictors of quality of life and pain in chronic prostatitis/chronic pelvic pain syndrome: findings from the National Institutes of Health Chronic Prostatitis Cohort Study, BJU 94(9):1279-1282, 2004.
4. Who should be screened for possible renalAirologic involvement? 5. What do the following terms mean? • Dyspareunia • Dysuria • Hematuria • Urgency 6. What is the difference between urge incontinence and stress incontinence? 7. What is the significance of "skin pain" over the T9/T10 dermatomes? 8. How do you screen for possible prostate involvement in a man with pelvic/low-back pain of unknown cause? 9. Explain why renalAirologic pain can be felt in such a wide range of dermatomes (i.e., from the T9 to LI dermatomes). 1 0 . What is the mechanism of referral for urologic pain to the shoulder?
14. Schultz PL, Donnell RF: Prostatitis: the cost of disease and therapies to patients and society, Curr Urol Rep 5(4):317319, 2004. 15. Litwin MS, McNaughton-Collins M, Fowler FL: Prostatitis: The National Institutes of Health Chronic Prostatitis Symptoms Index (NIH-CPSI), Smithshire, Illinois, 2002, Prostatitis Foundation. Retrieved July 25, 2006 from http://www.prostatitis.org/symptomindex.html. 16. Rex L: Evaluation and treatment of somatovisceral dysfunction of the gastrointestinal system, Edmonds, Washington, 2004, URSA Foundation. 17. Zvara P, Folsom JB, Plante MK: Minimally invasive therapies for prostatitis, Curr Urol Rep 5(4):320-326, 2004. 18. Sokolov AV: Transrectal microwave hyperthermia in the treatment of chronic prostatitis, Urologiia 5:20-26, 2003. 19. Cornel EB, van Haarst EP: Chronic pelvic pain syndrome type 3 successfully treated with biofeedback physical therapy (Abstract), Presented at the American Urological Association 2004 Annual Meeting, May 8-13, 2004, San Francisco, California. Available on line: http://www. prostatitis.org/AmericanUrologicalMeeting04.html. 20. Ruzaev ML, Levitskii EF, Kolmatsui IA: Rehabilitation of patients with chronic prostatitis in combination with reflex syndromes of lumbar osteochondrosis (Russian), Vopr Kurortol Fizioter Lech Fiz Kult 1:35-37, 2004. 21. Sheeler R: Enlarged prostate. Know when to seek treatment, Mayo Clinic Health Letter 22(8): 1-3, 2004. 22. National Cancer Institute. Prostate cancer. Available at: http://www.nci.nih.gov/cancertopics/types/prostate. Posted June 21, 2004. Accessed February 2, 2005. 23. Jemal A, Murray T, Ward E, et al: Cancer statistics, CA Cancer J Clin 55(1): 10-31, 2005.24. Carroll PR, Nelson WG: Report to the nation on prostate cancer: introduction, Medscape Hematology-Oncology 7(2), 2004. Available at: http://www.medscape.com/viewarticle/489635. Accessed February 3, 2005. 25. Logothetis CJ, Lin SH: Osteoblasts in prostate cancer metastasis to bone, Nat Rev Cancer 5(l):21-28, 2005.
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26. U.S. Department of Health & Human Services. Diseases and conditions. Available at: www.hhs.gov/. Accessed February 7, 2005. 27. Shafik A, Shafik IA: Overactive bladder inhibition in response to pelvic floor muscle exercises, World J Urol 20(6):374-377, 2003. 28. Schultz JM: Urinary incontinence. Solving a secret problem, Nursing2003 (Suppl) 33(11):5-10, 2003. 29. Bo K, Borgen JS: Prevalence of stress and urge urinary incontinence in elite athletes and controls, Med Sci Sports Exerc 33(11):1797-1802, 2001. 30. Sherburn M, Guthrie JR, Dudley EC, et al: Is incontinence associated with menopause? Obstet Gynecol 98(4):628-633, 2001. 31. Hulme J: Regaining bowel and bladder control after cancer, Missoula, Montana, 2003, Phoenix Publishers. 32. Grise P, Thurman S: Urinary incontinence following treatment of localized prostate cancer, Cancer Control 8(6):532-539, 2002. Available on-line at: http://www. medscape.com/viewarticle/423513. 33. Yim PS, Peterson AS: Urinary incontinence, Postgrad Med 99(5):137-150, 1996. 34. Evans N, Forsyth E: End-stage renal disease in people with type 2 diabetes: systemic manifestations and exercise implications, Phys Ther 84(5):454-463, 2004. 35. Peterson GM: Selecting nonprescription analgesics, Am J Ther 12(l):67-79, 2005. 36. Elseviers MM, De Broe ME: Analgesic abuse in the elderly. Renal sequelae and management, Drugs Aging 12(5):391-400, 1998. 37. National Kidney Foundation (NKF): Can analgesics hurt kidneys? Available at: http://www.kidney.org/atoz/ atozPrint.cfm?id=23. Accessed February 5, 2005.
38. Holub C, Lamont M: The reliability of the six-minute walk test in patients with end stage renal disease, Acute Care Perspectives, 11(4):8-11, 2002. 39. Paton M: Continuous renal replacement therapy, Nursing2003, 33(6):40-50, 2003. 40. Best treatments for beating bladder cancer, Johns Hopkins Medical Letter 15(l):6-7, 2004. 41. Bladder cancer in women: no time to wait, Harvard Women's Health Watch ll(7):3-5, 2004. 42. National Cancer Institute: What you need to know about bladder cancer, Accessed www.cancer.gov/cancertopics/wyntk/bladder. September 2002. 43. Ongoing care of patients after primary treatment for their cancer: genitourinary cancers, bladder and kidney, CA Cancer J Clin 53(3):190-191, 2003. 44. National Cancer Institute: What you need to know about kidney cancer, www.cancer.gov/cancertopics/wyntk/ kidneys. Accessed March 30, 2004. 45. American Cancer Society: Detailed guide: testicular cancer. What are the risk factors for testicular cancer? Available at: http://www.cancer.org. Accessed February 10, 2005. 46. Goodman CC, Boissonnault WG: Pathology: implications for the physical therapist, ed 2, Philadelphia, 2000, WB Saunders. 47. Polich S, Faynor S: Interpreting lab test values, PT Magazine 4(l):76-88, 1996. 48. Irion GL: Lab values update, Acute Care Perspectives 13(1):1, 3-5, 2004.
Screening for Endocrine and Metabolic Disease
E
ndocrinology is the study of ductless (endocrine) glands that produce hormones. A hormone acts as a chemical agent that is transported by the bloodstream to target tissues, where it regulates or modifies the activity of the target cell. The endocrine system cannot be understood fully without consideration of the effects of the nervous system on the endocrine system. The endocrine system works with the nervous system to regulate metabolism, water and salt balance, blood pressure, response to stress, and sexual reproduction. The endocrine system is slower in response and takes longer to act than the nervous system in transferring biochemical information. The pituitary (hypophysis), thyroid, parathyroids, adrenals, and pineal are glands of the endocrine system whose functions are solely endocrine related and have no other metabolic functions (Fig. 11-1). The hypothalamus controls pituitary function and thus has an important indirect influence on the other glands of the endocrine system. Feedback mechanisms exist to keep hormones at normal levels. The endocrine system meets the nervous system in a complex series of interactions that link behavioral-neural-endocrine-immunologic responses. The hypothalamus and the pituitary form an integrated axis that maintains control over much of the endocrine system. The discovery and study of this complex interface axis is called psychoneuroimmunology (PNI) and has provided a new understanding of interactive biologic signaling. The hypothalamus exerts direct control over both the anterior and posterior portions of the pituitary gland and can synthesize and release hormones from its axon terminals directly into the blood circulation. These neurosecretory cells are so called because the neurons have a hormonesecreting function. Although neurons can have a hormone-secreting function, the opposite pathway is also present. Hormones that can stimulate the neural mechanism (e.g., acetylcholine) are called neurohormones. Acetylcholine is a neurotransmitter and a neurohormone. It is released at synapses to allow messages to pass along a nerve network, resulting in the release of both hormones and chemicals.
ASSOCIATED NEUROMUSCULAR AND MUSCULOSKELETAL SIGNS AND SYMPTOMS The musculoskeletal system is composed of a variety of connective tissue structures in which normal growth and development are influenced strongly and sometimes controlled by various hormones and metabolic processes. Alterations in these control systems can result in structural changes and altered function of various connective tissues, producing systemic and musculoskeletal signs and symptoms (Table 11-1). 467
468
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S E C T I O N II
Pineal Anterior
Hypothalamus
lobe •Pituitary(hypophysis)
Posterior lobe
Thyroid •
Parathyroids (posterior view of larynx and thyroid) Thymus
Fig. 1 1 - 1 • Location of the nine endocrine glands. (From Butts-Krakoff D: Structure and function: assessment of clients with metabolic disorders. In Black JM, Matassarin-Jacobs E, editors: Luckmann and Sorensen's medical-surgical nursing, ed 4, Philadelphia, 1993, Saunders, p. 1759.)
Adrenals
- Pancreas (islets of Langerhans)
Ovaries (female)
Testes (male)
TABLE 11-1
Signs and Symptoms of Endocrine Dysfunction
Neuromusculoskeletal Signs and symptoms associated with rheumatoid arthritis Muscle weakness Muscle atrophy Myalgia Fatigue Carpal tunnel syndrome Synovial fluid changes Periarthritis Adhesive capsulitis (diabetes) Chondrocalcinosis Spondyloarthropathy Osteoarthritis Hand stiffness Arthralgia
Systemic Excessive or delayed growth Polydipsia Polyuria Mental changes (nervousness, confusion, depression) Changes in hair (quality and distribution) Changes in skin pigmentation Changes in vital signs (elevated body temperature, pulse rate, increased blood pressure) Heart palpitations Increased perspiration Kussmaul's respirations (deep, rapid breathing) Dehydration or excessive retention of body water
From Goodman CC, Boissonnault WG, Fuller KS: Pathology: implications for the physical therapist, Philadelphia, 2003, Saunders, p 323.
Muscle Weakness, Myalgia, and Fatigue Muscle weakness, myalgia, and fatigue may be early manifestations of thyroid or parathyroid disease, acromegaly, diabetes, Cushing's syn-
drome, and osteomalacia. Proximal muscle weakness associated with endocrine disease is usually painless and unrelated to either the severity or the duration of the underlying disease. The muscular system is sometimes, but not
CHAPTER 11
always, restored with effective treatment of the underlying condition.
Bilateral Carpal Tunnel Syndrome Bilateral carpal tunnel syndrome (CTS), resulting from median nerve compression at the wrist, is a common finding in a variety of systemic and neuromusculoskeletal conditions but especially with certain endocrine and metabolic disorders (Table 11-2). The fact that the majority of persons with CTS are women at or near menopause suggests that the soft tissues about the wrist could be affected in some way by hormones. " Thickening of the transverse carpal ligament in certain systemic disorders (e.g., acromegaly, myxedema) may be sufficient to compress the 2
TABLE 11-2
469
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5
median nerve. Any condition that increases the volume of the contents of the carpal tunnel (e.g., neoplasm, calcium, and gouty tophi deposits) can compress the median nerve. The signs and symptoms often associated with CTS include paresthesia, tingling, and numbness and/or pain with cutaneous distribution of the median nerve to the thumb, index, middle, and radial half of the ring finger. Nocturnal paresthesia is a common complaint, and this discomfort causes sleep disruption. It can be partially relieved by shaking of the hand. Pain may radiate into the palm and up the forearm and arm. It should be noted that bilateral tarsal syndrome affecting the feet also can occur either alone or in conjunction with CTS, although the incidence of 6
Causes of Carpal Tunnel Syndrome
Neuromusculoskeletal Amyloidosis Anatomic sequelae of medical or surgical procedures Basal joint (thumb) arthritis Cervical disc lesions Cervical spondylosis Congenital anatomic differences Cumulative trauma disorders (CTD) Peripheral neuropathy Poor posture (may also be associated with TOS) Repetitive strain injuries (RSI) Tendinitis Trigger points Tenosynovitis Thoracic outlet syndrome (TOS) Wrist trauma (e.g., Colles' fracture)
Systemic Alcohol Arthritis (rheumatoid, gout, polymyalgia rheumatica) Benign tumors (lipoma, hemangioma, ganglia) Leukemia (tissue infiltration) Liver disease Medications NSAIDs Oral contraceptives Statins Alendronate (Fosamax) Multiple myeloma (amyloidosis deposits) Obesity Pregnancy Scleroderma Use of oral contraceptives Hemochromatosis Vitamin deficiency (especially vitamin B ) 1
6
Endocrine Acromegaly Diabetes mellitus Hormonal imbalance (menopause; posthysterectomy) Hyperparathyroidism Hyperthyroidism (Graves' disease) Hypocalcemia Hypothyroidism (myxedema) Gout (deposits of tophi and calcium) •
Infectious Disease Atypical mycobacterium Histoplasmosis Rubella Sporotrichosis
Modified from Goodman CC, Boissonnault WG: Pathology: implications for the physical therapist, Philadelphia, 2003, Saunders, Table 38-7, p 1149.
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tarsal tunnel syndrome is not high. Bilateral median nerve neuritis can be characteristic of many systemic diseases, including rheumatoid arthritis, myxedema, localized amyloidosis, sarcoidosis, and infiltrative leukemia. ' Whenever a client presents with bilateral symptoms, it represents a red flag. With bilateral CTS the therapist can screen for medical disease by using the Special Questions to Ask: Bilateral Carpal Tunnel Syndrome section (see Appendix B-4). 7 8
Periarthritis and Calcific Tendinitis Periarthritis (inflammation of periarticular structures, including the tendons, ligaments, and joint capsule) and calcific tendinitis occur most often in the shoulders of people who have endocrine disease. Treatment of the underlying endocrine impairment often improves the clinical picture; physical therapy intervention may have a temporary palliative effect. Chondrocalcinosis Chondrocalcinosis is the deposition of calcium salts in the cartilage of joints. When accompanied by attacks of goutlike symptoms, it is called pseudogout. Chondrocalcinosis is commonly seen on x-ray films as calcified hyaline or fibrous cartilage. There is an associated underlying endocrine or metabolic disease in approximately 5% to 10% of individuals with chondrocalcinosis (Table 11-3).
Spondyloarthropathy and Osteoarthritis Spondyloarthropathy (disease of joints of the spine) and osteoarthritis occur in individuals with various metabolic or endocrine diseases, including hemochromatosis (disorder of iron metabolism with excess deposition of iron in the tissues; also known as bronze diabetes and iron storage disease),
TABLE 11-3
Endocrine and Metabolic Disorders Associated with Chondrocalcinosis
Endocrine Hypothyroidism Hyperparathyroidism Acromegaly
Metabolic Hemochromatosis Hypomagnesemia Hypophosphatasis Ochronosis Oxalosis Wilson's disease
Modified from Louthrenoo W, Schumacher HR: Musculoskeletal clues to endocrine or metabolic disease, J Musculoskel Med 7(9):41, 1990.
ochronosis (metabolic disorder resulting in discoloration of body tissues caused by deposits of alkapton bodies), acromegaly, and diabetes mellitus.
Hand Stiffness and Hand Pain Hand stiffness and hand pain, as well as arthralgias of the small joints of the hand, can occur with endocrine and metabolic diseases. Hypothyroidism is often accompanied by CTS; flexor tenosynovitis with stiffness is another common finding.
ENDOCRINE PATHOPHYSIOLOGY Disorders of the endocrine glands can be classified as primary (dysfunction of the gland itself) or secondary (dysfunction of an outside stimulus to the gland) and are a result of either an excess or an insufficiency of hormonal secretions. Secondary dysfunction may also occur (iatrogenically) as a result of chemotherapy, surgical removal of the glands, therapy for a nonendocrine disorder (e.g., the use of large doses of corticosteroids resulting in Cushing's syndrome), or excessive therapy for an endocrine disorder.
Pituitary Gland Diabetes
Insipidus
Diabetes insipidus is caused by a lack of secretion of vasopressin (antidiuretic hormone [ADH]). This hormone normally stimulates the distal tubules of the kidneys to reabsorb water. Without ADH, water moving through the kidney is not reabsorbed but is lost in the urine, resulting in severe water loss and dehydration through diuresis. Central or neurogenic diabetes insipidus, which is the most common type, can be idiopathic (primary) or related to other causes (secondary), such as pituitary trauma, head injury, infections such as meningitis or encephalitis, pituitary neoplasm, and vascular lesions such as aneurysms. If the person with diabetes insipidus is unconscious or confused and is unable to take in necessary fluids to replace those fluids lost, rapid dehydration, shock, and death can occur. Because sleep is interrupted by the persistent need to void (nocturia), fatigue and irritability result. Clinical Signs and Symptoms of
Diabetes Insipidus • •
Polyuria (increased urination) Polydipsia (increased thirst, which occurs subsequent to polyuria in response to the loss of fluid)
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• Dehydration • Decreased urine specific gravity (1.001 to 1.005) • Nocturia, fatigue, irritability • Increased serum sodium (more than 145mEq/dL; resulting from concentration of serum from water loss)
Syndrome of Inappropriate Antidiuretic Hormone
Secretion
of
Syndrome of inappropriate secretion of ADH (SIADH) is an excess or inappropriate secretion of vasopressin that results in marked retention of water in excess of sodium in the body. Urine output decreases dramatically as the body retains large amounts of water. Almost all the excess water is distributed within body cells, causing intracellular water gain and cellular swelling (water intoxication). RISK FACTORS
Risk factors for the development of SIADH include pituitary damage caused by infection, trauma, or neoplasm; secretion of vasopressin-like substances from some types of malignant tumors (particularly pulmonary malignancies); and thoracic pressure changes from compression of pulmonary or cardiac pressure receptors, or both. CLINICAL P R E S E N T A T I O N
Symptoms of SIADH are the clinical opposite of symptoms of diabetes insipidus. They are the result of water retention and the subsequent dilution of sodium in the blood serum and body cells. Neurologic and neuromuscular signs and symptoms predominate and are directly related to the swelling of brain tissue and sodium changes within neuromuscular tissues. Clinical Signs and Symptoms of Syndrome of
Inappropriate Secretion of Antidiuretic H o r m o n e •
Headache, confusion, lethargy (most signifi-
• • • • • •
cant early indicators) Decreased urine output Weight gain without visible edema Seizures Muscle cramps Vomiting, diarrhea Increased urine specific gravity (greater than
1.03) •
Decreased serum sodium (less than 135 mEq/dL; caused by dilution of serum from water)
471
Acromegaly Acromegaly is an abnormal enlargement of the extremities of the skeleton resulting from hypersecretion of growth hormone (GH) from the pituitary gland. This condition is relatively rare and occurs in adults, most often owing to a tumor of the pituitary gland. In children, overproduction of GH stimulates growth of long bones and results in gigantism, in which the child grows to exaggerated heights. With adults, growth of the long bones has already stopped, so the bones most affected are those of the face, jaw, hands, and feet. Other signs and symptoms include amenorrhea (in women), diabetes mellitus, profuse sweating, and hypertension. CLINICAL P R E S E N T A T I O N
Degenerative arthropathy may be seen in the peripheral joints of a client with acromegaly, most frequently attacking the large joints. On x-ray studies, osteophyte formation may be seen, along with widening of the joint space because of increased cartilage thickness. In late-stage disease, joint spaces become narrowed, and occasionally chondrocalcinosis may be present. Stiffness of the hand, typically of both hands, is associated with a broad enlargement of the fingers from bony overgrowth and with thickening of the soft tissue. Thickening and widening of the phalangeal tufts are typical x-ray findings in soft tissue. In clients with these x-ray findings, much of the pain and stiffness is believed to be due to premature osteoarthritis. Carpal tunnel syndrome (CTS) is seen in up to 50% of people with acromegaly. The CTS that occurs with this growth disorder is thought to be caused by compression of the median nerve at the wrist from soft tissue hypertrophy or bony overgrowth or by hypertrophy of the median nerve itself. Myopathy in people with acromegaly is commonly reported but poorly understood. Changes in muscle size and strength are associated with acromegaly and are probably multifactoral in origin. Screening individuals with acromegaly for muscle weakness and poor exercise tolerance is now recommended. About half the individuals with acromegaly have back pain. X-ray studies demonstrate increased intervertebral disc spaces and large osteophytes along the anterior longitudinal ligament (ALL), mimicking diffuse idiopathic skeletal hyperostosis (DISH). DISH (also known as Forestier's disease) is characterized by abnormal ossification of the ALL, 9
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resulting in an x-ray image of large osteophytes seemingly "flowing" along the anterior border of the spine. DISH is particularly common in the thoracic spine and has been reported to be more prevalent among persons with diabetes than among the nondiabetic population. DISH appears to be an age-related predisposition to ossification of tendon, joint capsule, and ligamentous attachments. Identification of the presence of DISH syndrome prior to surgery is important in the prevention of heterotropic bone formation. 10
Clinical Signs and Symptoms of
Acromegaly •
Bony enlargement (face, jaw, hands, feet)
• • • • • • • •
Amenorrhea Diabetes mellitus Profuse sweating (diaphoresis) Hypertension Carpal tunnel syndrome Hand pain and stiffness Back pain (thoracic and/or lumbar) Myopathy and poor exercise tolerance
Adrenal Glands The adrenals are two small glands located on the upper part of each kidney. Each adrenal gland consists of two relatively discrete parts: an outer cortex and an inner medulla. The outer cortex is responsible for the secretion of mineralocorticoids (steroid hormones that regulate fluid and mineral balance), glucocorticoids (steroid hormones responsible for controlling the metabolism of glucose), and androgens (sex hormones). The centrally located adrenal medulla is derived from neural tissue and secretes epinephrine and norepinephrine. Together, the adrenal cortex and medulla are major factors in the body's response to stress.
Adrenal
Insufficiency
PRIMARY ADRENAL INSUFFICIENCY Chronic adrenocortical insufficiency (hyposecretion by the adrenal glands) may be primary or secondary. Primary adrenal insufficiency is also referred to as Addison's disease (hypofunction), named after the physician who first studied and described the associated symptoms. It can be treated by the administration of exogenous Cortisol (one of the adrenocortical hormones). Primary adrenal insufficiency occurs when a disorder exists within the adrenal gland itself. This adrenal gland disorder results in decreased production of Cortisol and aldosterone, two of the
primary adrenocortical hormones. The most common cause of primary adrenal insufficiency is an autoimmune process that causes destruction of the adrenal cortex. The most striking physical finding in the person with primary adrenal insufficiency is the increased pigmentation of the skin and mucous membranes. This discoloration may vary in the white population from a slight tan or a few black freckles to an intense generalized pigmentation, which has resulted in persons being mistakenly considered to be of a darker-skinned race. Members of darkerskinned races may develop a slate-gray color that may be obvious only to family members. Melanin, the major product of the melanocyte, is largely responsible for the coloring of skin. In primary adrenal insufficiency, the increase in pigmentation is initiated by the excessive secretion of melanocyte-stimulating hormone (MSH) that occurs in association with increased secretion of ACTH. ACTH is increased in an attempt to stimulate the diseased adrenal glands to produce and release more Cortisol. Most commonly, pigmentation is visible over extensor surfaces, such as the backs of the hands; elbows; knees; and creases of the hands, lips, and mouth. Increased pigmentation of scars formed after the onset of the disease is common. However, it is possible for a person with primary adrenal insufficiency to demonstrate no significant increase in pigmentation. SECONDARY ADRENAL INSUFFICIENCY
Secondary adrenal insufficiency refers to a dysfunction of the gland because of insufficient stimulation of the cortex owing to a lack of pituitary ACTH. Causes of secondary disease include tumors of the hypothalamus or pituitary, removal of the pituitary, or rapid withdrawal of corticosteroid drugs. Clinical manifestations of secondary disease do not occur until the adrenals are almost completely nonfunctional and are primarily related to Cortisol deficiency only. Clinical Signs and Symptoms of
A d r e n a l Insufficiency •
•
Dark pigmentation of the skin, especially mouth and scars (occurs only with primary disease; Addi son si
Hypotension (low blood pressure causing orthostatic symptoms) • Progressive fatigue (improves with rest) • Hyperkalemia (generalized weakness and muscle flaccidity)
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Gastrointestinal (Gl) disturbances Anorexia and weight loss Nausea and vomiting Arthralgias, myalgias (secondary only) Tendon calcification Hypoglycemia
Cushing's
Syndrome
Cushing's syndrome (hyperfunction of the adrenal gland) is a general term for increased secretion of Cortisol by the adrenal cortex. When corticosteroids are administered externally, a condition of hypercortisolism called iatrogenic Cushing's syndrome occurs, producing a group of associated signs and symptoms. Hypercortisolism caused by excess secretion of ACTH (e.g., from pituitary stimulation) is called ACTH-dependent Cushing's syndrome. Therapists often treat people who have developed Cushing's syndrome after these clients have received large doses of Cortisol (also known as hydrocortisone) or Cortisol derivatives (e.g., dexamethasone) for a number of inflammatory disorders (Case Example 11-1). It is important to remember that whenever corticosteroids are administered externally, the increase in serum Cortisol levels triggers a nega-
473
tive feedback signal to the anterior pituitary gland to stop adrenal stimulation. Adrenal atrophy occurs during this time, and adrenal insufficiency will result if external corticosteroids are abruptly withdrawn. Corticosteroid medications must be reduced gradually so that normal adrenal function can return. Because Cortisol suppresses the inflammatory response of the body, it can mask early signs of infection. Any unexplained fever without other symptoms should be a warning to the therapist of the need for medical follow-up. Clinical Signs and Symptoms of
Cushing's S y n d r o m e •
11
• • • • • • •
"Moonface" appearance (very round face; Fig. 11-2) Buffalo hump at the neck (fatty deposits) Protuberant abdomen with accumulation of fatty tissue and stretch marks Muscle wasting and weakness Decreased density of bones (especially spine) Hypertension Kyphosis and back pain (secondary to bone loss) Easy bruising Continued on p. 474
CASE EXAMPLE
11-1
Cushing's Syndrome
A 53-year-old woman with Cushing's syndrome resulting from long-term use of Cortisol for systemic lupus erythematosus reports the following problems: • Hair and nail thinning and breaking easily • Temperature intolerance (always cold) • Muscle cramps • Generalized weakness and fatigue Her primary complaint and reason for referral to physical therapy is for sacroiliac (SI) joint pain as a result of stepping down off an uneven curb. You realize the signs and symptoms are of an endocrine origin, but you do not know whether they are part of the Cushing's syndrome or a separate endocrine problem. Should you send this client to a physician (or back to the referring physician)? Not necessarily. This is more a case of need for additional information. Requesting a copy of the client's most recent physician's notes may
answer all of your questions. Reading the physician's systems review portion of the exam may reveal a record of these signs and symptoms with a corresponding medical problem list and plan. If there is no mention of any of these associated signs and symptoms, a phone call to the physician's office may be the next step. If you speak with the physician directly, identify yourself and your connection with the client by name. Briefly mention why you are seeing this client and make the following observation: "Mrs. Jones reports muscle cramps and generalized weakness that do not seem consistent with her SI problem. She complains of temperature intolerance and hair and nail bed changes. These symptoms are outside the scope of my practice. Can you help me understand this? Are they part of her lupus, Cushing's syndrome, or something else?"
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A
B
Fig. 11-2 • A, Comparison of hyperfunction of the adrenal cortex (Addison's disease) and hypofunction (Cushing's syndrome). B, Individuals treated with corticosteroids can develop clinical features of Cushing's syndrome called cushingoid features including "moonface," obesity, and cutaneous striae as shown here. (From Damjanov I: Pathology for the health-related profession, ed 2, Philadephia, Saunders, 2000. Used with permission.)
• •
Psychiatric or emotional disturbances Impaired reproductive function (e.g., decreased libido and changes in menstrual cycle) • Diabetes mellitus • Slow wound healing • For women: Masculinizing effects (e.g., hair growth, breast atrophy, voice changes) EFFECTS OF CORTISOL ON CONNECTIVE TISSUE
Overproduction of Cortisol or closely related glucocorticoids by abnormal adrenocortical tissue leads
to a protein catabolic state. This overproduction causes liberation of amino acids from muscle tissue. The resultant weakened protein structures (muscle and elastic tissue) cause a protuberant abdomen, poor wound healing, generalized muscle weakness, and marked osteoporosis (demineralization of bone causing reduced bone mass), which is made worse by an excessive loss of calcium in the urine. Excessive glucose resulting from this protein catabolic state is transformed mainly into fat and appears in characteristic sites, such as the
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abdomen, supraclavicular fat pads, and facial cheeks. The change in facial appearance may not be readily apparent to the client or to the therapist, but pictures of the client taken over a period of years may provide a visual record of those changes. The effect of increased circulating levels of Cortisol on the muscles of clients varies from slight to very marked. There may be so much muscle wasting that the condition simulates muscular dystrophy. Marked weakness of the quadriceps muscle often prevents affected clients from rising out of a chair unassisted. Those with Cushing's syndrome of long duration almost always demonstrate demineralization of bone. In severe cases, this condition may lead to pathologic fractures, but it results more commonly in wedging of the vertebrae, kyphosis, bone pain, and back pain Obesity, diabetes, polycystic ovarian syndrome, and other metabolic/endocrine problems can resemble Cushing's syndrome. It is important to recognize critical indicators of this particular disorder such as excessive hair growth, moonface, mood disorders, and increased muscle weakness as indicators for further endocrine diagnostic testing. The poor wound healing that is characteristic of this syndrome becomes a problem when any surgical procedures are required. Inhibition of collagen formation with corticosteroid therapy is responsible for the frequency of wound breakdown in postsurgical clients. 12
Thyroid Gland The thyroid gland is located in the anterior portion of the lower neck below the larynx, on both sides of and anterior to the trachea. The chief hormones produced by the thyroid are thyroxine (T ), triiodothyronine (T ), and calcitonin. Both T and T regulate the metabolic rate of the body and increase protein synthesis. Calcitonin has a weak physiologic effect on calcium and phosphorus balance in the body. Genetics plays a role in thyroid disease. A family history of thyroid disease is a risk factor. Age and gender are also factors; most cases occur after age 50. Women are more likely than men to develop thyroid dysfunction. Data gathered on the medical history of the orthopedic physical therapy outpatient population indicate a 7% incidence of thyroid disease in the female population. Thyroid function is regulated by the hypothalamus and pituitary feedback controls, as well as by an intrinsic regulator mechanism within the 4
3
3
4
12
13
475
gland itself. Basic thyroid disorders of significance to physical therapy practice include goiter, hyperthyroidism, hypothyroidism, and cancer. Alterations in thyroid function produce changes in hair, nails, skin, eyes, GI tract, respiratory tract, heart and blood vessels, nervous tissue, bone, and muscle. The risk of having thyroid diseases increases with age, but in people older than 60 years of age, it becomes more difficult to detect because it masquerades as other problems such as heart disease, depression, or dementia. Fatigue and weakness may be the first symptoms among older adults, often mistaken or attributed to normal aging. Newonset depression in the older adult population and anxiety syndromes are also symptoms that can indicate thyroid dysfunction. On the other hand, thyroid dysfunction can mimic signs and symptoms of aging such as hair loss, fatigue, and depression. The therapist may recognize problems early and make a medical referral, minimizing the client's symptoms. A simple and inexpensive blood test called a thyroidstimulating hormone (TSH) test is usually recommended to show whether the thyroid gland is hyper or hypofunctioning. 14
15
Goiter Goiter, an enlargement of the thyroid gland, occurs in areas of the world where iodine (necessary for the production of thyroid hormone) is deficient in the diet. It is believed that when factors (e.g., a lack of iodine) inhibit normal thyroid hormone production, hypersecretion of TSH occurs because of a lack of a negative feedback loop. The TSH increase results in an increase in thyroid mass. Pressure on the trachea and esophagus causes difficulty in breathing, dysphagia, and hoarseness. With the use of iodized salt, this problem has almost been eliminated in the United States. Although the younger population in the United States may be goiter free, older adults may have developed goiter during their childhood or adolescent years and may still have clinical manifestations of this disorder. Clinical Signs and Symptoms of
Goiter • •
Increased neck size Pressure on adjacent tissue (e.g., trachea and esophagus) • Difficulty in breathing • Dysphagia • Hoarseness
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Thyroiditis Thyroiditis is an inflammation of the thyroid gland. Causes can include infection and autoimmune processes. The most common form of this problem is a chronic thyroiditis called Hashimoto's thyroiditis. This condition affects women more frequently than men and is most often seen in the 30to 50-year-old age group. Destruction of the thyroid
CASE EXAMPLE
11-2
gland from this condition can cause eventual hypothyroidism (Case Example 11-2). Usually, both sides of the gland are enlarged, although one side may be larger than the other. Other symptoms are related to the functional state of the gland itself. Early involvement may cause mild symptoms of hyperthyroidism, whereas later symptoms cause hypothyroidism.
Hashimoto's Thyroiditis
Referral: A 38-year-old woman with rightsided groin pain was referred to physical therapy by her physician. She says that the pain came on suddenly without injury. The pain is worse in the morning and hurts at night, waking her up when she changes position. The woman's symptoms are especially acute when she tries to stand up after sitting, with weight bearing impossible for the first 5 to 10 minutes. The woman, who looks athletic, reports that before the onset of this problem, she was running 5 miles every other day without difficulty. The x-ray finding is reportedly within normal limits for structural abnormalities. Sed rate was 16mm/hr.* The client has chronic sinusitis and has had two surgeries for that condition in the last 3 years. She is not a smoker and drinks only occasionally on a social basis. This client was seen 6 weeks ago by another physical therapist, who tried ultrasound and stretching without improvement in symptoms or function. Clinical Presentation: The physical therapy evaluation today revealed a positive Thomas test for right hip flexion contracture. However, it was difficult to assess whether there was a true muscle contracture or only loss of motion as a result of muscle splinting and guarding. Patrick's test (FABER's) for hip pathology and the iliopsoas test for intraabdominal infection were both negative. Joint accessory motions appeared to be within normal limits, given that the movements were tested in the presence of some residual muscle tension
from protective splinting. A neurologic screen failed to demonstrate the presence of any neurologic involvement. Symptoms could be reproduced with deep palpation of the right groin area. There were no active or passive movements that could alter, provoke, change, or eliminate the pain. There were no trigger points in the abdomen or right lower quadrant that could account for the symptomatic presentation. There was no apparent cause for her movement system impairment. Physical therapy intervention with soft tissue mobilization and proprioceptive neuromuscular facilitation techniques were initiated and used as a diagnostic tool. There was no change in the client's symptoms or clinical presentation as the therapist continued trying a series of physical therapy techniques. Result: In a young and otherwise healthy adult, a lack of measurable, reportable, or observable progress becomes a red flag for further medical follow-up. The results of the physical therapy examination and lack of response to treatment constitute a valuable medical diagnostic tool. Further laboratory results revealed a medical diagnosis of Hashimoto's thyroiditis. Treatment with thyroxine (T ) resulted in resolution of the musculoskeletal symptoms. The correlation between groin pain and loss of hip extension with Hashimoto's remains unclear. Even so, response to the red flag (no change or improvement with intervention) resulted in a correct medical diagnosis. 4
* The sedimentation (SED) rate (an indication of possible infection or inflammation) was within normal limits for an adult woman.
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477
Clinical Signs and Symptoms of
Thyroiditis •
Painless thyroid enlargement
• Dysphagia or choking • Anterior neck, shoulder, or rib cage pain without biomechanical changes • Gland sometimes easily palpable over anterior neck (warm, tender, swollen)
Hyperthyroidism Hyperthyroidism (hyperfunction), or thyrotoxicosis, refers to those disorders in which the thyroid gland secretes excessive amounts of thyroid hormone. Graves' disease is a common type of excessive thyroid activity characterized by a generalized enlargement of the gland (or goiter leading to a swollen neck) and, often, protruding eyes caused by retraction of the eyelids and inflammation of the ocular muscles. CLINICAL P R E S E N T A T I O N
Excessive thyroid hormone creates a generalized elevation in body metabolism. The effects of thyrotoxicosis occur gradually and are manifested in almost every system (Fig. 11-3; Table 11-4). In more than 50% of adults older than 70, three common signs are tachycardia, fatigue, and weight loss. In clients younger than 50, clinical signs and symptoms found most often include tachycardia, hyperactive reflexes, increased sweating, heat intolerance, fatigue, tremor, nervousness, polydipsia, weakness, increased appetite, dyspnea, and weight loss. Chronic periarthritis is also associated with hyperthyroidism. Inflammation that involves the periarticular structures, including the tendons, ligaments, and joint capsule, is termed periarthritis. The syndrome is associated with pain and reduced range of motion. Calcification, whether periarticular or tendinous, may be seen on x-ray studies. Both periarthritis and calcific tendinitis occur most often in the shoulder, and both are common findings in clients who have endocrine disease (Case Example 11-3). Painful restriction of shoulder motion associated with periarthritis has been widely described among clients of all ages with hyperthyroidism. The involvement can be unilateral or bilateral and can worsen progressively to become adhesive capsulitis (frozen shoulder). Acute calcific tendinitis of the wrist also has been described in such clients. Although antiinflammatory agents may be needed for the acute symptoms, chronic periarthritis 16
Fig. 1 1 - 3 * Comparison of hyperthyroidism and hypothyroidism. (From Damjanov I: Pathology for the health-related profession, ed 2, Philadephia, Saunders, 2000. Used with permission.)
usually responds to treatment of the underlying hyperthyroidism. Proximal muscle weakness (most marked in the pelvic girdle and thigh muscles), accompanied by muscle atrophy known as myopathy, occurs in up to 70% of people with hyperthyroidism. Muscle strength returns to normal in about 2 months after medical treatment, whereas muscle wasting
478
TABLE 11-4
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Systemic Manifestations of Hyperthyroidism
CNS effects
Tremors Hyperkinesis (abnormally increased motor function or activity) Nervousness, irritability Emotional lability Weakness and muscle atrophy Increased deep tendon reflexes Fatigue
Cardiovascular and pulmonary effects
Joint integumentary effects
Ocular effects
Gl effects
GU effects
Increased pulse rate/tachycardia/palpitations Arrhythmias (palpitations) Weakness of respiratory muscles (breathlessness, hypoventilation) Increased respiratory rate Low blood pressure Heart failure
Chronic periarthritis Capillary dilation (warm flushed, moist skin) Heat intolerance Onycholysis (separation of the fingernail from the nail bed) Easily broken hair and increased hair loss Hyperpigmentation Hard, purple area over the anterior surface of the tibia with itching erythema, and occasionally pain
Weakness of the extraocular muscles (poor convergence, poor upward gaze) Sensitivity to light Visual loss Spasm and retraction of the upper eyelids (bulging eyes), lid tremor
Hypermetabolism (increased appetite with weight loss) Increased peristalsis Diarrhea, nausea, and vomiting Dysphagia
Polyuria (frequent urination) Amenorrhea (absence of menses) Female infertility First-trimester miscarriage and frequency of bowel movements
CASE EXAMPLE
1 1-3
G r a v e s ' Disease (Hyperthyroidism)
A 73-year-old woman who has rheumatoid arthritis has just joined the Physical Therapy Aquatic Program. Despite the climate-controlled facility, she becomes flushed, demonstrates an increased respiratory rate that is inconsistent with her level of exercise, and begins to perspire profusely. She reports muscle cramping of the arms and legs and sudden onset of a headache.
Questions • How would you handle this situation? • Can this client resume the aquatic program when her symptoms have resolved? Result: The client was quickly escorted from the pool. Her vital signs were taken and recorded for future reference. Later, the thera-
resolves more slowly. In severe cases normal strength may not be restored for months. The incidence of myasthenia gravis is increased in clients with hyperthyroidism, which in turn can aggravate muscle weakness. If the hyperthyroidism is corrected, improvement of myasthenia gravis follows in about two thirds of clients.
pist reviewed the client's health history and noted that the "thyroid medication" she reported taking was actually an antithyroid medication for Graves' disease. The heat intolerance associated with the Graves' disease (hyperthermia secondary to accelerated metabolic rate) presents a potential contraindication for aquatic or pool therapy. Heat intolerance contributes to exercise intolerance, and the client was exhibiting signs and symptoms of heat stroke, even when exercising in a climate-controlled facility. The physician was notified of the symptoms and how quickly the onset occurred (after only 5 minutes of warm-up exercises). Strenuous exercise or a conditioning program should be delayed until symptoms of heat intolerance, tachycardia, or arrhythmias are under medical control.
THYROID STORM
Life-threatening complications with hyperthyroidism are rare but still important for the therapist to recognize. Unrecognized disease, untreated disease, or incorrect treatment can result in a condition called thyroid storm. In addition, precipitating factors such as trauma, infection, or surgery
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can turn well-controlled hyperthyroidism into a thyroid storm. Thyroid storm includes severe tachycardia with heart failure, shock, and hyperthermia (up to 105.3 degrees F [40.7 degrees C]). Restlessness, agitation, abdominal pain, nausea and vomiting, and coma can occur. Medical referral is required to return the client to a normal thyroid state and prevent cardiovascular or hyperthermia collapse. Look for a recent history of the precipitating factors mentioned.
Hypothyroidism Hypothyroidism (hypofunction) is more common than hyperthyroidism, results from insufficient thyroid hormone, and creates a generalized depression of body metabolism. Hypothyroidism in fetal development and infants is usually a result of absent thyroid tissue and hereditary defects in thyroid hormone synthesis. Untreated congenital hypothyroidism is referred to as cretinism. The condition may be classified as either primary or secondary. Primary hypothyroidism results from reduced functional thyroid tissue mass or impaired hormonal synthesis or release (e.g., iodine deficiency, loss of thyroid tissue, autoimmune thyroiditis). Secondary hypothyroidism (which accounts for a small percentage of all cases of hypothyroidism) occurs as a result of inadequate stimulation of the gland because of pituitary disease. RISK FACTORS Women are 10 times more likely than men to have hypothyroidism. More than 10% of women over age 65 and 15% over age 70 are diagnosed with this disorder. Risk factors include surgical removal of the thyroid gland, external irradiation, and some medications (e.g., lithium, amiodarone). CLINICAL PRESENTATION As with all disorders affecting the thyroid and parathyroid glands, clinical signs and symptoms affect many systems of the body (Table 11-5). Because the thyroid hormones play such an important role in the body's metabolism, lack of these hormones seriously upsets the balance of body processes. Among the primary symptoms associated with hypothyroidism are intolerance to cold, excessive fatigue and drowsiness, headaches, and weight gain. In women, menstrual bleeding may become irregular, and premenstrual syndrome (PMS) may worsen. Physical assessment often reveals dryness of the skin and increasing thinness and brittleness
479
of the hair and nails. There may be nodules or other irregularities of the thyroid palpable during anterior neck examination. Ichthyosis, or dry scaly skin (resembling fish scales; the word ichthyosis is derived from the Latin word ichthus, which means "fish"), may be an inherited dermatologic condition (Fig. 11-4). It may also be the result of a thyroid condition. It must not be assumed that clients who present with this condition are merely in need of better hydration or regular use of skin lotion. A medical referral is needed to rule out underlying pathology. Myxedema A characteristic sign of hypothyroidism and more rarely associated with hyperthyroidism (Graves' disease) is myxedema (often used synonymously with hypothyroidism). Myxedema is a result of an alteration in the composition of the dermis and other tissues, causing connective tissues to be separated by increased amounts of mucopolysaccharides and proteins. This mucopolysaccharide-protein complex binds with water, causing a nonpitting, boggy edema especially around the eyes, hands, and feet and in the supraclavicular fossae (Case Example 11-4). The binding of this protein-mucopolysaccharide complex causes thickening of the tongue and the laryngeal and pharyngeal mucous membranes. This results in hoarseness and thick, slurred speech, which are also characteristic of untreated hypothyroidism. Clients who have myxedematous hypothyroidism may demonstrate synovial fluid that is highly distinctive. The fluid's high viscosity results in a slow fluid wave that creates a sluggish "bulge" sign visible at the knee joint. Often, the fluid contains calcium pyrophosphate dihydrate (CPPD) crystal deposits that may be associated with chondrocalcinosis (deposit of calcium salts in joint cartilage). Thus a finding of a highly viscous, "noninflammatory" joint effusion containing CPPD crystals may suggest to the physician possible underlying hypothyroidism. When such clients with hypothyroidism have been treated with thyroid replacement, some have experienced attacks of acute pseudogout caused by CPPD crystals remaining in the synovial fluid. Neuromuscular Symptoms Neuromuscular symptoms are among the most common manifestations of hypothyroidism. Flexor tenosynovitis with stiffness often accompanies CTS in people with hypothyroidism. CTS can develop before other signs of hypothyroidism become evident. It is thought that this CTS arises from deposition of myxedematous tissue in the carpal tunnel area. Acroparesthesias may occur as a result of median
480
Systemic Manifestations of Hypothyroidism
CNS effects
Pulmonary effects
Cardiovascular effects
Hematologic effects
Integumentary effects
Gl effects
GU effects
Proximal muscle weakness Myalgias Trigger points Stiffness, cramps Carpal tunnel syndrome Prolonged deep tendon reflexes (especially Achilles) Subjective report of paresthesias without supportive objective findings Muscular and joint edema Back pain Increased bone density Decreased bone formation and resorption
Dyspnea Respiratory muscle weakness Pleural effusion
Bradycardia Congestive heart failure Poor peripheral circulation (pallor, cold skin, intolerance to cold, hypertension) Severe atherosclerosis Angina Elevated blood pressure Increased cholesterol, triglycerides, LDL Cardiomyopathy
Anemia Easy bruising
Myxedema (periorbital and peripheral) Thickened, cool, and dry skin Scaly skin (especially elbows and knees) Carotenosis (yellowing of the skin) Coarse, thinning hair Intolerance to cold Nonpitting edema of hands and feet Poor wound healing Thin, brittle nails
Anorexia Constipation Weight gain disproportionate to caloric intake Decreased absorption of nutrients Decreased protein metabolism (retarded skeletal and soft tissue growth) Delayed glucose uptake Decreased glucose absorption
Infertility Menstrual irregularity Heavy menstrual bleeding
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
Slowed speech and hoarseness Anxiety, depression Slow mental function (loss of interest in daily activities, poor short-term memory) Hearing impairment Fatigue and increased sleep Headache Cerebellar ataxia
Musculoskeletal effects
SECTION II
TABLE 11-5
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481
Fig. 11 -5 • Lymph node regions of the head and neck. Palpable nodal disease associated with thyroid carcinoma is commonly located lateral to the sternocleidomastoid muscle in the lower portion of the posterior triangle overlying the scalene muscles (dark red triangle). (Modified from Swartz MH: Textbook of physical diagnosis, Philadelphia, 1989, Saunders.) Fig. 11 -4 • Ichthyosis of the legs in a woman with severe hypothyroidism. (From Callen JP, Jorizzo J, Greer KE, et al: Dermatological signs of internal disease, Philadelphia, Saunders, 1988. Used with permission.)
nerve compression at the wrist. The paresthesias are almost always located bilaterally in the hands. Most clients do not require surgical treatment because the symptoms respond to thyroid replacement. Proximal muscle weakness sometimes accompanied by pain is common in clients who have hypothyroidism. As mentioned earlier, muscle weakness is not always related to either the severity or the duration of hypothyroidism and can be present several months before the diagnosis of hypothyroidism is made. Muscle bulk is usually normal; muscle hypertrophy is rare. Deep tendon reflexes are characterized by slowed muscle contraction and relaxation (prolonged reflex). Characteristically, the muscular complaints of the client with hypothyroidism are aches and pains and cramps or stiffness. Involved muscles are particularly likely to develop persistent myofascial trigger points (TrPs). Of particular interest to the therapist is the concept that clinically any compromise of the energy metabolism of muscle aggravates and perpetuates TrPs. Treatment of the underlying hypothyroidism is essential in eliminating the TrPs, but new research also supports the need for soft tissue treatment to achieve full recovery. 17
18
There appears to be an association between hypothyroidism and fibromyalgia syndrome (FMS). Individuals with FMS and clients with undiagnosed myofascial symptoms may benefit from a medical referral for evaluation of thyroid function. " 19
22
Neoplasms Cancer of the thyroid is a relatively uncommon, slow-growing neoplasm that rarely metastasizes. It is often the incidental finding in persons being treated for other disorders (e.g., musculoskeletal disorders involving the head and neck). Primary cancers of other endocrine organs are rare and are not encountered by the clinical therapist very often. Risk factors for thyroid cancer include female gender, age over 40 years, Caucasian race, iodine deficiency, family history of thyroid cancer, and being exposed to radioactive iodine (1-131), especially as children. In addition, nuclear power plant fallout could expose large numbers of people to 1-131 and subsequent thyroid cancer. The use of potassium iodide (KI) can protect the thyroid from the adverse effects of 1-131 and is recommended to be made available in areas of the country near nuclear power plants in case of nuclear fallout. The initial manifestation in adults and especially in children is a palpable lymph node or nodule in the neck lateral to the sternocleidomastoid muscle in the lower portion of the posterior triangle overlying the scalene muscles (Fig. 11-5). 23
24
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CASE EXAMPLE
11-4
V I S C E R O G E N I C C A U S E S O F PAIN A N D D Y S F U N C T I O N
Myxedema
Referral: A 36-year-old African-American woman with a history of Graves' disease came to an outpatient hand clinic as a self-referral with painless swelling in both hands and feet. She had seen her doctor 6 weeks ago and was told that she did not have rheumatoid arthritis and should see a physical therapist. Past Medical History: The woman had a 3-year history of Graves' disease, which was treated with thyroid supplementation. She had a family history of thyroid problems, maternal history of diabetes, and history of early death from heart attack (father). Aside from symptoms of hyperthyroidism, she did not have any health problems. Clinical Presentation: There was a mild swelling apparent in the soft tissues of the fingers and toes. Presentation was painless and bilateral although asymmetric (second and third digits of the right hand were affected; third and fourth digits of the left hand were symptomatic). The therapist was alerted to the unusual clinical presentation by the following signs: • Thickening of the skin over the affected digits in the hands and feet • Clubbing of all digits (fingers and toes) • Nonpitting edema and thickening of the skin over the front of the lower legs down to the feet
A physician must evaluate any client with a palpable nodule because a palpable nodule is often clinically indistinguishable from a mass associated with a benign condition. The presence of new-onset hoarseness, hemoptysis, or elevated blood pressure is a red-flag symptom for systemic disease. Clinical Signs and Symptoms of
T h y r o i d Carcinoma •
Presence of asymptomatic nodule or mass in thyroid tissue
• • • • •
Nodule is firm, irregular, painless Hoarseness Hemoptysis Dyspnea Elevated blood pressure
The client did not think these additional symptoms were present at the time she saw her physician 6 weeks ago, but she could not remember exactly. Result: The therapist was unsure if the symptoms present were normal manifestations of Graves' disease or an indication that the client's thyroid levels were abnormal. The physician was contacted with information about the additional signs and questions about this client's clinical presentation. The physician requested a return visit from the client, at which time further testing was done. The skin changes and edema of the lower legs are called pretibial myxedema. Myxedema is more commonly associated with hypothyroidism. When accompanied by digital clubbing and new bone formation, the condition is called thyroid acropachy. This condition is seen most often in individuals who have been treated for hyperthyroidism. Drug therapy for the thyroid function does not change the acropachy; treatment is palliative for relief of symptoms. Physical therapy intervention can be prescribed but has not been studied to prove effectiveness for this condition.
Parathyroid Glands Two parathyroid glands are located on the posterior surface of each lobe of the thyroid gland. These glands secrete parathyroid hormone (PTH), which regulates calcium and phosphorus metabolism. Parathyroid disorders include hyperparathyroidism and hypoparathyroidism. The therapist may see clients with parathyroid disorders in acute care settings and postoperatively because these disorders can result from diseases and surgical procedures. If damage or removal of these glands occurs, the resulting hypoparathyroidism (temporary or permanent) causes hypocalcemia, which can result in cardiac arrhythmias and neuromuscular irritability (tetany). Disorders of the parathyroid glands may produce periarthritis and tendinitis. Both types of
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inflammation may be crystal-induced and can be associated with periarticular or tendinous calcification.
Hyperparathyroidism Hyperparathyroidism (hyperfunction), or the excessive secretion of PTH, disrupts calcium, phosphate, and bone metabolism. The primary function of PTH is to maintain a normal serum calcium level. Elevated PTH causes release of calcium by the bone and accumulation of calcium in the bloodstream. Symptoms of hyperparathyroidism are related to this release of bone calcium into the bloodstream. This causes demineralization of bone and subsequent loss of bone strength and density. At the same time, the increase of calcium in the bloodstream can cause many other problems within the body, such as renal stones. The incidence of hyperparathyroidism is highest in postmenopausal women. The major cause of primary hyperparathyroidism is a tumor of a parathyroid gland, which results in the autonomous secretion of PTH. Renal failure, another common cause of hyperparathyroidism, causes hypocalcemia and stimulates PTH production. Hyperplasia of the gland occurs as it attempts to raise the blood serum calcium levels. Thiazide diuretics (used for hypertension) and lithium carbonate (used for some psychiatric problems) can exacerbate or even cause hyperparathyroid disorders. 25
26
CLINICAL P R E S E N T A T I O N
Many systems of the body are affected by hyperparathyroidism (Table 11-6). Proximal muscle weakness and fatigability are common findings and may be secondary to a peripheral neuropathic process. Myopathy of respiratory muscles with associated respiratory involvement often goes
TABLE 11-6
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unnoticed. Striking reversal of muscle weakness and atrophy occur with successful treatment of the underlying hyperparathyroidism. Other symptoms associated with hyperparathyroidism are muscle weakness, loss of appetite, weight loss, nausea and vomiting, depression, and increased thirst and urination (Case Example 11-5). Hyperparathyroidism can also cause GI problems, pancreatitis, bone decalcification, and psychotic paranoia (Fig. 11-6). Bone erosion, bone resorption, and subsequent bone destruction from hypercalcemia associated with hyperparathyroidism occurs rarely today. In most cases, hypercalcemia is mild and detected before any significant skeletal disease develops. The classic bone disease osteitis fibrosa cystica affects persons with primary or renal hyperparathyroidism. Bone lesions called Brown tumors appear at the end stages of the cystic osteitis fibrosa. There are increasing reports of this condition in hyperparathyroidism secondary to renal failure because of the increasing survival rates of clients on hemodialysis. Currently, skeletal manifestations of primary hyperparathyroidism are more likely to include bone pain secondary to osteopenia, especially diffuse osteopenia of the spine with possible vertebral fractures. In addition, a number of articular and periarticular disorders have been recognized in association with primary hyperparathyroidism. The therapist may encounter cases of ruptured tendons caused by bone resorption in clients with hyperparathyroidism. Inflammatory erosive polyarthritis may be associated with chondrocalcinosis and CPPD deposits in the synovial fluid. This erosion is called osteogenic synovitis. Concurrent illness and surgery (most often parathyroidectomy) are recognized inducers of acute arthritic episodes.
Systemic Manifestations of Hyperparathyroidism
Early CNS symptoms Lethargy, drowsiness, paresthesia Slow mentation, poor memory Depression, personality changes Easily fatigued Hyperactive deep tendon reflexes Occasionally glove-and-stocking distribution of sensory loss
Musculoskeletal effects
Gl effects
GU effects
Mild-to-severe proximal muscle weakness of the extremities Muscle atrophy Bone decalcification (bone pain, especially spine; pathologic fractures; bone cysts) Gout and pseudogout Arthralgias involving the hands Myalgia and sensation of heaviness in the lower extremities Joint hypermobility
Peptic ulcers Pancreatitis Nausea, vomiting, anorexia Constipation
Renal colic associated with kidney stones Hypercalcemia (polyuria, polydipsia, constipation) Kidney infections
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CASE
EXAMPLE
11-5
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Rheumatoid A r t h r i t i s and Hyperparathyroidism
Referral: A 58-year-old man was referred to physical therapy by his primary care physician with a diagnosis of new-onset rheumatoid arthritis. Chief complaint was bilateral sacroiliac (SI) joint pain and pain on palpation of the hands and wrists. When asked if he had any symptoms of any kind anywhere else in the body, he mentioned constipation, nausea, and loss of appetite. The family took the therapist aside and expressed concerns about personality changes, including apathy, depression, and episodes of paranoia. These additional symptoms were first observed shortly after the hand pain developed. Past Medical History: The client had a motorcycle accident 2 years ago but reported no major injuries and no apparent residual problems. He had a family history of heart disease and hypertension but was not hypertensive at the time of the physical therapy interview. There was no other contributory personal or family past medical history. Clinical Presentation: The therapist was unable to account for the sacroiliac joint pain. There were no particular movements that made it better or worse and no objective findings
Hypoparathyroidism Hypoparathyroidism (hypofunction), or insufficient secretion of PTH, most commonly results from accidental removal or injury of the parathyroid gland during thyroid or anterior neck surgery. A less common form of the disease can occur from a genetic autoimmune destruction of the gland. Hypofunction of the parathyroid gland results in insufficient secretion of PTH and subsequent hypocalcemia, hyperphosphatemia, and pronounced neuromuscular and cardiac irritability. CLINICAL PRESENTATION Hypocalcemia occurs when the parathyroids become inactive. The resultant deficiency of calcium in the blood alters the function of many tissues in the body. These altered functions are described by the systemic manifestations of signs and symptoms associated with hypoparathyroidism (Table 11-7).
to suggest an underlying movement system impairment. Other red flags included age, bilateral hand and SI symptoms, gastrointestinal distress, and psychologic/behavioral changes observed by the family. Result: The therapist contacted the referring physician with the results of her evaluation. During the telephone conversation, the therapist mentioned the family's concerns about the client's personality change and the fact that the client had bilateral symptoms that could not be provoked or relieved. Additional gastrointestinal symptoms were also discussed. At the physician's request, the client completed a short course of physical therapy intervention with an emphasis on posture, core training, and soft tissue mobilization. The client returned to the physician for a follow-up examination 4 weeks later. His symptoms were unchanged. After additional testing, the client was eventually diagnosed with hyperparathyroidism and treated accordingly. Both his hand and SI pain went away as well as most of the gastrointestinal problems.
The most significant clinical consequence of hypocalcemia is neuromuscular irritability. This irritability results in muscle spasms, paresthesias, tetany, and life-threatening cardiac arrhythmias. Muscle weakness and pain have been reported along with hypocalcemia in clients with hypoparathyroidism. Hypoparathyroidism is primarily treated through pharmacologic management with intravenous calcium gluconate, oral calcium salts, and vitamin D. Acute hypoparathyroidism is a lifethreatening emergency and is treated rapidly with calcium replacement, anticonvulsants, and prevention of airway obstruction.
Pancreas The pancreas is a fish-shaped organ that lies behind the stomach. Its head and neck are located in the curve of the duodenum, and its body extends horizontally across the posterior abdominal wall.
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485
Psychosis paranoia
Fig. 11 -6 • The pathologic processes of body structures as a result of excess parathyroid hormone. (From Muthe NC: Endocrinology: a nursing approach, Boston, 1 9 8 1 , Little, Brown, P 115.)
Kidney stones, secondary infections, and uremia
Bone decalcification pathologic fracture
Parathyroids on posterior surface of the thyroid
Heart failure associated with vascular damage and kidney pathology
Pancreatitis
TABLE 11-7
Peptic ulcers and other G.I. symptoms: nausea, vomiting, stipation
Calcium deposits in blood vessels resulting in hypertension
Systemic Manifestations of Hypoparathyroidism
CNS effects
Personality changes (irritability, agitation, anxiety, depression)
Musculoskeletal effects*
Cardiovascular effects*
Integumentary effects
Gl effects
Hypocalcemia (neuromuscular excitability and muscular tetany, especially involving flexion of the upper extremity) Spasm of intercostals muscles and diaphragm compromising breathing Positive Chvostek's sign (twitching of facial muscles with tapping of the facial nerve in front of the ear)
Cardiac arrhythmias Eventual heart failure
Dry, scaly, coarse, pigmented skin Tendency to have skin infections Thinning of hair, includeing eyebrows and eyelashes Fingernails and toenails become brittle and form ridges
Nausea and vomiting Constipation or diarrhea Neuromuscular stimulation of the intestine (abdominal pain)
* The most common and important effects for the therapist to be aware of are the musculoskeletal and cardiovascular effects.
The pancreas has dual functions. It acts as both an endocrine gland, secreting the hormones insulin and glucagon, and an exocrine gland, producing digestive enzymes. Disorders of endocrine function are included in this chapter, whereas disorders of exocrine function affecting digestion are included in Chapter 8.
Diabetes
Mellitus
Diabetes mellitus (DM) is a chronic disorder caused by deficient insulin or defective insulin action in the body. It is characterized by hyperglycemia (excess glucose in the blood) and disruption of the metabolism of carbohydrates, fats, and proteins. Over time, it results in serious small
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vessel and large vessel vascular complications and neuropathies. Type 1 DM is a condition in which little or no insulin is produced. It occurs in about 10% of all cases and usually occurs in children or young adults. Type 2 DM commonly occurs after age 40 and is a condition of defective insulin and/or impaired cell receptor binding of insulin. Table 11-8 depicts the major differences between type 1 and type 2 in presentation and treatment. Native Americans, Latino Americans, Native Hawaiians, and some Asian Americans and Pacific Islanders have been identified at particularly high risk for type 2 diabetes mellitus and its complications. 27
CLINICAL PRESENTATION Specific physiologic changes occur when insulin is lacking or ineffective. Normally, the blood glucose level rises after a meal. A large amount of this glucose is taken up by the liver for storage or for use by other tissues, such as skeletal muscle and fat. When insulin function is impaired, the glucose in the general circulation is not taken up or removed by these tissues; thus it continues to accumulate in the blood. Because new glucose has not been "deposited" into the liver, the liver synthesizes more glucose and releases it into the general circulation, which increases the already elevated blood glucose level. Protein synthesis is also impaired because amino acid transport into cells requires insulin.
TABLE 11-8
The metabolism of fats and fatty acids is altered, and instead of fat formation, fat breakdown begins in an attempt to liberate more glucose. The oxidation of these fats causes the formation of ketone bodies. Because the formation of these ketones can be rapid, they can build quickly and reach very high levels in the bloodstream. When the renal threshold for ketones is exceeded, the ketones appear in the urine as acetone (ketonuria). The accumulation of high levels of glucose in the blood creates a hyperosmotic condition in the blood serum. This highly concentrated blood serum then "pulls" fluid from the interstitial areas, and fluid is lost through the kidneys (osmotic diuresis). Because large quantities of urine are excreted (polyuria), serious fluid losses occur, and the conscious individual becomes extremely thirsty and drinks large amounts of water (polydipsia). In addition, the kidney is unable to resorb all the glucose, so glucose begins to be excreted in the urine (glycosuria). Certain medications can cause or contribute to hyperglycemia. Corticosteroids taken orally have the greatest glucogenic effect. Any person with diabetes taking corticosteroid medications must be monitored for changes in blood glucose levels. Other hormones produced by the body also affect blood glucose levels and can have a direct influence on the severity of diabetic symptoms. Epinephrine, glucocorticoids, and growth hormone can cause
Primary Differences Between Type 1 and Type 2 Diabetes Type 1
Type 2
Age of onset
Usually younger than 30
Type of onset Endogenous (own) insulin production Incidence Ketoacidosis Insulin injections Body weight at onset Management Etiology
Abrupt Little or none
Usually older than 35 (Can be younger if history of childhood obesity) Gradual Below normal or above normal
Factors
Hereditary Risk factors
5%-10% May occur Required Normal or thin Diet, exercise, insulin Possible viral/autoimmune, resulting in destruction of islet cells Yes May be autoimmune, environmental, genetic
90%-95% Unlikely Needed in 20% to 30% of clients 80% are obese Diet, exercise, oral hypoglycemic agents or insulin Obesity-associated insulin receptor resistance Yes Prediabetic Ethnicity • Native American • Hispanic/Latin • Native Hawaiian, Pacific Islanders
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significant elevations in blood glucose levels by mobilizing stored glucose to blood glucose during times of physical or psychologic stress. When persons with DM are under stress, such as during surgery, trauma, pregnancy, puberty, or infectious states, blood glucose levels can rise and result in the need for increased amounts of insulin. If these insulin needs cannot be met, a hyperglycemic emergency such as diabetic ketoacidosis can result. It is essential to remember that clients with DM who are under stress will have increased insulin requirements and may become symptomatic even though their disease is usually well controlled in normal circumstances. Clinical Signs and Symptoms of
Untreated o r Uncontrolled Diabetes M e l l i t u s The classic clinical signs and symptoms of untreated or uncontrolled diabetes mellitus usually include one or more of the following: • Polyuria: increased urination caused by osmotic diuresis •
Polydipsia: increased thirst in response to polyuria • Polyphagia: increased appetite and ingestion of food (usually only in type 1) • Weight loss in the presence of polyphagia: weight loss caused by improper fat metabolism and breakdown of fat stores (usually only in type 1) • Hyperglycemia: increased blood glucose level (fasting level greater than 126mg/dL) • Glycosuria: presence of glucose in the urine • Ketonuria: presence of ketone bodies in the urine (by-product of fat catabolism) • Fatigue and weakness • Blurred vision • Irritability • Recurring skin, gum, bladder, or other infections • Numbness/tingling in hands and feet • Cuts/bruises that are difficult and slow to heal
DIAGNOSIS To be diagnosed with diabetes, a person must have fasting plasma glucose (FPG) readings of 126 mg/dL or higher on two different days. The previous cutoff, set in 1979, was 140 mg/dL. This change occurred as a result of research showing that individuals with readings as low as the mid1208 have already started developing tissue damage from diabetes. A value greater than 100 mg/dL is
487
considered "pre-diabetic" and is a risk factor for future diabetes and cardiovascular disease. The American Diabetes Association offers consumers a risk test for diabetes (http://www. diabetes.org/risk-test.jsp). All adults should take this risk test; anyone 45 or older should be tested for diabetes every 3 years. Individuals with prediabetes should be tested every 1 to 2 years. The therapist can offer clients with pre-diabetes information on increased activity and exercise as a means of lowering their risk of developing diabetes. 28
PHYSICAL COMPLICATIONS At presentation, the client with DM may have a variety of serious physical problems. Infection and atherosclerosis are the two primary long-term complications of this disease and are the usual causes of severe illness and death in the person with diabetes. Blood vessels and nerves sustain major pathologic changes in the person affected by DM. Atherosclerosis in both large vessels (macrovascular changes) and small vessels (microvascular changes) develops at a much earlier age and progresses much faster in the individual with DM. The blood vessel changes result in decreased blood vessel lumen size, compromised blood flow, and resultant tissue ischemia. The pathologic endproducts are cerebrovascular disease (CVD), coronary artery disease (CAD), renal artery stenosis, and peripheral vascular disease. Microvascular changes, characterized by the thickening of capillaries and damage to the basement membrane, result in diabetic nephropathy (kidney disease) and diabetic retinopathy (disease of the retina). Diabetes is the leading cause of kidney failure and new cases of blindness in the United States as of 2002. Poorly controlled DM can lead to various tissue changes that result in impaired wound healing. Decreased circulation to the skin can further delay or diminish healing. Skin eruptions called xanthomas (Fig. 11-7) may appear when high lipid levels (e.g., cholesterol and triglycerides) in the blood cause fat deposits in the skin over extensor surfaces such as the elbows, knees, back of the head and neck, and heels. Yellow patches on the eyelids are another sign of hyperlipidemia. Medical referral is required to normalize lipid levels. 27
PHYSICAL COMPLICATIONS OF DIABETES MELLITUS • Atherosclerosis • Macrovascular disease
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• Carpal tunnel syndrome (mononeuropathy; ischemia of median nerve) • Charcot's joint (diabetic arthropathy) • Periarthritis • Hand stiffness • Limited joint mobility (LJM) syndrome • Flexor tenosynovitis • Dupuytren's contracture • Complex Regional Pain Syndrome (CRPS) Depression Depression is common in individuals with type 2 diabetes (see Box 3-10) and is linked with increased mortality in this population. Adults with diabetes and depression are less likely to follow recommendations for nutrition and exercise. They are less likely to check their blood glucose levels routinely and more likely to take drug "holidays" from their other medications (e.g., for hyperlipidemia or hypertension). Clients with diabetes who are depressed are more likely to miss health care appointments for prevention and intervention. Diabetic Neuropathy Neuropathy is the most common chronic complication of long-term DM. Neuropathy in the client with DM is thought to be related to the accumulation in the nerve cells of sorbitol, a by-product of improper glucose metabolism. This accumulation then results in abnormal fluid and electrolyte shifts and nerve cell dysfunction. The combination of this metabolic derangement and the diminished vascular perfusion to nerve tissues contributes to the severe problem of diabetic neuropathy. Risk Factors Other than glycemic control, there is no curative intervention for diabetic neuropathy. Identifying potentially modifiable risk factors for neuropathy is crucial; the therapist can have a key role in providing risk factor assessment for clients with diabetes. Risk factors for the development of diabetic neuropathy include the duration and severity of diabetes, elevated triglycerides, higher body mass index, and a history of smoking or hypertension. Clinical Presentation Neuropathy may affect the central nervous system, peripheral nervous system, or autonomic nervous system. Peripheral neuropathy usually develops first as a sensory impairment of the extremities. Autonomic involvement is more common with long-standing disease. Most common among the peripheral neuropathies are chronic sensorimotor distal symmetric polyneuropathy (DPN). Polyneuropathy affects peripheral nerves in distal lower extremities, causing burning and numbness in the feet. It 29
30,31
Fig. 1 1 - 7 * Multiple eruptive xanthomas over the extensor surface of the elbow in a client with poorly controlled diabetes. These lipid-filled nodules characterized by an intracellular accumulation of cholesterol develop in the skin, often around the extensor tendons. Medical referral is required; xanthomas in this population are a sign that the health-care team, including the therapist, must work with the client to provide further education about diabetes, gain better control of glucose levels, and prevent avoidable complications. These skin lesions will go away when the diabetes is under control. Xanthomas can occur in any condition with disturbances of lipoprotein metabolism (not just diabetes). (From Callen JP, Jorizzo J, Greer KE, et al: Dermatological signs of internal disease, Philadelphia, Saunders, 1 988. Used with permission.)
Cerebrovascular disease (CVD) Coronary artery disease (CAD) Renal artery stenosis Peripheral vascular disease (PVD) • Microvascular disease Nephropathy Retinopathy Decreased microcirculation to skin/body organs • Infection/impaired wound healing • Neuropathy • Autonomic (gastroparesis, diarrhea, incontinence, postural hypotension, decreased heart rate) • Peripheral (polyneuropathy, diabetic foot) • Diabetic amyotrophy
32,33
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can result in muscle weakness, atrophy, and foot drop. Diabetic neuropathy can produce a syndrome of bilateral but asymmetric proximal muscle weakness called diabetic amyotrophy. Although the muscle enzyme levels are usually normal, muscle biopsy reveals atrophy of type II muscle fibers. CTS (mononeuropathy) is also a common finding in persons with DM; it represents one form of diabetic neuropathy. As many as 5% to 16% of people with CTS have underlying diabetes. The mechanism is thought to be ischemia of the median nerve resulting from diabetes-related microvascular damage. This ischemia then causes increased sensitivity to even minor pressure exerted in the carpal tunnel area. Autonomic involvement affects the pace of the heart beat, blood pressure, sweating, and bladder function and can cause symptoms such as erectile dysfunction and gastroparesis (delayed stomach emptying).
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sensation that marks diabetic neuropathy. Severe degenerative arthritis similar to Charcot's joint has been noted in clients with CPPD crystal deposition disease. Shoulder, hand, and foot disorders are very common, and evaluation of clients with DM should include examination of these areas (Case Example 11-6). ' 35
36
Clinical Signs and Symptoms of
Charcot's J o i n t s Severe unilateral swelling (bilateral in 20% of cases but not bilateral at the same time) • Increased skin warmth • Redness •
•
Deep pressure sensation but significantly less pain than anticipated
• Normal x-rays initially but changes over time • Joint deformity
32
Clinical Signs and Symptoms of
Diabetic N e u r o p a t h y (at least two or more are present) Peripheral (Motor and Sensory) • • • • • • •
Sensory, vibratory impairment of the extremities Burning, stabbing, pain, or numbness distal lower extremities Extreme sensitivity to touch Muscle weakness and atrophy (diabetic amyotrophy) Absence of distal deep tendon reflexes (knee, ankle) Loss of balance Carpal tunnel syndrome
Autonomic • Gastroparesis (delayed emptying of the stomach) • Constipation or diarrhea • Erectile dysfunction (sex drive unaffected; sexual function decreased) • Urinary tract infections; urinary incontinence • Profuse sweating •
Lack of oil production resulting in dry, cracked skin susceptible to bacteria and infection • Pupillary adjustment restricted (difficulty seeing at night) • Orthostatic hypotension • Loss of heart rate variability
Charcot's joint, or neuropathic arthropathy, is a well-known complication of DM. This condition is due, at least in part, to the loss of proprioceptive
The large- and small-vessel changes that occur with DM contribute to the changes in the feet of individuals with diabetes. Sensory neuropathy, which may lead to painless trauma and ulceration, can progress to infection. Neuropathy can result in drying and cracking of the skin, which creates more openings for bacteria to enter. The combination of all these factors can ultimately lead to gangrene and eventually require amputation. Prevention of these problems by meticulous care of the diabetic foot can reduce the need for amputation by 50% to 75%. An annual foot screen by a health care provider is currently recommended for anyone with diabetes. This screen includes examination of toenails for length, thickness, and ingrown position. All calluses should be examined because ulceration can occur underneath them. General skin integrity, color, circulation, and structure should also be assessed. Whether a poorly controlled blood glucose level is a causative factor in the development of the longterm physical complications of diabetes is still controversial, but it does seem clear that these complications increase with the duration of the disease. Stable glycemic control, which prevents the fluctuation of blood glucose levels, has been shown to be helpful in decreasing neuropathic pain. Periarthritis Musculoskeletal disorders of the hand and shoulder, including periarthritis of the shoulder, is five times as common in this group as it is in individuals who do not have diabetes. The condition most often affects insulin-dependent people, and involvement is typically bilateral. 37
38
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CASE EXAMPLE
11-6
VISCEROGENIC C A U S E S O F PAIN A N D D Y S F U N C T I O N
Charcot S h o u l d e r ( N e u r o a r t h r o p a t h y )
Referral: A 44-year-old wheelchair-dependent man with type 2 diabetes who was well-known to the physical therapy clinic came in with new symptoms of right shoulder pain. There was no known trauma or injury to account for the changes in his shoulder. He had previously been evaluated for an exercise program as part of his diabetes management. Past Medical History: The client was involved in a rock-climbing accident 15 years ago. He has had multiple reconstructive surgeries for broken bones and frostbite of the lower extremities associated with the accident. He was diagnosed with type 2 diabetes 3 years ago and uses an insulin pump but does not have consistent control of his blood glucose levels over time. The man remains active and has resumed rock climbing along with many other outdoor activities. This new onset of shoulder pain has limited his activities and impaired his ability to propel his wheelchair. There is no other significant history to report. The client is a nonsmoker, drinks only occasionally and then only socially (one or two glasses of wine). He has not had any other symptoms; there have been no constitutional symptoms, loss of appetite, or other gastrointestinal problems. Clinical Presentation: Cervical spine and elbow were cleared for any loss of motion, weakness, or other problems that might contribute to shoulder pain. Gross examination of motion and strength of the left shoulder revealed no problems. The skin was normal on both sides, no cervical or supraclavicular lymph node changes were observed or palpated, and no other observable changes in the upper quadrant were evident.
The mechanism of this association is unclear, but it is believed to be related to fibroblast proliferation in the connective tissue structures around joints or to microangiopathy (disorder involving small blood vessels) involving the tendon sheaths. This periarthritic condition can behave unpredictably: It may regress spontaneously, remain stable, or progress to adhesive capsulitis or frozen shoulder. 39
Range of motion of the right shoulder: • Active and passive abduction were equal and limited to 60 degrees and painful. • Active and passive flexion were equal and limited to 65 degrees and painful. • Biceps and deltoid strength were both 4/5; upper trapezius and triceps strength was normal (5/5). • Grip strength appeared normal. Further neurologic screening exam revealed severely decreased proprioception of the entire right upper extremity; no other neurologic changes were observed or reported. Radial pulses intact and equal bilaterally. Referral Decision: The therapist decided an x-ray might be helpful before initiating a program of physical therapy intervention. The client was very active and athletic and may have injured the joint or fractured the bone. Given the severity of his diabetic course over the last 3 years, an x-ray might be helpful in revealing any related arthritis that may be present. The physician agreed with the therapist's assessment, and a radiographic examination was ordered. Result: X-ray studies revealed destruction of two thirds of the right humeral head with microfractures and fragmentation throughout. The diagnosis of Charcot shoulder or neuroarthropathy was made. In this case, the therapist's knowledge of the client's past medical history and awareness of the physical complications possible with diabetes led to the referral decision before further damage was done to the bone and joint. It is unusual for someone with this severe of a condition to present with only mild symptoms. His extreme athleticism and stoic attitude may have masked the intensity of his symptoms.
Hand Stiffness Diabetic stiff hand, limited joint mobility (LJM) syndrome, cheirarthritis (inflammation of the hand and finger joints), and diabetic contractures are common in both types of DM in direct relation to the presence and duration of microvascular complications. Flexor tenosynovitis, caused by accumulation of excessive dermal collagen in the fingers, results in thickening and induration of the skin
CHAPTER 11
around the joints. This condition can lead to sclerodactyly (hardening and shrinking of fingers and toes), which in turn can mimic scleroderma. Dupuytren's contracture has a strong association with DM. The syndrome is characterized by nodular thickening of the palmar fascia and flexion contracture of the digits. Clients usually have pain in the palm and digits, with decreased mobility and contracture of the fingers. In clients with diabetes, Dupuytren's contracture must be differentiated from LJM, which may involve the entire hand and is frequently bilateral, and from flexor tenosynovitis, which is marked by trigger finger. Individuals with DM may develop complex regional pain syndrome (CRPS; formerly called reflex sympathetic dystrophy (RSD) syndrome), which is characterized by pain, hyperesthesia, vasomotor and dystrophic skin changes, and tenderness and swelling around the hands and feet.
TABLE 11-9
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INTERVENTION
Medical management of the client with diabetes is directed primarily toward maintenance of blood glucose values within the range of 80 to 120 mg/dL. The three primary treatment modalities used in the management of DM are diet, exercise, and medication (insulin and oral hypoglycemic agents; Table 11-9). Recommended preventive care services such as yearly eye and foot examinations as well as measurements of glycosylated hemoglobin (A1C) two or more times per year are critical in the prevention of diabetic complications such as blindness, amputation, and cardiovascular disease. A1C (also known as glycosylated hemoglobin, glycated hemoglobin, or glycohemoglobin) is an accurate, objective measurement of chronic glycemia in diabetes. Most laboratories list the normal reference range as 4% to 6%. The goal is to maintain consistent A1C levels below 7%, which correlates to an average daily blood glucose below 170 mg/dL. The 40
Types of Insulin and Insulin Action
Type
Name
Onset (hours)
Peak (hours)
Duration (hours)
Rapid-acting Insulin lispro
Humalog
Novolog
Peaks in about one hour 1-3 hours
Continues to work for 2 to 4 hours
Insulin aspart
Begins to work 5 min after injection 5-10 min
Regular or shortacting
Humulin-R (human) Novolin-R (human) Iletin-pork
Reaches bloodstream in first 30 minutes after injection
2-3
Effective for about 3-6 hours
Intermediate-acting
NPH (Humulin N, Novolin N) Lente (Humulin L, Novolin L) NPH (Iletin-pork)
Reaches bloodstream in about 2-4 hours after injection
4-12
Effective for about 12 to 18 hours
Long-acting
Ultralente (Humulin U)
Reaches bloodstream 6-10 hours after injection lhr
No peak (maintains consistent level)
Effective for 20 to 24 hours
30 min to 1 hour
Depends on mixture
Effective for 10-16 hours
Glargine (lantus) Premixed Insulins (combination of two types of insulin)
70/30 50/50 75/25 70/30
(%) (%) (%) (%)
NPH/regular NPH/regular (Humalog mix) (Novolog mix)
3-5 hours
Onset is how long it takes before the insulin reaches the bloodstream and starts to lower glucose levels. Peak is the time when insulin reaches its maximum strength. Duration defines how long the insulin continues to lower blood glucose. Data from American Diabetes Association: The Basics of Insulin, 2005. Available on-line at http://www.diabetes.org. Accessed January 11, 2006.
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A1C measurement gives the client and the therapist an indication of how successful diet, exercise, and medication are in controlling glucose levels over time. It can be used as a baseline from which to evaluate results of intervention. The therapist can conduct a careful screening examination (Box 11-1). All individuals with type 2 diabetes should be screened at the time of diagnosis and annually thereafter for diabetic peripheral neuropathies. Individuals with type 1 diabetes should be screened 5 years after diagnosis and annually thereafter. Screening should include checking knee and ankle reflexes, examining sensory function in the feet, asking about neuropathic symptoms, and examining the distal extremities for ulcers, calluses, and deformities. 34
EXERCISE-RELATED C O M P L I C A T I O N S
Any exercise can improve the body's ability to use insulin. Exercise causes a decrease in the amount of insulin the pancreas releases because muscle contractions are increasing blood glucose uptake. B O X 11-1
The Role of the Physical Therapist in Diabetes Screening
The therapist can provide education and prevention through the screening process including conducting periodic screening examinations for: • Neuropathy • Assess for early signs of neuropathy (e.g., deep tendon reflexes, vibratory and position sense, touch) • Education in avoiding late complications of neuropathy (e.g., annual foot and hand screening, preventive foot care; periodic footwear evaluation) • Assess for signs of neuropathic arthropathy (Charcot's joint) • Monitor blood glucose levels in association with exercise • Screen for neuromusculoskeletal disorders (e.g., adhesive capsulitis, Dupuytren disease, flexor tenosynovitis, carpal tunnel syndrome, complex regional pain syndrome) • Monitor vital signs (especially blood pressure) • Conduct periodic lower extremity vascular examination (see Box 4-15; Table 4-10) • Screen for depression; monitor depression (see Appendix B-8; see Table 3-11) The therapist can encourage the client to seek regular screening of: • A1C levels • Annual eye examination
For the person taking insulin, exercise adds to the effects of the insulin, dropping blood sugars to dangerously low levels. Exercise for the person with DM must be planned and instituted cautiously and monitored carefully because significant complications can result from exercise of higher intensity or longer duration. Exercise-related complications can be prevented by careful monitoring of the client's blood glucose level before, during, and after strenuous exercise sessions (safe levels are individually determined but usually fall between 100 and 250 mg/dL). The following recommendations are general guidelines. Exceptions are common depending on the type of exercise, training level of the participant, expected glycemic pattern, and whether or not the individual is using an insulin pump. If the blood glucose level is greater than 250 mg/dL at the start of the exercise, the client is experiencing a state of insulin deficiency. Exercise is likely to raise the blood sugars more; the exercise session should be postponed until the blood glucose level is under better control. If the blood glucose level is less than 100 mg/dL, a 10- to 15-g carbohydrate snack should be given and the glucose retested in 15 minutes to ensure an appropriate level. Clients with active retinopathy and nephropathy should avoid high-intensity exercise that causes significant increases in blood pressure because such increases can cause further damage to the retinas and kidneys. Any exercise that places the head below the waist causing increased intrathoracic and intracranial pressures can also aggravate retinal problems. Screening for neuropathies by testing deep tendon reflexes and vibratory and position sense are also very important in the prevention of exercise-related complications such as ulcerations or fractures. It is very important to have the client avoid insulin injection to active extremities within 1 hour of exercise because insulin is absorbed much more quickly in an active extremity. It is important to know the type, dose, and time of the client's insulin injections so that exercise is not planned for the peak activity times of the insulin. Clients with type 1 diabetes may need to reduce the insulin dose or increase food intake when initiating an exercise program. During prolonged activities, a 10- to 15-g carbohydrate snack is recommended for each 30 minutes of activity. Activities should be promptly stopped with the development of any symptoms of hypoglycemia, and blood glucose should be tested. In addition, individuals with diabetes should not exercise
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alone. Partners, teammates, and coaches must be educated regarding the possibility of hypoglycemia and the way to manage it.
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I N S U L I N PUMP D U R I N G EXERCISE
The therapist should become familiar with the features of each pump in use by clients. Knowledge of basic guiding principles for exercise with diabetes and general recommendations for insulin regimen changes is also helpful.
People with type 1 diabetes (and some individuals with insulin-requiring type 2 diabetes) may be using an insulin pump. Continuous subcutaneous insulin infusion (CSII) therapy, known as insulin pump therapy, can bring the hormonal and metabolic responses to exercise close to normal for the individual with diabetes. Although there are many benefits of pump use for active individuals with diabetes, there are a few drawbacks as well. Exercise can speed the development of diabetic ketoacidosis (DKA) when there is an interruption of insulin delivery, which can quickly become a life-threatening condition. Other considerations include the effect of excessive perspiration or water on the infusion set (needle into the skin at the infusion site gets displaced), ambient temperature (insulin degrades under extreme conditions of heat or cold), and the effect of movement or contact at the infusion site (this causes skin irritation). Insulin pump users who have pre-exercise blood glucose levels less than 100 mg/dL may not need a carbohydrate snack because they can reduce or suspend base insulin levels during an activity. The insulin reductions and required level of carbohydrate intake needed depends on the intensity and duration of the activity.
The two primary life-threatening metabolic conditions that can develop if uncontrolled or untreated DM progresses to a state of severe hyperglycemia (more than 400 mg/dL) are DKA and hyperglycemic, hyperosmolar, nonketotic coma (HHNC; Table 11-10). DKA occurs with severe insulin deficiency caused by either undiagnosed DM or a situation in which the insulin needs of the person become greater than usual (e.g., infection, trauma, surgery, emotional stress). It is most often seen in the client with type 1 diabetes but can, in rare situations, occur in the client with type 2 diabetes. Medical treatment is necessary. HHNC occurs most commonly in the older adult with type 2 diabetes. This complication is extremely serious and, in many cases, fatal. Factors that can precipitate this crisis are infections (e.g., pneumonia); medications that elevate the blood glucose level (e.g., corticosteroids); and procedures such as dialysis, surgery, or total parenteral nutrition (TPN). There are specific clinical features that identify HHNC. Some of these are similar to those of DKA, such as severe hyperglycemia (1000 to 2000 mg/dL)
41
41
TABLE 11-10
Severe Hyperglycemic States
Clinical Symptoms of Life-Threatening Glycemic States
Diabetic ketoacidosis (DKA) Gradual Onset Thirst Hyperventilation Fruity odor to breath Lethargy/confusion Coma Muscle and abdominal cramps (electrolyte loss) Polyuria, dehydration Flushed face, hot/dry skin Elevated temperature Blood glucose level >300 mg/dL Serum pH 300 mg/dL
Sudden Onset Sympathetic activity Pallor Perspiration Irritability/nervousness Weakness Hunger Shakiness CNS activity Headache Double/blurred vision Slurred speech Fatigue Numbness of lips/tongue Confusion Convulsion/coma Blood glucose level 7.45
Normal
>26
Nausea Vomiting Diarrhea Confusion Irritability Agitation Muscle twitch Muscle cramp Muscle weakness Paresthesias Convulsions Slow breathing
Compensated
Normal
>45
>26
Decreased respiratory rate
Uncompensated
1 cm in diameter that are firm and rubbery in consistency or tender are considered suspicious. Enlarged lymph nodes associated with infection are more likely to be tender, soft, and movable than slow-growing nodes associated with cancer. Lymph nodes enlarged in response to infections throughout the body require referral to a physician, especially in someone with a current or previous history of cancer. The physician should be notified of these findings, and the client should be advised to have the lymph nodes checked at the next follow-up visit with the physician if not sooner, depending on the client's particular circumstances. As always, changes in size, shape, tenderness, and consistency raise a red flag. Supraclavicular nodes are common metastatic sites for occult lung and breast cancers, whereas inguinal nodes implicate tumors arising in the legs, perineum, prostate, or gonads.
Other early symptoms may include unexplained fevers, night sweats, weight loss, and pruritus (itching). The itching occurs more intensely at night and may result in severe scratches because the client is unaware of scratching during the sleep state. The fever typically peaks in the late afternoon, and night sweats occur when the fever breaks during sleep. Fatigue, malaise, and anorexia may accompany progressive anemia. Some clients with Hodgkin's disease experience pain over the involved nodes after ingesting alcohol. Symptoms may arise when enlarged lymph nodes obstruct or compress adjacent structures, causing edema of the face, neck, or right arm secondary to superior vena cava compression, or causing renal failure secondary to urethral obstruction. Obstruction of bile ducts as a result of liver damage causes bilirubin to accumulate in the blood and discolor the skin. Mediastinal lymph node enlargement with involvement of lung parenchyma and invasion of the pulmonary pleura progressing to the parietal pleura may result in pulmonary symptoms, including nonproductive cough, dyspnea, chest pain, and cyanosis. Dissemination of disease from lymph nodes to bones may cause compression of the spinal cord, leading to paraplegia. Compression of nerve roots of the brachial, lumbar, or sacral plexus can cause nerve root pain. Clinical Signs and Symptoms of Hodgkin's
Disease
•
Painless, progressive enlargement of unilateral lymph nodes, often in the neck • Pruritus (itching) over entire body
•
Unexplained fevers, night sweats
• • • • •
Anorexia and weight loss Anemia, fatigue, malaise Jaundice Edema Nonproductive cough, dyspnea, chest pain, cyanosis • Nerve root pain • Paraplegia
Non-Hodgkin's Lymphoma Non-Hodgkin's lymphoma (NHL) is a group of lymphomas affecting lymphoid tissue and occurring in persons of all ages. It is more common in adults in their middle and older years (40 to 60 years).
CHAPTER 13
Risk
Factors
Males are affected more often than females and individuals with congenital or acquired immunodeficiencies (e.g., those undergoing organ transplantation and anyone with autoimmune diseases are all at increased risk for development of NHL). In addition some people who have been exposed to large levels of radiation (e.g., nuclear reactor accidents) or extensive radiation and chemotherapy for a different cancer site may be at increased risk for lymphoma. Individuals infected with the human immunodeficiency virus (HIV) are at increased risk for developing NHL and, to a lesser extent, Hodgkin's disease as well. Acquired immune deficiency syndrome-related lymphoma (ARL) is now the second most common cancer associated with HIV after Kaposi's sarcoma. The relative risk of developing lymphoma within 3 years of an AIDS diagnosis is increased by 165-fold when compared with people without A I D S . Several possible etiologic mechanisms are hypothesized for NHL. Immunosuppression, possibly in combination with viruses or exposure to certain infectious agents, could be the primary cause. Chemicals, ultraviolet light, blood transfusion, acquired and congenital immune deficiency, and autoimmune disorders increase the risk for NHL. Other studies link the disease to widespread environmental contaminants, such as benzene found in cigarette smoke, gasoline, automobile emissions, and industrial pollution. 104 1 0 5
105
106
Clinical Signs
and Symptoms
NHL presents a clinical picture broadly similar to that of Hodgkin's disease, except that the disease is usually initially more widespread and less predictable. The disease starts in the lymph nodes, although early involvement of the oropharyngeal lymphoid tissue or the bone marrow is common, as is abdominal mass or gastrointestinal involvement with complaints of vague back or abdominal discomfort. The most common manifestation is painless enlargement of one or more peripheral lymph nodes. Systemic symptoms are not as commonly associated with NHL as with Hodgkin's disease. Clients with non-Hodgkin's lymphomas often have remarkably few symptoms, even though many node areas or extranodal sites are involved. Most NHLs fall into two broad categories related to their clinical activity: indolent and aggressive lymphomas. Indolent disease may be minimally active and treatable for many years. However, the disease is frequently disseminated at the time of 104
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diagnosis. Surgery is usually used only for staging or debulking purposes. Combination chemotherapy, biotherapy (targeted monoclonal antibodies), and radiation therapies are now used as treatment for NHL. Radioactive isotope combinations with monoclonal antibodies are also in use for some types of N H L . 104
Clinical Signs and Symptoms of Non-Hodgkin's
Lymphoma
•
Enlarged lymph nodes
• • • • • •
Fever Night sweats Weight loss Bleeding Infection Red skin and generalized itching of unknown origin
Acquired Immunodeficiency Syndrome-Non-Hodgkin's Lymphoma (AIDS-NHL) Only recently has AIDS-NHL emerged as a major sequela of HIV infection. It now occurs frequently in clients who survive other consequences of AIDS. The etiologic basis of AIDS-NHL is still under investigation; profound cellular immunodeficiency plays a central role in lymphoma genesis. The molecular pathogenesis is a complex process involving both host factors and genetic alterations. Nearly 95% of all HIV-associated malignancies are either NHL or Kaposi's sarcoma. People with CNS lymphoma usually have advanced AIDS, are severely debilitated, and are usually thought to be at terminal stages of the disease. Epstein-Barr virus (EBV) often accompanies NHL. It is generally accepted that EBV acts in the pathogenesis of lymphoma owing to the alteration in balance between host and latent EBV infection in immunodeficiency states, with increased activity of the virus. 107
104
Risk
Factors
Infection with HIV and related immunodeficiencies resulting from HIV are the primary risk factors for this disease. NHL is more likely to develop among clients who have Kaposi's sarcoma, a history of herpes simplex infection, and a lower neutrophil count.
Clinical Signs
and Symptoms
The most common presentations of HIV-related NHL are systemic B symptoms (which may suggest
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an infectious process), a rapidly enlarging mass lesion, or both. At the time of diagnosis, approximately 75% of clients will have advanced disease. Extranodal disease frequently involves any part of the body, with the most common locations being the CNS, bone marrow, GI tract, and liver. Diagnosis of NHL in areas of the body other than the CNS is complicated by a history of fevers, night sweats, and weight loss and loss of appetite, which are also common symptoms related to HIV infection and AIDS. Although musculoskeletal lesions are not reported as commonly as pulmonary or CNS abnormalities in HIV-positive individuals, a wide variety of osseous and soft tissue changes are seen in this group. Diffuse adenopathy, lower extremity pain and swelling, subcutaneous nodules, and lytic lesions of the extremities are common. 108
Clinical Signs and Symptoms of AIDS-NHL •
Painless, enlarged mass
• •
Subcutaneous nodules Constitutional symptoms (fever, night sweats, weight loss) • Musculoskeletal lesions (lytic bone, pain, swelling)
PHYSICIAN REFERRAL Early detection of cancer can save a person's life. Any suspicious sign or symptom discussed in this chapter should be investigated immediately by a physician. This is true especially in the presence of a positive family history of cancer, a previous personal history of cancer, and environmental risk factors, and/or in the absence of medical or dental (oral) evaluation during the previous year. The therapist is not responsible for diagnosing cancer. The primary goal in screening for cancer is to make sure the client's problem is within the scope of a physical therapist's practice. In this regard, documentation of key findings and communication with the physician are both very important. When trying to sort out neurologic findings, remember to look for changes in DTRs, a myotomal weakness pattern, and changes in bowel/bladder function. These findings will not give you a definitive diagnosis but will provide you with valuable information to offer the physician if further medical testing is advised. Pain on weight bearing that is unrelieved by rest or change in position and does not respond to treatment, unremitting pain at night, and a
history of cancer are all red flags indicating that medical evaluation is needed. Any recently discovered lumps or nodules must be examined by a physician. Any suspicious finding by report, on observation, or by palpation should be checked by a physician. If any signs of skin lesions are described by the client, or if they are observed by the therapist, and the client has not been examined by a physician, a medical referral is recommended. If the client is planning a follow-up visit with the physician within the next 2 to 4 weeks, that client is advised to indicate the mole or skin changes at that time. If no appointment is pending, the client is encouraged to make a specific visit either to the family/personal physician or to a dermatologist.
Guidelines for Immediate Physician Referral • Presence of recently discovered lumps or nodules or changes in previously present lumps, nodules, or moles, especially in the presence of a previous history of cancer or when accompanied by carpal tunnel or other neurologic symptoms. • Detection of palpable, fixed, irregular mass in the breast, axilla, or elsewhere requires medical referral or a recommendation to the client to contact a physician for evaluation of the mass. Suspicious lymph node enlargement or lymph node changes; generalized lymphadenopathy. • Recurrent cancer can appear as a single lump, a pale or red nodule just below the skin surface, a swelling, a dimpling of the skin, or a red rash. Report any of these changes to a physician immediately. • Notify physician of any suspicious changes in lymph nodes; note the presence of lymphadenopathy, and describe the location and any observed or palpable characteristics. • Presence of any of the early warning signs of cancer, including idiopathic muscle weakness accompanied by decreased deep tendon reflexes. • Any unexplained bleeding from any area (e.g., rectum, blood in urine or stool, unusual or unexpected vaginal bleeding, breast, penis, nose, ears, mouth, mole, skin, or scar). • Any sign or symptom of metastasis in someone with a previous history of cancer (see individual cancer types for specific clinical signs and symptoms; see also Clues to Screening for Cancer). • Any man with pelvic, groin, sacroiliac, or low back pain accompanied by sciatica and a past history of prostate cancer.
CHAPTER 13
Clues to Screening f o r Cancer • Age older than 50 years • Previous personal history of any cancer, especially in the presence of bilateral carpal tunnel symptoms, back pain, shoulder pain, or joint pain of unknown or rheumatic cause at presentation • Previous history of cancer treatment (late physical complications and psychosocial complications of disease and treatment can present in a somatic presentation) • Any woman with chest, breast, axillary, or shoulder pain of unknown cause, especially with a previous history of cancer and/or over the age of 40 • Anyone with back, pelvic, groin, or hip pain accompanied by abdominal complaints, palpable mass • For women: Prolonged or excessive menstrual bleeding (or in the case of the postmenopausal woman who is not taking hormone replacement, breakthrough bleeding) • For men: Additional presence of sciatica and past history of prostate cancer • Recent weight loss of 10% of total body weight (or more) within 2-week to 1-month period of time without trying; weight gain is more typical with true musculoskeletal dysfunction because pain has limited physical activities • Musculoskeletal symptoms are made better or worse by eating or drinking (GI involvement) • Shoulder, back, hip, pelvic, or sacral pain accompanied by changes in bowel and/or bladder function or changes in stool or urine
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• Hip or groin pain is reproduced by heel strike/hopping test or translational/rotational stress (bone fracture from metastases) • When a back "injury" is not improving as expected or if symptoms are increasing • Early warning signs, including proximal muscle weakness and changes in deep tendon reflexes • Constant pain (unrelieved by rest or change in position); remember to assess constancy by asking, "Do you have that pain right now?" • Intense pain present at night (rated 7 or higher on a numeric scale from 0 for "no pain" to 10 for "worst pain") • Signs of nerve root compression must be screened for cancer as a possible cause • Development of new neurologic deficits (e.g., weakness, sensory loss, reflex change, bowel or bladder dysfunction) • Changes in size, shape, tenderness, and consistency of lymph nodes, especially painless, hard, rubbery lymph nodes present in more than one location • A growing mass, whether painless or painful, is assumed to be a tumor unless diagnosed otherwise by a physician. A hematoma should decrease in size over time, not increase • Disproportionate pain relieved with aspirin may be a sign of bone cancer (osteoid osteoma) • Signs or symptoms seem out of proportion to the injury and persist longer than expected for physiologic healing of that type of injury; no position is comfortable (remember to conduct a screening examination for emotional overlay) • Change in the status of a client currently being treated for cancer 109
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METASTASES Location:
Referral:
Integumentary system Pulmonary system Neurologic system Musculoskeletal Hepatic See Table 13-6
SKIN Location:
Referral: Description:
Intensity: Duration: Associated signs and symptoms:
(most commonly seen in a physical therapy setting)
(MELANOMA ONLY)
Anywhere on the body Women: Arms, legs, back, face Men: Head, trunk African Americans: Palms, soles, under the nails None Usually painless; see ABCD method of detection (text) Sore that does not heal Irritation and itching Cluster mole formation Tenderness and soreness around a mole Mild Constant None
PARANEOPLASTIC SYNDROMES Location: Referral Description:
Intensity: Duration: Associated signs and symptoms:
Remote sites from primary neoplasm Organ dependent Asymmetric joint involvement Lower extremities primarily Concurrent arthritis and malignancy Explosive onset at late age See Tables 13-7 and Box 13-3 Symptom dependent Symptom dependent Fever Skin rash Clubbing of the fingers Pigmentation disorders Arthralgias Paresthesias Thrombophlebitis Proximal muscle weakness Anorexia, malaise, weight loss Rheumatologic complaints
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ONCOLOGIC (CANCER) PAIN Location: Referral: Description:
Intensity: Duration: Associated signs and symptoms:
Localized bone pain; referred pain May follow nerve distribution Bone pain: Sharp, intense, constant Viscera: Colicky, cramping, dull, diffuse, boring, poorly localized Vein, artery, lymphatic channel: Dull, diffuse, burning, aching Nerve compression: Sharp, stabbing; follows nerve distribution or dull, poorly localized Inflammation: Sensitive tenderness Varies from mild to severe or excruciating Bone pain: Increases on movement or weight bearing Usually constant; may be worse at night With mild to moderate superficial pain: Sympathetic nervous system response (e.g., hypertension, tachycardia, tachypnea) With severe or visceral pain: Parasympathetic nervous system response (e.g., hypotension, tachypnea, weakness, fainting) Organ dependent (e.g., esophagus: difficulty eating or speaking; gallbladder: jaundice, nausea; nerve involvement: altered sensation, paresthesia; see individual visceral cancers)
SOFT TISSUE TUMORS Location: Referral: Description: Intensity: Duration: Associated signs and symptoms:
Any connective tissue (e.g., tendon muscle, cartilage, fat, synovium, fibrous tissue) According to the tissue involved Persistent swelling or lump, especially in the muscle Mild, increases progressively to severe Intermittent, increases progressively to constant Local swelling with tenderness and skin warmth Pathologic fracture
BONE TUMORS Location: Referral: Description:
Intensity: Duration: Associated signs and symptoms:
Can affect any bone in the body, depending on the specific type of bone cancer According to pattern and location of metastases Sharp, knifelike, aching bone pain Occurs on movement and weight bearing, with pathologic fractures Pain at night, preventing sleep Initially mild, progressing to severe Usually intermittent, progressing to constant Fatigue and malaise Significant unintentional weight loss Swelling and warmth over localized areas of tumor Soft, tender palpable mass over bone Loss of range of motion and joint function if limb bone is involved Fever Sciatica Unilateral edema
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PRIMARY CENTRAL NERVOUS SYSTEM: BRAIN TUMORS Location: Referral: Description: Intensity: Duration: Aggravating factors:
Relieving factors: Associated signs and symptoms:
Intracranial Specific symptoms depend on tumor location Headaches Bioccipital or bifrontal headache Mild to severe Worse in morning on awakening Diminishes or disappears soon after rising Activity that increases intracranial pressure (e.g., straining during bowel movements, stooping, lifting heavy objects, coughing, bending over) Prone/supine position at night during sleep Pain medications, including aspirin, acetaminophen Papilledema Altered mentation: Increased sleeping Difficulty in concentrating Memory loss Increased irritability Poor judgment Vomiting unrelated to food accompanies headaches Seizures Neurologic findings: Positive Babinski reflex Clonus (ankle or wrist) Sensory changes Decreased coordination Ataxia Muscle weakness Increased lower extremity deep tendon reflexes Transient paralysis
PRIMARY CENTRAL NERVOUS SYSTEM: SPINAL CORD TUMORS Location:
Referral: Description: Intensity: Duration: Aggravating factors:
Associated signs and symptoms:
Intramedullary (within the spinal cord) Extramedullary (within the dura mater) Extradural (outside the dura mater) Back pain at the level of the spinal cord lesion Pain may extend to the groin or legs Dull ache; sharp, knifelike sensation Mild to severe, progressive; night pain Intermittent, progressing to constant, or constant (Back pain) Lying down/rest Weight bearing Sneezing or coughing Muscle weakness Muscle atrophy Sensory loss Paraplegia/quadriplegia Chest or abdominal pain Bowel/bladder dysfunction (late findings)
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615
LEUKEMIA Location: Referral: Description: Intensity: Duration: Associated signs and symptoms:
Usually painless; may have pain in the left abdomen; bone and joint pain possible None Dull pain in the abdomen; may occur only on palpation Mild to moderate Intermittent (with applied pressure) Enlarged lymph nodes Unusual bleeding from the nose or rectum, or blood in urine Prolonged menstruation Easy bruising of the skin Fatigue Dyspnea Weight loss, loss of appetite Fevers and sweats
MULTIPLE MYELOMA Location: Referral: Description: Intensity: Duration: Associated signs and symptoms:
Skeletal pain, especially in the spine, sternum, rib, leg, or arm According to the location of the tumor Sharp, knifelike Moderate-to-severe Intermittent, progressing to constant Hypercalcemia: Dehydration (vomiting), polyuria, confusion, loss of appetite, constipation Bone destruction with spontaneous bone fracture Neurologic: Carpal tunnel syndrome; back pain with radicular symptoms; spinal cord compression (motor or sensory loss, bowel/bladder dysfunction, paraplegia)
HODGKIN'S DISEASE Location: Referral: Description: Intensity: Duration: Associated signs and symptoms:
Lymph glands, usually unilateral neck or groin According to the location of the metastases Usually painless, progressive enlargement of lymph nodes Not applicable Not applicable Fever peaks in the late afternoon, night sweats Anorexia and weight loss Severe itching over the entire body Anemia, fatigue, malaise Jaundice Edema Nonproductive cough, dyspnea, chest pain, cyanosis
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VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
NON-HODGKIN'S LYMPHOMA Location: Referral: Description: Intensity: Duration: Associated signs and symptoms:
(including AIDS-NHL)
Peripheral lymph nodes Not applicable Usually painless enlargement Not applicable Not applicable Constitutional symptoms (fever, night sweats, weight loss) Bleeding Generalized itching and reddened skin AIDS-NHL: Musculoskeletal lesions, subcutaneous nodules
K E Y P O I N T S T O REMEMBER / When put to the task of screening for cancer, always remember our three basic clues: / Past Medical History / Clinical Presentation / Associated Signs and Symptoms / Any suspicious lesions or red flag symptoms, especially in the presence of a past medical history of cancer or risk factors for cancer, should be investigated further. With the increasing number of people diagnosed with cancer, recognizing hallmark findings of cancer is important. / Knowing the systems most often affected by cancer metastasis and the corresponding clinical manifestations is a good starting point. Any time a client reports a past medical history of cancer, we must be alert for signs or indications of cancer recurrence (locally or via metastasis). / Knowing the most common risk factors for cancer in general and risk factors for specific cancers is the next step. Risk factor assessment and cancer prevention are a part of every health care professional's role as educator and in primary prevention. / Whether you are working in an oncology setting or in a general practice with an occasional client, good resource information is available. Thorough, reliable,
and up-to-date information about specific types of cancer, cancer treatments, and recent breakthroughs in cancer research is available from The Abramson Cancer Center of the University of Pennsylvania (Philadelphia, PA) at: http://oncolink.upenn.edu / Spinal malignancy involves the lumbar spine more often than the cervical spine and is usually metastatic rather than primary. / Spinal cord compression from metastases may appear as back pain, leg weakness, and bowel/bladder symptoms. / Fifty percent of clients with back pain from a malignancy have an identifiable preceding trauma or injury to account for the pain or symptoms. Always remember that clients may erroneously attribute symptoms to an event. / Back pain may precede the development of neurologic signs and symptoms in any person with cancer. / The presence of jaundice in association with any atypical presentation of back pain may indicate liver metastasis. / Signs of nerve root compression may be the first indication of cancer, in particular, lymphoma, multiple myeloma, or cancer of the lung, breast, prostate, or kidney.
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KEY POINTS TO REMEMBER—cont'd / The five most common sites of metastasis are the lymph nodes, liver, lung, bone, and brain. / Lung, breast, prostate, thyroid, and the lymphatics are the primary sites responsible for most metastatic bone
/ Besides the seven early warning signs of cancer, the therapist should watch for idiopathic muscle weakness accompanied by decreased deep tendon reflexes.
disease. / Monitoring physiologic responses (vital signs) to exercise is important in the immunosuppressed population. Watch closely for early signs (dyspnea, pallor, sweating, and fatigue) of cardiopulmonary complications of cancer treatment. / To determine appropriate exercise levels for clients who are immunosuppressed, review blood test results (WBCs, RBCs, hematocrit, platelets). When these are not available, monitor vital signs and use rate of perceived exertion (RPE) as a guideline.
/ Changes in size, shape, tenderness, and consistency of lymph nodes raise a red flag. Supraclavicular nodes and inguinal nodes are common metastatic sites for cancer. / No reliable physical signs distinguish between benign and malignant soft tissue lesions. All soft tissue lumps that persist or grow should be reported immediately to the physician. / Malignancy is always a possibility in children with musculoskeletal symptoms.
SUBJECTIVE
EXAMINATION
Special Q u e s t i o n s t o A s k
Special questions to ask will vary with each client and the clinical signs and symptoms presented at the time of evaluation. The therapist should refer to the specific chapter representing the client's current complaints. The case study provided here is one example of how to follow up with necessary questions to rule out a systemic origin of musculoskeletal findings. A previous history of drug therapy and current drug use may be important information to obtain because prolonged use of drugs such as phenytoin (Dilantin) or immunosuppressive drugs such as azathioprine (Imuran) and cyclosporine may lead to cancer. Postmenopausal use of estrogens has been linked with breast cancer. " 110
112
P a s t Medical H i s t o r y
A previous personal/family history of cancer may be significant, especially any history of breast, colorectal, or lung cancer that demonstrates genetic susceptibility. • Have you ever had cancer or do you have cancer now? If no, have you ever received chemotherapy, hormone therapy, or radiation therapy? If yes, what was the treatment for?
If yes to previous history of cancer, ask about type of cancer, date of diagnosis, stage (if known), treatment, and date of most recent follow-up visit with oncologist or other cancer specialist. Has your physician said that you are cancerfree? • Have you ever been exposed to chemical agents or irritants, such as asbestos, asphalt, aniline dyes, benzene, herbicides, fertilizers, wood dust, or others? (Environmental causes of cancer; see complete environmental/ occupational screening survey in Chapter 2 and Appendix B-13): Clinical P r e s e n t a t i o n : E a r l y W a r n i n g S i g n s
When using the seven early warning signs of cancer as a basis for screening (see Box 13-1), one or all of the following questions may be appropriate: • Have you noticed any changes in your bowel movement or in the flow of urination? — If yes, ask pertinent follow-up questions as suggested in Chapter 10; see also Appendix B-5. — If the client answers no, it may be necessary to provide prompts or examples of what changes you are referring to (e.g., difficulty in
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SECTION II
SUBJECTIVE
•
•
•
•
•
•
VISCEROGENIC CAUSES OF PAIN AND DYSFUNCTION
EXAMINATION —cont'd
starting or continuing the flow of urine, numbness or tingling in the groin or pelvis). Have you noticed any sores that have not healed properly? — If yes, where are they located? How long has the sore been present? Has your physician examined this area? Have you noticed any unusual bleeding (for women: including prolonged menstruation or any bleeding for the postmenopausal woman who is not taking hormone replacement) or prolonged discharge from any part of your body? — If yes, where? How long has this been present? Has your physician examined this area? Have you noticed any thickening or lump of any muscle, tendon, bone, breast, or anywhere else? — If yes, where? How long has this been present? Has your physician examined this area?* — If no (for women): Do you examine your own breasts? How often do you examine yourself? When was the last time you did a breast selfexamination (see Appendix D-6)? Do you have any pain, swelling, or unusual tenderness in the breasts? (Pain can be a symptom of cancer; cyclic pain is common with normal breasts, use of oral contraceptives, and fibrocystic disease.) — If yes, is this pain brought on by strenuous activity? (Spontaneous/systemic or related to specific musculoskeletal cause [e.g., use of one arm]) Have you noticed any rash on the breast or discharge from the nipple? (Medications such as oral contraceptives, phenothiazines, diuretics, digitalis, tricyclic tranquilizers, reserpine, methyldopa, and steroids can cause clear discharge from the nipple; blood-tinged discharge is always significant.) Have you noticed any difficulty in eating or swallowing? Have you had a chronic cough, recurrent
•
•
•
•
• •
•
laryngitis, hoarseness, or any difficulty with speaking? — If yes, how long has this been happening? Have you discussed this with your physician? Have you had any change in digestive patterns? Have you had increasing indigestion or unusual constipation? — If yes, how long has this been happening? Have you discussed this with your physician? Have you had a recent, sudden weight loss without dieting? (10% of client's total body weight in 10 days to 2 weeks is significant.) Have you noticed any obvious change in color, shape, or size of a wart or mole? — If yes, what have you noticed? How long has this wart or mole been present? Have you discussed this problem with your physician? Have you had any unusual headaches or changes in your vision? — If yes, please describe. (Brain tumors: bioccipital or bifrontal) — Can you attribute these to anything in particular? — Do you vomit (unrelated to food) when your headaches occur? (Brain tumors) Have you been more tired than usual or experienced persistent fatigue during the last month? Can you think of any time during the past week when you may have bumped yourself, fallen, or injured yourself in any way? (Ask when in the presence of local swelling and tenderness.) (Bone tumors) Have you noticed any bone pain or problems with any of your bones? Is the pain affected by movement? (Fractures cause sharp pain that increases with movement. Bone pain from systemic causes usually feels dull and deep and is unrelated to movement.)
Associated Signs and S y m p t o m s
• Are you having any symptoms of any kind anywhere else in your body?
* An asymptomatic mass that has been present for years and causes only cosmetic concern is usually benign, whereas a painful mass of short duration that has caused a decrease in function may be malignant.
CHAPTER 13
CASE
SCREENING FOR CANCER
619
STUDY
REFERRAL
A 56-year-old man has come to you for an evaluation without referral. He has not been examined by a physician of any kind for at least 3 years. He is seeking an evaluation on the insistence of his wife, who has noticed that his collar size has increased two sizes in the last year and that his neck looks "puffy." He has no complaints of any kind (including pain or discomfort), and he denies any known trauma, but his wife insists that he has limited ability in turning his head when backing the car out of the driveway. PHYSICAL THERAPY SCREENING INTERVIEW
First, read the client's Family/Personal History form with particular interest in his personal or family history of cancer, presence of allergies or asthma, use of medications or over-the-counter drugs, previous surgeries, available x-ray studies of the neck or spine, and/or history of cigarette smoking (or other tobacco use). An appropriate lead-in to the following series of questions may be: "Because you have not seen a physician before your appointment with me, I will ask you a series of questions to find out if your symptoms require examination by a physician rather than treatment in this office." CURRENT SYMPTOMS
What have you noticed different about your neck that brings you here today? When did you first notice that your neck was changing (in size or shape)? Can you remember having any accidents, falls, twists, or any other kind of potential trauma at that time? Do you ever notice any pain, stiffness, soreness, or discomfort in your neck or shoulders? If yes, please describe (as per the outline in the Core Interview, Chapter 2). Does this or any pain ever awaken you at night or keep you awake? (Night pain associated with cancer) If yes, follow up with appropriate questions (see the Core Interview, Chapter 2). ASSOCIATED SYMPTOMS
Have you noticed any numbness or tingling in your arms or hands? Have you noticed any swollen glands, lumps, or thickened areas of skin or muscle in your neck, armpits, or groin? (Cancer screen)
Do you have any difficulty in swallowing? Do you have recurrent hoarseness, flulike symptoms, or a persistent cough or cold that never seems to go away? (Cancer screen) Have you noticed any low-grade fevers or night sweats? (Systemic disease) Have you had any recent unexplained weight gain or loss? (You may need to explain that you mean a gain or loss of 10 to 15 pounds in as many days without dieting.) Have you had a loss of appetite? (Cancer screen or other systemic disease) Do you ever have any difficulty with breathing or find yourself short of breath at rest or after minimal exercise? (Dyspnea) Do you have frequent headaches, or do you experience any dizziness, nausea, or vomiting? (Systemic disease, carotid artery affected) FUNCTIONAL CAPACITY
• What kind of work do you do? • Do you have any limitations caused by this condition that affects you in any way at work or at home? (Occupational disease, limitations of activities of daily living [ADL] skills) FINAL QUESTIONS
How would you describe your general health? Have you ever been diagnosed with cancer of any kind? Is there anything that you would like to tell me that you think is important about your neck or your health in general? FIRST VISIT: ASSESSING THE MUSCULOSKELETAL SYSTEM
• Observation/Inspection • Observe for the presence of swelling anywhere, tender or swollen lymph nodes (cervical, supraclavicular, and axillary), changes in skin temperature, and unusual moles or warts. Perform a brief posture screen (general postural observations may be made while you are interviewing the client). Palpate for carotid artery and upper extremity pulses. Check vital signs and Take the Client's Oral Temperature! • Cervical active range of motion (AROM)/passive range of motion (PROM) • Assess for muscle tightness, loss of joint motion (including accessory movements, if indicated by a loss of passive motion). Assess for compromise of the vertebral artery, and, if negative, clear the cervical spine by using a quadrant test with
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STUDY —cont'd
overpressure (e.g., Spurling's test) and assess accessory movements of the cervical spine. Perform tests for thoracic outlet syndrome. Palpate the anterior cervical spine for pathologic protrusion while the client swallows. • Temporomandibular joint (TMJ) screen • Clear the joint above (i.e., TMJ) using AROM, observation, and palpation specific to the TMJ. • Shoulder screen • Clear the joint below (i.e., shoulder) by using a screening examination (e.g., AROM/PROM and quadrant testing). • Neurologic screen (see Chapter 4) Deep tendon reflexes, sensory screen (e.g., gross sensory testing for light touch), manual muscle test (MMT) screening using break testing of the upper quadrant, grip strength. If test(s) is abnormal, consider further neurologic testing (e.g., balance, coordination, stereognosia, in-depth sensory examination, dysmetria). Ask about the presence of recent visual changes, headaches, numbness, or tingling into the jaw or down the arm(s). It is always recommended that the therapist give the client ongoing verbal feedback during the examination regarding evaluation results, such as: "I notice you can't turn your head to the right as much as you can to the left—from checking your muscles and joints, it looks like muscle tightness, not any loss of joint movement." . . . or . . . "I notice your reflexes on each side aren't the same (your right arm reacts more strongly than the left)—let's see if we can find out why." RECOMMENDATION FOR PHYSICIAN VISIT
• I noticed on your intake form that you haven't listed the name of a personal or family physician. Do you have a physician? • If yes, when was the last time you saw your physician? Have you seen your physician for this current problem? Give the client a brief summary of your findings while making your recommendations, for example, "Mr. X., I notice today that although you don't have any ongoing neck pain, the lymph nodes in your neck and armpit are enlarged but not particularly
tender. Otherwise, all of my findings are negative. Your loss of motion on turning your head is not unusual for a person your age and certainly would not cause your neck to increase in size or shape. "Given the fact that you have not seen a physician for almost 3 years, I strongly recommend that you see a physician of your choice, or I can give you the names of several to choose from. In either case, I think some medical tests are necessary to rule out any underlying medical problem. For instance, a neck x-ray exam would be recommended before physical therapy treatment is started." If the client has indicated a positive family history of cancer, it might be appropriate to suggest, "Given your positive family history of previous medical illnesses, the 3 years since you have seen a physician, and the lack of musculoskeletal findings, I strongly recommend . . . " It is important to provide the client with all the information available to you, but without causing undue alarm and emotional stress, which could actually prevent the client from seeking further testing. If the client does give the name of a physician, you may ask for written permission (disclosure release) to send a copy of your results to the physician. If the client does not have a physician and requests recommendations from you, you may offer to send a copy of your results to the physician with whom the client makes an appointment. If you think that a problem may be potentially serious and you want this person to receive adequate follow-up without causing alarm, you may offer to let him make the appointment from your office, suggest that your secretary or receptionist make the appointment for him, or even offer to make the initial telephone contact yourself. RESULTS
This client did comply with the therapist's suggestion to see a physician and was diagnosed as having Hodgkin's disease (a cancer of the lymph system) without constitutional symptoms (i.e., without evidence of weight loss, fever, or night sweats). Medical intervention was initiated, and physical therapy treatment was not warranted.
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PRACTICE QUESTIONS 1. Name three predisposing factors to cancer that the therapist must watch for during the interview process as red flags. 2. How do you monitor exercise levels in the oncology patient without laboratory values? 3. In a physical therapy practice, clients are most likely to present with signs and symptoms of metastases to: a. Skeletal system, hepatic system, pulmonary system, central nervous system b. Cardiovascular system, peripheral vascular system, enteric system c. Hematologic and lymphatic systems d. None of the above 4. What is the significance of nerve root compression in relation to cancer? 5. Complete the following mnemonic: C
A U T
I
6.
7.
8.
9. 10.
11.
O N Whenever a therapist observes, palpates, or receives a client report of a lump or nodule, what three questions must be asked? How can the therapist determine whether a client's symptoms are caused by the delayed effects of radiation as opposed to being signs of recurring cancer? Give a general description and explanation of the changes seen in deep tendon reflexes associated with cancer. Why is weight loss a significant red flag sign in a physical therapy practice? When tumors produce signs and symptoms at a site distant from the tumor or its metastasized sites, these "remote effects" of malignancy are called: a. Bone metastases b. Vitiligo c. Paraneoplastic syndrome d. Ichthyosis A client who has recently completed chemotherapy requires immediate medical referral if he has which of the following symptoms? a. Decreased appetite b. Increased urinary output c. Mild fatigue but moderate dyspnea with exercise d. Fever, chills, sweating
12. A suspicious skin lesion requiring medical evaluation has a. Round, symmetrical borders b. Notched edges c. Matching halves when a line is drawn down the middle d. A single color of brown or tan 13. What is the significance of Beau's lines in a client treated with chemotherapy for leukemia? a. Impaired nail formation from death of cells b. Temporary longitudinal groove or ridge through the nail c. Increased production of the nail by the matrix as a sign of healing d. A sign of local trauma 14. A 16-year-old boy was hurt in a soccer game. He presents with exquisite right ankle pain on weight bearing but reports no pain at night. Upon further questioning, you find he is taking ibuprofen at night before bed, which may be masking his pain. What other screening examination procedures are warranted? a. Perform a heel strike test. b. Review response to treatment. c. Assess for signs of fracture (edema, exquisite tenderness to palpation, warmth over the painful site). d. All of the above 15. When is it advised to take a work or military history? a. Anyone with head and/or neck pain who uses a cell phone more than 8 hours/day b. Anyone over age 50 c. Anyone presenting with joint pain of unknown cause accompanied by multiple other signs and symptoms d. This is outside the scope of a physical therapist's practice 16. A 70-year-old man came to out-patient physical therapy with a complaint of pain and weakness of his fingers and morning stiffness lasting about an hour. He presented with bilateral swelling of the metacarpophalangeal joints of the index and ring fingers. He saw his family doctor 4 weeks ago and was given diclofenac, which has not changed his symptoms. Now he wants to try physical therapy. Since he last saw his physician, he has developed additional joint pain in the left knee and right shoulder.
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PRACTICE QUESTIONS—cont'd How can you tell if this is cancer, polyarthritis, or a paraneoplastic disorder? a. Ask about a previous history of cancer and recent onset of skin rash. b. You can't. This requires a medical evaluation. c. Look for signs of digital clubbing, cellulitis, or proximal muscle weakness. d. Assess vital signs. 17. A 49-year-old man was treated by you for bilateral synovitis of the proximal interphalangeal (PIP) joints in the second, third, and fourth fingers. His symptoms went away with treatment, and he was discharged. Six weeks later, he returned with the same symptoms. There was obvious soft tissue swelling with morning stiffness worse than before. He also reports problems with his bowels but isn't able to tell you exactly what's wrong. There are no other changes in his health. He is not taking any medications or over-thecounter drugs and does not want to see a doctor. Are there enough red flags to warrant medical evaluation before resumption of physical therapy intervention? a. Yes; age, bilateral symptoms, progression of symptoms, report of GI distress b. No; treatment was effective before—it's likely that he has done something to exac-
erbate his symptoms and needs further education about joint protection. 18. A client with a past medical history of kidney transplantation (10 years ago) has been referred to you for a diagnosis of rheumatoid arthritis. His medications include tacrolimus, methotrexate, Fosamax, and wellbutrin. During the examination, you notice a painless lump under the skin in the right upper anterior chest. There is a loss of hair over the area. What other symptoms should you look for as red flag signs and symptoms in a client with this history? a. Fever, muscle weakness, weight loss b. Change in deep tendon reflexes, bone pain c. Productive cough, pain on inspiration d. Nose bleeds or other signs of excessive bleeding 19. A 55-year-old man with a left shoulder impingement also has palpable axillary lymph nodes on both sides. They are firm but movable, about the size of an almond. What steps should you take? a. Examine other areas where lymph nodes can be palpated. b. Ask about history of cancer, allergies, or infections. c. Document your findings and contact the physician with your concerns. d. All of the above
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SECTION
Systemic Origins of Neuromuscular or Musculoskeletal Pain and Dysfunction
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SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
T
he potential for referral of pain from systemic diseases to specific muscles and joints is well documented in the medical literature. These referral patterns most often affect the back and shoulder but may also appear in the chest, thorax, hip, pelvis, groin, sacrum, or sacroiliac joint. Up to this point the text has focused on each organ system and the pain or other signs and symptoms referred from organs to musculoskeletal sites. In this third section the focus is turned around so that the reader can quickly refer to the site of presenting pain or other symptoms and determine possible systemic involvement. The therapist may then question the client, as suggested, and determine the possible need for referral to a physician or other appropriate resource. The reader is referred to the individual chapters within this text for an in-depth discussion of the specific visceral or systemic causes of musculoskeletal signs or symptoms.
DECISION-MAKING PROCESS In Chapter 1, a model for decision making in the screening process was presented including: • Client history (client demographics, past medical history, personal and family history, psychosocial history)
• Risk-factor assessment • Clinical presentation, including assessment of pain patterns and pain types and conducting a systems review • Associated signs and symptoms of systemic diseases • Review of Systems The therapist uses this screening model during the screening interview to gather important information and then correlate the subjective findings with the objective findings to recognize presenting conditions that require medical follow-up. Accordingly, the therapist will want to obtain the client's history, conduct a systems review as outlined in the Guide, and remain familiar with types of pain, pain patterns, and signs and symptoms that may suggest systemic origins of problems appearing in the musculoskeletal or neuromuscular system. Taking a step back and looking at the entire case presentation, called the Review of Systems, is often the final step in the screening process. These guidelines for collecting and correlating subjective and objective information are suggested for any client who demonstrates one or more of the characteristics outlined in Chapter 1.
Screening the Head, Neck, and Back
I
t is estimated that 80% to 90% of the western population will experience an episode of acute back pain at least once during their lifetime, making it one of the most common problems physical therapists evaluate and treat. " Most cases of back pain in adults are related to age-related degenerative processes, physical loading, and musculoligamentous injuries. Many mechanical causes of back pain resolve within 1 to 4 weeks without serious problems. Sacroiliac (SI) joint dysfunction can mimic low back pain and discogenic disease with pain referred below the knee to the foot. Studies show SI joint dysfunction is the primary source of low back pain in up to 30% of people with low back pain. As always, when conducting a physical examination the therapist must consider the possibility of a mechanical problem above or below the area of pain or symptom presentation. A smaller number of people will develop chronic pain without organic pathology or they may have an underlying serious medical condition. The therapist must be aware that many different diseases can appear as neck pain, back pain, or both at the same time (Table 14-1). For example rheumatoid arthritis affects the cervical spine early in the course of the disease but may go unrecognized at first. In this chapter general information is offered about back pain with a focus on clinical presentation while keeping in mind risk factors and associated signs and symptoms typical of each visceral system capable of referring pain to the head, neck, and back. Neck and back pain may arise in the spine from infection, fracture, or inflammatory, metabolic, or neoplastic disorders. Additionally low back pain can be referred from abdominal or pelvic disease. Nonsteroidal antiinflammatory drug (NSAID) use is a typical cause of intraperitoneal or retroperitoneal bleeding causing low back pain. People most often taking NSAIDs have a history of inflammatory conditions such as osteoarthritis. Although the incidence of back pain from NSAIDs is fairly low (i.e., number of people on NSAIDs who develop GI problems and referred pain), the prevalence (number seen in a physical therapist's practice) is much higher. " In other words physical therapists are seeing a majority of people with arthritis or other inflammatory conditions who are taking one or more prescription and/or over-the-counter NSAID. Screening for medical disease is an important part of the evaluation process that may take place more than once during an episode of care (see Fig. 1-4). The clues about the quality of pain, the age of the client, and the presence of systemic complaints or associated signs and symptoms indicate the need to investigate further. 1
2
4
5,6
7
8
10
11
629
SECTION III
630
TABLE 14-1
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Viscerogenic Causes of N e c k and
Back Pain
Cervical
Thoracic/scapular
Lumbar
Cancer
Metastatic lesions (leukemia, Hodgkin's disease) Cervical bone tumors Cervical cord tumors Lung cancer; Pancoast's tumor Esophageal cancer Thyroid cancer
Mediastinal tumors Metastatic extension Pancreatic cancer Breast cancer
Metastatic lesions Prostate cancer Testicular cancer Pancreatic cancer Colorectal cancer Multiple myeloma Lymphoma
Cardiovascular
Angina Myocardial infarction Aortic aneurysm
Angina Myocardial infarction Aortic aneurysm
Abdominal aortic aneurysm Endocarditis Myocarditis Peripheral vascular: • Post-operative bleeding from anterior spine surgery
Pulmonary
Lung cancer; Pancoast's tumor Tracheobronchial irritation Chronic bronchitis Pneumothorax
Respiratory or lung infection Empyema Chronic bronchitis Pleurisy Pneumothorax Pneumonia
Renal/Urologic
Gastrointestinal
Gynecologic
Esophagitis Esophageal cancer
Acute pyelonephritis Kidney disease
Kidney disorders: • Acute pyelonephritis • Perinephritic abscess • Nephrolithiasis • Ureteral colic (kidney stones) • Urinary tract infection • Dialysis (first-use syndrome) • Renal tumors
Esophagitis (severe) Esophageal spasm Peptic ulcer Acute cholecystitis Biliary colic Pancreatic disease
Small intestine: • Obstruction (neoplasm) • Irritable bowel syndrome • Crohn's disease Colon: • Diverticular disease Pancreatic disease Appendicitis Gynecologic disorders: • Cancer • Retroversion of the uterus • Uterine fibroids • Ovarian cysts • Endometriosis • Pelvic inflammatory disease (PID) • Incest/sexual assault • Rectocele, cystocele • Uterine prolapse Normal pregnancy Multiparity
CHAPTER 14
TABLE 14-1
Other
SCREENING THE HEAD, NECK, A N D BACK
Viscerogenic Causes of N e c k and
631
Back Pain—cont'd
Cervical
Thoracic/scapular
Lumbar
Infection: • Vertebral osteomyelitis • Meningitis • Lyme disease • Retropharyngeal abscess; epidural abscess (post-steroid injection) Osteoporosis Fibromyalgia Psychogenic (nonorganic causes; see chapter 3) Rheumatoid arthritis Fracture Viral myalgias
Infection: • Vertebral osteomyelitis • Herpes zoster • HIV Osteoporosis Fibromyalgia Psychogenic (nonorganic) Acromegaly Cushing's syndrome Fracture
Infection: • Vertebral osteomyelitis • Herpes zoster • Spinal tuberculosis • Candidiasis (yeast) • Psoas abscess • HIV Ankylosing spondylitis Fibromyalgia Osteoporosis Psychogenic (nonorganic) Fracture Cushing's syndrome Type III Hypersensitivity disorder (back/flank pain) Post-regional anesthesia
USING THE SCREENING MODEL TO EVALUATE THE HEAD, NECK, OR BACK Past Medical History A carefully taken, detailed medical history is the most important single element in the evaluation of a client who has musculoskeletal pain of unknown origin or cause. It is essential for the recognition of systemic disease that may be causing integumentary, muscle, nerve, or joint symptoms. The history combined with the physical therapy examination provides essential clues in determining the need for referral to a physician or other appropriate health care provider. A history of cancer is most important, however long ago. If a client has had a low backache for years, progressive serious disease is unlikely, though the therapist should not be misled by a chronic history of back pain because the client may be presenting with a new episode of serious back pain. Six weeks to 6 months of increasing backache, often in an older client, may be a signal of lumbar metastases, especially in a person with a past history of cancer. Watch for history of rheumatologic disorders, tuberculosis, and any recent infection (Case Example 14-1). A history of fever and chills with or without previous infection anywhere in the body may indicate a low-grade infection. Symptoms are likely to appear some time before striking physical signs of disease are evident and before laboratory tests are useful in detecting disordered physiology. Thus an accurate and suffi-
ciently detailed history provides historical clues that can be significant in determining when the client should be referred to a physician or other appropriate health care provider. The therapist must always ask about a history of motor vehicle accident, blunt impact, repetitive injury, sudden stress caused by lifting or pulling, or trauma of any kind. Even minor falls or lifting when osteoporosis is present can result in severe fracture in older adults (Case Example 14-2).
Risk Factor Assessment Understanding who is at risk and what the risk factors are for various illnesses, diseases, and conditions will alert the therapist early on as to the need for screening, education, and prevention as part of the plan of care. Educating clients about their risk factors is a key element in risk factor reduction. Risk factors vary depending on family history, previous personal history, and disease, illness, or condition present. For example, risk factors for heart disease will be different from risk factors for osteoporosis or vestibular/balance problems. When it comes to the musculoskeletal system, risk factors such as heavy nicotine use, injection drug use, alcohol abuse, diabetes, history of cancer, or corticosteroid use may be important. Always check medications for potential adverse side effects causing muscular, joint, neck, or back pain. Long-term use of corticosteroids can lead to vertebral compression fractures (Case Example 14-3). Fluoroquinolones (antibiotic) can cause neck,
632
CASE
SECTION III
EXAMPLE
1 4 - 1
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Bilateral Facial Pain
Background: A 79-year-old woman was in a rehabilitation facility following a stroke with resultant left hemiplegia. She told the therapist she was starting to have some new symptoms in her face. She could not smile on her "good" side and was having trouble closing her eyes, which was not a problem after her stroke. Clinical Presentation: There were no apparent changes in hearing, sensation, or motor control of the right arm. The therapist conducted a new neurologic screening examination and found the following results: Cranial nerve VII: client was unable to raise and lower either eyebrow or close the eyes tightly; there was bilateral facial drooping; as reported, the client was unable to smile with the right side of her face. There was no change in sensory or motor findings from the initial evaluation post-CVA. However, deep tendon reflexes were absent in both arms led the therapist to check deep tendon reflexes in the lower extremities, which were also absent. There were no other
chest, or back pain. Headache is a common side effect of many medications. Keep in mind that physical and sexual abuse are risk factors for chronic head, neck, and back pain for men, women, and children (see Appendix B-3). Age is a risk factor for many systemic and viscerogenic problems. The risk of certain diseases associated with back pain increases with advancing age (e.g., osteoporosis, aneurysm, myocardial infarction, cancer). Under the age of 20 or over the age of 50 are both red flag ages for serious spinal pathology. As with all decision-making variables, a single risk factor may or may not be significant and must be viewed in context of the whole patient/client presentation. See Appendix A-2 for a list of some possible health risk factors. Routine screening for osteoporosis, hypertension, incontinence, cancer, vestibular or balance problems, and other potential problems can be a part of the physical therapist's practice. Therapists can advocate disease prevention, wellness, and promotion of healthy lifestyles by delivering health
significant neurologic changes from the initial evaluation. The therapist reviewed the Special Questions to Ask: Neck or Back (Pain Assessment and General Systemic) to look for any other screening questions and asked about a recent history of infection. The client reported a mild upper respiratory infection two weeks ago. There were no other obvious red flag findings. Result: The therapist reported the new episode of signs and symptoms. Red flags observed included bilateral symptoms, absent muscle stretch reflexes, and recent history of infection. A medical evaluation was carried out and a diagnosis of Guillain Barre was made. The client continued to get worse with involvement of the respiratory muscles, foot drop, and numbness in the hands and feet. A new episode of care was initiated to include physical therapy to strengthen facial musculature and prevent atrophy on the right side and to prevent pneumonia from respiratory muscle involvement.
care services intended to prevent health problems or maintain health and by offering wellness screening as part of primary prevention.
Clinical Presentation During the examination the therapist will begin to get an idea of the client's overall clinical presentation. The client interview, systems review of the cardiopulmonary, musculoskeletal, neuromuscular, and integumentary systems, and assessment of pain patterns and pain types form the basis for the therapist's evaluation and eventual diagnosis. Assessment of pain and symptoms is often a large part of the interview. In this final section of the text, pain and dysfunction associated with each anatomic part (e.g., back, chest, shoulder, pelvis, sacrum/sacroiliac, hip, and groin) are discussed and differentiated as systemic from musculoskeletal whenever possible. Characteristics of pain, such as onset, description, duration, pattern, aggravating and relieving factors, and associated signs and symptoms, are presented in Chapter 3 (see Table 3-2; see also
CHAPTER 14
CASE EXAMPLE
14-2
SCREENING THE HEAD, NECK, A N D BACK
Minimal Trauma
Background: An in-patient acute care therapist was working with a 75-year-old woman who was 1-day status post right total hip replacement (THR). The patient reported getting out of bed by herself early in the morning and falling against the night stand. She complained of low back pain when the therapist arrived to help her sit up in bed and stand. The pain was in the left lumbar area without radiation. Past Medical History: Past medical history included osteoporosis (treated with bisphosphonate medication, calcium, and vitamin D), breast cancer with mastectomy 30 years ago, and hypothyroidism treated with medication (Synthroid). Clinical Presentation: No pre-operative baseline information was available regarding the client's physical function, gait pattern, or range of motion for the spine or hips. There was moderate tenderness to palpation and percussion of the sacrum on the left side. Mild tenderness was reported with percussion to the upper and lower lumbar spine. There were no apparent skin changes, bruising, warmth, or swelling. The patient could ambulate slowly with a walker but reported pain in both hips with each step. She could only take small steps moving approximately 2 to 4 inches forward with each
Appendix C-4). Reviewing the comparison in Table 3-2 will assist the therapist in recognizing systemic versus musculoskeletal presentation of signs and symptoms.
Effect
633
of Position
When seen early in the course of symptoms, neck or back pain of a systemic or viscerogenic origin is usually accompanied by full and painless range of motion without limitations. When the pain has been present long enough to cause muscle guarding and splinting, then subsequent biomechanical changes occur. Typically systemic back pain is not relieved by recumbency. In fact the bone pain of metastasis or myeloma tends to be more continuous, progressive, and prominent when the client is recumbent.
step. Lumbar range of motion was very limited in flexion, side bending, and extension. She was unable to straighten up to a fully upright standing position due to her low back/sacral pain. Outcome: The therapist filed an incident report with the hospital unit clerk and spoke directly with the nursing supervisor requesting an ortho consult before continuing with the standard THR rehabilitation protocol. The patient was diagnosed with a sacral insufficiency fracture on the left at S3. X-rays and MRI also revealed scoliosis of the lumbosacral spine, moderate degenerative arthritis, and marked narrowing of the intervertebral disc spaces throughout the lumbar spine, and old compression fractures at T i l and T12. There was no evidence of bone lesions suggestive of breast cancer metastasis. Moderate foraminal stenosis was observed at the right L3 nerve root. The client returned to physical therapy with an altered rehabilitation program consisting of weight-bearing exercises on the left (to stimulate osteoblastic bone formation) as tolerated given the compromise on both sides. She had a minimally invasive hip procedure so aquatic therapy was approved when there were no openings in the skin at the incision site (1 week later).
Beware of the client with acute backache who is unable to lie still. Almost all clients with regional or nonspecific backache seek the most comfortable position (usually recumbency) and stay in that position. In contrast, individuals with systemic backache tend to keep moving trying to find a comfortable position. In particular, visceral diseases, such as pancreatic neoplasm, pancreatitis, and posterior penetrating ulcers, often have a systemic backache that causes the client to curl up, sleep in a chair, or pace the floor at night. Back pain that is unrelieved by rest or change in position, or pain that does not fit the expected mechanical or neuromusculoskeletal pattern, should raise a red flag. When the symptoms cannot be reproduced, aggravated, or altered in any way
634
SECTION III
CASE EXAMPLE 1 4 - 3
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Corticosteroid Use
Referral: A 73-year-old man was referred to a physical therapist by his family practitioner for evaluation of middle to low back pain that started when he stepped down from a curb. He was not experiencing radiating pain or sciatica and appeared to be in good general health. His medical history included bronchial asthma treated with oral corticosteroids and an abdominal hernia repaired surgically 10 years ago. Clinical Presentation: Vital signs were measured and appeared within normal limits for the client's age. There were no constitutional symptoms, no fever present, and no other associated signs or symptoms reported. There was a marked decrease in thoracic and lumbar range of motion from T10 to LI and tenderness throughout this same area. No other objective findings were noted despite a careful screening examination. The client was treated conservatively over a 2-week period but without change in his painful symptoms and without improvement in spinal movement. A second therapist in the same clinic was consulted for a reevaluation without significant differences in findings. Several suggestions were made for alternative treatment techniques. After 1 more week without change in client symptoms, the client was reevaluated. What is the next step in the screening process? Using Table 14-1 the therapist can scan down the Thoracic/Scapular and Lumbar columns for any screening clues. Prostate and testicular cancers are listed along with metastatic lesions. Given the client's age, questions should be asked
during the examination, additional questions to screen for medical disease are indicated.
Night
Pain
Pain at night can signal a serious problem such as tumor, infection, or inflammation. Long-standing night pain unaltered by positional change suggests a space-occupying lesion, such as a tumor. Systemic back pain may get worse at night, especially when caused by vertebral osteomyelitis,
about a past history of cancer and any associated urinary signs and symptoms. Given his age, cardiovascular causes of back pain are also possible. Review past medical history, risk factors, and ask about signs and symptoms associated with angina, myocardial infarction, and aneurysm. The therapist can continue to review Table 14-1 for potential pulmonary and gastrointestinal causes of this client's back pain and ask any further questions regarding possible risk factors and past history. Record all positive findings and conduct a final Review of Systems. Use the Special Questions to Ask: Neck or Back at the end of this chapter to reassess the client's general health and clinical presentation. Not all questions must be asked; the therapist will use his or her judgment based on known history for this client and current clinical findings. Result: In this case the client's age, lack of improvement with a variety of treatment techniques, and history of long-term corticosteroid use necessitated a return to the referring physician for further medical evaluation. Long-term corticosteroid therapy and radiation therapy for cancer are risk factors for ischemic or avascular necrosis. Hip or back pain in the presence of these factors should be examined carefully. Radiographic testing demonstrated ischemic vertebral collapse secondary to chronic corticosteroid administration. Diffuse osteopenia and a compression fracture of the tenth thoracic vertebral body were also mentioned in the medical report.
septic discitis, Cushing's disease, osteomalacia, primary and metastatic cancer, Paget's disease, ankylosing spondylitis, or tuberculosis (of the spine) (see Chapter 3 and Appendix B-22).
Associated Signs and Symptoms After reviewing the client history and identifying pain types or pain patterns, the therapist must ask the client about the presence of additional signs and symptoms. Signs and symptoms associated
CHAPTER 14
SCREENING THE HEAD, NECK, A N D BACK
with systemic disease are often present but go unidentified either because the client does not volunteer the information or the therapist does not ask. To assess for associated signs and symptoms, the therapist can end the client interview with the following question: Follow-Up
Questions
• Are there any other else in your body that about or we haven't not have to be related symptoms.
symptoms anywhere you haven't told me discussed? They do to your back pain or
The client with back pain and bloody diarrhea or the person with mid-thoracic or scapular pain in the presence of nausea and vomiting may not think the two symptoms are related. If the therapist only focuses on the chief complaint of back, neck, shoulder, or other musculoskeletal pain and does not ask about the presence of symptoms anywhere else, an important diagnostic clue may be overlooked. Other possible associated symptoms may include fatigue, dyspnea, sweating after only minor exertion, and GI symptoms (see also Appendix A-2 for a more complete list of possible associated signs and symptoms). If the therapist fails to ask about associated signs and symptoms, the Review of Systems offers one final step in the screening process that may bring to light important clues.
Review of Systems Clusters of these associated signs and symptoms usually accompany the pathologic state of each organ system (see Box 4-17). As part of the physical assessment, the therapist must conduct a Review of Systems. General questions about fevers, excessive weight gain or loss, and appetite loss should be followed by questions related to specific organ systems. Medications should be reviewed for possible adverse side effects. Throughout the interview the therapist must remain alert to any yellow (cautionary) or red (warning) flags that may signal the need for further screening. Review of Systems is important even for clients who have been examined by a medical doctor. It has been reported that only 5% of physicians assess patients for "red flags." During the Review of Systems a pattern of systemic or viscerogenic origin may be seen as the therapist combines information from the client history, risk factors present, associated signs and symptoms, and yellow or red flag findings.
Red Flag
Signs
635
and Symptoms
Watch for the most common red flags associated with back pain of a systemic origin (Box 14-1). Individuals with serious spinal pathology almost always have one or more of these red flags; they can be missed when the clinician (physician or therapist) assumes the client's symptoms are the result of mechanical-induced back pain. See also Appendix A-2. Key findings are age older than 50, significant recent weight loss, previous malignancy, and constant pain that is not relieved by positional change or rest and is present at night, disturbing the person's sleep. Back pain in children is always a red flag especially if it has been present for more than 6 weeks. Children are less likely to report associated signs and symptoms and must be interviewed carefully. Ask about any other joint involvement, swelling anywhere, changes in range of motion, and the presence of any constitutional and GI symptoms. A recent history of viral illnesses may be linked to myalgias and discitis. Most common causes of back pain in children are listed in Table 14-2. Red flags requiring medical evaluation or reevaluation include back pain or symptoms that
BOX 14-1
M o s t C o m m o n Red Flags A s s o c i a t e d w i t h Back Pain of Systemic
• • • • • • • • • • • •
12
• •
Origin
Age less than 20 or over 50 Previous history of cancer Constitutional symptoms (e.g., fever, chills, unexplained weight loss) Recent urinary tract infection History of injection drug use Immunocompromised condition (e.g., prolonged use of corticosteroids, transplant recipient, autoimmune diseases) Failure to improve with conservative care (usually over 4 to 6 weeks) Pain is not relieved by rest or recumbency Severe, constant nighttime pain Progressive, neurologic deficit; saddle anesthesia Back pain accompanied by abdominal, pelvic, or hip pain History of falls or trauma (screen for fracture, osteoporosis, domestic violence, alcohol use) Significant morning stiffness with limitation in all spinal movements (ankylosing spondylitis or other inflammatory disorder) Skin rash (inflammatory disorder, e.g., Crohn's disease, ankylosing spondylitis)
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SECTION III
TABLE 1 4 - 2
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Causes of Back Pain in C h i l d r e n
I n f l a m m a t o r y conditions Discitis Vertebral osteomyelitis Spinal abscess Non-spinal infections (e.g., pancreatitis, pyelonephritis) Rheumatoid arthritis (cervical spine involved most often) Ankylosing spondylitis (presents during adolescence)
Developmental conditions
Trauma
Neoplastic disease
Other
Spondylolysis Spondylolisthesis Scheuermann's syndrome Scoliosis
Muscle strain Stress fracture Overuse syndrome Physical abuse
Leukemia Hodgkin's disease Non-Hodgkin's lymphoma Ewing's sarcoma (primary) Osteogenic sarcoma (osteosarcoma)[primary] Rhabdomyosarcoma (rare; skeletal metastasis)
Mechanical Psychosomatic
Behrman RE, editor: Nelson's textbook of pediatrics, ed 17, Philadelphia, 2004, WB Saunders. Used with permission.
are not improving as expected, steady pain irrespective of activity, symptoms that are increasing, or the development of new or progressive neurologic deficits, such as weakness, sensory loss, reflex changes, bowel or bladder dysfunction, or myelopathy. Use the Quick Screen Checklist (see Appendix A - l ) to conduct a consistent and complete screening examination. A few key screening questions might include: Follow-Up
Questions
• Have you had an injury or trauma to your head, face, neck, or back? • Do you have (or have you recently had) a fever? Headache? Sore throat? Skin rash? • Have you ever had cancer of any kind? Ever been treated with chemotherapy or radiation therapy? • Are you taking any medications? • Have you had any problems with your bowels or bladder?
LOCATION OF PAIN AND SYMPTOMS There are many ways to examine and classify head, neck, and back pain. Pain can be divided into anatomic location of symptoms (where is it located?); cervical, thoracic, scapular, lumbar, and sacroiliac joint/sacral (as shown in Table 14-1). For example, intrathoracic disease refers more often to the neck, midthoracic spine, shoulder, and upper
trapezius areas. Visceral disease of the abdomen and/or pelvis is more likely to refer pain to the low back region. Later in this section spine pain is presented by the source of symptoms (what is causing the problem?). Whenever faced with the need to screen for medical disease the therapist can review Table 141. First identify the location of the pain. Then scan the list for possible causes. Given the client's history, risk factors, clinical presentation, and associated signs and symptoms, are there any conditions on this list that could be the possible cause of the client's symptoms? Is age or gender a factor? Is there a positive family or personal history? Sometimes reviewing the possible causes of pain based on location gives the therapist a direction for the next step in the screening process. What other questions should be asked? Are there any tests that will help differentiate symptoms of one anatomical area from another? Are there any tests that will help identify symptoms that point to one system versus another?
Head The therapist may evaluate pain and symptoms of the face, scalp, or skull. Headaches are a frequent complaint given by adults and children. It may not be the primary reason for seeing a physical therapist but is often mentioned when asked if there are any other symptoms of any kind anywhere else in the body. The brain itself does not feel pain because it has no pain receptors. Most often the headache is caused by an extracranial disorder and is consid-
CHAPTER 14
ered "benign." Headache pain is related to pressure on other structures such as blood vessels, cranial nerves, sinuses, membrane surrounding the brain. Serious causes have been reported in 1% to 5% of the total cases, most often attributed to tumors and infections of the central nervous s y s t e m . In the past, headache was viewed as many disorders along a continuum. Better headache classifications have brought about the development of many discrete entities among these disorders. The International Headache Society (HIS) has published commonly used International Classification of Headache Disorders (edition 2, revised), which divides headaches into three parts: primary headache, secondary headache, and cranial neuralgias. Primary headache includes migraine, tensiontype headache, and cluster headache. Secondary headaches, of which there is a large number, are attributed to some other causative disorder specified in the diagnostic criteria attached to them. 113
1415
16,17
TABLE 14-3
SCREENING THE HEAD, NECK, A N D BACK
637
The therapist often provides treatment for secondary headache called cervicogenic headache (CGH). This type of headache is defined as referred pain in any part of the head caused by musculoskeletal tissues innervated by cervical nerves (C1-C4). CGHs are frequently associated with chronic tension or acute whiplash injury, intervertebral disc disease, or progressive facet joint arthritis (e.g., cervical spondylosis, cervical arthrosis) (Table 14-3). 18
Causes
of
Headaches
Headache can be a symptom of neurologic impairment, hormonal imbalance, neoplasm, side effect of medication, or other serious condition (Box 14-2). Headache may be the only symptom of hypertension, cerebral venous thrombosis, or impending stroke. Sudden, severe headache is a classic symptom of temporal vasculitis (arteritis), a condition that can lead to blindness if not recognized and treated promptly. 15
19
Clinical Signs a n d S y m p t o m s o f M a j o r H e a d a c h e Types
Migraine Can be headache-free Migraines with headache are often described as throbbing or pulsating Often one-sided (unilateral); often around or behind one eye Associated with nausea, vomiting Common triggers: • Alcohol • Food • Hormonal changes • Hunger • Lack of sleep • Perfume • Stress • Medications • Environmental factors (e.g., pollutants, air pressure changes, temperature) May be preceded by prodromal symptoms: • Visual changes (aura) • Motor weakness • Dizziness • Paresthesias Facial pallor, cold hands and feet History of headaches in childhood; family history of migraines
Tension
Cervicogenic
Described as dull pressure Sensation of band or vise around the head Headache pain is bilateral or global (entire head) Muscular tenderness or soreness in soft tissues of the upper cervical spine Not usually accompanied by associated signs and symptoms May get worse with loud sounds or bright lights Current diagnosis or history of anxiety, depression, or panic disorder
Pain starts in the occipital region and spreads anteriorly toward the frontal area Usually bilateral Pain intensity fluctuates from mild to severe Often made worse by neck movements or sustained postures Can resemble migraines with throbbing pain, nausea, phonophobia, photophobia History of trauma (e.g., whiplash), disc disease, or arthritis may be helpful
638
BOX 1 4 - 2
S E C T I O N III
S Y S T E M I C O R I G I N S O F PAIN A N D D Y S F U N C T I O N
Systemic O r i g i n s of H e a d a c h e
Cancer
Primary neoplasm Chemotherapy; brain radiation Cardiovascular
Migraine Ischemia (atherosclerosis; vertebrobasilar insufficiency) Cerebral vascular thrombosis Arteriovenous malformation Subarachnoid hemorrhage Giant cell arteritis; vascular arteritis; temporal vasculitis Hypertension Febrile illnesses Hypoxia Systemic lupus erythematosus Pulmonary
Obstructive sleep apnea Hyperventilation (e.g., associated with anxiety or panic attacks) Renal/Urologic
Kidney failure; renal insufficiency Dialysis (first-use syndrome) Gynecologic
Pregnancy Dysmenorrhea Neurologic
Post-seizure Disorder of cranium, cranial structures (e.g., nose, eyes, ears, teeth, neck) Cranial neuralgia (e.g., trigeminal, Bell's palsy, occipital, Herpes zoster, optic neuritis) Brain abscess Hydrocephalus Other
History of physical or sexual abuse Side effect of medications Allergens (environmental or food) Overuse of medications (analgesic rebound effect) Psychogenic/psychiatric disorder Substance abuse/withdrawal (drugs and/or alcohol) Caffeine use/withdrawal Candidiasis (yeast) Trauma (e.g., cervicogenic headache, fracture, eating disorders with forced vomiting) Infection (e.g., meningitis, sinusitis, syphilis, tuberculosis, sarcoidosis, herpes) Post-dural puncture Scuba diving Hantavirus Paget's disease (when skull is affected) Hypoglycemia Fibromyalgia
Recognizing associated signs and symptoms and performing vital sign assessment, especially blood pressure monitoring, are important screening tools for vascular-induced headaches (see Chapter 4 for information on monitoring blood pressure). Stress and inadequate coping are risk factors for persistent headache. Headache can be part of anxiety, depression, panic disorder, and substance abuse. Headaches have been linked with excessive caffeine consumption or withdrawal in children, adolescents, and adults. Therapists often encounter headaches as a complaint in clients with post-traumatic brain injury, post-whiplash injury, or post-concussion injury. A constellation of other symptoms are often present such as dizziness, memory problems, difficulty concentrating, irritability, fatigue, sensitivity to noise, depression, anxiety, and problems with making judgments. Symptoms may resolve in the first 4 to 6 weeks following the injury but can persist for months to years causing permanent disability. 20
21
22
CANCER
The greatest concern is always whether or not there is brain tumor causing the headaches. Only a minority of individuals who have headaches have brain tumors. Risk factors include occupational exposure to gases and chemicals and history of cranial radiation therapy for fungal infection of the scalp or for other types of cancer. A previous history of cancer, even long past history, is a red flag for insidious onset of head and occipital neck pain. Metastatic lesions of the upper cervical spine are difficult to diagnose. Plain radiographs generally appear negative, which can delay diagnosis of clients with C1-C2 metastatic disease. The alert therapist may recognize the need for further imaging studies or medical evaluation. Persistent documentation of clinical findings and nonresponse to physical therapy intervention with repeated medical referral may be required. Although primary head and neck cancers can cause headaches, neck pain, facial pain, and/or numbness in the face, ear, mouth, and lips are more likely. Other signs and symptoms can include sore throat, dysphagia, a chronic ulcer that does not heal, a lump in the neck, and persistent or unexplained bleeding. Color changes in the mouth known as leukoplakia (white patches) or erythroplakia (red patches) may develop in the oral cavity as a premalignant sign. Cancer recurrence is not uncommon within the first 3 years after treatment for cancers of the head and neck; often these cancers are not diagnosed 23
24
CHAPTER 14
until an advanced stage due to neglect on the part of the affected individual. Cervical spine metastasis is most common with distant metastases to the lungs, although any part of the body can be affected. Anyone with a history of head and neck cancer should be screened for cancer recurrence when seen by a therapist for any problem. As always, prevention and early detection improve survival rates. Education is important because most of the risk factors (tobacco and alcohol use, betel nut, syphilis, nickel exposure, woodworking, sun exposure, dental neglect) are modifiable. Tension-type or migraine headaches can occur with tumors. Rapidly growing tumors are more likely to be associated with headache and will eventually present with other signs and symptoms such as visual disturbances, seizures, or personality changes. Headaches associated with brain tumors are usually bioccipital or bifrontal, intermittent, and of increasing duration. The headache is worse on awakening because of differences in CNS drainage in the supine and prone positions and usually disappears soon after the person arises. It may be intensified or precipitated by any activity that increases intracranial pressure, such as straining during a bowel movement, stooping, lifting heavy objects, or coughing. Often, the pain can be relieved by taking aspirin, acetaminophen, or other moderate painkillers. Vomiting with or without nausea (unrelated to food) occurs in about 25% to 30% of people with brain tumors and often accompanies headaches when there is an increase in intracranial pressure. If the tumor invades the meninges, the headaches will be more severe. Recognizing the need for medical referral for the client with complaints of headaches can be difficult. Past medical history can be complex in adults and screening clues are often confusing. Careful review of the clinical presentation is required. For example, although pain associated with the CGH can be constant (a red flag symptom) the intensity often varies with activity and postures. Sustained posture consistently increases intensity of painful symptoms. 25
26
MIGRAINES
Migraine headaches are often accompanied by nausea, vomiting, and visual disturbances, but the pain pattern is also often classic in description. Age is a yellow flag because migraines generally begin in childhood to early adulthood. Migraines can first occur in an individual beyond the age of 50 (especially in peri-menopausal or menopausal women); advancing age makes other types of headaches
639
SCREENING THE HEAD, NECK, A N D BACK
more likely. A family history is usually present, suggesting a genetic predisposition in migraine sufferers. In addition to the typical clinical presentation there are usually normal examination results. Migraines can present with paralysis or weakness of one side of the body mimicking a stroke. A medical examination is required to diagnose migraine, especially in cases of hemiplegic migraines. Medical evaluation and treatment for migraines in general is recommended. There is a role for the physical therapist because the beneficial effects of exercise on migraine headaches has been documented. ' Physical therapy is most effective for the treatment of migraine when combined with other treatments such as thermal biofeedback and relaxation training. When present, associated signs and symptoms offer the best yellow or red flag warnings. For example, throbbing headache with unexplained diaphoresis and elevated blood pressure may signal a significant cardiovascular event. Daytime sleepiness, morning headache, and reports of snoring may point to obstructive sleep apnea. Headache-associated visual disturbances or facial numbness raises the suspicion of a neurologic origin of symptoms. Other red flags are listed in Box 14-3. The therapist is advised to follow the same screening decision-making model introduced in Chapter 1 (see Box 1-7) and reviewed briefly at the beginning of this chapter. Physical examination should include measurement of vital signs, a general assessment of cardiac and vascular signs, and a thorough head and neck examination. A screening neurologic examination should address mental status (including pain behavior), cranial nerves, motor function, reflexes, sensory systems, coordination, and gait (see Chapter 4). Special Questions to Ask: Headache are listed at the end of this chapter and in Appendix B-15. 27
28
29
Cervical Spine Neck pain is very common and has many mechanical and systemic causes. Neck and shoulder pain and neck and upper back pain often occur together making the differential diagnosis more difficult. Traumatic and degenerative conditions of the cervical spine, such as whiplash syndrome and arthritis are the major primary musculoskeletal causes of neck pain. The therapist must always ask about a history of motor vehicle accident or trauma of any kind, including domestic violence. 30
640
B O X 14-3
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Red Flag Signs a n d S y m p t o m s Associated with
Headache
Listed in descending order of importance the therapist should watch for any of the following red flags and report them to a medical doctor. A complete screening interview and examination can establish a baseline of information and aid in the medical referral decision-making process. • Headache that wakes the individual up or is present upon awakening (e.g., hypertension, tumor) • Headache accompanied by documented elevated blood pressure changes • Insidious or new onset of headache (less than six months) • New onset of headache with associated neurologic signs and symptoms (e.g., confusion, dizziness, gait or motor disturbances, fatigue, irritability or mood changes) • New onset of headache accompanied by constitutional symptoms (e.g., fever, chills, sweats) or stiff neck (infection, arteritis) • Episodes of "blacking out" during headache (seizures, hemorrhage, tumor) • Sudden severe headache accompanied by flulike symptoms, aching muscles, jaw pain when eating, and visual disturbances (temporal arteritis) • No previous personal or family history of migraine headaches
Cervical or neck pain with or without radiating arm pain or symptoms may be caused by a local biomechanical dysfunction (e.g., shoulder impingement, disc degeneration, facet dysfunction) or a medical problem (e.g., infection, tumor, fracture). Referred pain presenting in these areas from a systemic source may occur from infectious disease, such as vertebral osteomyelitis, or from cancer, cardiac, pulmonary, or abdominal disorders (see Table 14-1). Rheumatoid arthritis is often characterized by poly arthritic involvement of the peripheral joints but the cervical spine is often affected early on (first 2 years) in the course of the disease. Deep aching pain in the occipital, retroorbital, or temporal areas may be present with pain referred to the face, ear, or subocciput from irritation of the C2 nerve root. Some clients may have atlantoaxial subluxation and report a sensation of the head falling forward during neck flexion or a clunking sensation during neck extension as the A-A joint is
reduced spontaneously. Symptoms of cervical radiculopathy are common with A-A joint involvement. Radicular symptoms accompanied by weakness, coordination impairment, gait disturbance, bowel or bladder retention or incontinence, and sexual dysfunction can occur whenever cervical myelopathy occurs, whether from a mechanical or medical cause. An imaging study is usually needed to differentiate biomechanical from medical cause of radicular pain, especially when conservative care fails to bring about improvement. 7
31
Clinical Signs and Symptoms of Cervical •
Myelopathy
W i d e - b a s e d spastic g a i t
•
Clumsy hands
•
V i s i b l e c h a n g e in h a n d w r i t i n g
•
Difficulty
manipulating
burtons
or
handling
coins •
Hyperreflexia
•
Positive B a b i n s k i test
•
Positive H o f f m a n sign
•
Lhermitte's s i g n
•
U r i n a r y retention f o l l o w e d b y o v e r f l o w i n c o n t i n e n c e (severe m y e l o p a t h y )
Torticollis of the sternocleidomastoid muscle may be a sign of underlying thyroid involvement. Anterior neck pain that is worse with swallowing and turning the head from side to side may be present with thyroiditis. Ask about associated signs and symptoms of endocrine disease (e.g., temperature intolerance; hair, nail, skin changes; joint or muscle pain; see Box 4-17) and a previous history of thyroid problems. Palpate the anterior spine and have the client swallow during palpation. Palpation of a soft tissue mass or lump should be noted. See guidelines for palpation in Chapter 4. Palpation of a firm, fixed, and immoveable mass raises a red flag of suspicion for neoplasm. Visually inspect and palpate the trachea for lateral deviation to either side. Anterior disc bulge into the esophagus or pharynx and/or anterior osteophyte of the vertebral body may give the sensation of difficulty swallowing or feeling a lump in the throat when swallowing. Anxiety can also cause a sensation of difficulty swallowing with a lump in the throat. Conduct a cranial nerve assessment for cranial nerves V and VII (see Table 4-9). See also Appendix B-8. 32
33
CHAPTER 14
Vertebral artery syndrome caused by structural changes in the cervical spine is characterized by the client turning the whole body instead of turning the head and neck when attempting to look at something beyond his or her peripheral vision. Combined cervical motions such as extension, rotation, and side bending cause dizziness, visual disturbances, and nystagmus. Decreased blood flow to the brain, referred to as cerebral ischemia, may be caused by vertebrobasilar insufficiency (VBI) and occurs when decreased vertebral height, osteophyte formation, postural changes, and ligamentous changes reduce the foraminal space and encroach on the vertebral artery. Tests for vertebral artery patency may help identify the underlying cause of neck pain; these tests must be carried out carefully especially with older adults.
Thoracic Spine As with the cervical spine and any musculoskeletal part of the body, the therapist must look for the cause of thoracic pain at the level above and below the area of pain and dysfunction. Shoulder impingement and mechanical problems in the cervical spine can refer pain to the thoracic spine. Systemic origins of musculoskeletal pain in the thoracic spine (Table 14-4) are usually accompa-
TABLE 14-4
SCREENING THE HEAD, NECK, A N D BACK
641
nied by constitutional symptoms and other associated symptoms. Often these additional symptoms develop after the initial onset of back pain, and the client may not relate them to the back pain and therefore may fail to mention them. The close proximity of the thoracic spine to the chest and respiratory organs requires careful screening for pleuropulmonary symptoms in anyone with back pain of unknown cause or past medical history of cancer or pulmonary problems. Thoracic pain can also be referred from the kidney, biliary duct, esophagus, stomach, gallbladder, pancreas, and heart. Thoracic aortic aneurysm, angina, and acute myocardial infarction are the most likely cardiac causes of thoracic back pain. Usually, there is a cardiac history and associated signs and symptoms, such as weak or thready pulse, extremely high or extremely low blood pressure, or unexplained perspiration and pallor. Tumors occur most often in the thoracic spine because of its length, the proximity to the mediastinum, and direct metastatic extension from lymph nodes with lymphoma, breast, or lung cancer. The client may report symptoms typical of cancer. Tumor involvement in the thoracic spine may produce ischemic damage to the spinal cord or early cord compression since the ratio of canal
Location of Systemic T h o r a c i c / S c a p u l a r Pain
Systemic origin
Location
Cardiac Myocardial infarct Aortic aneurysm
Midthoracic spine Thoracic spine; thoracolumbar spine
Pulmonary Basilar pneumonia Empyema Pleurisy Pneumothorax
Right upper back Scapula Scapula Ipsilateral scapula
Renal Acute pyelonephritis
Costovertebral angle (posteriorly)
Gastrointestinal Esophagitis Peptic ulcer: stomach/duodenal Gallbladder disease Biliary colic Pancreatic carcinoma
Midback between scapulae Sixth through tenth thoracic vertebrae Midback between scapulae; right upper scapula or subscapular area Right upper back; midback between scapulae; right interscapular or subscapular areas Midthoracic or lumbar spine
Other Acromegaly Breast cancer
Midthoracic or lumbar spine Midthoracic spine or upper back
642
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
diameter to cord size is small, resulting in rapid deterioration of neurologic status (Case Example 14-4). Peptic ulcer can refer pain to the midthoracic spine between T6 and T10. The therapist should look for a history of NSAID use and ask about blood in the stools and the effect of eating food on pain
CASE
EXAMPLE
14-4
Midthoracic
Back
Background: A 55-year-old woman presents with sharp pain in the midback region around T5 to T6. The pain started after vacuuming her house last week. She has been taking Tylenol, but the pain is unrelieved. She reports being unable to find a comfortable position; the pain is keeping her awake at night. History reveals a previous episode of pain in the same area two months ago. The pain started after she went grocery shopping and carried the heavy bags into her house. At that time, Tylenol quickly relieved her symptoms. The pain from the previous episode was described as "aching," not sharp like today. Past Medical History: Past medical history includes breast cancer 15 years ago, surgical hysterectomy 10 years ago, and hypothyroidism. She does not remember what kind of breast cancer she had. She was treated with a lumpectomy and radiation. She has not had a mammography or clinical breast exam in the past five years. She does not perform self-breast examination on a regular or consistent basis. She takes Synthroid for her thyroid problem, but is not taking any other prescription medication. She takes a daily vitamin and 1200 mg of calcium, but no other supplements. Tylenol is the only other over-the-counter product. She does not smoke or drink, even socially. She does not use any other substances of any kind. She reports there are no other symptoms of any kind anywhere else in her body. Clinical Presentation: Vital signs are normal. There are no visible or palpable lesions in the upper quadrant on either side. Axillary and supraclavicular lymph nodes are not enlarged or palpable. Submandibular lymph nodes are palpable, but not tender or hard.
and bowel Chapter 2).
function
(see
further
discussion,
Scapula Most causes of scapular pain occur along the vertebral border and result from various primary musculoskeletal lesions. However, cardiac, pul-
Pain
Neurologic screening exam is normal including bowel and bladder function, although the client reports a sensation of intermittent "weakness" in her left arm. There is exquisite pain on palpation of the thoracic spine from T4 to T6. There was no apparent movement dysfunction observed. How can you differentiate between a disc problem and bony metastases? A differential diagnosis of this type is outside the scope of the physical therapist's practice and requires a medical evaluation. The physician's differential diagnosis may include mammography, x-rays, and CT scan or MRI to assist in the diagnosis. Severe back pain that is unrelieved by rest or change of position and present at night in a woman with a past history of breast cancer requires immediate referral. Breast cancer has a predilection for axial skeletal bony metastases. Metastases can also occur hematogenously to the lungs (see Table 13-5). The therapist can perform a pulmonary system screening examination and ask about specific pulmonary signs and symptoms. Reviewing Table 14-1 for possible viscerogenic causes of midthoracic back pain in a 57 year old, the screening process can also include a brief cardiovascular examination and questions about GI function. Baseline information of this type can be extremely helpful later when documenting change in status or condition. Rather than provide physical therapy intervention and assessing the results, immediate medical evaluation is in the best interest of this client. If the medical tests come back negative or if there is a disc problem, then the appropriate physical therapy intervention can be prescribed.
CHAPTER 14
monary, renal, and GI disorders can cause scapular pain. Specific questions to rule out potential systemic origin of symptoms are listed in each individual chapter. For example, if the client reports any renal involvement, the therapist can use the questions at the end of Chapter 10 to screen further for urologic involvement. Appendix A contains a series of screening questions based on the presence of specific factors (e.g., gender, joint pain, night pain, shortness of breath).
Lumbar Spine Low back pain (LBP) is very prevalent in the adult population, affecting up to 80% of all adults sometime in their lifetimes. In most cases, acute symptoms resolve within a few weeks to a few months. Individuals reporting persistent pain and activity limitation must be given a second screening examination. As Table 14-1 shows, there is a wide range of potential systemic causes of low back pain. Older adults with more comorbidities are at increased risk for LBP. Bone and joint diseases (inflammatory and non-inflammatory), lung and heart diseases, and enteric diseases top the list of conditions contributing to LBP in older adults. 34
Sacrum/Sacroiliac Sacral or sacroiliac pain in the absence of trauma and in the presence of a negative spring test (posterior-anterior glide of sacrum between the innominates) must be evaluated more closely. The most common etiology of serious pathology in this anatomic region comes from the spondyloarthropathies (disease of the joints of the spine) such as ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis, and arthritis associated with chronic inflammatory bowel (enteropathic) disease. Spondyloarthropathy is characterized by morning pain accompanied by prolonged stiffness that improves with activity. There is limitation of motion in all directions and tenderness over the spine and sacroiliac joints. The most significant finding in ankylosing spondylitis is that the client has night (back) pain and morning stiffness as the two major complaints, but asymmetric sacroiliac involvement with radiation into the buttock and thigh can occur. In addition to back pain, these rheumatic diseases usually include a constellation of associated signs and symptoms, such as fever, skin lesions, anorexia, and weight loss that alert the therapist to the presence of systemic disease. Such symp-
SCREENING THE HEAD, NECK, A N D BACK
643
toms present a red flag identifying clients who should be referred to a physician. Age, gender, and risk factors are important in assessing for systemic origin of symptoms associated with any of these inflammatory conditions. Clients with these diseases have a genetic predisposition to these arthropathies, which are triggered by a number of environmental factors such as trauma and infection. Each of these clinical entities has been discussed in detail in Chapter 12. Polymyalgia rheumatica and fibromyalgia syndrome are muscle syndromes associated with lumbosacral pain. Fibromyalgia syndrome refers to a syndrome of pain and stiffness that can occur in the low back and sacral areas with localized tender areas. Both these disorders are also discussed in Chapter 12.
SOURCES OF PAIN AND SYMPTOMS Pain can be evaluated by the source of symptoms (what is causing the problem?). It could be visceral, neurogenic, vasculogenic, spondylogenic, or psychogenic in origin. Specific symptoms and characteristics of pain (frequency, intensity, duration, description) help identify sources of back pain (Table 14-5). The therapist must look at the history and risk factors, too. Any associated signs and symptoms that might reflect any one (or more) of these sources should be identified. Again, the therapist can use the tables in this chapter along with screening questions provided in Appendix A to help guide the screening process.
Viscerogenic Visceral pain is not usually confused with pain originating in the head, neck, and back because sufficient specific symptoms and signs are often present to localize the problem correctly. It is the unusual presentation of systemic disease in the therapist's practice that will make it more difficult to recognize. Low back pain is more likely to result from disease in the abdomen and pelvis than from intrathoracic disease, which usually refers pain to the neck, upper back, and shoulder. Disorders of the GI, pulmonary, urologic, and gynecologic systems can cause stimulation of sensory nerves supplied by the same segments of the spinal cord, resulting in referred back pain. As discussed in Chapter 3, the central nervous system may not be able to distinguish which part of the body is responsible for the input into common neurons. 35
644
TABLE 14-5
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
N e c k a n d Back Pain: S y m p t o m s a n d Possible C a u s e s
Symptom Night pain unrelieved by rest or change in position; made worse by recumbency Fever, chills, sweats Unremitting, throbbing pain Abdominal pain radiating to midback; symptoms associated with food; symptoms worse after taking NSAIDs Morning stiffness that improves as day goes on Leg pain increased by walking and relieved by standing Leg pain increased by walking, unaffected by standing, but sometimes relieved by sitting or prolonged rest "Stocking glove" numbness Global pain Long-standing back pain aggravated by activity Pain increased by sitting Sharp, narrow band of pain radiating below the knee Chronic spinal pain Back pain dating to specific injury Back pain in athletic teenager Exquisite tenderness over spinous process Back pain preceded or accompanied by skin rash
Possible cause Tumor Infection Aortic aneurysm Pancreatitis, gastrointestinal disease, peptic ulcer Inflammatory arthritis Vascular claudication Neurogenic claudication Referred pain, nonorganic pain Nonorganic pain Deconditioning Discogenic disease Herniated disc Stress/psychosocial factors (unsatisfying job, fear-avoidance behavior) Strain or sprain, fracture Epiphysitis, juvenile discogenic disease, spondylolysis, or spondylolisthesis Tumor, fracture, infection Inflammatory bowel disease
Modified from Nelson BW: A rational approach to the treatment of low back pain, J Musculoskel Med i0(5):75, 1993.
Back pain can be associated with distention or perforation of organs, gynecologic conditions, or gastroenterologic disease. Pain can occur from compression, ischemia, inflammation, or infection affecting any of the organs (Fig. 14-1). Referred pain can also originate in organs that share pain innervation with areas of the lumbosacral spine. Collicky pain is associated with spasm in a hollow viscus. Severe, tearing pain with sweating and dizziness may originate from an expanding abdominal aortic aneurysm. Burning pain may originate from a duodenal ulcer. Muscle spasm and tenderness along the vertebrae may be elicited in the presence of visceral impairment. For example spasm on the right side at the 9th and 10th costal cartilages can be a symptom of gallbladder problems. The spleen can cause tenderness and spasm at the level of T9 through T i l on the left side. The kidneys are more likely to cause tenderness, spasm, and possible cutaneous pain or sensitivity at the level of the 11th and 12th ribs. Most often, past medical history, clinical presentation, and associated signs and symptoms will alert the therapist to an underlying systemic origin of musculoskeletal symptoms. Any client older than 50 with back pain, especially with insidious
Liver Stomach Abdominal muscles -Spine Intestines' •Rectum Pelvic organs Puborectalis muscle Fig.
14-1
•
External anal sphincter muscle
Sagittal v i e w of a b d o m i n a l a n d pelvic cavities
to show the p r o x i m i t y of viscera to the spine. The a b d o m i n a l muscles a n d muscles of the pelvic floor provide anterior a n d inferior support, respectively. A n y dysfunction of the musculature can alter the relationship of the viscera; likewise anything that impacts the viscera can affect the d y n a m i c tension a n d ultimately the function of the muscles. Pathology of the organs can refer p a i n t h r o u g h shared p a t h w a y s or by direct distention as a result of compression f r o m inflammation a n d tumor.
CHAPTER 14
onset or unknown cause, must have vital signs taken, including body temperature. Careful questioning can elicit important information that the client withheld, thinking it was irrelevant to the problem, such as low back pain alternating with abdominal pain at the same level or back pain alternating with bouts of bloody diarrhea. The therapist should look for clusters of signs and symptoms that may suggest involvement of a particular system. Using the Systems Review chart in Chapter 4 (see Box 4-17) can be very helpful in identifying visceral sources of symptoms.
Neurogenic Neurogenic pain is not easily differentiated. Radicular pain results from irritation of axons of a spinal nerve or neurons in the dorsal root ganglion whereas referred pain results from activation of nociceptive free nerve endings (nociceptors) in somatic or visceral tissue. Neurologic signs are produced by conduction block in motor or sensory nerves, but conduction block does not cause pain. Thus, even in a client with back pain and neurologic signs, whatever causes the neurologic signs is not causing the back pain by the same mechanism. Therefore, finding the cause of the neurologic signs does not always identify the cause of the back pain. The therapist must look further. Conditions such as radiculitis may cause both pain and neurologic signs but in that case the pain occurs in the lower limb, not in the back or in the upper extremity, not in the neck. If root inflammation also happens to involve the nerve root sleeve, neck or back pain might also arise. In such a case the individual will have three problems each with a different mechanism: neurologic signs due to conduction block, radicular pain due to nerve-root inflammation, and neck or back pain due to inflammation of the dura. Identifying a mechanical cause of pain does not always rule out serious spinal pathology. For example neurogenic pain can be caused by a metastatic lesion applying pressure or traction on any of the neural components. The therapist must rely on history, clinical presentation, and the presence of any associated signs and symptoms to make a determination about the need for medical referral. Sciatica alone or sciatica accompanying back pain is an important but unreliable symptom. For example, diabetic neuropathy can cause nerve root irritation. Prostatic metastases to the lumbar and pelvic regions or other neoplasms of the spine can 36
36
645
SCREENING THE HEAD, NECK, A N D BACK
B
Spinal Stenosis Vertebral body
A
Facet joint
1
Normal
Ligamentum flavum
Intervertebral disc (degenerative)
C
Osteophyte S b tenotic
Fig. 14-2 •
Spinal stenosis. A, A g i n g causes a loss of disc
height a n d compression of the vertebral
body. The b o n e
attempts to cushion itself by f o r m i n g a lip or extra rim a r o u n d the p e r i p h e r y of the endplates. This l i p p i n g c a n extend far e n o u g h to obstruct the o p e n i n g to the vertebral c a n a l . At the same time, the l i g a m e n t u m flavum begins to h y p e r t r o p h y or thicken a n d osteophytes (bone spurs) d e v e l o p . Degenerative disease c a n cause the a p o p h y s e a l (facet) joints to flatten out or become misshapen. A n y or all of these v a r i a b l e s c a n c o n tribute to spinal stenosis. B, N o r m a l , healthy vertebral b o d y w i t h a w i d e l y o p e n vertebral c a n a l . C, Stenotic spine f r o m a variety of contributing factors. M a n y clients have all of these changes, but some do not. The presence of p a t h o l o g i c changes is not a l w a y s a c c o m p a n i e d by clinical symptoms.
create a clinical picture that is indistinguishable from sciatica of musculoskeletal origin (see Table 16-1 Sciatica). This similarity may lead to long and serious delays in diagnosis. Such a situation may require persistence on the part of the therapist and client in requesting further medical follow up. Spinal stenosis caused by a narrowing of the spinal canal, nerve root canals, or intervertebral foramina may produce neurogenic claudication (Fig. 14-2). The canal tends to be narrow at the lumbosacral junction, and the nerve roots in the cauda equina are tightly packed. Pressure on the cauda equina from tumor, disc protrusion, infection, or inflammation can result in cauda equina syndrome, which is a medical emergency. Clinical Signs and Symptoms of Cauda
Equina
Syndrome
•
Low b a c k p a i n
•
U n i l a t e r a l or b i l a t e r a l s c i a t i c a
•
Saddle anesthesia; perineal hypoesthesia
Continued on p. 646
646
•
Change
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
in
bladder
bowel
and/or
obtained when the spine is flexed forward. Some individuals will bend over or squat as if to tie their shoelaces to assume a flexed spine position in public situations. Position of the spine (e.g., flexion or extension) does not affect symptoms of a vascular origin.
function
(e.g., difficulty initiating flow of urine, urine r e t e n t i o n , u r i n a r y o r fecal i n c o n t i n e n c e , c o n s t i p a t i o n , d e c r e a s e d a n a l t o n e a n d sensation) •
Lower extremity motor weakness a n d sensory deficits
•
Diminished
or
absent
lower
extremity
deep
Vasculogenic
t e n d o n reflexes
The emerging nerve root exits through a shallow lateral recess and also may be compressed easily. Any combination of degenerative changes, such as disc protrusion, osteophyte formation, and ligamentous thickening, reduces the space needed for the spinal cord and its nerve roots (see Fig. 14-2). Confusion with spinal stenosis syndromes may occur when atheromatous change in the internal iliac artery results in ischemia to the sciatic nerve. The subsequent sciatic pain with vascular claudication-like symptoms may go unrecognized as a vascular problem. The therapist may be able to recognize the need for medical intervention by combining a careful subjective and objective examination with knowledge of vascular and neurogenic pain patterns (Table 14-6). This is especially true in the treatment of unusual cases of sciatica or back pain with leg pain. The client with a neurogenic source of back pain may develop a characteristic pattern of symptoms, with back pain, discomfort in the buttock, thigh, or leg and numbness and paresthesia in the leg developing after the person walks a few hundred yards (neurogenic claudication). The person may be forced to stop walking and obtains relief after long periods of rest. The pattern of symptoms is similar to that of intermittent claudication associated with vascular insufficiency, the major differences being immediate response to rest and position of the spine (see Fig. 14-4; see also Fig. 14-2). The vertebral canal is wider when the spine is flexed, so relief from neurogenic pain may be
TABLE 1 4 - 6
Pain of a vascular origin may be mistaken for pain from a wide variety of musculoskeletal, neurologic, and arthritic disorders. Conversely, in a client with known vascular disease, a primary musculoskeletal disorder may go undiagnosed (e.g., discogenic disease, spinal cord tumor, peripheral neuritis, arthritis of the hip) because all symptoms are attributed to cardiovascular insufficiency. Vasculogenic pain can originate from both the heart (viscera) and the blood vessels (soma), primarily peripheral vascular disease. Back pain has been linked to atherosclerotic changes in the posterior wall of the abdominal aorta in older adults. The therapist can rely on special clues regarding vasculogenic-induced pain in the screening process (Box 14-4). Vascular injury to the great vessels, which are in proximity to the vertebral column can occur during lumbar disc surgery or can present as a complication post-operatively. In rare cases severe bleeding can result in back pain and hypotension in the acute care phase. Late complications of back pain from pseudoaneurysms can occur years after spine surgery. Once the history has been reviewed, the therapist assesses the pain pattern present on clinical examination, asks about associated signs and symptoms, and conducts a review of systems. Vascular back pain may be described as "throbbing" and almost always is increased with any activity that requires greater cardiac output and diminished or even relieved when the workload or 37
38
Back Pain: Vascular or N e u r o g e n i c ?
Vascular Throbbing Diminished, absent pulses Trophic changes (skin color, texture, temperature) Pain present in all spinal positions Symptoms with standing: no Pain increases with activity; promptly relieved by rest or cessation of activity
Neurogenic Burning No change in pulses No trophic changes; look for subtle strength deficits (e.g., partial foot drop, hip flexor or quadriceps weakness; calf muscle atrophy) Pain increases with spinal extension, decreases with spinal flexion Symptoms with standing: yes Pain may respond to prolonged rest
CHAPTER 14
BOX 14-4
Clues to V a s c u l o q e n i c Pain
Pain of a vascular origin may be: Described as "throbbing" Accompanied by leg pain that is relieved by standing still or rest Accompanied by leg pain that is described as "aching, cramping or tired" Present in all spinal positions and increased by exertion Accompanied by a pulsing sensation in abdomen or palpable abdominal pulse Caused by a back injury (lifting) in someone with known heart disease or past history of aneurysm Accompanied by pelvic pain, leg pain, or buttock pain Presented as arm pain when working with the arms overhead Accompanied by temperature changes in the extremities An early or late complication of lumbar surgery; ask about a history of previous spine surgery
activity is stopped. A "throbbing" headache may be a vascular headache from a variety of causes. Women in the peri- and menopausal states may experience vascular headaches from fluctuating hormonal levels. Clients on cardiac medication such as glyceryl trinitrate, which relaxes smooth muscle especially blood vessels and is used to prevent angina, may also report episodes of throbbing headaches. Vascular symptoms of this kind require medical evaluation. Atherosclerosis and the resulting peripheral arterial disease are the underlying causes of most vascular back pain. Often the client history will reveal significant cardiovascular risk factors such as smoking, hypertension, diabetes, advancing age, or elevated serum cholesterol (see Table 6-3 and discussion of peripheral vascular disease in Chapter 6). Older age is an important red flag when assessing for pain of a vasculogenic origin. Most often, clients with back pain and any of the vascular clues listed are middle-aged and older. A personal or family history of heart disease is a second red flag. Continuous midthoracic pain can be a symptom of myocardial infarction, especially in a postmenopausal woman with a positive family history of heart disease. Older clients with long-term nonspecific lower back pain may have occluded lumbar/middle sacral arteries associated with disc degeneration. Back
SCREENING THE HEAD, NECK, A N D BACK
647
pain and neurogenic symptoms in the presence of high serum LDL cholesterol levels raises a red flag. 39
Spondylogenic Bone tenderness and pain on weight bearing usually characterize spondylogenic back pain (or the symptoms produced by bone lesions). Associated signs and symptoms may include weight loss, fever, deformity, and night pain. There are numerous conditions capable of producing bone pain, but the most common pathologic disorders are fracture from any cause, osteomalacia, osteoporosis, Paget's disease, infection, inflammation, and metastatic bone disease (Case Example 14-5). The acute pain of a compression fracture superimposed on chronic discomfort, often in the absence of a history of trauma, may be the only presenting symptom. The client may recall a "snap" associated with mild pain, or there may have been no pain at all after the "snap." More intense pain may not develop for hours or until the next day. Back pain over the thoracic or lumbar spine that is intensified by prolonged sitting, standing, and the Valsalva maneuver may resolve after 3 or 4 months as the fractures of the vertebral bodies heal. Clients who undergo kyphoplasty or vertebroplasty often have immediate pain relief. The pain of untreated vertebral compression fractures may persist because of microfractures of biomechanical effects from deformity. Other symptoms include pain on percussion over the fractured vertebral bodies, paraspinal muscle spasms, loss of height, and kyphoscoliosis. When asking about the presence of any associated symptoms the therapist must keep in mind that older adults with vertebral compression fractures or kyphotic posture for any reason may report other pulmonary, digestive, and skeletal problems. These symptoms may not be indicative of back pain from a systemic cause but rather organic dysfunction from a skeletal cause (i.e., somatic-visceral response from the effects of a forward bent, kyphotic posture on the viscera). Sacral stress fractures should be considered in low back pain of postmenopausal women with risk factors and athletes, particularly runners, volleyball players, and field hockey players (see further discussion on spondylogenic causes of sacral pain in Chapter 15). 43
Psychogenic Psychogenic pain is observed in the client who has anxiety that amplifies or increases the person's perception of pain. Depression has been implicated
648
CASE
SECTION III
EXAMPLE
1 4 - 5
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Osteoporosis
A 59-year-old man came to physical therapy for midthoracic back pain that seemed to come on gradually over the last few weeks and was starting to make his job as a janitor more difficult. There were no other symptoms to report: no neck, chest, or arm pain. Past medical history was without incident. The client had never missed a day of work due to illness, never been hospitalized, had no previous history of surgery. He has a 40-pack year history of smoking and "throws back a few beers" every night (six-pack daily for the last 15 years). Clinical Presentation: Postural examination revealed a significant thoracic kyphosis with limited passive and active extension to neutral. Range of motion in the lumbar spine was within normal limits. Range of motion in the hip and knee was also normal. The client could take a deep breath without increasing his pain but not without setting off a
in many painful conditions as the primary underlying problem. Anxiety, depression, and panic disorder (see Chapter 3 for further discussion of anxiety, depression, and panic disorder) can lead to muscle tension, more anxiety, and then to muscle spasm. Signs and symptoms of these conditions are listed in Tables 3-9 and 3-10. Other signs of psychogenicinduced back pain may be: • Paraplegia with only stocking glove anesthesia • Reflexes inconsistent with the presenting problem or other symptoms present • Cogwheel motion of muscles for weakness • SLR in the sitting versus the supine position (person is unable to complete SLR in supine but can easily perform an SLR in a sitting position) • SLR supine with plantar flexion instead of dorsiflexion reproduces symptoms The client may use words to describe painful symptoms characterized as "emotional." Recognizing these descriptors will help the therapist identify the possibility of an underlying psychologic or emotional etiology. An "exploding" or "vicious" headache, "agonizing" neck pain, or "punishing" backache are all red flag descriptors of psychogenic origin (see Table 3-1). The client who is unable to concentrate on anything except the symptoms and who reports the symptoms interfere with every activity may need
long series of coughing. There was local tenderness palpable in the midthoracic paraspinal, and rhomboid muscles without evidence of erythema, swelling, or other skin changes. Neurologic screening examination was normal. What are the red flags? Is a medical referral needed before initiating treatment? Red flags include age and a significant history of tobacco and alcohol abuse. All three are risk factors for reduced bone mass and fracture. Osteopenia and osteoporosis are often overlooked in men and occur more often than previously appreciated. Thirty percent of osteoporotic fractures occur in men. An x-ray would be a good idea in this case before beginning a program of back extension exercises or applying any manual therapy. 40,41
42
a psychologic/psychiatric referral. The therapist can screen for illness behavior as described in Chapter 3. Recognizing illness behavior helps the therapist clarify the physical assessment and alerts the therapist to the need for further psychologic assessment. Many studies have now shown a link between psychosocial distress and chronic neck or back pain. " Factors associated with chronic low back pain may include job dissatisfaction, depression, fear-avoidance behavior, and compensation issues. It may be necessary to conduct a social history to assess the client's recent life stressors and history of depression, drug, or alcohol abuse. The presence of psychosocial risk factors does not mean the pain is any less real nor does it reduce the need for symptom control. The therapist concentrates on pain management issues and improving function. Tools to screen for emotional overlay and fear-avoidance behavior are available in Chapter 3 of this text. 1
44
46
47,48
SCREENING FOR ONCOLOGIC CAUSES OF BACK PAIN Cancer is a possible cause of referred pain. Head and neck pain from cancer is discussed earlier in this chapter (see Causes of Headache).
CHAPTER 14
Multiple myeloma is the most common primary malignancy involving the spine often resulting in diffuse osteoporosis and pain that is not relieved while the person is recumbent. For most oncologic causes of back pain, the thoracic and lumbosacral areas are affected. As a general rule thoracic pain must be screened for metastatic carcinoma. Pain and dysfunction in the lumbosacral area may be caused by direct spread of cancer from the abdomen or pelvic areas. When the lumbar spine is affected by metastases it is usually from breast, lung, prostate, or kidney neoplasm. GI cancer, myelomas, and lymphomas can also spread to the spine via the paravertebral venous plexus. This thin-walled and valveless venous system probably accounts for the higher incidence of metastases in the thoracic spine from breast carcinoma and in the lumbar region from prostatic carcinoma.
Past Medical History Prompt identification of malignancy is important, starting with knowledge of previous cancers. Past
CASE
EXAMPLE
14-6
SCREENING THE HEAD, NECK, A N D BACK
history of cancer anywhere in the body is a red flag warning that careful screening is required. Always ask clients who deny a previous personal history of cancer about any previous chemotherapy or radiation therapy. Early recognition and intervention does not always improve prognosis for survival from metastatic cancer, but it does reduce the risk of cord compression and paraplegia. It is important to remember that the history can be misleading. For example, almost 50% of clients with back pain from a malignancy have an identifiable (or attributable) antecedent injury or trauma (Case Example 14-6). It is unclear if this is a coincidence or merely reflective of weakness in the musculoskeletal system leading to loss of balance and strength and, ultimately, an injury. If the trauma results in significant injury (e.g., fracture), then the underlying cancer is usually identified right away. But if soft tissue injury does not necessitate an x-ray or other imaging study, then the underlying oncologic cause 49
Multiple Myeloma Presenting
Background: A 41-year-old woman presented with low back pain (LBP) after a skiing accident 6 months ago. She continued skiing, but reinjured her back a month later while loading bicycles onto a car. She did not seek help at that time, thinking the pain would resolve with healing and time. She took acetaminophen and over-the-counter NSAIDs but did not think these helped with her symptoms. She reports her stress level as "high" due to family problems. She reports her fatigue level to be "high" also because of caring for four preschool aged children and a sick husband. She has lost 6 pounds in the last month trying to keep up with work and home activities. She currently reports her height and weight as 5 feet 4 inches tall and 108 pounds. She reports her LBP is "always there," but gets worse with activity or movement. There is no numbness or tingling, but the pain does radiate into the buttocks on both sides. When asked if there were any symptoms anywhere else in her body, she mentioned a mild discomfort in the lower thorax/chest that gets worse when she coughs or takes a deep breath.
649
as
Back
Pain
She has seen her family physician and told that the LBP is post-repetitive trauma and that she needs to give it time to heal. She was advised to avoid activities that could strain her back. She decided to see a physical therapist for exercises. Past Medical History • Benign breast cyst reported as negative 5 months ago • Cesarean section delivery of all four children without complications Clinical Presentation Posture: Standing and sitting postures appeared natural; normal lumbar lordosis Thin and pale, but in no acute distress Vital signs: all normal Alert and oriented to time, place, and person Neurologic screen Cranial nerves MMT Sensory exam DTR
WNL WNL (5/5 all extremities) WNL (light touch, pinprick) Brisk 3+, equal in all 4 extremities
SECTION III
650
CASE
EXAMPLE
14-6
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Multiple
M y e l o nr i a
SLR
Limited to 25 degrees, bilaterally because of back pain and apprehension Romberg WNL Unable to test physiologic (accessory, joint play) motions of the spine due to painful response Unable to test for hip motion or overpressure of the sacroiliac joint because of pain Positive tapping test (percussion over spinous processes) from L4 to SI Walking pattern unremarkable; no antalgic gait Able to walk in tandem and squat Able to stand and walk on both heels and toes, bilaterally Associated Signs and Symptoms No report of fever, chills, night sweats, or night pain No report of GI or GU dysfunction Mild discomfort in the lower thorax/chest that gets worse when she coughs or takes a deep breath What else do you need to know in the screening process? Past history of infections of any kind? Cancer? Recent or current medications besides over-thecounter NSAIDs? Tobacco use? Substance use (especially injection drugs with back pain)? Did the physician examine your spine? Were any x-rays or other imaging studies done? Did you have a urinalysis or blood test done? Recheck her vital signs on another day. Ask her to report any sweats, chills, or fever over the next 24 to 72 hours. Any cough or shortness of breath? (Remember to ask about any functional limitations, not just ask if the client is having these symptoms.) Any other respiratory signs and symptoms or red flags? Take a more detailed birth/delivery history. Type of birth control used (intrauterine contraceptive device?) Date of last pap smear and mammogram. Has she had a hysterectomy (consider surgical menopause and osteoporosis)? Ask about sexually transmitted infections or the possibility of physical or sexual assault.
Presenting
as
Back
Pain—cont'd
Any pelvic symptoms? Vaginal discharge? Unusual bleeding? Missed menses? What other steps can you take in the screening process? Turn to Table 14-1. As you look this over, does anything else come to mind given the client's age, gender, and history? Vertebral osteomyelitis is one possibility. Review the risk factors for this condition. Making a diagnosis of vertebral osteomyelitis would be outside the scope of a physical therapist's practice but identifying risk factors and associated signs and symptoms aids the therapist in making a referral decision. Review Clues Suggesting Systemic Head, Neck, or Back Pain at the end of this chapter. After looking this list over, the therapist may be prompted to ask if there are any other painful or symptomatic joints anywhere else in the body. The therapist can scan the Special Questions to Ask: Back to see if there have been any questions left out or that now seem appropriate to ask based on the information gathered so far. Review Special Questions for Women. Given the information you have, would you treat or refer this client? Even though the vital signs are unremarkable and the neurologic screen appears negative, there are plenty of red flags here. Weight loss of 6 pounds even with emotional or psychologic stress in a thin person must be considered significant until proven otherwise. Her age is borderline at 41 but there is an increased risk for diseases and illnesses with increasing age. Her pain appears to be constant, but can be made worse with activity or movement. The fact that she injured her back 6 months ago, but is too still too acute to examine today is a red flag for possible orthopedic involvement that requires additional medical testing. This is not the expected clinical picture. The positive tapping test with percussion over the spine is another orthopedic red flag. Radiating pain into the buttocks on both sides (bilateral) raises a red flag. It may be neurologic from a disc problem. There is also a possibility of vascular cause of bilateral buttock pain. The client is not as old as one might expect with vascular claudication but at age 41 it still must be considered. Palpate for abdominal pulse (possi-
CHAPTER 14
CASE EXAMPLE
14-6
SCREENING THE HEAD, NECK, A N D BACK
M u l t i p l e M y e l o nrta
ble aneurysm). Check the width of the aortic pulse. Pain on inspiration should prompt auscultation of respiratory sounds. Screening for psychogenic or emotional overlay may be appropriate. If the therapist decides to treat the client as part of the diagnostic process without the aid of imaging studies, caution is advised with any intervention. Obtaining the medical records is important, especially the physician's notes from the client's most recent visit. Do not hesitate to contact the physician with your findings first and wait for agreement with your treatment plan. What the therapist observes during the examination may not be what the physician saw (e.g., acute presentation, positive tapping test, bilateral buttock pain). If the client does not respond to physical therapy intervention, consider it the final red flag and refer immediately. Result: The therapist made a judgment for immediate medical consultation by phone and by sending a faxed copy of the physical therapy evaluation. After conferring with the physician, an MRI scan was requested along with a com-
Presenting
as
Back
651
Pain—cont'd
plete blood cell count. The client had a compression fracture involving the central aspect of both the superior and inferior endplates of L5. Blood cell counts were significantly decreased below normal (WBC, hemoglobin, hematocrit, and platelets). Erythrocyte sedimentation rate (ESR or sed rate) and total protein levels were elevated. Further diagnostic testing revealed a diagnosis of multiple myeloma. The diagnosis was confirmed by bone marrow biopsy, which showed infiltration of plasma cells. Further radiologic imaging revealed metastatic involvement of several ribs on both sides of the thoracic cage, right tibial head, and left ulna. Physical therapy intervention was not appropriate in this case. A 41-year-old woman with LBP following repetitive injuries can be very deceiving. Multiple myeloma is unusual in people younger than 40 years and affects more men than women and more blacks than whites. Exposure to radiation, wood dust, or pesticides can contribute to the development of multiple myeloma. The therapist did not ask any questions about occupational or environmental exposures because there was nothing in the history or clinical presentation to suggest it.
Data from: Dajoyag-Mejia MA, Cocchiarella A: Multiple myeloma presenting as low back pain, J Musculoskel Med 21(4):229-232, 2004.
may go undetected. Once again the therapist may be the first to recognize the cluster of clinical signs and symptoms and/or red flag findings to suggest a more serious underlying pathology.
Risk Factors As mentioned, a previous history of cancer is a primary risk factor for cancer recurrence with metastases to the spine. Until now there has been an emphasis on advancing age as a key red flag. Back pain at a young age is a red flag as well. As a general rule, persistent backache due to extraspinal causes is rare in children. However, primary bone cancer occurs most often in adolescents and young adults, hence the new red flag: age younger than 20 years. The axial skeleton is affected more than the spine in this age group, but metastases to the vertebrae can occur.
Clinical Signs and Symptoms of Oncologic Spine Pain •
Severe weakness w i t h o u t p a i n
•
W e a k n e s s w i t h full r a n g e
•
Sciatica
caused
by
metastases
to
bones
of
pelvis, l u m b a r spine, or femur •
Pain
does
not v a r y w i t h
activity or position
(intense, c o n s t a n t ) ; n i g h t p a i n •
Skin t e m p e r a t u r e d i f f e r e n c e s f r o m s i d e to side
•
Progressive n e u r o l o g i c deficits
•
Positive
percussive t a p test to o n e or m o r e
s p i n o u s process •
Occipital
headache,
neck
pain,
palpable
e x t e r n a l mass i n neck o r u p p e r t o r s o •
Cervical
pain or symptoms accompanied
by
urinary incontinence •
Look f o r signs a n d s y m p t o m s a s s o c i a t e d w i t h other
visceral
systems
monary, gynecologic)
(e.g.,
Gl,
GU,
pul-
652
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Clinical Presentation Back pain associated with cancer is usually constant, intense, and worse at night or with weightbearing activities, although vague, diffuse back pain can be an early sign of non-Hodgkin's lymphoma and multiple myeloma. Pain with metastasis to the spine may become quite severe before any radiologic manifestations appear. Back pain associated with malignant retroperitoneal lymphadenopathy from lymphomas or testicular cancers is characterized as persistent, poorly localized low back pain present at night but relieved by forward flexion. Pain may be so excruciating while lying down that the person can sleep only while sitting in a chair hunched forward over a table. Palpate the midline of the spinous processes for any abnormality or tenderness. Perform a tap test (percussion over the involved spinous process). Reproduction of pain or exquisite tenderness over the spinous process(es) is a red flag sign requiring further investigation and possible medical referral. Neoplasm (whether primary or secondary) may interfere with the sympathetic nerves; if so, the foot on the affected side is warmer than the foot on the unaffected side. Paresis in the absence of nerve root pain suggests a tumor. Severe weakness without pain is very suggestive of spinal metastases. Gross muscle weakness with a full range of straight leg raise (SLR) and without a history of recent acute sciatica at the upper two lumbar levels is also suggestive of spinal metastases. A short period of increasing central backache in an older person is always a red flag symptom, especially if there is a previous history of cancer. The pain spreads down both lower limbs in a distribution that does not correspond with any one nerve root level. Bilateral sciatica then develops, and the back pain becomes worse. X-rays do not show bone destruction from metastatic lesions until the lytic process has destroyed 30% to 50% of the bone. The therapist cannot assume metastatic lesions do not exist in the client with a past medical history of cancer now presenting with back pain and "normal" x-rays. " 50
51
53
Associated Signs and Symptoms Clinical signs and symptoms accompanying back pain from an oncologic cause may be system related (e.g., GI, GU, gynecologic, spondylogenic) depending on where the primary neoplasm is located and the location of any metastases (Case Example 14-7).
The therapist must ask about the presence of constitutional symptoms, symptoms anywhere else in the body, and assess vital signs as part of the screening process. Review the red flags in Box 141 and conduct a Review of Systems to identify any clusters of signs and symptoms.
SCREENING FOR CARDIAC CAUSES OF NECK AND BACK PAIN Vascular pain patterns originate from two main sources: cardiac (heart viscera) and peripheral vascular (blood vessels). The most common referred cardiac pain patterns seen in a physical therapy practice are angina, myocardial infarction, and aneurysm. Pain of a cardiac nature referred to the soma is based on multisegmental innervation. For example, the heart is innervated by the C3 through T4 spinal nerves. Pain of a cardiac source can affect any part of the soma (body) also innervated by these levels. This is why someone having a heart attack can experience jaw, neck, shoulder, arm, upper back, or chest pain. See Chapter 3 for an in-depth discussion of the origins of viscerogenic pain patterns affecting the musculoskeletal system. On the other hand, pain and symptoms from a peripheral vascular problem are determined by the location of the underlying pathology (e.g., aortic aneurysm, arterial or venous obstruction). Peripheral vascular patterns will be reviewed later in this chapter.
Angina Angina may cause chest pain radiating to the anterior neck and jaw, sometimes appearing only as neck and/or jaw pain and misdiagnosed as temporomandibular joint (TMJ) dysfunction. Postmenopausal women are the most likely candidates for this type of presentation. Angina and/or myocardial infarction can appear as isolated midthoracic back pain in men or women (see Figs. 6-4 and 6-8). There is usually a lag time of 3 to 5 minutes between increase in activity and onset of musculoskeletal symptoms caused by angina.
Myocardial Ischemia Heart disease and myocardial infarction (MI), in particular, can be completely asymptomatic. In fact, sudden death occurs without any warning in 50% of all Mis. Back pain from the heart (cardiac pain pattern) can be referred to the ante-
CHAPTER 14
CASE
EXAMPLE
14-7
Skin
653
SCREENING THE HEAD, NECK, A N D BACK
Lesions
A 52-year-old woman presented in physical therapy with low back pain radiating down the right leg to the knee. She had recently completed chemotherapy for acute myelocytic leukemia and was referred to physical therapy by the oncology nurse. Bone marrow biopsy one month ago was negative for leukemic cells. Clinical Presentation: The client presented with acute low back pain described as "going across my low back area." She had a normal gait pattern but decreased lumbar motions in forward bending, right side bending, and left rotation. Her pain was relieved by forward bending. Pain was too intense to conduct accessory motion testing because the client was unable to lie down for more than a minute before having to sit up. Neurologic screen revealed a positive straight-leg raise on the right, intact sensation, and decreased ankle reflex on the right (patellar tendon reflex was assessed as normal). Manual muscle strength testing was deferred due to the client's extreme agitation during testing. There were no reported changes in bowel or bladder. When asked if there were any other symptoms of any kind anywhere else, the client raised her shirt and showed the therapist several
rior neck and/or midthoracic spine in both men and women. When pain does present, it may look like one of the patterns shown in Fig. 6-9. There are usually some associated signs and symptoms such as unexplained perspiration (diaphoresis), nausea, vomiting, pallor, dizziness, extreme anxiety, and/or abnormal vital signs. Age and past medical history are important when screening for angina or MI as possible causes of musculoskeletal symptoms. Vital sign assessment is a key clinical assessment (Case Example 14-8).
Abdominal Aortic Aneurysm (AAA) On occasion, an abdominal aortic aneurysm (see Fig. 6-11) can cause severe back pain. An aneurysm is an abnormal dilation in a weak or diseased arte-
nodules on her skin. They were not tender or oozing any discharge. The client reported she first noticed them about a week before her back pain started. She had not remembered to tell the nurse or her doctor about them. Outcome: This is a good case to point out that even though the client has a known condition such as cancer and the referral comes from a health care professional, screening for medical disease as the cause of the pain or symptoms is still very important. The therapist made phone contact with the referring nurse and reported findings from the evaluation. Of particular concern were the skin lesions and neurologic changes. The nurse was unaware of these changes. The therapist requested a medical evaluation before starting a physical therapy program. The client was diagnosed with cancer metastases to the spine and cauda equina syndrome. Cauda equina syndrome caused by mechanical compression of the spinal nerve roots by tumor (or infection) requires immediate medical attention. The client underwent urgent total spine irradiation, which did relieve her back pain. She declined further medical care (i.e., chemotherapy) and decided to continue with physical therapy to regain motion and strength.
rial wall causing a saclike protrusion. Prompt medical attention is imperative because rupture can result in death. Aneurysms can occur anywhere in any blood vessel, but the two most common places are the aorta and cerebral vascular system. AAA occurs most often in men in the sixth or seventh decade of life.
Risk
Factors
The major risk factors for AAA include age, male gender, smoking, and family history. Although the underlying cause is most often atherosclerosis, the therapist should be aware that aging athletes involved in weight lifting are at risk for tears in the arterial wall, resulting in an aneurysm. There is often a history of intermittent claudication and decreased or absent peripheral pulses. Other risk factors include congenital malformation and 54
654
CASE
SECTION III
EXAMPLE
14-8
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Back Pain
and Dizziness
An 87-year-old woman visiting her daughter from out of town fell and suffered a compression fracture of L I . She reported having "heart problems" during a colonoscopy several weeks before this fall. She has had extreme back pain and is being given Vicodin (opioid analgesic for mild pain). She is nauseated and attributes this to the pain medication. Blood pressure is 200/90 with pulse in the low 80s. There is no respiratory distress, no heart palpitations and no fever. She reports being on many blood pressure and heart medications and thyroid meds. The family reports she has dizzy spells and is weak. She frequently loses her balance, but does not fall. She is extremely tired and the family reports she sleeps much during the day. She has been referred to physical therapy through a home health agency. Since she is from out of town, she does not have a primary care physician. The daughter took her to a local walkin clinic. The nurse practitioner then referred her to home health. Physical therapy was prescribed for the dizziness and falling. You suspect the symptoms of dizziness, drowsiness, and weakness may be druginduced. What do you do in a case like this? Conduct an evaluation and gather as much information as you can from the client and family members. Use the Quick Screen Checklist and complete a Review of Systems. Organize
vasculitis. Often the presence of these risk factors remains unknown until an aneurysm becomes symptomatic.
Clinical
Presentation
Pain presents as deep and boring in the midlumbar region. The pattern is usually described as sharp, intense, severe or knifelike in the abdomen, chest, or anywhere in the back (including the sacrum). The location of the symptoms is determined by the location of the aneurysm (Fig. 6-11). Most aortic aneurysms (95%) occur just below the renal arteries. An objective examination may reveal a pulsing abdominal mass or abnormally widened aortic pulse width (see Fig. 4-52). Obesity and abdominal ascites or distention makes this examination more difficult. The thera-
after
Colonoscopy
the information you obtain from the evaluation so that the need for any other screening questions can be identified. Look up potential side effects of Vicodin and ask the client about the presence of any other symptoms of any kind. See if any of the reported signs and symptoms point to side effects of medication. Conduct a cardiovascular screening examination (see Chapter 4). Do not hesitate to contact the local clinic/nurse practitioner and ask if the client's symptoms could be cardiac or drug-induced. Report the abnormal vital signs. There may be a change in drug dosage, suggested drug administration (with or without food, time of day), or change in prescribed drug that can alleviate symptoms while still controlling pain. Vital signs may return to normal with better pain control unless there is an underlying cardiovascular reason for her symptoms. Assess muscle weakness, vestibular function, and balance. Look for modifiable risk factors. Offer as much intervention as possible, given the temporary visiting situation and short-term episode of care. Document findings, problem list, and plan of care and communicate these results with the referring agency. Medical referral may be advised given the client's age, vital signs, history of heart disease, and use of multiple medications.
pist can also listen for bruits. Bruits are abnormal blowing or swishing sounds heard on auscultation of the arteries. Bruits with both systolic and diastolic components suggest the turbulent blood flow of partial arterial occlusion. The client will be hypertensive if the renal artery is occluded as well. Peripheral pulses may be diminished or absent. Other historical clues of coronary disease or intermittent claudication of the lower extremities may be present. Monitoring vital signs is important, especially among exercising senior adults. Teaching proper breathing and abdominal support without using a Valsalva maneuver is important in any exercise program, but especially for those clients at increased risk for aortic aneurysm.
CHAPTER 14
SCREENING THE HEAD, NECK, A N D BACK
When assessing back pain for the possibility of a vascular cause, remember peripheral vascular disease can cause back pain. The location of the pain or symptoms is determined by the location of the pathology (Fig. 14-3).
Clinical Signs and Symptoms of Impending
655
Rupture or Actual
Rupture of the Aortic A n e u r y s m
• Rapid onset of severe neck or back pain • Pain may radiate to chest, between the scapulae, or to posterior thighs • Pain is not relieved by change in position • Pain is described as "tearing" or "ripping" • Other signs: cold, pulseless lower extremities, blood pressure differences between arms (more than lOmmHg diastolic)
Aorta (abdominal) Common iliac artery External iliac a.
The U.S. Preventive Services Task Force (USPSTF) updated its guidelines for medical screening for AAA in 2005. The new guidelines recommend ultrasound screening for men aged 65 to 75 years old who are current or former smokers. Only one study of AAA screening in women has been done and showed no significant reduction in AAA-related mortality with routine screening. The therapist should advise men in this age group who have ever smoked to discuss their risk for AAA with a medical doctor. Any male with these two risk factors especially presenting with any of these signs or symptoms must be referred immediately. The orthopedic or acute care therapist must be aware that aortic damage (not an aneurysm but sometimes referred to as a pseudo-aneurysm) can occur with any anterior spine surgery (e.g., spinal fusion, spinal fusion with cages). Blood vessels are moved out of the way and can be injured during surgery. If the client (usually a postoperative inpatient) has internal bleeding from this complication there may be: • Distended abdomen • Changes in blood pressure • Changes in stool • Possible back and/or shoulder pain In such cases, the client's recent history of anterior spinal surgery accompanied by any of these symptoms is enough to notify nursing or medical staff of concerns. Monitoring post-operative vital signs in these clients is essential.
Pulse site
Femoral a.
54
SCREENING FOR PERIPHERAL VASCULAR CAUSES OF BACK PAIN Most physical therapists are very familiar with the signs and symptoms of peripheral vascular disease (PVD) affecting the extremities, including both arterial and venous disease (see previous discussion, Chapter 6).
Popliteal a. Pulse site
— Anterior tibial a. Posterior tibial a.
- Dorsalis pedis a. Pulse site - Dorsal arch Pulse site
F i g . 1 4 - 3 • Arteries in the lower extremities. As you look at this illustration, note the location of the arteries in the lower extremities starting with the aorta branching into the common iliac artery, which descends on both sides into the legs. Once the common iliac artery passes through the pelvis to the femur, it becomes the femoral artery and then the popliteal artery behind the knee before branching into the popliteal artery. The final split comes as the popliteal artery divides to form the anterior tibial artery down the front of the lower leg and the posterior tibial artery down the back of the lower leg. The anterior tibial artery also becomes the dorsalis pedis artery. Note the pulse points shown with bold, black ovals and remember that distal pulses disappear with aging and the presence of atherosclerosis causing peripheral vascular disease. (From Jarvis C: Physical examination and health assessment, ed 4.
Philadelphia, 2004, WB Saunders; Fig 20-2, pg 535.)
656
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
With obstruction of the aortic bifurcation, the client may report back pain alone, back pain with any of the following features, or any of these signs and symptoms alone (Table 14-7): • Bilateral buttock and/or leg pain or discomfort • Weakness and fatigue of the lower extremities • Atrophy of the leg muscles • Absent lower extremity pulses • Color and/or temperature changes in the feet and lower legs Symptoms are often (but not always) bilateral because the obstruction occurs before the aorta divides (i.e., before it becomes the common iliac artery and supplies each leg separately). Frequently, someone with symptomatic atherosclerotic disease in one blood vessel has similar pathology in other blood vessels as well. Over time, there may be a progression of symptoms as the disease worsens and blood vessels become more and more clogged with plaque and debris. With obstruction of the iliac artery the client is more likely to present with pain in the low back, buttock, and/or leg of the affected side and/or numbness in the same area(s). Obstruction of the
TABLE 1 4 - 7
femoral artery can result in thigh and/or calf pain, again with distal pulses diminished or absent. Ipsilateral calf/ankle pain or discomfort (intermittent claudication) occurs with obstruction of the popliteal artery and is a common first symptom of PVD. Adults over the age of 50 presenting with back pain of unknown cause and mild to moderate elevation of blood pressure should be screened for the presence of peripheral vascular disease.
Back Pain: Vascular or Neurogenic? The medical differential diagnosis is difficult to make between back pain of a vascular versus neurogenic origin. Frequently, vascular and neurogenic claudication occurs in the same age group (over 60 and even more often, after age 70). Sometimes clients are referred to physical therapy to help make the differentiation (Case Example 14-9). Vascular and neurogenic disease often coexists in the same person with an overlap of symptoms of each. There are several major differences to look for but especially response to rest (i.e., activ-
B a c k a n d Leg P a i n f r o m A r t e r i a l O c c l u s i v e D i s e a s e
The location of discomfort, pain, or other symptoms is determined by the location of the pathology (arterial obstruction). Site of occlusion
Signs a n d symptoms
Aortic bifurcation
• Sensory and motor deficits • Muscle weakness and atrophy • Numbness (loss of sensation) • Paresthesias (burning, pricking) • Paralysis • Intermittent claudication (pain or discomfort relieved by rest): bilateral buttock and/or leg, low back, gluteal, thigh, calf • Cold, pale legs with decreased or absent peripheral pulses
Iliac artery
• Intermittent claudication (pain or discomfort in the buttock, hip, thigh of the affected leg; can be unilateral or bilateral; relieved by rest) • Diminished or absent femoral or distal pulses • Impotence in males
Femoral and popliteal artery
• • • • • •
Intermittent claudication (pain or discomfort; calf and foot; may radiate) Leg pallor and coolness Dependent rubor Blanching of feet on elevation No palpable pulses in ankles and feet Gangrene
Tibial and common peroneal artery
• • • •
Intermittent claudication (calf pain or discomfort; feet occasionally) Pain at rest (severe disease); possibly relieved by dangling leg Same skin and temperature changes in lower leg and foot as described above Pedal pulses absent; popliteal pulses may be present
From Goodman CC, Fuller K, Boissonnault WG: Pathology: implications for the physical therapist, ed 2, Philadelphia, 2003, WB Saunders.
CHAPTER 14
CASE
EXAMPLE
14-9
Spinal
SCREENING THE HEAD, NECK, A N D BACK
657
Stenosis
Background: A 68-year-old woman with a long history of degenerative arthritis of the spine was referred to physical therapy for conservative treatment toward a goal of improving function despite her painful symptoms. She was a nonsmoker with no other significant previous medical history. Her symptoms were diffuse bilateral lumbosacral back pain into the buttocks and thighs, which increased with walking or any activity and did not subside substantially with rest (except for prolonged rest and immobility). Clinical Presentation: On examination, this client moved slowly and with effort, complaining of the painful symptoms described. There was no tenderness of the sacroiliac joint or sciatic notch but a subjective report of tenderness over L4 to L5 and L5 to SI. Tap test was negative; the client reported mild diffuse tenderness. There was no palpable step-off or dip of the spinous processes for spondylolisthesis and no paraspinal spasm, but a marked right lumbar scoliosis was noted. The client reported knowledge of scoliosis since she was a child. A neurologic screening examination revealed normal straight leg raise and normal sensation and reflexes in both lower extremities. Motor examination was unremarkable for an inactive 68-year-old woman. Dorsalis pedis and posterior tibialis pulses were palpable but weak bilaterally. Despite physical therapy treatment and compliance on the part of the client with a home
ity pain), position of the spine, and the presence of any trophic (skin) changes (see Table 14-6). Vascular-induced back and/or leg pain or discomfort is alleviated by rest and usually within 1 to 3 minutes. Conversely, activity (usually walking) brings the symptoms on within 1 to 3, sometimes 3 to 5 minutes. Neurogenic-induced symptoms often occur immediately with use of the affected body part and/or when adopting certain positions. The client may report the pain is relieved by prolonged rest or not at all. What is the effect of changing the position of the spine on pain of a vascular nature? Are the vascu-
program, her symptoms persisted and progressively worsened. What is the Next Step in the Screening Process? Re-evaluate the client's movement dysfunction and the selected intervention to date. Was the right treatment approach taken? Reassess red flag findings (age, lack of improvement with intervention) and conduct a review of systems (if this has not already been done). In this case the client's age, negative neurologic screening examination, and diminished lower extremity pulses suggested a second look for vascular cause of symptoms. Vital signs were assessed along with a peripheral vascular screening examination. The Bike Test was administered but the results were unclear with increased pain reported in both extension and flexion. Result: She returned to her physician with a report of these findings. Further testing showed that in addition to degenerative arthritis of the lumbosacral spine, there was secondary stenosis and marked aortic calcification, indicating a vascular component to her symptoms. Surgery was scheduled: an L4 to L5 laminectomy with fusion, iliac crest bone graft, and decompression foraminotomies. Postoperatively, the client subjectively reported 80% improvement in her symptoms with an improvement in function, although she was still unable to return to work.
lar structures compromised in any way by forward bending, side bending, or backward bending (Fig. 14-4)? Are we asking the diseased heart or compromised blood vessels to supply more blood to this area? It is not likely that movements of the spine will reproduce back pain of a vascular origin. What about back pain of a neurogenic cause? Forward bending opens the vertebral canal (vertebral foramen) giving the spinal cord (through LI) additional space. This is important in preventing painful symptoms when spinal stenosis is present as a cause of neurogenic claudication.
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Lumbar Spine, Side View
Anterior Bend
Posterior Bend
Aorta Intervertebral disc Lumbar vertebra
Vertebral arteries
Spinal nerve Spinal cord Aorta
Lumbar Spine, Anterior View Lateral Bend
Intervertebral disc
Vertebral arteries
F i g . 1 4 - 4 • Vascular supply is not compromised by position of the spine so there is usually no change in back pain that is vascular-induced with change of position. Forward bend, extension, and side bending do not aggravate or relieve symptoms. Rather, increased activity requiring increased blood supply to the musculature is more likely to reproduce symptoms; likewise, rest may relieve the symptoms. Watch for a lag time of 3 to 5 minutes after the start of activity or exercise before symptoms appear or increase as a sign of a possible vascular component.
Unless there is a spinal neuroma, a true stenosis with spinal cord pressure does not occur in the lumbar region since the spinal cord ends at LI in most people. Neural symptoms at LI to L3 are rare and more likely indicate a spinal tumor rather than disc or facet pathology. Nerve pressure leading to radicular symptoms (e.g., pain, numbness, myotomal weakness) below L2 is not true stenosis of the vertebral canal, but rather intervertebral foraminal stenosis with encroachment of the peripheral nerve as it leaves the spinal canal through the neural foramina. The position of comfort for someone with back pain associated with spinal stenosis is usually lumbar flexion. The client may lean forward and rest the hands on the thighs or lean the upper body against a table or cupboard.
The Bike Test The van Gelderen Bicycle Test is one way to assess the cause of back pain (Fig. 14-5). It offers clues to the source (neurogenic or vascular), but it is not a definitive test by itself. The Bike Test is based on two of the three variables listed earlier:
(1) response to rest, and (2) position of the spine. Trophic (skin) changes are assessed separately. In theory, if someone has back pain of a vascular origin, what is the effect of peddling a stationary bicycle? Increased demand for oxygen can result in back pain when the cardiac workload/oxygen need is greater than the ability of the affected coronary arteries to supply the necessary oxygen. Normally, the response would be angina (chest pain or discomfort or whatever pattern the client typically experiences). In the case of referred pain patterns, the client may experience midthoracic or even lumbar pain. How soon do these symptoms appear? With musculoskeletal pain of a cardiac origin, there is a 3- to 5-minute lag time before the onset of symptoms. Immediate reproduction of painful symptoms is more indicative of neuromusculoskeletal involvement. After peddling for 5 minutes and observing the client's response, ask him or her to lean forward and continue peddling. What is the expected response if the back, buttock, or leg pain is vascular-induced? In other words, what is the response
CHAPTER 14
SCREENING THE HEAD, NECK, A N D BACK
A Fig. 1 4 - 5 •
659
B
Bicycle test. Assessing the u n d e r l y i n g cause of intermittent c l a u d i c a t i o n : Vascular or neurogenic? The effect of stoop-
ing over w h i l e p e d a l i n g on vascular claudication is n e g l i g i b l e , w h e r e a s a c h a n g e in spine position c a n a g g r a v a t e or relieve claudication of a neurogenic o r i g i n . A, The client is seated on an exercise bicycle a n d asked to pedal against resistance w i t h o u t using the upper extremities except for support. If p a i n into the buttock a n d posterior thigh occurs, f o l l o w e d by t i n g l i n g in the affected lower extremity, the first p a r t of the test is positive, but whether it is vascular or neurogenic remains u n d e t e r m i n e d . B, W h i l e p e d a l i n g , the client leans f o r w a r d . If the p a i n subsides over a short time, the second p a r t of the test is positive for neurogenic claudication but negative for vascular-induced symptoms. The test is c o n f i r m e d for neurogenic cause of symptoms w h e n the client sits upright a g a i n a n d the p a i n returns. (From M a g e e DJ: Orthopedic physical assessment, ed 4, P h i l a d e l p h i a , 2 0 0 2 , WB Saunders.)
to a change in position when someone has back pain of a vascular origin? Typically there is no change because a change in position does not reproduce or alleviate vascular symptoms. The therapist can palpate pulses before and after the test to confirm the presence of vascular symptoms. What about neurogenic impairment? The client with neurogenic back pain may report a decrease in pain intensity or duration with forward flexion. Leaning forward (spinal flexion) can increase the diameter of the spinal canal, reducing pressure on the neural tissue. When using the bike test to look for neurogenic claudication, the client starts pedaling while leaning back slightly. This position puts the lumbar spine in a position of extension. If the pain is reproduced, the first part of the test is positive for a neurogenic source of symptoms. The client then leans forward while still pedaling. If the pain
is less or goes away, the second part of the test is positive for neurogenic claudication. With neurogenic claudication, the pain returns when the individual sits upright again. There is one major disadvantage to this test. Many clients in their sixth and seventh decades have both spinal stenosis and atherosclerosis contributing to painful back and/or leg symptoms. What if the client has back pain before even getting on the bicycle that is not relieved when bending forward? What diagnostic information does that provide? The client could be experiencing neurogenic back pain that would normally feel better with flexion, but now while pedaling vascular compromise occurs. In some cases neurogenic pain lasts for hours or days despite change in position because once the neurologic structures are irritated, pain signals can persist.
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The bike test has its greatest use when only one source of back pain is present: either vascular or neurogenic and even then, chronic neurogenic pain may not be modulated by change in position. The therapist must rely on results of the screening interview and examination, taking time to perform a Review of Systems to identify clients who may need further medical evaluation. In some cases medical referral is not required. Identifying the underlying pathologic mechanism directs the therapist in choosing the most appropriate intervention.
SCREENING FOR PULMONARY CAUSES OF NECK AND BACK PAIN There are many potential pulmonary causes of back pain. The lungs occupy a large area of the upper trunk (see Fig. 7-1), with an equally large anterior and posterior thoracic area where pain can be referred. The most common conditions known to refer pulmonary pain to the somatic areas are pleuritis, pneumothorax, pulmonary embolus, cor pulmonale, and pleurisy.
Past Medical History A recent history of one of these disorders in a client with neck, shoulder, chest or back pain raises a red flag of suspicion. In keeping with model for screening the therapist should review (1) past medical history, (2) risk factors, (3) clinical presentation, and (4) associated signs and symptoms (Box 14-5).
Clinical Presentation Pulmonary pain patterns vary in their presentation based, in part, by the lobe(s) or segment(s) involved and by the underlying pathology. Several different pain patterns are presented in Chapter 7 (see Fig. 7-10). Autosplinting is considered a valuable red flag of possible pulmonary involvement. Autosplinting occurs when the client prefers to lie on the involved side. Because pain of a pulmonary source is referred from the ipsilateral side, putting pressure on the involved lung field reduces respiratory movements and therefore reduces pain. It is uncommon for a person with a true musculoskeletal problem to find relief from symptoms by lying on the involved side. The therapist should perform the following tests for clients with back pain who have a suspicious history or concomitant respiratory symptoms: • Vital sign assessment • Auscultation
BOX 14-5
Screening for PulmonaryI n d u c e d N e c k or Back Pain
History:
Previous history of cancer (any kind, but especially lung, breast and bone cancer) Previous history of recurrent upper respiratory infection (URI) or pneumonia Recent scuba diving, accident, trauma or overexertion (pneumothorax) Risk F a c t o r s :
Smoking Trauma (e.g., rib fracture, vertebral compression fracture) Prolonged immobility Chronic immunosuppression (e.g., corticosteroids, cancer chemotherapy) Malnutrition, dehydration Chronic diseases: diabetes mellitus, chronic lung disease, renal disease, cancer Upper respiratory infection or pneumonia Pain p a t t e r n :
Sharp, localized Aggravated by respiratory movements Prefer to sit upright Autosplinting decreases the pain ROM does not reproduce symptoms (e.g., shoulder and/or trunk movements) Associated Signs a n d S y m p t o m s
Dyspnea Persistent cough Constitutional symptoms: fever, chills Weak and rapid pulse with concomitant fall in blood pressure (e.g., pneumothorax)
• Assess the effect of reproducing respiratory movements on symptoms (e.g., does deep breathing, laughing, or coughing reproduce the painful symptoms?) • ROM: assess active trunk side bending and rotation • Can pain or symptoms be reproduced with palpation (e.g., palpate the intercostals)? Although reproducing pain or increased pain on respiratory movements is considered a hallmark sign of pulmonary involvement, symptoms of pleural, intercostal, muscular, costal, and dural origin all increase with coughing or deep inspiration. Only pain of a cardiac origin is ruled out when symptoms increase in association with respiratory movements. For this reason the therapist must always carefully correlate clinical presentation
CHAPTER 14
SCREENING THE HEAD, NECK, A N D BACK
with client history and associated signs and symptoms when assessing for pulmonary disease. Forceful coughing from an underlying pulmonary problem can cause an intercostal tear, which can be palpated. Even if some symptoms can be reproduced with palpation, the problem may still be pulmonary-induced, especially if the cause is repeated, forceful coughing from a pulmonary etiology. Pancoast's tumors of the lung may invade the roots of the brachial plexus as they enlarge, appearing as pain in the C8 to Tl region. Other signs may include wasting of the muscles of the hand and/or Horner's syndrome with unilateral constricted pupil, ptosis, and loss of facial sweating (see the section on Lung Cancer in Chapter 7). Tracheobronchial irritation can cause pain to be referred to sites in the neck or anterior chest at the same levels as the points of irritation in the air passages (see Fig. 7-2). This irritation may be caused by inflammatory lesions, irritating foreign materials, or cancerous tumors.
Associated Signs and Symptoms Assessing for associated signs and symptoms will usually bring to light important red flags to assist the therapist in recognizing an underlying pulmonary problem. Neck or back pain that is reproduced, increased with inspiratory movements, or accompanied by dyspnea, persistent cough, cyanosis, or hemoptysis must be evaluated carefully. Clients with respiratory origins of pain usually also show signs of general malaise or constitutional symptoms.
SCREENING FOR RENAL AND UROLOGIC CAUSES OF BACK PAIN When considering the possibility of a renal or urologic cause of back pain, the therapist can use the same step-by-step approach of looking at the history, risk factors, clinical presentation, and associated signs and symptoms. For example, in anyone with back pain reported in the T9 to LI area corresponding to pain patterns from the kidney or urinary tract (see Figs. 10-7 and 10-8), ask about a history of kidney stones, urinary tract infections (UTIs), and trauma (fall, blow, lift).
Origin of Pain Patterns As discussed in Chapter 3 there can be at least three possible explanations for visceral pain patterns including embryologic development, multi-
661
segmental innervation, and direct pressure on the diaphragm. All three of these mechanisms are found in the urologic system. The embryologic origin of urologic pain patterns begins with the testicles and ovaries. These reproductive organs begin in utero where the kidneys are in the adult and then migrate during fetal development following the pathways of the ureters. A kidney stone down the pathway of the ureter causes pain in the flank radiating to the scrotum (male) or labia (female). Evidence of the influence of multisegmental innervation is observed when skin pain over the kidneys is reported. Visceral and cutaneous sensory fibers enter the spinal cord close to each other and converge on the same neurons. When visceral pain fibers are stimulated, cutaneous fibers are stimulated, too. Thus, visceral pain can be perceived as skin pain. None of the components of the lower urinary tract comes in contact with the diaphragm, so the bladder and urethra are not likely to refer pain to the shoulder. Lower urinary tract impairment is more likely to refer pain to the low back, pelvic, or sacral areas. However, the upper urinary tract can impinge the diaphragm with resultant referred pain to the costovertebral area or shoulder.
Past Medical History Kidney disorders such as acute pyelonephritis and perinephric abscess of the kidney may be confused with a back condition. Most renal and urologic conditions appear with a combination of systemic signs and symptoms accompanied by pelvic, flank, or low back pain. The client may have a history of recent trauma or a past medical history of urinary tract infections to alert the clinician to a possible renal origin of symptoms.
Clinical Presentation Acute pyelonephritis (see Fig. 7-4) and other kidney conditions appear with aching pain at one or several costovertebral areas, posteriorly, just lateral to the muscles at T12 to L I , from acute distention of the capsule of the kidney. The pain is usually dull and constant, with possible radiation to the pelvic crest or groin. The client may describe febrile chills, frequent urination, hematuria, and shoulder pain (if the diaphragm is irritated). Percussion to the flank areas reveals tenderness; the therapist should perform Murphy's percussion test (see Fig. 4-51). Nephrolithiasis (kidney stones) may appear as back pain radiating to the flank or the iliac crest
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(see Fig. 7-4) (Case Example 14-10). Kidney stones may occur in the presence of diseases associated with hypercalcemia (excess calcium in the blood), such as hyperparathyroidism, metastatic carcinoma, multiple myeloma, senile osteoporosis, specific renal tubular disease, hyperthyroidism, and Cushing's disease. Other conditions associated with calculus formation are infection, urinary stasis, dehydration, and excessive ingestion or absorption of calcium. Ureteral colic, caused by passage of a kidney stone (calculus), appears as excruciating pain that radiates down the course of the ureter into the urethra or groin area. The pain is unrelieved by rest or change in position. These attacks are intermittent and may be accompanied by nausea, vomiting, sweating, and tachycardia. Localized abdominal muscle spasm may be present. The urine usually contains erythrocytes or is grossly bloody. Urinary tract infection affecting the lower urinary tract is related directly to irritation of the
CASE
EXAMPLE
1 4 - 1 0
Back and
Flank
Background and Description of Client: JH is a 57-year-old male with a history of mild mental retardation, seizure disorder, obesity, osteoarthritis, hypertension, and cervical disc disease (MRI reveals herniation at C7-T1 and spondylosis at C5-C6). He resides at a residential facility and is well known to PT over the past 6 years because of 5 separate PT examinations related to complaints of insidious onset of back pain. These previous episodes of back pain resolved without PT intervention. JH presented in physical therapy this time with complaints of low back and right hip pain that he and his primary physician attributed to a minor fall 2 months prior to the PT examination. PT was not consulted during the initial period after the fall, because x-rays were unremarkable and JH had not complained of any symptoms at that time. When asked to point to the area of pain, JH indicated his right lower lumbar area and along the right hip and flank. He was unable to describe the pain due to some cognitive limitations, but he did report that it was unrelieved with rest and occurred intermittently.
bladder and urethra. The intensity of symptoms depends on the severity of the infection. Although low back pain may be the client's chief complaint, further questioning usually elicits additional urologic symptoms. The therapist should ask about • Urinary frequency, urgency, dysuria (burning pain on urination), nocturia (frequency at night) • Constitutional symptoms (fever, chills, nausea, vomiting) • Blood in urine • Testicular pain Clients can be asymptomatic with regard to urologic symptoms, making the physical therapy diagnosis more difficult.
Screening Questions: Renal and Urologic System It is important to ask questions about the presence of urologic symptoms (see Appendix B-5). Many people (therapists and clients alike) are uncomfortable discussing the details of bladder (or bowel)
Pain
JH works full-time in a sheltered workshop doing piecework. He reported that the pain kept him from performing his job fully, and he found that lifting boxes was particularly difficult due to the bending. He also reported that prolonged ambulation or exercise caused an increase in the flank pain. He was taking over-the-counter ibuprofen for his pain; however, it was not effective. JH is on the following medications: Colace (for constipation), Allegra (for allergy), Tegretol (for seizures), Zoloft (for obsessive-compulsive disorder), Risperdal (for psychosis), Buspar (for anxiety), and ibuprofen (PRN for pain). Clinical Presentation: Vital signs were as follows: HR: 65; BP: 130/70; RR: 12; Temp: 99°. These were not significantly different from JH's normal vital signs. Gait analysis was significant for an antalgic gait, slight increase in base of support, decreased trunk and pelvic rotation, significant ankle pronation, and pes planus bilaterally (JH does not like to wear his orthotics). He is an independent ambulator on all surfaces without the use of an assistive device. He lives in a 2-
CHAPTER 14
CASE
EXAMPLE
1 4 - 1 0
Back and
SCREENING THE HEAD, NECK, A N D BACK
Flank
story home and is able to ascend and descend stairs independently without complaints of pain. Posture in standing was significant for decreased lumbar lordosis, rounded shoulders, and forward head, left shoulder mildly depressed. Strength testing revealed strength of 4+/5 throughout upper extremities, trunk, and left lower extremity. JH was very hesitant with resisted strength testing on his right lower extremity for fear of pain; therefore no formal data was obtained. JH did report pain upon mildly resisted right hip flexion, abduction, and adduction. PROM was all within functional limits. There was no apparent evidence of inflammation in bilateral knees or hips. PT was unable to reproduce symptoms with palpation along spine and bilateral hips and knees. Right knee extension AROM in sitting revealed pain in right flank. Right SLR test in supine also revealed similar pain in right flank. Right side bending produced right flank pain. Left side bending produced no symptoms. Neurologic examination revealed intact sensation to light touch along dermatomal pattern. DTR's were 1+ throughout. Evaluation: JH's symptoms appeared inconsistent and dependent upon level of physical activity. It seemed counterintuitive that a minor fall 2 months prior to this examination could cause the current symptoms. The location of the pain also raised some concerns, because JH had never before complained of flank pain. PT did not have access to the prior x-rays taken at the time of the fall. Therefore, PT requested further x-rays of JH's hip and spine from the orthopedic surgeon serving as consultant to rule out a more serious orthopedic or systemic issue. Physical therapy was deferred until the x-ray results were examined and reviewed by the orthopedic consultant and PT. Outcome and Discussion: AP pelvis and frog view x-rays of hips were reviewed by the orthopedic consultant and PT, and it was
663
Pain—cont'd
concluded that the x-rays were unremarkable. AP and lateral x-rays of JH's TLS spine at first glance also appeared to be unremarkable, and the x-ray report agreed with our initial assessment. However, upon closer inspection, there was a circular 2-cm suspicious area that appeared on film at the level and location of JH's right kidney. The orthopedic surgeon ordered further imaging to confirm a diagnosis of kidney stone. An intravenous pyelogram (IVP) did confirm the diagnosis. After appropriate treatment for the kidney stones, JH reported that the pain on his right side had resolved. JH was well known to the physical therapy department due to his previous examinations. JH was a challenging case because of the previous "false alarms" and because he does not always accurately communicate his symptoms due to his mild cognitive limits. He also has comorbidities that warrant a more cautious approach in treating and assessing his complaints. These include hypertension and a seizure disorder and the multitude of medication that he takes. It is up to the physical therapist to understand him and try to interpret his meanings as closely as she/he can. Fortunately in this case, JH's chief complaint of flank pain was different enough from previous complaints, and the films clearly showed a systemic cause of JH's symptoms. Instructor's Comments: Some additional screening questions/information that might help with a case like this: 1. Did he have any symptoms of genitourinary distress (pain on urination? blood in the urine? difficulty starting or continuing a flow of urine? nocturia? frequency? or changes in bladder function)? 2. Did he have a past medical history of kidney stones? 3. Was Murphy's percussion test positive? 4. Was there a report of any constitutional symptoms (night sweats? spiked temps? flulike symptoms)?
Used with permission. Josephine Yee, DPT: Case report submitted as part of course requirements in fulfillment of DPT 910, New York, 2002, Stony Brook.
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function. If presented in a professional manner with a brief explanation, both parties can be put at ease. For example, the interview may go something like this: "I'm going to ask a few other questions that may not seem like they fit with the back pain (shoulder pain, pelvic pain) you're having. There are many possible causes of back pain and I want to make sure I don't leave anything out. If I ask you anything you don't know, please pay attention over the next few days and see if you notice something. Don't hesitate to bring this information back to me. It could be very important." To the therapist: The important thing to look for is CHANGE. Many people have problems with incontinence, nocturia, or frequency. If someone has always experienced a delay before starting a flow of urine, this may be normal for him (or her). Many women have nocturia after childbirth but most men do not get up at night to empty their bladders until after age 65. They may not even be aware that this has changed for them. Often, it is the wife or partner who answers the question about getting up at night as "yes!" Likewise if a man has always had a delay in starting a flow of urine, he may not be aware that the delay is now twice as long as before. Or he may not recognize that being unable to continue a flow of urine is not "normal" and in fact, requires medical evaluation.
Pseudorenal Pain Sometimes clients appear to have classic symptoms of a kidney problem, but without any associated signs and symptoms. Such a situation can occur with someone who has a mechanical derangement of the costovertebral or costotransverse joint or irritation of the costal nerve (radiculitis, T10-T12). What does this look like in the clinic? How does the therapist make the differentiation? Use the same guidelines for decision making in the screening process presented throughout this text (e.g., history, risk factors, associated signs, and symptoms).
HistoryTrauma is often the underlying etiology. The client may or may not report assault. The individual may not remember any specific trauma or accident. Pseudorenal pain can occur when floating ribs
become locked with the ribs above, but this is a rare cause of these symptoms. Radiculitis or mechanical derangement of the T10 to T12 costovertebral or costotransverse joint(s) is more likely.
Risk
Factors
Unknown or none for this condition.
Clinical
Presentation
Pain pattern is affected by change in position: • Lying on that side increases pain (remember clients with renal pain prefer pressure on the involved side; musculoskeletal symptoms are often made worse by lying on the affected side). • Prolonged sitting increases pain; slumped sitting especially increases pain; the therapist can have the client try this position and see what effect it has on symptoms. • Symptoms are reproduced with movements of the spine (especially forward flexion and side bending). • Presence of costovertebral angle tenderness: the therapist may be able to reproduce pain with palpation; Murphy's sign is negative (see Fig. 4-51). A positive Murphy's test for renal involvement elicits kidney pain or reproduces the referred back pain and must be reported to the physician. A negative response occurs when there is no discomfort or pain or pain that can be reproduced by local palpation at the costovertebral angle. The therapist must ask about the presence of signs and symptoms associated with renal disease. One final note about pseudorenal back pain: thoracic disc disease can mimic kidney disease and presents with flank, buttock, and/or leg pain. MRIs are negative, but may show only the lumbar spine. In the case of a possible thoracic disc mimicking renal involvement, the therapist can provide the physician with clinical findings and the reason for the referral. Look for a history of straining, lifting, accident, or other mechanical injury to the thoracic spine. The therapist must look carefully for evidence of neurologic involvement. Perform a screening neurologic assessment as outlined in Chapter 4. There may be bladder changes, which can be confusing; are these urologic-induced or disc-related? Report any suspicious symptoms.
Associated
Signs
and
Symptoms
Usually none when pseudorenal pain is present.
CHAPTER 14
SCREENING FOR GASTROINTESTINAL CAUSES OF BACK PAIN Back pain of a visceral origin occurs most often as a result of gastrointestinal (GI) problems. Pain patterns associated with the GI system can present as sternal, shoulder, scapular, midback, low back, or hip pain and dysfunction. If the client had primary symptoms of GI impairment (abdominal pain, nausea, diarrhea, or constipation; see Fig. 8-16), he or she would see a medical doctor. As it is, the referred pain patterns are quite convincing that the musculoskeletal region described is the problem. Referred pain patterns for the GI system are presented in Fig. 8-17 (anterior and posterior). These are the pain patterns the therapist is most likely to see.
Past Medical History and Risk Factors Taking a closer look at past medical history, risk factors, and clinical presentation and asking about associated signs and symptoms may reveal important red flags and clues pointing to the GI system. The most significant and common history is one of long-term or chronic use of nonsteroidal antiinflammatory drugs (NSAIDs). Risk factors and assessment of risk for NSAID-induced gastropathy are discussed in detail in Chapter 8. Other significant risk factors in the history include the long-term use of immunosuppressants, past history of cancer, history of Crohn's disease (also known as regional enteritis), or previous bowel obstruction.
Signs and Symptoms of GI Dysfunction The most common signs and symptoms associated with the GI system are listed in Box 14-6 and disBOX 14-6
Signs a n d Symptoms of Gastrointestinal
Dysfunction
Anterior neck pain or back pain accompanied by any of the following is a red flag: • • • • • • • •
Esophageal pain Epigastric pain with radiation to the back Dysphagia (difficulty swallowing) Odynophagia (pain with swallowing) Early satiety; symptoms associated with meals Bloody diarrhea Fecal incontinence Melena (dark, tarry, sticky stools caused by oxidized blood) • Hemorrhage (blood in the toilet)
SCREENING THE HEAD, NECK, A N D BACK
665
cussed in greater detail in Chapter 8. Back pain (as well as hip, pelvic, sacral, and lower extremity pain) with any of these accompanying features should be considered a red flag for the possibility of GI impairment. Anterior neck (esophagea) /pain may occur, usually with a burning sensation ("heartburn") or other symptoms related to eating or swallowing (e.g., dysphagia, odynophagia). Esophageal varices associated with chronic alcoholism may appear as anterior neck pain but usually occur at the xiphoid process and are recognized as heartburn. Anterior neck pain can also occur as a result of a discogenic lesion requiring a careful history and neurologic screening to document findings. Clients with eating disorders who repeatedly binge and then purge by vomiting may report anterior neck pain without realizing the correlation between eating behaviors and symptoms. When assessing neck pain, the therapist should look for other associated signs and symptoms, such as sore throat; pain that is relieved with antacids, the upright position, fluids, or avoidance of eating; and pain that is aggravated by eating, bending, or recumbency. Dysphagia or difficulty swallowing, odynophagia (painful swallowing), and epigastric pain are indicative of esophageal involvement. Certain types of drugs (e.g., antidepressants, antihypertensives, asthma medications) can make swallowing difficult, requiring a careful evaluation during the client interview. Early satiety (the client takes one or two bites of food and is no longer hungry) is another red flag symptom of the GI system (Case Example 14-11Early Satiety and Weight Loss). In general back pain made better, worse, or altered in any way by eating is a red flag symptom. If the change in symptom(s) occurs immediately to within 30 minutes of eating, the upper gastrointestinal tract or stomach/duodenum may be a possible cause. Change in symptoms 2 to 4 hours after eating is more indicative of the lower GI tract (intestines/colon). Bloody diarrhea, fecal incontinence, and melena are three additional signs of lower GI involvement. It is important to ask the client about the presence of specific signs that may be too embarrassing to mention (or the client may not see the connection between back pain and bowel smears on the underwear). Asking someone with back pain about bowel function can be accomplished in a very professional manner. The therapist may tell the client:
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SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
"I am going to ask you a series of questions
about your bowels. This may not seem like it is connected to your current problem, so just bear with me. These are important questions to make sure we have covered every possibility. If you do not know the answer to the question, pay attention over the next day or two to see how everything is working. If you notice anything unusual or different, please let me know when you come in next time." Follow-Up
Questions
• When was your last bowel movement? (Look for a change of any kind in the client's normal elimination pattern. Additionally, failure to have a bowel movement over a much longer period of time than expected for that client may be a sign of impaction/obstruction/ obstipation.) • Are you having any diarrhea? • Is there any blood in your stool? • Have you ever been told you have hemorrhoids or do you know that you have hemorrhoids? • Do you have difficulty wiping yourself clean? • Do you find smears on your underwear later after a bowel movement? • Do you have small amounts of stool leakage? Again, when it comes to something like bowel smears on the underpants, it is important to distinguish between pathology and poor hygiene. The key to look for is change such as the new appearance of a problem that was not present before the onset of back pain or other symptoms. With blood in the stools, a medical doctor must differentiate between internal versus external bleeding. Melena is a dark, tarry stool caused by oxidation of blood in the GI tract (usually the upper GI tract, but it can be the lower GI tract). The most common causes of abdominal bleeding are chronic use of NSAIDs leading to ulceration, Crohn's disease, or ulcerative colitis, and diverticulitis or diverticulosis. Anyone with a history of these problems presenting with new onset of back pain must be screened for medical disease. Hemorrhage or visible blood in the toilet may be a sign of anal fissures, hemorrhoids, or colon cancer. The etiology must be determined by a medical doctor. Be aware that there is an increased incidence of rectal bleeding from anal fissures and local tissue damage associated with anal intercourse. This occurs predominantly in the male homosexual or bisexual population, but can be seen
in heterosexual partners who engage in anal intercourse. There are also increasing reports of adolescents engaging in oral and anal intercourse as a form of birth control. It may be necessary to take a sexual history. The therapist should offer the client a clear explanation for any questions concerning sexual activity, sexual function, or sexual history. There is no way to know when someone will be offended or claim sexual harassment. It is in the therapist's best interest to maintain the most professional manner possible. There should be no hint of sexual innuendo or humor injected into any of the therapist's conversations with clients at any time. The line of sexual impropriety lies where the complainant draws it and includes appearances of misbehavior. This perception differs broadly from client to client. 50
You may need to include the following questions (see also Appendix B-29). Always offer an explanation for taking a sexual history. For example, "There are a few personal questions I'll need to ask that may help sort out where your symptoms are coming from. Please answer these as best you can." Follow-Up
Questions
• Are you sexually active? "Sexually active" does not necessarily mean engaging in sexual intercourse. Sexual touch is enough to transmit many sexually transmitted infections. The therapist may have to explain this to the client to clarify this question. Oral and anal intercourse are often not viewed as "sexual intercourse" and will result in the client answering the question with "No" when, in fact, for screening purposes, the answer is "Yes." • Have you had more than one sexual partner (one at a time or during the same time period)? • Have you ever been told you have a sexually transmitted infection or disease such as herpes, chlamydia, gonorrhea, venereal, HIV, or other disease? • Is there any chance the bleeding you are having could be related to sexual activity? For w o m e n :
• What form of birth control are you using? (Risk factor: IUCD) • Is there any possibility you could be pregnant? • Have you ever had an abortion?
CHAPTER 14
CASE
EXAMPLE
14-11
SCREENING THE HEAD, NECK, A N D BACK
Early Satiety a n d
Background: A 78-year-old female was referred to physical therapy by her orthopedic surgeon 6 weeks status post total knee replacement (TKR). Her active knee flexion was 70 degrees; passive knee flexion was only 86 degrees. There was a 15-degree extensor lag. During the course of her rehabilitation program, her adult daughters took turns bringing her to the clinic. They all commented on how much weight she had lost, though to the therapist she looked quite obese. When asked about the weight loss, she replied, "Oh, I take a bite or two and then I'm not very hungry." This symptom (early satiety with weight loss) had been present for the last 2 months (starting prior to the TKR). She did not have any other signs or symptoms associated with the GI system. There were no reported changes in bowel function or the appearance of her stools, no blood in the stools, no back or sacral pain, no night pain that was not directly related to her knee, and no other changes in her health. Her social history included the recent death of a spouse. She had taken care of her husband at home for the last 3 years after he had a severe stroke. She knew she needed a knee replacement, but put it off because of her husband's poor health. Within 6 weeks of his death, she scheduled the needed operation. Could her weight loss be a delayed grieving reaction? Emotional overlay? How can you tell? The screening process often begins with the recognition and categorization of red flags. It is not within the scope of a physical therapist's practice to diagnose psychologic or emotional problems. Clearly, many of the clients and patients in our clinics have significant psychologic needs and emotional responses to their illnesses, injuries, or conditions. Identifying a cluster of signs and symptoms suggestive of a psychologic or behavioral component may help determine the need for behavioral counseling or a psych consult. However, the
Weight
667
Loss
therapist's plan of care may include the use of specific client management skills based on observation of particular behavioral patterns. What do you see in the history, clinical presentation, and associated signs and symptoms as they are presented here that raise a red flag? • History: age and positive social history for recent personal loss • Clinical Presentation: unremarkable; consistent with orthopedic diagnosis • Associated Signs and Symptoms: early satiety with weight loss Viewing the whole client or patient and identifying the presence of emotional overlay to symptoms can be accomplished using the McGill Pain questionnaire, Waddell's nonorganic signs adapted for the knee, and listening to the client's response to her condition and the rehabilitation program (symptom magnification). These 3 assessment tools are discussed in Chapter 3. There are really only 2 red flags here (age and early satiety with weight loss), but they are significant enough to warrant contact with her physician. The next question is: to whom do you send her? The referring orthopedist or her family doctor (if she has one)? It may be best to communicate all findings with the referring physician or health care provider. The therapist can leave the door open by asking any one of the following questions: • Do you want to see Mrs. So-and-So back in your office or shall I send her to her family physician? • Do you want Mr. X/Mrs. Y to check with his/her family doctor or do you prefer to see him/her yourself? • How do you want to handle this? or How do you want me to handle this? Outcome: The orthopedic surgeon recommended referral to her primary care physician. Examination and diagnostic tests resulted in a diagnosis of esophageal cancer (early stage). The client was treated successfully for the cancer while completing her rehabilitation program.
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—If yes, follow up with careful (sensitive) questions about how many, when, where, and any immediate or delayed complications (physical or psychologic). Back pain from any cause may impair sexual function. Many health care professionals do not address this issue; the therapist can offer much in the way of education, pain management, improved function, and proper positioning for work and recreation. Some publications are available to assist therapists discuss sexual function and pain control for the client with back pain. ' 56
57
Esophagus Esophageal pain will occur at the level of the lesion and is usually accompanied by epigastric pain and heartburn. Severe esophagitis (see Fig. 8-11) may refer pain to the anterior cervical or more often, the midthoracic spine. The pain pattern will most likely present in a band of pain starting anteriorly and spreading around the chest wall to the back. Rarely, pain will begin in the midback and radiate around to the front. Referred pain to the midthoracic spine occurs around T56. As with cervical pain of GI origin, there may be a history of alcoholism with esophageal varices, cirrhosis, or an underlying eating disorder. If liver impairment is an underlying factor, there may be signs such as asterixis (liver flap or napping tremor), palmar erythema, spider angiomas, and carpal (tarsal) tunnel syndrome (see discussion, Chapter 9). Keep in mind that this same type of midthoracic back pain can occur with thoracic disc disease. Look for a history of trauma and neurologic changes typically associated with disc degeneration (e.g., bowel and bladder changes, numbness and tingling or paresthesias in the upper extremities); these are not usually present with esophageal impairment. Lower thoracic disc herniation can cause groin pain, leg pain, or mimic kidney pain.
Stomach and Duodenum Long-term use of NSAIDs is the most common cause of back pain referred from the stomach or duodenum. Ulceration and bleeding into the retroperitoneal area can cause pain in the back or shoulder. The primary and referred pain patterns for pain of a stomach or duodenal source are shown in Fig. 8-12. The referred pain to the back is at the level of the lesion, usually between T6 and T10. For the client with midthoracic spine pain of unknown
cause or which does not fit the expected musculoskeletal presentation, ask about associated signs and symptoms such as • Blood in the stools • Symptoms associated with meals • Relief of pain after eating (immediately or 2 hours later) • Increased symptoms with or during a bowel movement • Decreased symptoms after a bowel movement The pain of peptic ulcer (see Figs. 8-7 and 8-12) occasionally occurs only in the midthoracic back between T6 and T10, either at the midline or immediately to one side or the other of the spine. Posterior penetration of the retroperitoneum with blood loss and resultant referred thoracic pain is most often caused by long-term use of nonsteroidal antiinflammatory drugs (NSAIDs). The therapist should look for a correlation between symptoms and the timing of meals, as well as the presence of blood in the feces or relief of symptoms with antacids.
Small Intestine Diseases of the small intestine (e.g., Crohn's disease, irritable bowel syndrome, obstruction from neoplasm) usually produce mid-abdominal pain around the umbilicus (see Fig. 8-2), but the pain may be referred to the back if the stimulus is sufficiently intense or if the individual's pain threshold is low (see Fig. 8-13) (Case Example 14-12). For the client with low back pain of unknown cause or suspicious presentation, ask if there is ever any abdominal pain present. Alternating abdominal/low back pain at the same level is a red flag that requires medical referral. Since both symptoms do not always occur together, the client may not recognize the relationship or report the symptoms. The therapist must be sure and ask appropriate screening questions (Case Example 14-13). Look for a known history of Crohn's disease (regional enteritis), irritable bowel syndrome, bowel obstruction, or cancer. Low back, sacral, or hip pain may be a new symptom of an already established disease. The client may not be aware that 25% of the people with GI disease have concomitant back or joint pain. Enteric-induced arthritis can be accompanied by a skin rash that comes and goes. A flat red or purple rash or raised skin lesion(s) is possible, usually preceding the joint or back pain. The therapist must ask the client if he/she has had any skin rashes in the last few weeks.
CHAPTER 14
CASE
EXAMPLE
14-12
Crohn's
SCREENING THE HEAD, NECK, A N D BACK
Disease a n d
A 23-year-old ballet dancer with "shin splints" comes to you from a sports medicine doctor. Beside anterior lower leg pain, she also reports low back pain that seems to come and go with overuse. She has a history of Crohn's disease. Can symptoms of anterior compartment syndrome be caused by Crohn's disease? It is very unlikely. There are no reported cases to date. Crohn's disease is linked with low back, hip, and sometimes knee pain (knee pain is usually associated with hip pain and usually does not occur alone). Anterior compartment syndrome is easily reproducible with tenderness on palpation of the anterior tibial region. The pain pattern and etiology is fairly typical and symptoms respond to treatment. If the soft tissues are acutely inflamed, surgical intervention may be required. What questions can you ask to rule out a GI cause for her back pain? • Ask about the presence of GI signs and symptoms: Are you having any nausea, vomiting, diarrhea, or constipation?
The therapist may treat joint or back pain when there is an unknown or unrecognized enteric cause. Palliative intervention for musculoskeletal symptoms or apparent movement impairment can make a difference in the short-term, but does not affect the final outcome. Eventually the GI symptoms will progress; symptoms that are unrelieved by physical therapy intervention are red flags. Medical treatment of the underlying disease is essential to correcting the musculoskeletal component.
SCREENING FOR LIVER AND BILIARY CAUSES OF BACK PAIN The primary pain pattern for liver disease is right over the liver. In primary liver pathology, palpation of the organ will reproduce the symptoms and the examiner can feel the liver distention. The normal, healthy liver is located up under the right side of the diaphragm and ribs. The gallbladder is tucked up under the liver (see also Fig. 9-2). When a referred pain pattern occurs, there may be pain on palpation of the liver, but the primary
Back
669
Pain
Any change in your bowel movements? Any trouble wiping yourself clean after a bowel movement? Any blood in the stools? • Any other symptoms of any kind? (headaches, sweats, fever) • Is there abdominal pain and is it at the same level as the back pain? • Does the abdominal and/or back pain change with food intake (assess from 30 minutes to 2 hours after eating)? • Is there relief of back pain with passing gas or having a bowel movement? • Is there a recent (chronic) history of antibiotic and/or NSAID use? • Has the client experienced any joint pain anywhere else in the body? Any skin rashes anywhere? A " y e s " answer to any of these questions is a significant red flag and must be evaluated in context of the overall clinical presentation and findings from the Review of Systems.
complaint is of back pain. There is no report of anterior pain to alert the examiner to the need for liver palpation. In anyone with the referred pain patterns depicted and described in Fig. 9-10, liver palpation may be required as part of the physical assessment (see Figs. 4-48 and 4-49). In addition to a painful and distended liver, the client may report • Pain/nausea 1 to 3 hours after eating (gallstones) • Pain immediately after eating (gallbladder inflammation) • Muscle guarding/tenderness and fever/chills in the right upper quadrant (posterior) Other signs and symptoms associated with liver impairment are discussed in detail in Chapter 9 and include • Liver flap (asterixis) • Nail bed changes (Nail of Terry) • Palmer erythema (liver palms) • Spider angiomas • Ascites, jaundice Gallbladder and biliary disease may also refer pain to the interscapular or right subscapular area.
670
CASE
SECTION III
EXAMPLE
1 4 - 1 3
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
A b d o m i n a l a n d Back Pain at the S a m e Level
Background: A 68-year-old accountant came to physical therapy as a self-referral for low back pain. He reported slipping on a patch of ice as the mechanism of injury. Symptoms were mild, but distressing to this gentleman. He reported pain as "sore" and "aching" with any spinal twisting or side bending to the right. The pain was present across the low back on both sides. The client reported symptoms of stomach distress from time to time. He attributed this to his trips overseas, eating foods from Ireland, Scotland, Germany, and the Netherlands. Lumbar range of motion was fairly typical of a nearly 70 year old with most of his functional forward flexion from the hips and thoracic spine. True physiologic motion in the lumbar spine was negligible. Accessory spinal motions were also limited globally. Active rotation and side bending were stiff and limited to both sides, but only painful to the right. Neurologic screening exam was negative. The therapist did not ask about the presence of any other symptoms of any kind anywhere else in his body. No questions were asked about changes in the pattern of his bowel movements or appearance of his stools. Given the examination results as tested, a conditioning exercise program seemed most appropriate. The client began a stationary bicycling program alternating with walking when the weather permitted. He reported gradual relief from his symptoms and return of motion and function to his previous levels. Four months later this same client reported another injury while walking with subsequent back pain.
The therapist should be observant for any report of fever and chills, nausea and indigestion, changes in urine or stool, or signs of jaundice. The client may not associate GI symptoms with the scapular pain or discomfort. The therapist can use specific questions to rule out potential GI problems (see Special Questions to Ask in this chapter and in greater detail in Chapter 8).
What are the red flag findings? What is the next step in the screening process? The client's age (over 50) is the first red flag. Back pain across both sides can be considered bilateral and therefore a red flag until further assessment is completed. The presence of back pain and abdominal pain or discomfort warrants some additional questions. The therapist should conduct a more thorough pain assessment and ask about the location of the symptoms as well as the presence of any additional GI symptoms. Back pain and abdominal pain at the same level is always a red flag. Screening questions related to the back and GI dysfunction are available at the end of this chapter. Questions about changes in bowel function may reveal some important clues. A screening physical assessment of the abdomen including visual inspection, palpation, and auscultation as described in Chapter 4 may be helpful. Vital sign assessment is always recommended. Result: The key red flag in this case was alternating back and abdominal pain at the same level. The client did not see a connection between these two episodes of pain. When his back hurt he did not have any abdominal pain and vice versa. The client was advised to see his regular physician for an evaluation. He was diagnosed with colon cancer in advanced stages and died 6 weeks later. Earlier detection may have made a difference in this case but the cyclical nature of his presentation masked the true significance of his symptoms.
The Pancreas Acute pancreatitis may appear as epigastric pain radiating to the midthoracic spine (see Fig. 8-15). Pain from the head of the pancreas is felt to the right of the spine, whereas pain from the body and tail is perceived to the left of the spine. More rarely, pain may be referred to the upper back and midscapular areas.
CHAPTER 14
SCREENING THE HEAD, NECK, A N D BACK
There may be a history of alcohol and tobacco use. Associated symptoms, which are usually GI related, may include diarrhea, anorexia, pain after a meal, and unexplained weight loss. The pain is relieved initially by heat, which decreases muscular tension, and may be relieved by leaning forward, sitting up, or lying motionless. The therapist should remain alert for the client with low back pain who seems to benefit from heat modalities but then suddenly gets worse and does not improve with physical therapy intervention.
SCREENING FOR GYNECOLOGIC CAUSES OF BACK PAIN Gynecologic disorders can cause midpelvic or low back pain and discomfort. Gynecologic-induced back pain occurs most often in women of childbearing ages (commonly between ages 20 and 45). How can the therapist recognize when a woman
CASE
EXAMPLE
14-14
671
may be experiencing back pain from a gynecologic cause? As always, the model for screening includes history, presence of any risk factors, clinical presentation, and associated signs and symptoms. Obviously, gender is a clear red flag of possible gynecologic involvement in the case of back (or pelvic, groin, hip, sacral or SI) symptoms. Whenever there is an absence of objective musculoskeletal findings, a history of gynecologic involvement, or associated signs and symptoms of gynecologic disorders, the therapist is encouraged to ask appropriate questions to determine the need for a gynecologic evaluation (Case Example 14-14). The therapist must determine what phase the woman is in her reproductive life cycle (see previous discussions of Life Cycles and Menopause in Chapter 2). If the client is an adolescent, has she begun her menstrual cycle (menses)? If a young to middle-aged adult, is she menstruating, or has she
M o v e m e n t Disorder
A 28-year-old woman in the twentieth week of her first pregnancy reported low back pain of approximately 2 weeks' duration. She could not recall any injury or cause for her pain and attributed it to her pregnancy. She did report a 6-year history of back pain caused by exercise (military press); prior to this episode her back pain could be relieved by rest, heat, and massage therapy. The current back pain was located bilaterally in the thoracolumbar paraspinal region and described as a "nagging ache." The client rated her pain as a 7 to 9 on the Numeric Rating Scale (NRS; see Fig. 3-6), worse in the afternoon and evening. Pain was aggravated by sitting more than 20 minutes and bending forward. She reported episodes of night pain that could be relieved by a change in position. There were no other symptoms anywhere in her body; she was not taking any medications except for prenatal vitamins. She reported her pregnancy was "normal" with appropriate weight gain. There has been no spotting or vaginal bleeding during the pregnancy. Vital signs were within normal limits (WNL).
Is a Medical Screening Examination Needed? The client's age is not a red flag at this time. Although she reports an insidious onset for her symptoms, the pain is not constant and can be relieved with a change in position. The pain wakes her up at night but she is able to get back to sleep by getting up and walking or by changing position. Vital signs were normal and there were no constitutional symptoms. At this point the evaluation can proceed as usual. The therapist should include a screening neurologic assessment as part of the examination. Movement testing further confirmed an extension syndrome with worse symptoms during trunk flexion and improved pain after repetitive trunk extension. No further medical screening is required unless additional red flag symptoms develop. The client's improvement with physical therapy intervention confirmed the decision that medical referral was not necessary.
Data from: Requejo, SM, Barnes R, Kulig K, et al: The use of a modified classification system in the treatment of low back pain during pregnancy: a case report, JOSPT 32(7):318-326, 2002.
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SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
had a hysterectomy and experienced surgically induced menopause?
Past Medical History Gynecologic conditions causing back pain can include retroversion (tipping back) of the uterus, ovarian cysts, uterine fibroids, endometriosis, pelvic inflammatory disease, or normal pregnancy (Case Example 14-15). Usually, there is a history of a chronic or longstanding gynecologic disorder, and the association between back pain and gynecologic disorder has been established. There may be a history of sexual assault, incest, sexually transmitted disease, ectopic pregnancy, use of an intrauterine contraceptive device, dysuria, or abortion.
Risk Factors Often the history and risk factors for back or pelvic pain are synonymous, especially multiple pregnancies and births, with administration of an epidural during delivery, prolonged pushing, and/or use of forceps. Other risk factors include abnormal uterine position, endometriosis, ovarian cysts and uterine fibroids, ectopic pregnancy, and
CASE EXAMPLE
1 4 - 1 5
Back Pain Dur ng
A 32-year-old Native American woman in the third trimester of her second pregnancy presented with acute onset of mid- to right-sided lumbar pain. She reported pain radiating around to the right side. An abdominal sonogram was negative and all lab values were within normal limits. The client declined any further imaging studies and requested a referral to physical therapy. What will you need to do to make sure this client's problem is within the scope of a physical therapy practice? Take a thorough history (including childbirth histories) and evaluate pain pattern(s) carefully. Screen for domestic abuse sometime during the evaluation or early treatment intervention. Ask about the presence of any other symptoms, even if they seem unrelated to her pregnancy or back pain. See if you can reproduce the symptoms by palpation or through position or movement; assess for trigger points.
the use of an intrauterine contraceptive device (IUCD). Back pain is common during pregnancy beginning most often during the second trimester between the fifth and seventh months of gestation. ' Women who have had multiple pregnancies or births may have sacroiliac or low back pain associated with poor abdominal tone and ligamentous laxity. The risk of developing chronic postpartum back pain may be doubled among women who received epidural anesthesia during labor. Additionally, women who have had one or more abortions may seek health care months to years later with a variety of physical and psychologic symptoms referred to as post-abortion syndrome or post-abortion survivor's syndrome. This condition has not been classified in the Diagnostic and Statistical Manual and its existence remains controversial. 58
59
60
Multiple
Pregnancies
and
Births
Even though pregnancy and childbirth are natural physiologic processes, these events can be traumatic to the soft tissues of the pelvic floor. Referred pain to the low back from the consequences of this
Pregnancy
Take all vital signs and ask about the presence of constitutional symptoms. Assess for rectus abdominis diastasis (separation of the rectus abdominal muscles) as a possible contributing factor. Outcome: During palpation of the ribs, the therapist noted an outward flaring of the lower ribs. There were pain and tenderness at the interchondral junctions between the eighth and tenth ribs. The history was significant for chronic cough from smoking. The woman reported feeling the child in a horizontal position pushing against the lower ribs. Based on these findings, the therapist telephoned the physician and asked if there was any chance a rib fracture could be causing the painful symptoms. The client agreed to an x-ray and the radiograph showed a fracture of the right tenth rib.
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SCREENING THE HEAD, NECK, A N D BACK
event is possible. If the woman's history includes a recent birth or multiple previous births, she may not recognize the association between her current symptoms and her pregnancy/delivery history.
Abnormal
Uterine
Positions
Having an understanding of the normal female reproductive anatomy (see Fig. 15-4) can help the therapist better appreciate musculoskeletal pain and dysfunction that can occur with abnormal uterine positions (see Fig. 15-5). Taking a careful history and correlating symptoms with a woman's monthly cycle can help the therapist determine when to refer a client for a possible gynecologic cause of back, pelvic, or sacral pain/symptoms. Many problems affecting the pelvic floor musculature can be treated successfully by a physical therapist and do not require medical referral.
Endometriosis Endometriosis is an estrogen-dependent disorder defined by the presence of endometrial tissue (lining of the uterus) outside of the uterus. Each month as the woman's body prepares for a fertilized egg, the uterus becomes engorged with blood, providing a fertile place for the egg to attach and begin growing. If and when the unfertilized egg passes out of the body, the uterus sloughs off the lining of blood and the woman has a flow of menstrual blood for about 3 to 5 days. Endometriosis occurs when the uterus sheds this blood up into the body, rather than down and out through the vagina. Endometrial tissue found outside of the uterus on other organs or structures within the pelvic cavity and the body responds each month the same way as the endometrium during the menstrual cycle. The misplaced tissue engorges with blood just as it would when lining the uterus. The blood cannot drain out of the body and the result is lesions or "chocolate cysts" wherever the endometrial tissue is located, with subsequent swelling, bleeding, and scarring. These pockets of blood can be deposited anywhere in the body. Whereas it was once thought that the blood just reached the pelvic and abdominal cavities, coating the viscera contained within, it is clear now that endometrial tissue migrates throughout the body. It has been recovered from bone, lungs, and even the brain. Pain can occur anywhere, but often the woman experiences back, pelvic, hip, and/or sacral pain that can be mistaken for a musculoskeletal, musculoligamentous, or neuromuscular impairment of the lumbar spine (Case Example 14-16). 61
62
673
The key to recognizing this condition is that often it is cyclical. Symptoms come and go with the menstrual cycle. After menopause pain can persist from scar tissue. There may be urinary tract and bowel involvement with associated symptoms ranging from urinary frequency, intermittent dysuria, and bloody stools to ureteral or bowel obstruction. This condition is more common than previously thought. It is estimated that up to 50% of the female population who are infertile are affected by endometriosis. It is not clear what, if any, risk factors increase a woman's risk of developing endometriosis. Endometriosis has been linked with other health problems such as chronic fatigue syndrome, hypothyroidism, fibromyalgia, rheumatoid arthritis, multiple sclerosis, and systemic lupus erythematosus. Endometriosis is a risk factor for ovarian and breast cancer. A cure has not been found at the present time but for many women it can be managed with medications and/or surgery. The therapist can be helpful in providing pain management strategies that can reduce sick leave and improve daily function. See Box 15-5 for more information on this condition. 62
63
62
Clinical Signs and Symptoms of Endometriosis •
Intermittent, c y c l i c a l , o r c o n s t a n t p e l v i c a n d / o r back pain (unilateral or bilateral)
• •
Pain d u r i n g or a f t e r s e x u a l i n t e r c o u r s e Painful b o w e l m o v e m e n t s o r p a i n f u l u r i n a t i o n during menstrual period
•
S m a l l b l o o d loss (spotting) b e f o r e or b e t w e e n periods
• •
Heavy or irregular menstrual bleeding B l e e d i n g a n y w h e r e else (nose b l e e d s , c o u g h i n g u p b l o o d , b l o o d i n u r i n e o r stools)
•
Fatigue
•
History
of
ectopic
pregnancy,
miscarriage,
infertility •
GI problems (abdominal bloating a n d cramping, nausea, d i a r r h e a , constipation)
Ovarian
Cysts
and
Uterine
Fibroids
Ovarian cysts are often asymptomatic until they grow large enough to pull the ovary out of its normal position, sometimes cutting off the blood supply to the ovary. As the weight of the ovary causes a change in position, pressure is exerted against the uterus, bladder, intestines, or vagina causing a variety of symptoms.
674
CASE
SECTION III
EXAMPLE
1 4 - 1 6
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Endometriosis
Case Description: A 25-year-old female was referred for physical therapy with a diagnosis of nonspecific low back pain. She presented with the sudden onset of pain in the left lumbosacral region, left lower abdominal quadrant, and left buttock and anterior thigh which was constant and severe. Medical examination ruled out a renal source of pain and diagnosed the client with a low back sprain. X-rays and MRIs were negative and ruled out a spondylogenic, oncologic, or discogenic lesion. She was given an injection of Demerol and prescription for non-steroidal antiinflammatory drugs and anti-spasmodics and referred to physical therapy. Past Medical History and Risk Factors: The client was a nonsmoker and consumed alcohol only on occasion. Personal family history was unremarkable; she reported that her mother had rheumatoid arthritis and hypothyroidism. Clinical Presentation: The client was seen in physical therapy 3 weeks after the initial painful episode. She presented with a chief complaint of sharp, constant pain in the left lumbosacral region, which occasionally radiated into the left lower abdominal quadrant and into the left buttock and the anterior thigh as far distally as the knee. The pain was worse when sitting or walking. She was only able to sleep 1 to 2 hours at a time because of the severity of the pain. There was no report of bowel or bladder changes. The hip and sacroiliac joint were ruled out as the sources of pain. A neurologic screening examination was negative. Trunk motions were mildly restricted with increased pain during forward flexion. There was a positive left straight-leg raise test at 60 degrees. The client appeared to have a musculoskeletal based movement impairment. Physical examination determined the most significant clinical finding to be exquisite tenderness in the left lower abdominal quadrant. The client reported marked tenderness with palpation over the left lower abdominal quadrant just proximal to the ASIS. She also reported
tenderness with palpation directly over the left lumbar paraspinal region just superior to the iliac crest. Red Flags: The sudden onset, intensity, severity, and duration of the client's back pain raised a red flag. The left lower quadrant was the location of greatest tenderness and severe subjective pain, both experienced at rest and with activity. The client's gender and childbearing age raise yellow warning flags. Should the therapist treat this client and reassess symptoms and clinical presentation in 2 weeks or refer immediately? Once again, the decision to carry out a physical therapy plan of care with direct intervention versus making a medical referral is based on clinical judgment. Given the presentation of this case, either decision could be justified. Since she was evaluated by a medical doctor who sent her to physical therapy, a telephone call would be more appropriate than suggesting the client go back to her doctor. In this case the therapist made the decision not to treat the client given the fact that a delay in diagnosis with risk for increased morbidity and possible mortality is possible with low back pain from serious pelvic pathology. Outcomes: The therapist conferred with the referring orthopedic surgeon and a referral was made to a gynecologist. Further testing provided a diagnosis of endometriosis and ovarian cyst. The client underwent laparoscopy; the diagnosis of endometriosis was confirmed. Following medical and surgical intervention, the lower quadrant pain was abolished, and the low back pain and leg pain significantly diminished in frequency and intensity, enabling the client to return to her normal activities. Discussion: Given the prevalence of endometriosis, physical therapists are likely to encounter clients with this disorder in orthopedic physical therapy practice. Proper differential diagnosis is necessary to identify the risk factors and physical findings that would provide early diagnosis of endometriosis and avoid the morbidity associated with this and other pelvic disorders.
From Troyer, MR: Differential diagnosis of endometriosis in a patient with nonspecific low back pain. Case report presented in partial fulfillment of DPT 910, Principles of Differential Diagnosis, Institute for Physical Therapy Education, Widener University, Chester, Pennsylvania, 2005. Used with permission.
CHAPTER 14
SCREENING THE HEAD, NECK, A N D BACK
Lower abdominal or pelvic pain is most common but back pain associated with ovarian cysts and uterine fibroids can occur, usually presenting in a cyclical pattern associated with the menstrual cycle similar to endometriosis. A physician must determine the underlying gynecologic cause of back (hip, pelvic, sacral) pain or symptoms. In a screening context, we look for red flag histories, clinical presentation, risk factors, and associated signs and symptoms. Obesity may be a risk factor because more than half of the women affected by this disorder are obese but other risk factors remain unknown. Ovarian cysts present as part of the polycystic ovarian syndrome put the woman at increased risk for insulin resistance and potentially at increased risk for cardiovascular disease as a result. ' If the Review of Systems points to a gynecologic source of pain/symptoms, further questions can be asked and a referral made if appropriate. Low back pain is a late finding for some women with ovarian cancer (see Chapter 15). 64
65
675
the hemorrhage is significant enough to impinge both sides of the diaphragm. The pain is usually of a sudden onset (when rupture and hemorrhage occur) with intense, constant pain. Situations of this type represent a medical emergency. Most likely the client did not come to the therapist for this problem but may develop emerging symptoms while being treated for some other orthopedic or neurologic problem. Consider it a red flag when any woman of childbearing age who is sexually active has sudden, intense pain as described. Take her blood pressure and other vital signs while asking appropriate screening questions. Seek immediate medical assistance. Clinical Signs and Symptoms of Ectopic •
Pregnancy
Amenorrhea
or
irregular
bleeding
and
spotting •
Diffuse, a c h i n g lower a b d o m i n a l q u a d r a n t or l o w b a c k p a i n ; can cause ipsilateral shoulder
Clinical Signs and Symptoms of Ovarian
pain •
Cysts
pain
•
A b d o m i n a l pressure, p a i n , o r b l o a t i n g
•
Discomfort
during
urination,
bowel
move-
ments, o r sexual i n t e r c o u r s e • •
I r r e g u l a r menses, infertility Dull a c h i n g l o w b a c k , b u t t o c k , p e l v i c , o r g r o i n pain
•
Sudden,
sharp
pain
with
rupture
or
hemorrhage
Ectopic
M a y p r o g r e s s to a s h a r p e r , i n t e r m i t t e n t t y p e of
Pregnancy
An ectopic pregnancy is a live pregnancy that takes place outside the uterus. As shown in Fig. 15-6, this may occur in a variety of places such as the ovary, the tube (tubal pregnancy), outside lining of the uterus, or along the peritoneal cavity. None of these locations can sustain a viable ovum and the woman will have a spontaneous abortion (miscarriage). Risk factors include sexually transmitted diseases, prior tubal surgery, and current use of an intrauterine contraceptive device. Depending on the location of the ectopic pregnancy, symptoms can include back, hip, sacral, abdominal, pelvic, and/or shoulder pain. Shoulder pain is more likely to occur if there is retroperitoneal bleeding when rupture of the developing embryo and hemorrhage occurs with pressure on the diaphragm. It is usually unilateral on the same side as the bleeding, but can cause bilateral shoulder pain if
Intrauterine
Contraceptive
Device
(IUCD)
The intrauterine contraceptive device (IUCD is the current medical term; known by most women as an IUD) has become popular once again, having gone out of favor in the 1970s when the copper T caused so many problems. Although this contraceptive device has been improved, there are still potential problems (Fig. 14-6). The body may recognize this as a foreign object and set up an immune response Fallopian tube
IUCD
Ovary 'Uterus
Vagina Fig. 14-6
•
Intra-uterine contraceptive device (IUCD or IUD)
a potential source of l o w b a c k , pelvic, sacral, or even h i p p a i n in a n y w o m a n of reproductive a g e w h o is using this f o r m of birth control.
SECTION III
676
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
or try to wall it off. The IUCD can become embedded in the tissue of the uterus, causing inflammation, infection and scarring. For any woman with low back, pelvic, sacral or hip pain who is in the reproductive age range it may be necessary to ask about her method of birth control: Are you using an IUD for birth control?
Back pain that is associated with the menstrual cycle occurs most often at or around the point of ovulation (between day 10 and day 14 for most women) and again just prior to or during menstrual flow (between days 23 and 28 for most women). Day 1 is counted as the first day the woman experiences bleeding with her menstrual cycle. Back pain associated with the menstrual cycle may be a regular feature for a woman, it may occur intermittently, or it may be new onset, and the woman is unaware of the link between the two until she charts her monthly cycle and correlates it with her back pain. A woman may have back pain accompanied by or alternating with sharp, bilateral, and cramping pain in the lower abdominal and/or pelvic quadrants. Menstrual pain can be referred to the rectum, lower sacrum, or coccyx. Tumors, masses, or even endometriosis may involve the sacral plexus or its branches, causing severe, burning pain.
Associated Signs and Symptoms After gathering information during the examination, the therapist performs a Review of Systems looking for clusters of signs and symptoms suggesting a gynecologic cause of low back pain. If appropriate, the next step is to ask a few final screening questions.
Missed
Disorders
menses,
irregular menses,
h i s t o r y of
menstrual disturbances, painful menstruation •
Tender breasts
•
Nausea, vomiting
•
Chronic constipation (with laxative a n d enema dependency)
•
Pain on d e f e c a t i o n
•
Fever, n i g h t s w e a t s , chills
•
Low
blood
pressure
ectopic pregnancy) •
Vaginal discharge
Late menstrual periods w i t h persistent bleeding
•
Spotting before p e r i o d or between periods
•
Irregular, longer, heavier menstrual periods, n o specific p a t t e r n
• •
A n y postmenopausal bleeding
Urinary
problems
(intermittent
dysuria,
fre-
SCREENING FOR MALE REPRODUCTIVE CAUSES OF BACK PAIN Men can experience back pain (as well as hip, groin, SI, and sacral pain) caused by referred pain from the male reproductive system. Prostate cancer is the second most common cancer in males over the age of 60 in the United States. The incidence of prostate cancer has risen 60% to 75% in the Western world in the last 15 years and is expected to continue to rise over the next 20 years, making it very likely that the therapist will treat clients with prostate pathology. Testicular cancer, though relatively rare, is the most common cancer in males ages 15 to 35 years and on the rise. Details of both conditions are discussed in Chapter 10. Benign prostatic hyperplasia (BPH) is one of the most common disorders of the aging male population affecting 50% of men over age 50. 66
67
Risk Factors Risk factors for prostate dysfunction include advancing age, family history, ethnicity (greater risk for African American men), diet, and possibly exposure to chemicals. Not all disorders of this system occur with aging, so the therapist must remain alert for red flag symptoms in males of any age.
Clinical Presentation
Clinical Signs and Symptoms of
•
A b n o r m a l vaginal bleeding •
quency, urgency, hematuria)
Clinical Presentation
Gynecologic
•
(hemorrhaging
with
Back pain, changes in bladder function, and sexual dysfunction are the most common symptoms associated with male reproductive disorders. Any obstruction, growth, or inflammation of the prostate can directly affect the urethra, resulting in difficulty starting a flow of urine, continuing a flow of urine, frequency, and/or nocturia. Prostate cancer is often asymptomatic and only diagnosed when the man seeks medical assistance because of symptoms of urinary obstruction or sciatica. Sciatic pain affects the low back, hip, and leg and is caused by metastasis to the bones of the pelvis, lumbar spine, or femur.
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SCREENING THE HEAD, NECK, A N D BACK
Associated symptoms may include melena, sudden moderate to high fever, chills, and changes in bowel or bladder function. Men who have reached the fifth decade or more are most commonly affected. Testicular cancer presents most often as a painless swelling nodule in one gonad, noted incidentally by the client or his sexual partner. This is described as a lump or hardness of the testis, with occasional heaviness or a dull, aching sensation in the lower abdomen or scrotum. Acute pain is the presenting symptom in about 10% of affected men. Involvement of the epididymis or spermatic cord may lead to pelvic or inguinal lymph node metastases, although most tumors confined to the testis itself will spread primarily to the retroperitoneal lymph nodes. Subsequent cephalad drainage may be to the thoracic duct and supraclavicular nodes. Hematogenous spread to the lungs, bone, or liver may occur as a result of direct tumor invasion. In about 10% of affected individuals, dissemination along these pathways results in thoracic, lumbar, supraclavicular, neck, or shoulder pain or mass as the first symptom. Other symptoms related to this pathway of dissemination may include respiratory symptoms or GI disturbance. As discussed earlier, back pain caused by neoplasm is typically progressive, is more pronounced at night, and may not have a clear association with activity level (as is more characteristic of mechanical back pain). The usual progression of symptoms in clients with cord compression is back pain followed by radicular pain, lower extremity weakness, sensory loss, and, finally, loss of sphincter (bowel and bladder) control.
Associated Signs and Symptoms Besides changes in urinary patterns, the therapist must ask about discharge from the penis, constitutional symptoms, and pain in any of the nearby soft tissue areas (groin, rectum, scrotum). Is there any blood in the urine (or change in color from yellow to orange or red)? Recurrent urinary tract infection is common in prostatitis, but does not lead to prostate cancer. Because the therapist is not going to be treating any of these problems, any red flags should be reported to the physician. A rectal exam may be needed. Access to the prostate is easiest through this type of exam. By pressing on the inflamed or infected prostate, the physician can reproduce painful symptoms as part of the differential diagnosis (see Fig. 10-5).
677
Many men are reluctant to pursue diagnosis and treatment whenever the male reproductive system is involved. Early detection and treatment of these conditions can result in a good outcome. Screening questions for men are a good way to elicit red flag history, risk factors, and signs or symptoms. The therapist must follow up with the client and make sure contact is made with the appropriate health care professional. Clinical Signs and Symptoms of Prostate • •
Pathology
M a y be asymptomatic early on Urinary
dysfunction
(hesitancy,
frequency,
urgency, nocturia, dysuria) •
Low b a c k ,
inner thigh,
or perineal
p a i n or
stiffness •
S u p r a p u b i c or pelvic p a i n
•
Testicular or p e n i s p a i n
•
S c i a t i c a ( p r o s t a t e c a n c e r metastases)
•
B o n e p a i n , l y m p h e d e m a o f the g r o i n , a n d / o r l o w e r e x t r e m i t i e s ( p r o s t a t e c a n c e r metastases)
•
Neurologic pression
changes
(prostate
from
cancer
spinal
cord
metastases
comto
the
vertebrae) •
Sexual dysfunction (difficulty h a v i n g an erection, painful ejaculation, cramping/discomfort after ejaculation)
•
C o n s t i t u t i o n a l s y m p t o m s w i t h prostatitis
•
B l o o d in u r i n e or s e m e n
SCREENING FOR INFECTIOUS CAUSES OF BACK PAIN Drug abuse, immune suppression, and human immunodeficiency virus (HIV) may predispose to infection. Fever in anyone taking immunosuppressants is a red flag symptom indicating a possible underlying infection. Many people with a spinal infection do not have a fever; they are more likely to have a red flag history or risk factors. 1
Vertebral Osteomyelitis Vertebral osteomyelitis is a bone infection most often affecting the first and second lumbar vertebrae, causing low back pain. There are many causative factors. Osteomyelitis may occur in diabetics, injection drug users (IDUs), alcoholics, clients taking corticosteroid drugs, clients with spinal cord injury and neurogenic bladder, and otherwise debilitated or immune-suppressed clients. Older children can be affected although the most common peak is after the third decade of life.
678
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SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Vertebral osteomyelitis is increasingly being reported as a complication of nosocomial bacteremia. Staphylococcus aureus, often methicillinresistant (MRSA), is the most common causative organism. Osteomyelitis also can occur after surgery, open fractures, penetrating wounds, skin breakdown and ulcers, and systemic infections. It may result from a hematogenous spread through arterial and venous routes secondary to surgically implanted hardware for internal fixation of the spine, pelvic inflammatory disease, or genitourinary tract infection. A physician should evaluate new onset of back pain in anyone who has been treated with vancomycin therapy for MRSA. Vancomycin therapy may give the appearance of being effective with resolution of fever and the return of white blood cell counts to normal ranges but in fact be insufficient to prevent or reverse the progression of hematogenous MRSA vertebral osteomyelitis. In the adult, usually two adjacent vertebrae and their intervening disc are involved, and the vertebral body(ies) may undergo destruction and collapse. Abscess formation may result, with possible neurologic involvement. The abscess can advance anteriorly to produce an abscess that can extend to the psoas muscle producing hip pain. The most consistent clinical finding is marked local tenderness over the spinous process of the involved vertebrae with "nonspecific backache." The classic history describes pain that has been increasing in severity over a period of 1 to 3 weeks. Movement is painful, and there is marked muscular guarding and spasm of the paravertebral muscles and the hamstrings. The involved vertebrae are usually exquisitely sensitive to percussion, and pain is more severe at night. There may be no rise in temperature or abnormality in white blood cell count because generalized sepsis is not present, but an elevated erythrocyte sedimentation rate is likely. A lowgrade fever is most common in adults when body temperature changes do occur. Children are more likely to present with acute, severe complaints including high fever, intense pain, and localized manifestations such as edema, erythema, and tenderness. Acute hematogenous osteomyelitis seen in children usually originates in the metaphysis of a long bone. Precipitating trauma is often present in the history, and welllocalized, acute bone pain of 1 day to several days' duration is the primary symptom. The pain is most commonly severe enough to limit or restrict the use of the involved extremity, and fever and malaise consistent with sepsis are usual. 68
Clinical Signs and Symptoms of Vertebral •
Osteomyelitis
Pain a n d local tenderness o v e r the i n v o l v e d s p i n o u s process(es); p o s s i b l e s w e l l i n g , redness, a n d w a r m t h i n the a f f e c t e d a r e a
• •
Night pain Stiff
back
with
difficulty
bearing
weight,
moving, walking •
P a r a v e r t e b r a l muscle g u a r d i n g or s p a s m
•
Positive s t r a i g h t leg raise (SLR)
•
Hip
pain
if
infection
s p r e a d s to the
psoas
muscle •
May
be
constitutional
symptoms
(fever,
malaise) •
Recent
history
of
bacterial
infection
(e.g.,
p h a r y n g i t i s , otitis m e d i a i n c h i l d r e n )
Disc Space Infection Disc space infection is a form of subacute osteomyelitis involving the vertebral end-plates and the disc in both children and adults. The lower thoracic and lumbar spines are the most common sites of infection. Symptoms associated with postoperative disc space infection occur 2 to 8 weeks after discectomy. Discitis of an infectious type occurs following bacteremia secondary to urinary tract infection, with or without instrumentation (e.g., catheterization or cystoscopy). Low-grade viral or bacterial infection (e.g., gastroenteritis, upper respiratory infection, urinary tract infection) is most often implicated in young children with discitis (4 years old and younger). Ask the parent, guardian, or caretaker of any young child with back pain if there has been a recent history of sore throat, cold, ear infection, or other upper respiratory illness. Adults with disc space infection often complain of low back pain localized around the disc area. The pain can range from mild to "excruciating" sometimes described as "knifelike." Such severe pain is accompanied by restricted movement and constant pain, present both day and night. The pain is usually made worse by activity, but unlike most other causes of back pain, it is not relieved by rest. If the condition becomes chronic, pain may radiate into the abdomen, pelvis, and lower extremities. Children present with a history of increasingly severe localized back pain often accompanied by a limp or refusal to walk. There may be an increased lumbar lordosis. Pain may occur in the flank, abdomen, or hip. Symptoms may get worse with passive straight leg raise testing or other hip motion. A neurologic screening examination is usually negative.
CHAPTER 14
SCREENING THE HEAD, NECK, A N D BACK
Physical examination may reveal localized tenderness over the involved disc space, paraspinal muscle spasm, and restricted lumbar motion. A straight-leg raise (SLR) may be positive, and fever is common (Case Example 14-17).
Bacterial Endocarditis Bacterial endocarditis often presents initially with musculoskeletal symptoms, including arthralgia, arthritis, low back pain, and myalgias. Half of these clients will have only musculoskeletal symptoms, without other signs of endocarditis. The early onset of joint pain and myalgia is more likely if the client is older and has had a previously
CASE EXAMPLE
1 4 - 1 7
679
diagnosed heart murmur or prosthetic valve (risk factors). Other risk factors include injection drug use, previous cardiac surgery, recent dental work, and recent history of invasive diagnostic procedures (e.g., shunts, catheters). Almost one third of clients with bacterial endocarditis have low back pain. In many persons it is the principal musculoskeletal symptom reported. Back pain is accompanied by decreased range of motion and spinal tenderness. Pain may affect only one side, and it may be limited to the paraspinal muscles. Endocarditis-induced low back pain may be very similar to the pain pattern associated with a
Septic Discitis
Background: A 72-year-old man with leg myalgia and stabbing back pain of 2 weeks' duration was referred to physical therapy for evaluation by a rural nurse practitioner. When questioned about past medical history, the client reported a prostatectomy 22 years ago with no further problems. He was not aware of any other associated signs and symptoms but reported a recurring dermatitis that was being treated by his nurse practitioner. There were no skin lesions associated with the dermatitis present at the time of the physical therapist evaluation. Clinical Presentation: The examination revealed spasm of the thoracolumbosacral paraspinal muscles bilaterally. The client reported extreme sensitivity to palpation of the spinous processes at L3 and L4; tap test reproduced painful symptoms. Spinal accessory motions could not be tested because of the client's state of acute pain and immobility. Hip flexion and extension reproduced the symptoms and produced additional radiating flank pain. A straight-leg raise (SLR) caused severe back pain with each leg at 30 degrees on both sides. A neurologic examination was otherwise within normal limits. Vital signs were taken: blood pressure of 180/100 mm Hg; heart rate of 100 beats/min; temperature of 101°F. What are the red flags in this case? • Age • Recurring dermatitis
• Positive tap test • Bilateral SLR • Vital signs Result: The therapist contacted the nurse practitioner by telephone to report the findings, especially the vital signs and results of the SLR. It was determined that the client needed a medical evaluation, and he was referred to a physician's center in the nearest available city. A summary of findings from the physical therapist was sent with the client along with a request for a copy of the physician's report. The client returned to the physical therapist's clinic with a copy of the physician's report with the following diagnosis: Clostridium perfringens septic discitis (made on the basis of blood culture). The prescribed treatment was intravenous antibiotic therapy for 6 weeks, progressive mobilization, and a spinal brace to be provided and fitted by the physical therapist. The client's back pain subsided gradually over the next 2 weeks, and he was followed up at intervals until he was weaned from the brace and resumed normal activities. Septic discitis may occur following various invasive procedures, or it may be related to occult infections, urinary tract infections, septicemia, and dermatitis. Contact dermatitis was the most likely underlying cause in this case.
680
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
herniated lumbar disc; it radiates to the leg and may be accentuated by raising the leg, coughing, or sneezing. The key difference is that neurologic deficits are usually absent in clients with bacterial endocarditis. The therapist can review history and risk factors and conduct a Review of Systems to help in the screening process.
PHYSICIAN REFERRAL Most adults with an episode of acute back pain experience recovery within 1 to 4 weeks. As many as 90% of affected individuals resume normal activity levels during this time. All clients who have not regained usual activity after 4 weeks should be formally reassessed including a review of the history and examination, looking for yellow or red flags, testing for any neurologic deficit, and conducting a review of systems to identify any evidence of systemic disease. Reassessment of movement dysfunction is critical at this stage to look for alternate impairments not previously observed or identified. The therapist must consider whether the underlying primary problem is spinal or nonspinal, mechanical or medical, and what specific structures are involved. Review concepts from the screening physical assessment in Chapter 4 to make sure the evaluation is complete. Inspection, palpation, and auscultation may reveal key findings previously missed. Assessment of fear-avoidance may be needed as discussed in Chapter 3. Medical referral is made on the basis of a comparison of baseline data with findings upon reassessment. Providing the physician with concise but comprehensive information about findings and concerns is a helpful part of the medical differential diagnostic process. 69
Guidelines for Immediate Medical Attention Immediate medical referral is not always required when a client presents with any one of the red flags listed in Box 14-1. When viewed as a whole, the history, risk factors, and any cluster of red flag findings will guide the therapist in making a final intervention versus referral decision. • Neck pain with evidence of vertebrobasilar insufficiency (VBI) (e.g., reproduction of symptoms with vertebral artery testing such as vertigo, visual changes, headaches, nausea) requires medical attention. VBI can develop into cerebral or brainstem ischemia, leading to severe morbidity or death. 70
• Immediate medical attention is required when anyone with low back pain (LBP) presents with symptoms of cauda equina (e.g., saddle anesthesia, fecal incontinence, motor weakness of the legs, radiculopathy, unable to heel or toe walk, altered knee or ankle deep tendons reflexes). Acute mechanical compression of nerves in the lower extremities, bowel, and bladder as they pass through the caudal sac may be a surgical emergency. • Massive midline rupture of a disk in the lower lumbar levels can lead to LBP, rapidly progressive bilateral motor weakness and sciatica, saddle anesthesia (buttock and medial and posterior thighs; the area that would come in contact with a saddle when sitting on a horse), and bowel and bladder incontinence or urinary retention. • Men between the ages of 65 and 75 who ever smoked should undergo medical screening for abdominal aortic aneurysm. Any male with these two risk factors, especially presenting with signs or symptoms of AAA must be referred immediately. • Sudden, intense back and/or shoulder pain in a sexually active woman of childbearing age may signal the end of an ectopic pregnancy. Sudden change in blood pressure, pallor, pain, and dizziness will alert the therapist to the need for immediate medical attention. 71
Guidelines for Physician Referral • Red flags requiring physician referral or reevaluation include back pain or symptoms that are not improving as expected, steady pain irrespective of activity, symptoms that are increasing, or the development of new or progressive neurologic deficits, such as weakness, sensory loss, reflex changes, bowel or bladder dysfunction, or myelopathy. • A positive Sharp-Purser test for atlantoaxial subluxation in the client with rheumatoid arthritis (sensation of head falling forward during neck flexion and clunking during neck extension) must be evaluated by an orthopedic surgeon. • The erythrocyte sedimentation rate, serum calcium level, and alkaline phosphatase level are usually elevated if cancer is present. • Reproduction of pain or exquisite tenderness over the spinous process(es) is a red flag sign requiring further investigation and possible medical referral. 7
72
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SCREENING THE HEAD, NECK, A N D BACK
Clues to Screening Head, Neck, or Back Pain General • Age younger than 20 and older than 50 with no history of a precipitating event • Back pain in children is uncommon and constitutes a red flag finding, especially back pain that lasts more than 3 weeks • Nocturnal back pain that is constant, intense, and unrelieved by change in position • Pain that causes constant movement or makes the client curl up in the sitting position • Back pain with constitutional symptoms: fatigue, nausea, vomiting, diarrhea, fever, sweats • Back pain accompanied by unexplained weight loss • Back pain accompanied by extreme weakness in the leg(s), numbness in the groin or rectum, or difficulty controlling bowel or bladder function (cauda equina syndrome; rare but requires immediate medical attention) • Back pain that is insidious in onset and progression (remember to assess for unreported sexual assault or physical abuse) • Back pain that is unrelieved by recumbency • Back pain that does not vary with exertion or activity • Back pain that is relieved by sitting up and leaning forward (pancreas) • Back pain that is accompanied by multiple joint involvement (gastrointestinal, rheumatoid arthritis, fibromyalgia) or by sustained morning stiffness (spondyloarthropathy) • Severe, persistent back pain with full and painless movement of the spine • Sudden, localized back pain that does not diminish in 10 days to 2 weeks in postmenopausal women or osteoporotic adults (osteoporosis with compression fracture)
Past
Medical
History
• Previous history of cancer, Crohn's disease, or bowel obstruction • Long-term use of nonsteroidal antiinflammatory drugs (gastrointestinal bleeding), steroids, or immunosuppressants (infectious cause) • Recent history or previous history of recurrent upper respiratory infection or pneumonia • Recent history of surgery, especially back pain 2 to 8 weeks after discectomy (infection) • History of osteoporosis and/or previous vertebral compression fracture(s) (fracture)
681
• History of heart murmur or prosthetic valve in an older client who currently has low back pain of unknown cause (bacterial endocarditis) • History of intermittent claudication and heart disease in a man with deep midlumbar back pain; assess for pulsing abdominal mass (abdominal aortic aneurysm) • History of diseases associated with hypercalcemia, such as hyperparathyroidism, multiple myeloma, senile osteoporosis, hyperthyroidism, Cushing's disease, or specific renal tubular disease not appearing with back pain radiating to the flank or iliac crest (kidney stone)
Oncologic • Back pain with severe lower extremity weakness without pain, with full range of motion and recent history of sciatica in the absence of a positive straight leg raise • Bilateral leg pain with motor and reflex impairments • Bone tenderness over the spinous processes (infection or neoplasm) • Temperature differences: involved side warmer when tumor interferes with sympathetic nerves • Associated signs and symptoms: significant weight loss; night pain disturbing sleep; extreme fatigue; constitutional symptoms such as fever, sweats; other organ/system-dependent symptoms such as urinary changes (urologic), cough, and dyspnea (pulmonary); abdominal bloating or bloody diarrhea (gastrointestinal)
Cardiovascular • Back pain that is described as "throbbing" • Back pain accompanied by leg pain that is relieved by standing still or rest • Back pain that is present in all spinal positions and increased by exertion • Back pain accompanied by a pulsating sensation or palpable abdominal pulse • Low back, pelvic, and/or leg pain with temperature changes from one leg to the other (involved side warmer: venous occlusion or tumor; involved side colder: arterial occlusion) • Back injury occurred during weight lifting in someone with known heart disease or past history of aneurysm
Pulmonary • Associated signs and symptoms (dyspnea, persistent cough, fever and chills) • Back pain aggravated by respiratory movements (deep breathing, laughing, coughing)
682
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
• Back pain relieved by breath holding or Valsalva maneuver • Autosplinting by lying on the involved side or holding firm pillow against the chest/abdomen decreases the pain • Spinal/trunk movements (e.g., trunk rotation, trunk side bending) do not reproduce symptoms (exception; an intercostal tear caused by forceful coughing from underlying diaphragmatic pleurisy can result in painful movement but is also reproduced by local palpation) • Weak and rapid pulse accompanied by fall in blood pressure (pneumothorax)
• Back pain associated with food or meals (increase or decrease in symptoms) • Back pain accompanied by heartburn or relieved by antacids • Associated signs and symptoms (dysphagia, odynophagia, melena, early satiety with weight loss, tenderness over McBurney's point, positive iliopsoas or obturator sign, bloody diarrhea) • Sacral pain occurs when the rectum is stimulated, such as during a bowel movement or when passing gas and relieved after each of these events
Renal/Urologic
Gynecologic
• Renal and urethral pain is felt throughout T9 to LI dermatomes; pain is constant but may crescendo (kidney stones) • Kidney pain of an inflammatory nature can be relieved by a change in position. However, renal colic (e.g., infection) remains unchanged by a change in position. But there are usually constitutional symptoms associated with either inflammation or infection to tip off the alert therapist. • Back pain at the level of the kidneys can be caused by ovarian or testicular cancer • Back pain and shoulder pain, either simultaneously or alternately, may be renalAirologic in origin • Side bending to the same side and pressure placed along the spine at that level is "more comfortable;" pain may be reduced, but it is not eliminated when the kidney is involved. The client with kidney disease/disorder may prefer this position because it moves the kidney out away from the spine and away from any compressive forces causing painful symptoms. • Associated signs and symptoms (blood in urine, fever, chills, increased urinary frequency, difficulty starting or continuing stream of urine, testicular pain in men) • Assess for costovertebral angle tenderness; pain is affected by change of position (pseudorenal pain) • History of traumatic fall, blow, lift (musculoskeletal)
Gastrointestinal • Back and abdominal pain at the same level (may occur simultaneously or alternately); check for gastrointestinal history or associated signs and symptoms • Back pain with abdominal pain at a lower level than the back pain; look for its source in the back
• History or current gynecologic disorder (e.g., uterine retroversion, ovarian cysts, uterine fibroids, endometriosis, pelvic inflammatory disease, sexual assault/incest, intrauterine contraceptive device, multiple births with prolonged labor or forceps use) • Associated signs and symptoms (missed or irregular menses, tender breasts, cyclic nausea and vomiting, chronic constipation, vaginal discharge, abnormal uterine bleeding or bleeding in a postmenopausal woman) • Low back and/or pelvic pain developing soon after a missed menstrual cycle; blood pressure may be significantly low, and there may be concomitant shoulder pain when hemorrhaging occurs (ectopic pregnancy) • Low back and/or pelvic pain occurring intermittently but with regularity in response to menstrual cycle (e.g., ovulation around days 10 to 14 and onset of menses around days 23 to 28)
Nonorganic Chapter 3)
(Psychogenic)
(see
discussion,
• Widespread, nonanatomic low back tenderness with overreaction to superficial palpation • Assess for nonorganic signs such as axial loading (downward pressure on the top of the head) or shoulder-hip rotation (client rotates shoulder and hips with feet planted); Waddell's nonorganic signs (see Table 3-12) • Regional (whole leg) pain, numbness, weakness, sensory disturbances • Chronic use of (or demand for) narcotics
Pediatrics • Children presenting with back pain are very different from adults with the same problem; children are less likely than adults to report
CHAPTER 14
SCREENING THE HEAD, NECK, A N D BACK
symptoms when there is no organic cause for the complaint • Eighty-five percent (85%) of children with back pain lasting more than 2 months have a diagnosable lesion 73
683
• Children with persistent reports of low back pain must be evaluated and reevaluated until a diagnosis is reached; X-rays and laboratory values are needed
74
Angina
Myocardial Infarction
Aortic Aneurysm Esophagus Liver Gallbladder Common bile duct
Pancreas-
Stomach Duodenum
Small intestine Colon
Pleuropulmonary Pain can occur anywhere over the affected lung fields (not shown)
Renal/Urologic
Gastrointestinal
F i g . 1 4 - 7 • Composite picture of referred back p a i n patterns. N o t pictured: gynecologic p a i n patterns.
684
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
KEY POINTS TO REMEMBER •
•
Clients m a y i n a c c u r a t e l y a t t r i b u t e s y m p t o m s to a p a r t i c -
if t h e y persist b e y o n d the e x p e c t e d t i m e for the n a t u r e o f the i n j u r y , m e d i c a l r e f e r r a l m a y b e i n d i c a t e d .
At presentation, a n y person w i t h musculoskeletal p a i n past medical
o r n e u r o m u s c u l o s k e l e t a l p a t t e r n s h o u l d serve a s r e d f l a g
Q u e s t i o n s f o r M e n a n d W o m e n m a y b e h e l p f u l i n this
warnings. •
•
•
musculoskeletal
B a c k a c h e m a y b e the e a r l i e s t a n d o n l y m a n i f e s t a t i o n o f
elsewhere. •
5 0
referring
the client
P o s t o p e r a t i v e i n f e c t i o n o f a n y k i n d m a y not a p p e a r w i t h
•
M u s c l e w e a k n e s s w i t h o u t p a i n , w i t h o u t h i s t o r y o f sciati c a , a n d w i t h o u t a positive s t r a i g h t leg r a i s i n g is s u g -
in children but c o m m o n in adults.
gestive o f s p i n a l metastases.
5 0
C h i l d r e n , a d o l e s c e n t s , a n d e s p e c i a l l y athletes r e p o r t i n g
presentation.
•
femur. •
7 5
L u m b a r s p a s m ( n o t h y p e r t o n u s ) m a y o c c u r i n the p r e s renal
t u m o r s , abscesses,
lymphoma)
appendicitis,
•
U r i n a r y incontinence concomitant with cervical
spine
possible medical referral. •
A n t e r i o r neck p a i n , m o v e m e n t d y s f u n c t i o n , a n d t o r t i c o l lis of the s t e r n o c l e i d o m a s t o i d muscle m a y be a sign of
Back p a i n a c c o m p a n i e d b y recent h i s t o r y o f i n f e c t i o n
underlying thyroid involvement.
( e s p e c i a l l y u r i n a r y t r a c t i n f e c t i o n ) o r i n the p r e s e n c e o f c o n s t i t u t i o n a l s y m p t o m s ( e . g . , fever, c h i l l s , n a u s e a ; see
Back p a i n m a y be a s y m p t o m of d e p r e s s i o n . p a i n requires a neurologic screening examination a n d
k i d n e y stones,
5 0
S c i a t i c a m a y be the first s y m p t o m of p r o s t a t e c a n c e r m e t a s t a s i z e d t o the b o n e s o f the pelvis, l u m b a r s p i n e , o r
e n c e o f severe p a i n f r o m r e t r o p e r i t o n e a l diseases ( e . g . ,
•
before
Persistent b a c k a c h e d u e to e x t r a s p i n a l p a t h o l o g y is r a r e
m e d i c a l r e f e r r a l , d e p e n d i n g o n the h i s t o r y a n d c l i n i c a l
•
symptoms
a n y clinical signs/symptoms for weeks or months.
N e c k o r b a c k p a i n i n the p r e s e n c e o f n o r m a l r a n g e o f
back pain of more than 3 weeks duration m a y need
•
A l w a y s rule o u t t r i g g e r points as a possible cause of
p a i n , e s p e c i a l l y w o m e n w i t h a h i s t o r y o f cancer.
m o t i o n a n d strength i s a y e l l o w f l a g s y m p t o m . •
q u e s t i o n s t o screen f o r m e d i c a l disease a r e i n d i c a t e d .
5 0
Perform a breast e x a m on a n y w o m a n w i t h upper back
W h e n symptoms cannot be reproduced, aggravated, or a l t e r e d i n a n y w a y d u r i n g the e x a m i n a t i o n , a d d i t i o n a l
C o n s i d e r v i s c e r a l o r i g i n o f b a c k p a i n i n the a b s e n c e o f
visceral d i s e a s e . •
Pain t h a t is u n r e l i e v e d by rest or c h a n g e in p o s i t i o n or p a i n / s y m p t o m s that d o not fit the e x p e c t e d m e c h a n i c a l
cancer should be screened for medical disease. Special
muscular spasm, tenderness, a n d i m p a i r e d m o v e m e n t .
•
•
history of
screening process.
•
W h e n s y m p t o m s seem o u t o f p r o p o r t i o n t o the i n j u r y , o r
causative factors. of u n k n o w n cause a n d / o r a
•
•
u l a r i n c i d e n t o r activity, o r t h e y m a y fail t o r e c o g n i z e
•
The t h e r a p i s t m a y n e e d to screen f o r illness b e h a v i o r
B o x 1 -3) must be s c r e e n e d m o r e c a r e f u l l y .
a n d the n e e d f o r p s y c h o l o g i c e v a l u a t i o n . M a n y clients
N o n p a i n f u l p a r e s t h e s i a s c a n b e the result o f n e u r a l c o m -
w i t h chronic back pain have both a physical problem
pression but also occur f r o m ischemia (atherosclerosis,
and
t u m o r , p r o d r o m a l sign o f a m i g r a i n e h e a d a c h e ) ; p a i n f u l
b e h a v i o r a l sign o r s y m p t o m m a y b e n o r m a l ; m u l t i p l e
varying
p a r e s t h e s i a s a r e m o r e likely i n d i c a t i v e o f a n i n f l a m m a -
findings
t o r y or m e c h a n i c a l process.
significant.'
of
degrees several
of
illness
different
behavior.
kinds
are
A
much
single more
CHAPTER 14
SUBJECTIVE
SCREENING THE HEAD, NECK, A N D BACK
685
EXAMINATION
Special Questions to A s k ;
Headache
See Appendix C-4 for a complete pain assessment. History
• Do other family members have similar headaches? • What major life changes or stressors have you had in the last six months? • Have you ever had a head injury? Cancer of any kind? A hysterectomy? High blood pressure? A stroke? Seizures? • Have you been hit or kicked in the head, neck, or face? Pushed against a wall or other object? Pulled or thrown by the hair? • For women of childbearing age: Is it possible you are pregnant? Site
• Where do you feel the headache? Can you point to it with one finger (localized vs. diffuse)? Does it move? Onset
• Do you recall your first headache of this type? • Was it caused by a fall or trauma? (Therapist may have to screen for trauma associated with domestic violence as a potential cause) Frequency
• How often do you have this type of headache? Intensity
• On a scale from 0 (no pain) to 10 (worst pain), how would you rate your headache now? Worst it has been? • Does the pain keep you from your daily activities? From exercise or recreation? From work? Duration
• How long do your headaches last? Description
• What do your headaches feel like? (The client may have more than one type of headache.) • Alternate question: What words would you use to describe the pain? Pattern
• Is there a pattern to your headaches (e.g., weekly? Monthly? Morning to evening?) • Do you wake up in the early morning hours with a headache? (occipital pain: hypertension)
• For women who are perimenopausal or menopausal (natural or surgically induced): Are the headaches cyclical? (Monthly? Right before or right after the menstrual flow?) Aggravating
Factors
• What makes the headache worse? • Are you aware of any triggers that can bring the headache on? (Alcohol, noise, lights, food, coughing or sneezing, fatigue or lack of sleep, stress, caffeine withdrawal; for women: menstrual cycle) • Do you grind your teeth during the day or at night? —If yes, assessment of the cervical spine and temporomandibular joints is indicated. Referral to a dentist may be required. • Are you taking any medications? (Headache can be a side effect of many different medications, but especially NSAIDs, muscle relaxants, antianxiety and antidepressant agents, food and drugs containing nitrates, calcium, and beta blockers.) Relieving Factors
• Is there anything you can do to make the headache better? —If yes, how? (caffeine, medications, sleep, avoid certain foods, alcohol, cigarettes) [Ask follow up questions about use of over-thecounter or prescription drugs and/or herbs or pharmaceuticals.] How does rest affect your symptoms? Associated
Symptoms
• Do you have any symptoms of any kind anywhere else in your head or body? (Follow up with questions about vision changes, dizziness, ringing in the ears, mood changes, nausea, vomiting, nasal congestion, nose bleeds, light or sound sensitivity, paresthesias such as numbness and tingling of the face or fingers, difficulty swallowing, hoarseness, fever, chills.) For t h e t h e r a p i s t
• Take the client's blood pressure and pulse and assess for cardiovascular risk factors. • Auscultate for bruits in the temporal and carotid arteries (temporal arteritis, carotid stenosis). • Headaches that cannot be linked to a neuromuscular or musculoskeletal cause (e.g., dys-
686
SECTION III
SUBJECTIVE
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
EXAMINATION —cont'd
function of the cervical spine, thoracic spine, or temporomandibular joints; muscle tension, poor posture, nerve impingement) may need further medical referral and evaluation. Special Questions to Ask:
Neck or Back
To the therapist: If a more complete screening interview is required, see Special Questions to Ask at the end of each chapter for further questions related to the individual organ systems. P a i n A s s e s s m e n t (See also Appendix C-4) • When did the pain or symptoms start? • Did it (they) start gradually or suddenly? (Vascular versus trauma problem) • Was there an illness or injury before the onset of pain? • Have you noticed any changes in your symptoms since they first started to the present time? • Is the pain aggravated or relieved by coughing or sneezing? (Nerve root involvement, muscular) • Is the pain aggravated or relieved by activity? • Are there any particular positions (sitting, lying, standing) that make your back pain feel better or worse? • Does the pain go down the leg? If so, how far does it go? • Have you noticed any muscular weakness? • Have you been treated previously for back disorders? • How has your general health been both before the beginning of your back problem and today? • How does rest affect the pain or symptoms? • Do you feel worse in the morning or evening . . . OR . . . What difference do you notice in your symptoms from the morning when you first wake up until the evening when you go to bed? General Systemic
Most of these questions may be asked of clients who have pain or symptoms anywhere in the musculoskeletal system. • Have you ever been told that you have osteoporosis or brittle bones? • Have you ever fractured your spine? • Have you ever been diagnosed or treated for cancer in any part of your body?
If no, have you ever had chemotherapy or radiation therapy for anything? (Rectal bleeding is a sign of radiation proctitis.) • Do you ever notice sweating, nausea, or chest pains when your current symptoms occur? • What other symptoms have you had with this problem? For example, have you had: Numbness Burning, tingling Nausea, vomiting Loss of appetite Unexpected or significant weight gain or loss Diarrhea, constipation, blood in your stool or urine Difficulty in starting or continuing the flow of urine or incontinence (inability to hold your urine) Hoarseness or difficulty in swallowing Heart palpitations or fluttering Difficulty in breathing while just sitting or resting or with mild effort (e.g., when walking from the car to the house) Unexplained sweating or perspiration Night sweats, fever, chills Changes in vision: blurred vision, black spots, double vision, temporary blindness Fatigue, weakness, sudden paralysis of one side of your body, arm, or leg (Transient ischemic attack) Headaches Dizziness or fainting spells • Have you had a recent cold, sore throat, upper respiratory infection, or the flu? Have you ever been diagnosed with HIV? Cardiovascular
• Have you ever been told you have high blood pressure or heart trouble? • Do you ever have chest pain or discomfort when your back hurts or just before your back starts hurting? • Do you ever have swollen feet or ankles? If yes, are they swollen when you get up in the morning? (Edema/congestive heart failure) • Do you ever get cramps in your legs if you walk for several blocks? (Intermittent claudication) • Do you ever have bouts of rapid heart action, irregular heartbeats, or palpitations of your heart? • Have you ever felt a "heartbeat" in your abdomen when you lie down?
CHAPTER 14
SUBJECTIVE
SCREENING THE HEAD, NECK, A N D BACK
687
EXAMINATION —cont'd
—If yes, is this associated with low back pain or left flank pain? (Abdominal aneurysm) • Do you ever notice sweating, nausea, or chest pain when your current symptoms (e.g., head, neck, jaw, back pain) occur? Pulmonary
• Are you able to take a deep breath? • Do you ever have shortness of breath or breathlessness with your back pain? —How far can you walk before you feel breathless? —What symptoms stop your walking (e.g., shortness of breath, heart pounding, chest tightness, or weak legs)? • Have you had any trouble with coughing lately? —If yes, have you strained your back from coughing? Renal/Urologic
• Have you noticed any changes in the flow of urine since your back/groin pain started? —If no, it may be necessary to provide prompts or examples of what changes you are referring to (e.g., difficulty in starting or continuing the flow of urine, numbness or tingling in the groin or pelvis, increased frequency, getting up at night) • Have you had burning with urination during the last 3 to 4 weeks? Fever and/or chills? • Do you ever have blood in your urine or notice blood in the toilet going to the bathroom? • Do you have any problems with your kidneys or bladder? If so, describe. • Have you ever had kidney or bladder stones? If so, how were these stones treated? • Have you ever had an injury to your bladder or to your kidneys? If so, how was this treated? • Have you had any infections of the bladder, and how were these infections treated? —Were they related to any specific circumstances (e.g., pregnancy, intercourse)? • Have you had any kidney infections, and how were these treated? —Were they related to any specific circumstances (e.g., pregnancy, after bladder infections, a strep throat, or strep skin infections)? • Do you ever have pain, discomfort, or a burning sensation when you urinate? (Lower urinary tract irritation) • Have you noticed any changes in color or blood in your urine?
Gastrointestinal
• Are you having any stomach or abdominal pain either at the same time as the back pain or at other times? —If yes, assess the location and the presence of any GI symptoms. • Have you noticed any association between when you eat and when your symptoms increase or decrease? —Do you notice any change in your symptoms 1 to 3 hours after you eat? —Do you notice any pain beneath the breastbone (epigastric) or just beneath the wing bone (subscapular) 1 to 2 hours after eating? • Do you have a feeling of fullness after only one or two bites of food? (Early satiety) • Is your back pain relieved after having a bowel movement? (Gastrointestinal obstruction) • Do you have rectal, low back, or sacroiliac pain when passing stool or having a bowel movement? • Do you have any blood in your stools or change in the normal color of your bowel movements (e.g., black, red, mahogany color, gray color)? (Hemorrhoids, prostate problems, cancer) • Are you having any diarrhea, constipation, or other changes in your bowel function? • Do you have frequent heartburn or take antacids to relieve heartburn or acid indigestion? • Have you had any skin rashes or skin lesions in the last 6 weeks (Regional enteritis or Crohn's disease) To the therapist: It may be necessary to conduct a risk factor assessment for NSAIDinduced back pain (see discussion Chapter 8) or screen for eating disorders (see Appendix B-12) Special Questions to A s k : Sexual
History
There are a wide range of reasons why it may be necessary to ask questions about sexual function, birth control, and sexually transmitted diseases. For example, joint pain can be caused by sexually transmitted infections. Low back, sacral, and pelvic pain can be caused by sexual trauma or sexual violence. Sciatica accompanied by unreported impotence can be caused by prostate cancer metastasized to the skeletal system. Whenever taking a sexual history seems appropriate, remember to offer your clients a clear explanation for any questions asked concerning sexual activity, sexual function, or sexual history. The therapist may want to introduce the series of
688
SECTION III
SUBJECTIVE
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
EXAMINATION —cont'd
questions by saying, "When evaluating low back pain sometimes it's necessary to ask some more personal questions. Please answer as accurately as you can." The personal nature of some questions sometimes leads clients to feel embarrassed. It is important to assure them they will not be judged and that providing accurate information is crucial to providing good care. Investing in good history taking can lead to early detection and early treatment with less morbidity and better outcomes. Try to avoid medical terminology and jargon—a common pitfall among healthcare providers when they feel embarrassed. Listen to the words the clients use to describe sexual activities and practices and then use their preferred words when appropriate. Men who have sex with men may identify themselves as homosexual, bisexual, or heterosexual. No matter what label is used, these men are at increased risk for sexually transmitted diseases (STDs) as well as psychologic and behavioral disorders, drug abuse, and eating disorders. Avoid terms such as "gay," "queer," and "straight" when talking about sexual practices or sexual identity. There is no way to know when someone will be offended or claim sexual harassment. It is in your own interest to behave in the most professional manner possible. There should be no hint of sexual innuendo or humor injected into any of your conversations with clients at any time. The line of sexual impropriety lies where the complainant draws it and includes appearances of misbehavior. This perception differs broadly from client to client. It is also true that clients sometimes behave inappropriately; there may be times when the therapist must remind clients of appropriate personal boundaries. At the same time, the therapist must be prepared to hear just about anything if and when it is necessary to ask questions about sexual history or sexual practices. Be aware of your facial expressions, body language, and verbal remarks in response to a client's answers to these questions. What if a man or woman with pelvic or sacral pain tells you he or she has been the victim of repeated violent sexual acts? What if a client admits to being the victim of physical or emotional assault? The therapist must be prepared to respond in a professional and responsible way. Additional training in this area may be helpful. Many local organizations such as Planned Parent76
77
50
hood, Lambda Alliance, and AIDS Council may offer helpful information and/or training. The therapist may want to introduce the series of questions by saying, "When evaluating low back pain sometimes it's necessary to ask some more personal questions. Please answer as accurately as you can." • Are you sexually active? Follow up question: How does sexual activity affect your symptoms? "Sexually active" does not necessarily mean engaging in sexual intercourse. Sexual touch is enough to transmit many sexually transmitted infections. You may have to explain this to your client to clarify this question. Oral and anal intercourse are often not viewed as "sexual intercourse" and will result in the client answering the question with "No" when, in fact, for screening purposes, the answer is "Yes." • Do you have pain with certain positions? (e.g., For the therapist: a position with the woman on top can be more difficult with prolapsed uterus; the penis or other object touching inflamed cervix also can cause pain) • Have you had more than one sexual partner? (increases risk of sexually transmitted diseases) • Have you ever been told you have a sexually transmitted infection or disease such as herpes, genital warts, Reiter's disease, syphilis, "the clap," chlamydia, gonorrhea, venereal, HIV or other disease? • Have you ever had sexual intercourse without wanting to? Alternate: Have you ever been raped? • Do you have any blood in your urine or your stools? Alternate question: Do you have any bleeding when you go to the bathroom? • What do you think could be causing this? • If yes, do you have a history of hemorrhoids? Special Questions to Ask: W o m e n Experiencing Back, H i p , Pelvic, G r o i n , S a c r o i l i a c (SI), o r S a c r a l P a i n
Not all these questions will need to be asked. Use your professional judgment to decide what to ask based on what the woman has told you and what you have observed during the examination.
CHAPTER 14
SUBJECTIVE
SCREENING THE HEAD, NECK, A N D BACK
EXAMINATION —cont'd
Past M e d i c a l H i s t o r y
Have you ever been told that you have: • Retroversion of the uterus (tipped back) • Ovarian cysts • Fibroids or tumors • Endometriosis • Cystocele (sagging bladder) • Rectocele (sagging rectum) • Pelvic inflammatory disease (PID)? • Have you had vaginal surgery or a hysterectomy? (Hysterectomy: joint pain and myalgias may occur; vaginal surgery: incontinence) • Have you had a recent history of bladder or kidney infections? (Referred back pain) • Have you ever been told you have "brittle bones" or osteoporosis? • Have you ever had a compression fracture of your back? Menstrual
689
History
A menstrual history may be helpful when evaluating back or shoulder pain of unknown cause in a woman of reproductive age. Not all these questions will need to be asked. Use your professional judgment to decide what to ask based on what the woman has told you and what you have observed during the examination. • Is there any connection between your (back, hip, sacroiliac) pain/symptoms and your menstrual cycle (related to either ovulation, midcycle, or menses)? • Since your back/sacroiliac (or other) pain/ symptoms started, have you seen a gynecologist to rule out any gynecologic cause of this problem? • Where were you in your menstrual cycle when your injury or illness occurred? • Where are you in your menstrual cycle today (premenstrual/midmenstrual/postmenstrual)? (Appropriate question for shoulder or back pain of unknown cause) • Please describe any other menstrual irregularity or problems not already discussed. For t h e Y o u n g F e m a l e A d o l e s c e n t / A t h l e t e
• Have you ever had a menstrual period? If yes, do you have a menstrual period every month? (amenorrhea or irregular cycles can be a natural part of development but also the result of an eating disorder)
• Have you ever gone 3 months without having a period? • Do your periods change with your training regimen? • If yes, please describe. • Are you taking birth control pills or using a patch or injection? • If yes, are you using them for birth control, to regulate your menstrual cycle, or both? (Assess risk factors and monitor blood pressure.) • How long have you been on birth control? • When was the last time you saw the doctor who prescribed birth control for you? • Please describe any other menstrual irregularity or problems not already discussed. Reproductive
History
• Is there any possibility you could be pregnant? • Was your last period normal for you? • What form of birth control are you using? (If the client is using birth control pills, patches, or injections check her blood pressure.) • Do you have an intrauterine coil or loop contraceptive device (IUD or IUCD)? (PID and ectopic pregnancy can occur.) • For the pregnant woman: Are you under the care of a physician? Have you had any spotting or bleeding during your pregnancy? • Have you recently had a baby? (Birth trauma) If yes: Did you have an epidural (anesthesia)? (Postpartum back pain) If yes, Did you have any significant medical problem during your pregnancy or delivery? • Have you ever had a tubal or ectopic pregnancy? Is it possible that you may be pregnant now? • How many pregnancies have you had? • How many live births have you had? • Have you ever had an abortion or miscarriage? If yes, follow up with careful (sensitive) questions about how many, when, where, and any immediate or delayed complications (physical or psychologic). (Weakness secondary to blood loss, infection, scarring; blood in peritoneum irritating diaphragm causing lumbar and/or shoulder pain); ask about the onset of symptoms in relation to the incident. • Do you ever experience a "falling out" feeling or pelvic heaviness after standing for a long time? (Uterine prolapse; pelvic floor weakness; incontinence)
690
SECTION III
SUBJECTIVE
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
EXAMINATION —cont'd
• Do you ever leak urine with coughing, laughing, lifting, exercising, or sneezing? (Stress incontinence; tension myalgia of pelvic floor) If yes to incontinence: Ask several additional questions to determine the frequency, the amount of protection needed (as measured by the number and type of pads used daily), and how much this problem interferes with daily activities and lifestyle. See also Appendix B-5. • Do you have an unusual amount of vaginal discharge or vaginal discharge with an obvious odor? (Referred back pain) If yes, do you know what is causing this discharge? Is there any connection between when the discharge started and when you first noticed your back/sacroiliac (or other) symptoms? • For the postmenopausal woman: Are you taking hormone replacement therapy (HRT) or any natural hormone products? Special Questions to A s k : M e n Experiencing Back, H i p , Pelvic, G r o i n , or Sacroiliac Pain
• Have you ever had prostate problems or been told you have prostate problems? • Have you ever been told you have a hernia? Do you think you have one now? If yes, follow up with medical referral. Strangulation of the bowel can lead to serious compli-
cations. If the client has been evaluated by a physician and has declined treatment (usually surgery), encourage him to follow up on this recommendation. • Have you recently had kidney stones, bladder or kidney infections? • Have you had any changes in urination recently? • Do you ever have blood in your urine? • Do you ever have pain, burning, or discomfort on urination? • Do you urinate often, especially during the night? • Can you easily start a flow of urine? • Can you keep a steady stream without stopping and starting? • When you are done urinating, does it feel like your bladder is empty or do you feel like you still have to go, but you can't get any more out? • Do you ever dribble or leak urine? • Do you have trouble getting an erection? • Do you have trouble keeping an erection? • Do you have trouble ejaculating? (Therapists beware; this term may not be understood by all clients.) • Any unusual discharge from your penis? To the therapist: If the client is having difficulty with sexual function, it may be necessary to conduct a screening examination for bladder or prostate involvement. See Appendix B-5.
CHAPTER 14
CASE
STUDY:
STEPS
IN
SCREENING THE HEAD, NECK, A N D BACK
THE
REFERRAL
A 47-year-old man with low back pain of unknown cause has come to you for exercises. After gathering information from the client's history and conducting the interview, you ask him: Follow-Up
Questions
• Are there any other symptoms of any kind anywhere else in your body? The client tells you he does break out into an unexpected sweat from time to time, but does not think he has a temperature when this happens. He has increased back pain when he passes gas or a bowel movement, but then the pain goes back to the "regular" pain level [reported as 5 on a scale from 0 to 10]. Other reported symptoms include • Heartburn and indigestion • Abdominal bloating after meals • Chronic bronchitis from smoking [3 packs/day] • Alternating diarrhea and constipation Use the list of signs and symptoms in Box 4-17 to review this case. Do these symptoms fall into any one category? It appears that many of the symptoms may be gastrointestinal in nature. What is the next step in the screening process? Since the client has mentioned unexplained sweating but no known fevers, take the time to measure all vital signs, especially body temperature. Turn to Special Questions to Ask at the end of Chapter 8 and scan the list of questions for any that might be appropriate for this client. For example, find out about the use of nonsteroidal antiinflammatories (prescription and overthe-counter; be sure to include aspirin). Follow up with:
SCREENING Follow-Up
691
PROCESS
Questions
• Have you ever been treated for an ulcer or internal bleeding while taking any of these pain relievers? • Have you experienced any unexpected weight loss in the last few weeks? • Have you traveled outside the United States in the last year? • What is the effect of eating or drinking on your abdominal pain? Back pain? • Have the client pay attention to his symptoms over the next 24 to 48 hours: —Immediately after eating —Within 30 minutes of eating —One to two hours later • Do you have a sense of urgency so that you have to find a bathroom for a bowel movement or diarrhea right away without waiting? Ask any further questions that may be appropriate as listed in this chapter or from the more complete Special Questions to Ask section of Chapter 8 (see the subsection: Associated Signs and Symptoms: Change in bowel habits). You will make your decision to refer this client to a physician depending on your findings from the clinical examination and the client's responses to these questions. Use the Quick Screen Checklist in Appendix A-1 to see if you have left anything out that might be important. This does not appear to be an emergency since the client is not in acute distress. An elevated temperature or other unusual vital signs might speed the referral process along.
692
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
PRACTICE QUESTIONS 1. The most common sites of referred pain from systemic diseases are: a. Neck and back b. Shoulder and back c. Chest and back d. None of the above 2. To screen for back pain caused by systemic disease: a. Perform special tests (e.g., Murphy's percussion, Bike test) b. Correlate client history with clinical presentation and ask about associated signs and symptoms c. Perform a Review of Systems d. All of the above 3. What are two ways of classifying back pain (as presented in the text)? 4. Which statement is the most accurate? a. Arterial disease is characterized by intermittent claudication, pain relieved by elevating the extremity, and history of smoking. b. Arterial disease is characterized by loss of hair on the lower extremities, throbbing pain in the calf muscles that goes away by using heat and elevation. c. Arterial disease is characterized by painful throbbing of the feet at night that goes away by dangling the feet over the bed. d. Arterial disease is characterized by loss of hair on the toes, intermittent claudication, and redness or warmth of the legs that is accompanied by a burning sensation. 5. Pain associated with pleuropulmonary disorders can radiate to: a. Anterior neck b. Upper trapezius muscle c. Ipsilateral shoulder d. Thoracic spine e. All of the above 6. Which of the following are clues to the possible involvement of the GI system? a. Abdominal pain alternating with TMJ pain within a 2-week period of time b. Abdominal pain at the same level as back pain occurring either simultaneously or alternately c. Shoulder pain alleviated by a bowel movement d. All of the above 7. Percussion of the costovertebral angle resulting in the reproduction of symptoms signifies:
a. Radiculitis b. Pseudorenal pain c. Has no significance d. Medical referral is advised 8. A 53-year-old woman comes to physical therapy with a report of leg pain that begins in her buttocks and goes all the way down to her toes. If this pain is of a vascular origin she will most likely describe it as a. Sore, hurting b. Hot or burning c. Shooting or stabbing d. Throbbing, "tired" 9. Twenty-five percent of the people with GI disease such as Crohn's disease (regional enteritis), irritable bowel syndrome, or bowel obstruction have concomitant back or joint pain. a. True b. False 1 0 . Skin pain over T9 to T12 can occur with kidney disease as a result of multisegmental innervation. Visceral and cutaneous sensory fibers enter the spinal cord close to each other and converge on the same neurons. When visceral pain fibers are stimulated, cutaneous fibers are stimulated, too. Thus, visceral pain can be perceived as skin pain. a. True b. False 1 1 . Autosplinting is the preferred mechanism of pain relief for back pain caused by kidney stones. a. True b. False 1 2 . Back pain from pancreatic disease occurs when the body of the pancreas is enlarged, inflamed, obstructed or otherwise impinging on the diaphragm. a. True b. False 1 3 . A 53-year-old postmenopausal woman with a history of breast cancer 5 years ago with mastectomy presents with a report of sharp pain in her midback. The pain started after she lifted her 2-year-old granddaughter 3 days ago. Tylenol seems to help but the pain is keeping her awake at night. Once she wakes up, she cannot find a comfortable position to go back to sleep. What are the red flags? What will you do to screen for a medical cause of her symptoms?
CHAPTER 14
REFERENCES 1. Waddell G: The back pain revolution, ed 2, Edinburgh, 2004, Churchill Livingstone. 2. Jette AM, Davis KD: A comparison of hospital-based and private outpatient physical therapy practices, Phys Ther 71(5):366-381, 1991. 3. Jette AM, Smith K, Haley SM et al: Physical therapy episodes of care for patients with low back pain, Physical Therapy 74(2):101-115, 1994. 4. Freburger JK, Carey TS, Holmes GM: Management of back and neck pain: who seeks care from physical therapists? Physical Therapy 85(9):872-886, 2005. 5. Bernard TN Jr, Kirkaldy-Willis WH: Recognizing specific characteristics of nonspecific low back pain, Clin Orthop 217:266-280, 1987. 6. Shaw JA: The role of the sacroiliac joint as a cause of low back pain and dysfunction. In Vleeming A, Mooney V, Snijders C, et al, editors: The First Interdisciplinary World Congress on low back pain and its relation to the sacroiliac joint, Rotterdam, the Netherlands, 1992, ECO; pp 67-80. 7. Kim DH, Hilibrand AS: Rheumatoid arthritis in the cervical spine, J Am Acad Orthop Surg 13(7):463-474, 2005. 8. Boissonnault WG, Koopmeiners MB: Medical history profile: orthopaedic physical therapy outpatients, JOSPT 20:2-10, 1994. 9. Boissonault WG: Prevalence of comorbid conditions, surgeries, and medication use in a physical therapy outpatient population: a multi-centered study, JOSPT 29:506-519; discussion 520-525, 1999. 10. Boissonnault WG, Meek PD: Risk factors for antiinflammatory drug or aspirin induced gastrointestinal complications in individuals receiving outpatient physical therapy services, JOSPT 32:510-517, 2002. 11. Biederman RE: Pharmacology in rehabilitation: nonsteroidal antiinflammatory agents, JOSPT 35:356-367, 2005. 12. Bishop PB, Wing PC: Compliance with clinical practice guidelines in family physicians managing worker's compensation board patients with acute lower back pain, Spine Journal 3(6):442-450, 2003. 13. Leon-Diaz A, Gonzalez-Rabelino G, Alonso-Cervino M: Analysis of the etiologies of headaches in a pediatric emergency service, Rev Neurol 39(3):217-221, 1-15, 2004. 14. Olesen J, Steiner TJ: The international classification of headache disorders, ed 2 (ICDH-II), J Neurol Neurosurg Psychiatry 75(6):808-811, 2004. 15. Silberstein SD, Olesen J, Bousser MG, et al: The international classification of headache disorders, ed 2 (ICHD-II)— revision of criteria for 8.2 medication overuse headache, Cephalalgia 25(6):460-465, 2005. 16. Headache Classification Committee of the International Headache Society: Classification and diagnostic criteria for headache disorders, cranial neuralgias, and facial pain, Cephalalgia 8(Suppl 7): 1-96, 1988. 17. Headache Classification Committee of the International Headache Society: Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain, ed 2 (revised), Cephalalgia 25(12):460-465, 2004. 18. Petersen SM: Articular and muscular impairments in cervicogenic headache, JOSPT 33(l):21-30, 2003. 19. Agostoni E: Headache in cerebral venous thrombosis, Neurol Sci 25(Suppl 3):S206-S210, 2004. 20. Jacobson SA, Folstein MF: Psychiatric perspectives on headache and facial pain, Otolaryngol Clin North Am 36(6):1187-1200, 2003. 21. Hering-Hanit R, Gadoth N: Caffeine-induced headache in children and adolescents, Cephalalgia 23(5):332-335, 2003. 22. Ryan LM, Warden DL: Post concussion syndrome, Int Rev Psychiatry 15(4):310-316, 2003. 23. Phillips E, Levine AM: Metastatic lesions of the upper cervical spine, Spine 14(10):1071-1077, 1989.
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24. O'Reilly MB: Nonresectable head and neck cancer, Rehab Oncology 22(2):14-16, 2004. 25. Neville BW, Day TA: Oral cancer and precancerous lesions, CA J Clin 52(4): 195-215, 2002. 26. Purdy RA, Kirby S: Headaches and brain tumors, Neurol Clin 22(l):39-53, 2004. 27. Narin SO, Pinar L, Erbas D, et al: The effects of exercise and exercise-related changes in blood nitric oxide level on migraine headache, Clin Rehabil 17(6):624-630, 2003. 28. Sandor PS, Afra J: Nonpharmacologic treatment of migraine, Curr Pain Headache Rep 9(3):202-205, 2005. 29. Biondi DM: Physical treatments for headache: a structured review, Headache 45(6):738-746, 2005. 30. Gorski JM, Schwartz LH: Shoulder impingement presenting as neck pain, JBJS 85-A(4):635-638, 2003. 31. Slipman CW, Issac Z, Patel R, et al: Chronic neck pain: the specific syndromes, J Musculoskel Med 20(l):24-33, 2003. 32. Koopmeiners MB: Personal communication, 2003. 33. Boissonnault WG: Personal communication, 2003. 34. Hartvigsen J, Christensen K, Frederiksen H: Back pain remains a common symptom in old age. A population-based study of 4,486 Danish twins aged 70-102, Eur Spine J 12(5):528-534, 2003. 35. O'Neill CW, Kurgansky ME, Derby R, et al: Disc stimulation and patterns of referred pain, Spine 27(24):2776-2781, 2002. 36. Bogduk N: Evidence-based clinical guidelines for the management of acute low back pain, The National Musculoskeletal Medicine Initiative, 2002. Available online: http://www.emia.com.au/MedicalProviders/Evidence BasedMedicine/afmm/chl.html. Accessed September 15, 2005. 37. Kauppila LI, McAlindon T, Evans S, et al: Disc degeneration/back pain and calcification of the abdominal aorta. A 25-year follow-up study in Framingham, Spine 22:16421647, 1997. 38. Bingol H, Cingoz F, Yilmaz AT et al: Vascular complications related to lumbar disc surgery, J Neurosurg: Spine 100(3):249-253, 2004. 39. Kauppila LI, Mikkonen R, Mankinen P, et al: MR aortography and serum cholesterol levels in patients with longterm nonspecific lower back pain, Spine 29(19):2147-2152, 2004. 40. Seeman E: The dilemma of osteoporosis in men, Am J Med 98(2A):765S-88S, 1995. 41. Orwoll ES, Klein RF: Osteoporosis in men, Endocr Rev 16:87-116, 1995. 42. Blain H: Osteoporosis in men: epidemiology, physiopathology, diagnosis, prevention, and treatment, Rev Med Interne 25(Suppl 5):S552-S559, 2005. 43. Silverman SL: The clinical consequences of vertebral compression fracture, Bone 13:S27-S31, 1992. 44. Hoogendoorn WE, van Poppel MN, Bongers PM, et al: Systematic review of psychosocial factors at work and private life as risk factors for back pain, Spine 25: 2114-2125, 2000. 45. Marras WS, Davis KG, Heaney CA, et al: The influence of psychosocial stress, gender, and personality on mechanical loading of the lumbar spine, Spine 25(23):3045-3054, 2000. 46. Thorbjornsson CO, Alfredsson L, Fredriksson K, et al: Physical and psychosocial factors related to low back pain during a 24-year period, Occup Environ Med 55(2):84-90, 1998. 47. Kendall NAS, Linton SJ, Main CJ: Guide to assessing psychological yellow flags in acute low back pain: risk factors for long-term disability and work loss, Wellington, New Zealand, 1997, Accident Rehabilitation and Compensation Insurance Corporation of New Zealand and the National health Committee. 48. Borkan J, Van Tulder M, Reis S, et al: Advances in the field of low back pain in primary care. A report from the Fourth International Forum, Spine 27(5):E128-E132, 2002.
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49. Mazanec DJ, Segal AM, Sinks PB: Identification of malignancy in patients with back pain: red flags, Arthritis Rheum 36(suppl):S251-S258, 1993. 50. Rex L: Evaluation and treatment of somatovisceral dysfunction of the gastrointestinal system, Edmonds WA, 2004, URSA Foundation. 51. Deyo RA, Diehl AK: Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies, J Gen Intern Med 3(3):230-238, 1988. 52. Wong DA, Fornasier VL, MacNab I: Spinal metastases: the obvious, the occult, and the imposters, Spine 15(l):l-4, 1990. 53. Ross MD, Bayer E: Cancer as a cause of low back pain in a patient seen in a direct access physical therapy setting, JOSPT 35(10):651-658, 2005. 54. Fleming C, Whitlock EP, Beil TL, et al: Screening for abdominal aortic aneurysm: a best evidence systematic review for the U.S. Preventive Services Task Force, Ann Intern Med 142(3):203-211, 2005. 55. Herkowitz HN, editor: The spine, Philadelphia, 1999, WB Saunders. 56. Sex and Back Pain Video, Dixfleld, Maine, IMPACC, Inc. Available at: www.impaccusa.com. Accessed September 21, 2005. 57. Sex and Back Pain Patient Manual, Dixfield, Maine, IMPACC, Inc. Available at: www.impaccusa.com. Accessed September 21, 2005. 58. Padua L, Caliandro P, Aprile I, et al: Back pain in pregnancy, Eur Spine J 14(2):151-154, 2005. 59. Borg-Stein J, Dugan SA, Gruber J: Musculoskeletal aspects of pregnancy, Am J Phys Med Rehabil 84(3):180-192, 2005. 60. Pauls J: Physical therapy for women, PT Magazine 1(2):6467, 1993. 61. Deevey S: Endometriosis: Internet resources, Medical Ref Serv Quart 24(l):67-77, 2005. 62. Giudice LC, Kao LC: Endometriosis, The Lancet 364(9447):1789-1799, 2004. 63. Sinaii N, Cleary SD, Ballweg ML, et al: High rates of autoimmune and endocrine disorders, fibromyalgia, chronic
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69. 70. 71. 72. 73. 74. 75. 76. 77.
fatigue syndrome, and atopic diseases among women with endometriosis: a survey analysis, Hum Reprod 17(10):27152724, 2002. Svendsen PF, Nilas L, Norgaard K, et al: Polycystic ovary syndrome. New pathophysiological discoveries, Ugeskr Laeger 167(34):3147-3151, 2005. Dokras A, Bochner M, Hollinrake E, et al: Screening women with polycystic ovary syndrome for metabolic syndrome, Obstet Gynecol 106(1):131-137, 2005. Jemal A, Murray T, Ward E, et al: Cancer statistics 2005, CA A Cancer J Clin 55(l):10-30, 2005. Siddiqui E, Mumtaz FH, Gelister J: Understanding prostate cancer, J R Soc Health 124(5):219-221, 2004. Gelfand MS, Cleveland KO: Vancomycin therapy and the progression of methicillin-resistant Staphylococcus aureus vertebral osteomyelitis, South Med J 97(6):593-597, 2004. Patel RK, Everett CR: Low back pain: 20 clinical pearls, J Musculoskel Med 20(10):452-460, 2003. Asavasopon S, Jankoski J, Godges JJ: Clinical diagnosis of vertebrobasilar insufficiency: resident's case problem, JOSPT 35(10):645-650, 2005. Wiesel BB, Wiesel SW: Radiographic evaluation of low back pain: a cost-effective approach, J Musculoskel Med 21(10):528-538, 2004. Mazanec DJ: Recognizing malignancy in patients with low back pain, J Musculoskel Med 13(1):24-31, 1996. King H: Evaluating the child with back pain, Pediatric Clinics of North America 33(6):1489-1493, 1986. Behrman R, Kliegman RM, Arvin AM, editors: Nelson's textbook of pediatrics, ed 17, Philadelphia, 2004, WB Saunders. McTimoney CA, Micheli LJ: Managing back pain in young athletes, J Musculo Med 21(2):63-69, 2004. Goode B: Personal communication, Centers for Disease Control and Prevention, Raleigh, North Carolina, 2006. Knight D: Health care screening for men who have sex with men, Amer Fam Phys 69(9):2149-2156, 2004.
Screening the Sacrum, Sacroiliac, and Pelvis
F
ollowing the model for decision-making in the screening process outlined in Chapter 1 (see Box 1-7), we now turn our attention to pain from medical conditions, illnesses, and diseases referred to the sacrum, sacroiliac (SI), and pelvic regions. The basic premise is that physical therapists must be able to identify signs and symptoms of systemic origin that can mimic neuromuscular or musculoskeletal (neuromusculoskeletal, or NMS) dysfunction in these areas. In the screening process, therapists will watch for yellow (caution) or red (warning) flags to direct them. Clinicians rely on special questions to ask men and women with significant risk factors, significant past medical history, suspicious clinical presentation, or associated signs and symptoms. With a careful interview and the right screening questions, the therapist can identify clues suggestive of a problem outside the scope of a physical therapist's practice that may require medical referral. Specific tests to screen for an underlying infectious or inflammatory source of pelvic or abdominal pain are also presented with a suggested order of testing. When dealing with painful symptoms of the sacral and pelvic areas, the therapist may need to ask questions about sexual history or sexual practices. The therapist must remain aware of facial expressions, body language, and verbal remarks in response to a client's answers to these questions. The therapist must be prepared to respond in a professional and responsible way if a man or woman with pelvic or sacral pain reports that he or she has been the victim of repeated violent sexual acts, or if a client admits to physical or emotional assault. More about the client interview, the screening interview, and screening for assault and domestic (intimate partner) violence is included in Chapter 2 (see also Appendix B-29).
THE SACRUM AND SACROILIAC JOINT Evaluating the sacroiliac (SI) joint can be difficult in that no single physical examination finding can predict a disorder of the SI joint. Pain originating from the SI joint can mimic pain referred from lumbar disc herniation, spinal stenosis, facet joint dysfunction, or even a disorder of the hip. The most common clinical presentation of sacroiliac pain is associated with a memorable physical event that initiated the pain, such as a misstep off a curb, a fall on the hip or buttocks, lifting of a heavy object in a twisted position, or childbirth (Case Example 15-1). A history of previous spine surgery is very common in clients with SI intra-articular pain. The most typical systemic diseases that refer pain to the sacrum and sacroiliac joint include endocarditis, prostate cancer or other neoplasm, 1
1
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CASE
S E C T I O N III
EXAMPLE
15-1
SYSTEMIC ORIGINS OF PAIN A N D D Y S F U N C T I O N
Sacroiliac P a i n Caused by Pelvic F l o o r D y s f u n c t i o n
Background: A 33-year-old woman referred by her orthopedic surgeon presented with low back pain centered over the sacroiliac (SI) region. She described it as "sharp" and "knifelike." It comes and goes with no warning. Sometimes, it is so severe she cannot catch her breath and falls to her knees. After that, she cannot stand up straight for several hours and walks "hunched over." The pain presented on both sides intermittently, but the primary pain pattern was localized in the left SI area. Heat seems to help for a short time, but nothing brings complete relief all the time. She has a previous history of disc herniation with discectomy and laminectomy and complete resolution of symptoms. No cause is known for this new onset of SI symptoms. No radiating symptoms are apparent, and recent magnetic resonance imaging shows no sign of disc protrusion at this time. (She tried doing her previous program of McKenzie exercises, but no change in symptoms occurred.) Clinical Presentation: Physical therapy examination reveals the following: Antalgic gait secondary to pain. Trendelenburg sign: negative. Slight left lumbar lateral shift; posture within normal limits otherwise. Active lumbar motions are full, with a normal capsular end feel and no reproduction of symptoms. Repeated trunk and lumbar motions do not elicit painful symptoms. Neurologic screen: negative for abnormal reflexes, abnormal sensation, decreased strength, or altered neural tension. Hamstrings are tight bilaterally, but a straight leg raise does not increase symptoms. In fact, it is the only time in the assessment when the client reports a slight decrease in pain. Examination of the SI area revealed an upslip on the left (anterior superior iliac spine [ASIS] and posterior superior iliac spine [PSIS] on the left are higher than ASIS and PSIS on the right, indicating an upward movement of the ilium on the sacrum on the high side; leg length discrepancy or muscle spasm from a disc lesion can also cause an upslip). Given her past history of discogenic lesion, it is possible that altered muscle acti-
vation is the cause. This will have to be examined further. Is a screening examination for systemic origin of symptoms warranted? Why, or why not? Using our screening model, review the past medical history. Are there any red flags here? No, but the history is very incomplete. We know she had a previous discogenic lesion treated operatively. Nothing of her personal or family history is included. Even in a musculoskeletal assessment, we will want to know about pregnancy and birth histories; use of medications, over-the-counter drugs, and illicit drugs; smoking and drinking history or current use; levels of activity before the onset of symptoms; correlation of symptoms with menses or births; occupation and workrelated activities; and history of cancer. A general screening interview will ask about recent history of infection, the presence of joint pain or skin rash anywhere else, and the presence of any constitutional or other symptoms. Next, review the clinical presentation. Are there any red flags here? Not really. There is no night pain. There is the fact that nothing seems to make it better or worse, but one red flag by itself usually is not highly significant. We will tuck that bit of information in the back of our minds as we continue the evaluation process. Hamstring stretching brings some mild, temporary relief. This suggests a muscular component, but that has to be further evaluated. The SI upslip could be the cause of the symptoms, but this will not be determined until the alignment and cause of the upslip are corrected. A trigger point assessment may be needed as well. Step three involves a review of associated signs and symptoms. We do not know about constitutional symptoms, relationship of SI pain to menses, or the presence of any other symptoms associated with the viscera (e.g., gastrointestinal, urologic). It is always recommended to take the client's temperature in the presence of pain of unknown cause. What to Do: Several strategies are presented here. Intervention for the upslip may be the first step with reassessment of symptoms. If a lack of progress occurs, the therapist can go back and ask more specific questions. Or, the therapist
CHAPTER 15
CASE
EXAMPLE
15-1
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Sacroiliac P a i n Caused by Pelvic F l o o r Dysfunction—con t'd
can treat the upslip while continuing to interview the client each day, obtaining additional pertinent information before making a final decision. Result: In the end, it was discovered that the client had significant pelvic floor dysfunction with levator ani spasm and detrusor imbalance with urinary incontinence. She reported a complicated birth history with her first child, which was repeated with less severity during the births of her second and third children. Intercourse was extremely painful, but the client was too embarrassed to bring this up until the therapist asked directly about sexual activity. The client finally described a sensation as if "trying to deliver a baby through my rectum" during intercourse (a sign of levator ani dysfunction). Once all the additional information had been brought out and organized, the client shared the signs and symptoms with her gynecologist. An internal vaginal examination reproduced her symptoms exactly. The evaluating therapist was not trained in pelvic floor assessment and did not make this finding directly. In looking back, it is likely that development of the discogenic lesion was linked to birth/delivery problems (or perhaps, vice versa; it was never known for sure). Closer examination
gynecologic disorders, rheumatic diseases that target the sacroiliac area (e.g., spondyloarthropathies such as ankylosing spondylitis, Reiter's syndrome, or psoriatic arthritis), and Paget's disease (Table 15-1). Disorders of the large intestine and colon, such as ulcerative colitis, Crohn's disease (regional enteritis), carcinoma of the colon, and irritable bowel syndrome, can refer pain to the sacrum when the rectum is stimulated. A medical differential diagnosis may be needed to exclude fracture, infection, or tumor. Insufficiency fractures of the sacrum are not uncommon and usually occur in osteoporotic bone with minimal or unremembered trauma. (See further discussion in this chapter on spondylogenic causes of sacral pain.) 2
3
revealed a loss of lumbar stabilization because of multifidus impairment. Muscle impairment at the time of the disc lesion and births probably contributed to the gradual development of pelvic floor dysfunction. Changes were also noted in the abdominal muscles with a loss of co-contraction between the multifidus and the transversus abdominis. The levator ani and pelvic floor muscles were in a contract-hold pattern, contributing to the painful symptoms described. Heat relaxed the muscles, but only for a short time. Hamstring stretching may have brought about an inhibition to the pelvic floor muscles, reducing pain. A program directed at restoring normal muscle tone and function in the lumbar spine, abdominal muscles, and pelvic floor resulted in immediate reduction and eventual elimination of painful symptoms and return of comfortable coitus. Symptoms of urinary incontinence also were resolved. Although the SI upslip could be corrected, the client could not maintain the correction. Because she was pain free, she did not return to physical therapy for further evaluation of the underlying biomechanics around the SI upslip.
Using the Screening Model to Evaluate Sacral/SI Symptoms The principles guiding evaluation of sacroiliac joint or sacral pain are consistent with the information presented throughout this text and, in particular, in the chapter on back pain (see Chapter 14). Each of the disorders listed in Table 15-1 usually has its own unique clinical presentation with clues available in the past medical history. The presence of associated signs and symptoms is always a red flag. Most of these conditions have clear red flag clues that come to light if the client is interviewed carefully.
Clinical
Presentation
Insidious onset or unknown cause is always a red flag. Without a clear cause, the therapist looks for
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TABLE 15-1
S E C T I O N III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Causes of Sacral and Sacroiliac (SI) Pain Neuromuscular/musculoskeletal
Systemic
8
Infectious/Inflammatory Spondyloarthropathy: Idiopathic (unknown) Ankylosing spondylitis Trauma Myofascial or kinetic chain imbalance Reiter's syndrome Psoriatic arthritis Enthesis (tendon insertion)/ligamentous sprain Inflammatory bowel disease (arthritis associated with IBD) Degenerative joint disease Bone harvesting for grafts (may cause secondary instability) Vertebral osteomyelitis Lumbar spine fusion or hip arthrodesis Endocarditis Tuberculosis (uncommon) Myofascial syndromes (mimics SI joint pain) Discogenic disease (mimics SI joint pain) Spondylogenic Nerve root compression (mimics SI joint pain) Fracture (traumatic, insufficiency, pathologic), metabolic Zygapophyseal joint pain (mimics SI joint pain) bone disease i • Osteoporosis (insufficiency fractures) • Paget's disease • Osteodystrophy • Osteoarthritis Gynecologic Reproductive cancers Retroversion of the uterus Uterine fibroids Ovarian cysts Endometriosis Pelvic inflammatory disease (PID) Incest/sexual assault Rectocele, cystocele Uterine prolapse Normal pregnancy; multiparity (more than one pregnancy) Gastrointestinal Ulcerative colitis Colon cancer Irritable bowel syndrome Crohn's disease (regional enteritis) Cancer Primary tumors (rare: giant cell, chondrosarcoma, synovial villoadenoma) Metastatic lesions (history of cancer) • Prostate cancer • Colorectal cancer • Multiple myeloma Other Fibromyalgia Genital herpes simplex virus (rare)
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SCREENING THE SACRUM, SACROILIAC, AND PELVIS
something else in the history or accompanying signs and symptoms. Even with a known or assigned cause, it is important to keep other possibilities in mind and to watch for red flags (Box 15-1). Sacral pain in the absence of a history of trauma or overuse is a clue to the presentation of systemic backache. The amount and direction of pain radiation can offer helpful clues. Low back or sacral pain radiating around the flank suggests the renal or urologic system. In such cases, the therapist is likely to ask questions about bladder or urologic function. Low back or sacral pain radiating to the buttock or legs may be vascular. Questions about the effects of activity on symptoms and history of cardiovascular or peripheral vascular diseases are important (see discussion, Chapter 14). Sorting out pain of a vascular versus neurogenic cause is also discussed in Chapter 14. Most commonly, unless pain causes muscle spasm, splinting, and subsequent biomechanical changes, clients affected by systemic or viscerogenic causes of sacral or SI pain demonstrate a remarkable lack of objective findings to implicate the sacroiliac joint or sacrum as the causative factor for the presenting symptoms. Pain elicited
BOX 15-1
699
by pressing on the sacrum with the client in a prone position suggests sacroiliitis (inflammation of the sacroiliac joint) or mechanical derangement. S I J O I N T PAIN P A T T E R N
Whether from a mechanical or a systemic origin, the patient usually experiences pain over the posterior SI joint and buttock, with or without lower extremity pain. Pain may be unilateral or bilateral (Fig. 15-1) and can be referred to a wide referral 4
Red Flags Associated W i t h Sacroiliac/Sacral Pain or Symptoms
History • Sacroiliac/sacral pain without a history of trauma or overuse (rule out assault, anal intercourse) • Previous history of cancer • Previous history of gastrointestinal disease (ulcerative colitis, Crohn's disease, irritable bowel syndrome)
Risk Factors • Osteoporosis • Sexually transmitted infection • Long-term use of antibiotics (colitis)
Clinical Presentation • Lack of objective findings • Anterior pelvic, suprapubic, or low abdominal pain at the same level as the sacrum
Associated Signs and Symptoms • Pain relieved by passing gas or having a bowel movement • Presence of gastrointestinal, gynecologic, or urologic signs and symptoms
Fig. 15-1 • Unilateral sacroiliac (SI) pain pattern. Pain coming from the sacroiliac joint is usually centered over the area of the posterior superior iliac spine (PSIS), with tenderness directly over the PSIS. Lower lumbar pain occurs in 72% of cases; it rarely presents as upper lumbar pain above L5 (6%). It may radiate over the buttocks (94%), down the posterior-lateral thigh (50%), and even past the knee to the ankle (14%) and lateral foot (8%). Paresthesias in the leg are not a typical feature of SI joint pain. The affected individual may report abdominal (2%), groin or pubic (14%), or anterior thigh pain (10%). Anterior symptoms may occur alone or in combination with posterior symptoms. Occasionally, a client will report bilateral pain. (Data from Slipman CW, Jackson HB, Lipetz JS, et al: Sacroiliac joint pain referral zones. Arch Phys Med Rehab 81:334-338, 2000.)
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zone, including the lumbar spine, abdomen, groin, foot, and ankle. ' Clients with SI joint pain rarely have pain at or above the level of the L5 spinous process, although it is possible. The presence of midline lumbar pain tends to exclude the SI joint as a potential pain generator. A wide range of SI joint-referred pain patterns occur because innervation is highly variable and complex, or because pain may be somatically referred, as discussed in Chapter 3. Adjacent structures, such as the piriformis muscle, sciatic nerve, and L5 nerve root, may be affected by intrinsic joint disease and can become active nociceptors. Pain referral patterns also may be dependent on the distinct location of injury within the SI joint. SI pain can mimic discogenic disease with radicular pain down the leg to the foot. People who report midline lumbar pain when they rise from a sitting position are likely to have discogenic pain. Clients with unilateral pain below the level of the L5 spinous process and pain when they rise from sitting are likely to have a painful SI joint. Pain from SI joint syndrome may be aggravated by sitting or lying on the affected side. Pain gets worse with prolonged driving or riding in a car, weight bearing on the affected side, the Valsalva maneuver, and trunk flexion with the legs straight. SI pain can also mimic the pain pattern of kidney disease with anterior thigh pain, but with SI dysfunction, no signs and symptoms (e.g., constitutional symptoms, bladder dysfunction) are associated, as would be the case with thigh pain referred from the renal system. 1 5
6
7
6
7
Screening for Infectious/Inflammatory Causes of Sacroiliac Pain Joint infections spread hematogenously through the body and can affect the sacroiliac joint. Usually, the infection is unilateral and is caused by Pseudomonas aeruginosa, Staphylococcus aureus, Cryptococcus organisms, or Mycobacterium tuberculosis. Risk factors for joint infection include trauma, endocarditis, intravenous drug use, and immunosuppression. Postoperative infection of any kind may not appear with any clinical signs or symptoms for weeks or months. Infection can cause distention of the anterior joint capsule, irritating the lumbrosacral nerve roots. Inflammation of the sacroiliac joint may result from metabolic, traumatic, or rheumatic causes. Sacroiliitis is present in all individuals with ankylosing spondylitis. 8
9
Rheumatic Diseases as a Cause of Sacral or SI Pain The most common systemic causes of sacral pain are noninfected, inflammatory erosive rheumatic diseases that target the SI, including ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis, and arthritis associated with inflammatory bowel disease (IBD) such as regional enteritis (Crohn's disease). Reiter's syndrome (see Chapter 12) occurs most often in young men with venereal disease. Reiter's syndrome often presents as a triad of symptoms, including arthritis, conjunctivitis, and urethritis. These three symptoms in the presence of sacral pain raise a red flag. The therapist must ask about pain in other joints, urologic symptoms, and a recent (or current) history of conjunctivitis (red, painful inflammation of the eye). A positive sexual history or known diagnosis of venereal disease is helpful information. With sacral or SI pain, the therapist should always consider taking a sexual history (see Special Questions to Ask, Chapter 14 or Appendix B-29). Crohn's disease (see Chapter 8) may be accompanied by skin rash and joint pain. This enteric condition is well known for its arthritic component, which is present in up to 25% of all cases. The client may have had Crohn's disease for years and may not recognize the onset of these new symptoms as part of that condition. Skin rash may precede joint pain by days or weeks. The hips, thighs, and legs are affected most often; the rash may be raised or flat, purple or red. Knowing the history and association between skin lesions and joint pain can help the therapist direct screening questions and make a reasonable decision about referral.
Screening for Spondylogenic Causes of Sacraf/Sacroiliac Pain Metabolic bone disease (MBD) such as osteoporosis, Paget's disease, and osteodystrophy can result in loss of bone mineral density and deformity or fracture of the sacrum. The therapist should review cases of sacral pain for the presence of risk factors for any of these metabolic bone diseases (see the discussion on metabolic bone disease in Chapter 11). Neoplasm and fracture are two other possible bony causes of sacral pain. Neoplasm is discussed separately in this chapter.
Metabolic
Bone
Disease
Mild to moderate MBD may occur with no visible signs. Advanced cases of MBD include constipation, anorexia, fractured bones, and deformity.
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SCREENING THE SACRUM, SACROILIAC, AND PELVIS
OSTEOPOROSIS
Osteoporosis can cause insufficiency fractures of the sacrum. The therapist must assess for risk factors (see Boxes 15-2 and 11-3) in anyone with sacral pain, especially those in whom pain has an unknown cause, postmenopausal women, older men (over 65), and anyone with a known history of osteoporosis or Paget's disease. See further discussion, Osteoporosis, in Chapter 11, and Fractures, at the end of this section.
701
Trauma-related fatigue or stress fracture of the sacrum occurs most often in young active persons and older adults with osteoporosis. Fatigue or stress fractures can develop as a result of submaximal repetitive forces over time such as occur with overuse or overtraining in military personnel and athletes (e.g., runners, volleyball and field hockey players). Less often, pregnant or postpartum women experience sacral stress fractures, especially if they are participating in athletic training activities or running. Insufficiency fractures of the sacrum result from a normal stress acting on bone with deficient elastic resistance. Reduced bone integrity is most often associated with postmenopausal or corticosteroid-induced osteoporosis and radiation therapy. Insufficiency fractures occur insidiously or as a result of minor trauma, possibly even from weight bearing transmitted through the 12
PAGET'S DISEASE
Paget's disease as a cause of lumbar, sacral, sacroiliac (SI), or pelvic pain occurs most commonly in men over 70 years of age (although it can occur earlier and in women). It is the second most common metabolic bone disease after osteoporosis. Characterized by slowly progressive enlargement and deformity of multiple bones, it is associated with unexplained acceleration of bone deposition and resorption. The bones become weak, spongy, and deformed. Redness and warmth may be noted over involved areas, and the most common symptom is bone pain (see further discussion, Chapter 11, Paget's disease; see also excellent online article). 10
Fracture Three types of fractures affect the sacrum: traumatic, insufficiency, and pathologic. Trauma resulting in fracture occurs most often with lateral compression injuries seen in motor vehicle accidents or vertical shear injuries resulting from a fall from height onto the lower limbs. Less commonly, direct stress to the sacrum from a high fall landing on the buttocks can cause traumatic sacral fracture. Other risk factors for sacral fracture are listed in Box 15-2. 11
BOX 15-2
Risk Factors for Sacral Fractures
• Osteoporosis (see also Box 11-3) • Paget's disease • Gender (female) • Athletes, military personnel (overuse, overtraining, improper footwear or training surface) Athletic pregnant or postpartum women • • Pelvic radiation • Lumbar-sacral fusion (early postoperative) • Osteomyelitis • Multiple myeloma • Trauma (motor vehicle accident, fall, assault) • Prolonged use of corticosteroids
11
-
13
spine. Pathologic fracture describes fractures that occur as a result of bone weakened by neoplasm or other disease conditions (e.g., osteomyelitis, giant cell tumor, chordoma, Ewing's sarcoma, multiple myeloma). Insufficiency fractures are actually a subset of pathologic fractures confined to bones with structural alterations due to metabolic bone disease. Clinical manifestations of sacral fractures can present with a wide range of signs and symptoms, many of which are present inconsistently and are considered nonspecific. Bilateral or multiple stress fractures of the sacrum or pelvis have been reported. The client may report or demonstrate localized pain, tenderness with palpation, antalgic gait, and leg length discrepancy. With all sacral fractures, hip, low back, sacral, groin, or buttock pain may occur, especially with multiple stress fractures of the pelvic and sacral bones. Symptoms may mimic other conditions such as disc disease, recurrence of a local tumor, or metastatic disease. Diagnostic imaging may be needed to make the final medical diagnosis. Radiographic studies (xrays) are often negative in the early phases of stress reactions or fractures. More advanced diagnostic bone imaging may show changes when the client becomes symptomatic. New onset of sacral or buttock pain 1 to 2 weeks after multilevel lumbrosacral fusion with instrumentation should be evaluated for sacral insufficiency fractures, especially if the patient has a recent history of prolonged sitting. 11
14
15
11
16
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Screening for Gynecologic Causes of Sacral Pain
Screening for Tumors as a Cause of Sacral/Sacroiliac Pain
See discussion, Gynecologic Causes of Pelvic Pain, this chapter.
Primary sacral tumors include benign and malignant growths. Benign neoplasms include osteochondroma, giant cell tumor, and osteoid osteoma. The more common primary malignant lesions directly affecting the sacrum include chordoma, osteosarcoma, and myeloma. Metastatic bone disease to the sacrum from primary breast, lung, and prostate is far more common. Sacral insufficiency fractures after pelvic radiation for rectal carcinoma can occur, although these are rare. Although rare, sacral neoplasms usually are not diagnosed early in the disease course because of mild symptoms resembling low back pain or sciatica. Referral to a physical therapist before a correct medical diagnosis is made is not unusual. Giant cell tumor is a highly aggressive local tumor of the bone. The sacrum is the third most common site of involvement. Clients present with localized pain in the lower back and sacrum that may radiate to one or both legs. Swelling may be noted in the involved area. When asked about the presence of other symptoms anywhere in the body, the client may report abdominal complaints and neurologic signs and symptoms (e.g., bowel and bladder or sexual dysfunction, numbness and weakness of the lower extremity). Colorectal or anorectal cancer as a cause of sacral pain is possible as the result of local invasion. Severe sacral pain in the presence of a previous history of uterine, abdominal, prostate, rectal, or anal cancer requires immediate medical referral. Prostatic (males) or reproductive cancers in men and women can result in sacral pain. See further discussion under Testicular Cancer (see Chapters 10 and 14), Prostate Cancer (see Chapter 10), and Gynecologic Conditions (this chapter).
S c r e e n i n g for Gastrointestinal Causes of Sacral/Sacroiliac Pain The primary pain pattern for gastrointestinal (GI) disease involves the midabdominal region around the umbilicus. It is not likely that the therapist will see clients with this chief complaint; they are more likely to see a doctor or go to the emergency department. However, the therapist may be evaluating or treating a client for an orthopedic or neurologic problem who reports GI symptoms. When a client relates symptoms associated with the viscera or abdomen, the therapist must think in terms of screening questions to discern whether these symptoms require immediate medical assessment and intervention. The therapist is more likely to see clients with referred low back or sacral pain from the small or large intestine as it presents in the low back or sacral area (see Figs. 8-13 and 8-14). Although these illustrations depict the pain in small, very round areas, actual pain patterns can vary quite a bit. The location will be approximately the same, but individual variation does occur. The therapist must ask about the presence of abdominal pain or GI symptoms, occurring either simultaneously or alternating but at the same anatomic level as back or sacral pain. See Case Example 14-13 to review the importance of looking for this particular red flag. Sacral pain from a GI source may be reduced or relieved after the person passes gas or completes a bowel movement. It may be appropriate to ask a client the following: Follow-Up Questions • Is your pain relieved by passing gas or having a bowel movement? The patient may have a history of GI disease or medication use to treat conditions such as • Ulcerative colitis • Crohn's disease • Irritable bowel syndrome (IBS) • Colon cancer • Long-term use of antibiotics (colitis) Keep these conditions in mind when asking questions about past medical history of anyone with lumbar spine or sacral pain patterns.
17
18
19,20
THE COCCYX The coccyx or tailbone is a small triangular bone that articulates with the bottom of the sacrum at the sacrococcygeal joint. Injury or trauma to this area can cause coccygeal pain called coccygodynia.
Coccygodynia Most cases of coccygodynia or coccydynia (pain in the region of the coccyx) seen by the physical therapist occur as a result of trauma such as a fall directly on the tailbone or events associated with childbirth.
CHAPTER 15
Symptoms include localized pain in the tailbone that is usually aggravated by direct pressure such as that caused by sitting, passing gas, or having a bowel movement. Moving from sitting to standing may also reproduce or aggravate painful symptoms. Coccygodynia is reproduced on bidigital manipulation of the coccyx. A medical diagnosis is confirmed when at least 75% relief of coccygeal pain results from injection of local anesthetic into the sacrococcygeal joint on two separate occasions. In the case of persistent coccygodynia with a history of trauma, the therapist must keep in mind the possibility of rectal or bladder lesions (Box 15-3). When asked about the presence of other symptoms, clients with coccygodynia after a traumatic fall may also report bladder, bowel, or rectal symptoms. The therapist must ask whether bladder, bowel, or rectal symptoms were present before the fall. Because 50% of all clients with back or sacral pain from a malignancy have preceding trauma or injury, the apparent trauma (especially if the client reports associated symptoms that were present before the trauma) may be something more serious. For possible clues to treating a client with coccygodynia, the therapist should review Box 15-3, keeping in mind the risk factors for each of these conditions. The therapist should also conduct a neurologic screening examination to identify any signs or symptoms of disc disease. Past history of any of the problems listed is a yellow (warning) flag. Blood in the toilet after a bowel movement may be a sign of anal fissures, hemorrhoids, or colorectal cancer and requires medical evaluation. 21
BOX 15-3
Causes of Coccygeal Pain
• Discogenic disease (herniation) • Degenerative spondylolysis or spondylolisthesis • Lumbar spinal stenosis • Sacroiliac joint dysfunction • Anal fissures • Inflammatory cysts • Prostatitis • Thrombosed hemorrhoids • Chordoma (neoplasm) • Pilonidal cysts • Trauma (fall, childbirth, anal intercourse) • Nonunion fracture (sacrum, coccyx) • Coccygeal disc injury (rare) Data from Wood KB, Mehbod AA: Operative treatment for coccygodynia. J Spinal Disord Tech 17(6):511-515, 2004.
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SCREENING THE SACRUM, SACROILIAC, AND PELVIS
THE PELVIS Once again, the principles used in screening for systemic or viscerogenic causes of back, sacral, and SI pain also apply to pelvic pain. The history and associated signs and symptoms may vary somewhat according to the cause, but many of the causes are the same (e.g., cancer, GI, vascular, urogenital) (Table 15-2). The most common primary causes of pelvic pain seen in a physical therapy practice are musculoskeletal, neuromuscular, gynecologic, infectious, vascular, cancer, and gastrointestinal (in descending order). Infectious disease is the most common systemic cause of pelvic pain. Chronic pelvic pain is most commonly associated with endometriosis, adhesions, IBS, and interstitial cystitis. ' The therapist must keep in mind that pelvic pain and symptoms can be referred to the pelvis from the hip, sacrum, SI area, or lumbar spine. At the same time, pelvic diseases can refer pain or symptoms to the abdomen, low back, buttocks, groin, and thigh. This means that anytime a client presents with pain or dysfunction in any of these areas, pelvic disease must be considered as a possible cause. The anterior pelvic wall is part of the musculature of the abdominal cavity. The lateral walls are covered by the iliopsoas and obturator muscles, and inferiorly, the outlet is guarded by the levator ani and pubococcygeus muscles, with which the corresponding muscles of the opposite side form the pelvic diaphragm. These two anatomic regions are separated only by walls of muscle. Because the pelvic cavity is in direct communication with the abdominal cavity (see Fig. 14-1), any organ disease or systemic condition of the pelvic or abdominal cavity can cause primary pelvic pain or referred musculoskeletal pain, as is described in this section. The therapist should keep in mind that pelvic pain and low back pain often occur together or alternately. Whenever discussing pelvic pain, the therapist should ask about the presence of unreported low back pain. 22
23
Using the Screening Model to Evaluate the Pelvis When our screening model is followed, the same steps are always taken. A personal or family history is obtained, and risk factor assessment is performed. Once the history has been established, the pelvic pain pattern is reviewed. The therapist looks for red flags that may suggest systemic or viscerogenic causes. Additional questions may be
704
TABLE 15-2
S E C T I O N III
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
Causes of Pelvic Pain
Systemic
Neuromuscular/musculoskeletal
Gynecologic Pregnancy (including ectopic, ruptured or unruptured) Uterovaginal prolapse Vulvodynia Dysmenorrhea Endometriosis Premenstrual tension Tumors, fibroids, adhesions, polyps Ovarian cysts, varicosities, or torsion Gynecalgia Intrauterine contraceptive device (IUCD) Adnexal torsion (ovaries, fallopian tubes twisted) (rare) Infection/Inflammation Spontaneous, therapeutic, or incomplete abortion; postabortion syndrome Septic arthritis Ankylosing spondylitis Ileal Crohn's disease Acute or chronic appendicitis Herpes zoster Osteomyelitis Pelvic inflammatory disease (PID) Sexually transmitted infection Postpartum infection
Hip, sacroiliac joint, low back, sacral, or coccyx dysfunction* Muscle impairment (hamstrings, abdominals, rectus femoris, adductor muscles, pelvic floor muscles, levator ani)t Psoas abscess (abdominal or pelvic infectious process) Stress reactions/fractures Pubic strain/sprain/separation Sexual, birth, or activity-related trauma or injury: Levator ani syndrome Tension myalgia Coccygodynia Neurologic disorders Nerve entrapment Incomplete spinal cord lesion Multiple sclerosis Pudendal neuralgia Scoliosis Osteoporosis Somatization disorders
Vascular Disorders Arterial occlusion; ischemia Abdominal angina Abdominal aneurysm Pelvic congestion Varicosities or pelvic thrombophlebitis Cancer Gastrointestinal Disorders Inflammatory bowel disease (IBD) Crohn's disease Ulcerative colitis Irritable bowel syndrome (IBS) Diverticular disease Constipation (common in older adults) Neoplasm Hernia Urogenital Chronic urinary tract infection Interstitial cystitis Acute pyelonephritis Kidney stones (ureteric calculus) Chronic prostatitis, prostate cancer * The combined medical and physical therapy differential diagnosis includes many origins of pathokinesiologic conditions, including joint laxity; subluxations or displacements; thoracolumbar hypermobility; bursitis; osteoarthritis; spondyloarthropathy; fracture; and postural, ligamentous, or osteoporosis/osteomalacia. (This list is not exhaustive.) t As with joint dysfunction, the differential diagnosis of muscle pathokinesiologic conditions can include many origins (e.g., trigger points, tendinous avulsion, strain/sprain/tear, weakness, loss of flexibility, hypertonus or hypotonus, diastasis recti).
SCREENING THE SACRUM, SACROILIAC, A N D PELVIS
CHAPTER 15
TABLE 15-2
705
Causes of Pelvic Pain—cont'd Neuromuscular/musculoskeletal
Systemic Other Psychogenic; somatization disorder Trauma/sexual assault Surgery (abdominal/laparoscopic, tubal, pelvic) Fibromyalgia Autonomic nervous system dysfunction Paget's disease Lead or mercury toxicity Substance abuse (cocaine) Sickle cell anemia
needed to complete the screening process. These questions are presented for all causes of pelvic pain at the end of this chapter.
History Associated
With
Pelvic
Pain
With so many possible causes of pelvic pain, many different factors in the past medical history can raise a red flag. Pelvic pain is a very complex problem. Many medical texts are written about just this one anatomic area. This text does not attempt to explain or discuss all the possible causes of pelvic pain. Rather, the intent is for the Reader to learn how to screen for the possibility of systemic or viscerogenic sources of pelvic pain or symptoms. With a good understanding of what is important in the history and a list of possible follow-up questions, the therapist assesses each client, keeping in mind that medical referral may be needed. Some of the more common red flag histories associated with pelvic pain are listed in Box 15-4. With the use of categories from the medical screening model, risk factors, clinical presentation, and associated signs and symptoms also are listed. Most conditions that affect the pelvic structures are found in women, but men may also experience pelvic floor dysfunction and pain. Sexual assault, anal intercourse, prostate or colon cancer, and sexually transmitted disease are the most common causes for men. Prostate problems such as benign prostatic hyperplasia (BPH) or prostatitis can cause lower abdominal, back, thigh, or pelvic pain.
Clinical
Presentation
In the screening process, clinical presentation and especially pain patterns are very important. Mech-
anisms of viscerogenic pain (i.e., how these patterns develop) are discussed in Chapter 3. Pelvic pain may be visceral pain, caused by stimulation of autonomic nerves ( T i l to S3); somatic pain, caused by stimulation of sensory nerve endings in the pudendal nerves (S2, S3); or peritoneal pain (pressure from inflammation, infection, or obstruction of the lining of the pelvic cavity). Peritoneal pain may be caused by disruption of the autonomic nerve supply of the visceral pelvic peritoneum, which covers the upper third of the bladder, the body of the uterus, and the upper third of the rectum and the rectosigmoid junction. It is insensitive to touch but responds with pain on traction, distention, spasm, or ischemia of the viscus. Peritoneal pain may also occur in relation to the parietal pelvic peritoneum, which covers the upper half of the lateral wall of the pelvis and the upper two thirds of the sacral hollow—all supplied by somatic nerves. These somatic nerves also supply corresponding segmental areas of skin and muscles of the trunk and the anterior abdominal wall. Painful stimulation of the parietal pelvic peritoneum may cause referred segmental pain and spasm of the iliopsoas muscle and muscles of the anterior abdominal wall. Knowing the characteristics of pain patterns typical of each system is essential. When the client describes these patterns, it is possible for the therapist to recognize them for what they are and to see how the clinical presentation differs from neuromuscular or musculoskeletal impairment and dysfunction. Pelvic disease may cause primary pelvic pain and may also refer pain to the low back, thigh,
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S E C T I O N III
B O X 15-4
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
Red Flags Associated with Pelvic Pain or Symptoms
History*
Clinical Presentation
•
•
• • • • • • • • • • •
History of reproductive, colon, or breast cancer History of dysmenorrhea, ovarian cysts, pelvic inflammatory disease, sexually transmitted disease Endometriosis Chronic bladder or urinary tract infections Chronic irritable bowel syndrome Previous history of pelvic/bladder surgeries, especially hysterectomy Recent abortion or miscarriage History of assault, incest, trauma History of prolonged labor; use of forceps or vacuum extraction during delivery History of multiple births Chronic yeast/vaginal infections History of varicose veins in the lower extremities (risk factor for pelvic congestion syndrome)
Risk Factors
• • • • •
Recent intrauterine contraceptive device (rejection) or long-term use, especially without medical follow-up (scar tissue) Perimenopause, menopause (vaginitis) Sexual activity without use of a condom Multiple sexual partners Childbirth, recent abortion, multiple abortions
•
• • •
•
Poorly localized, diffuse; client unable to point to one spot Aggravated by increased intra-abdominal pressure (e.g., standing, walking, sexual intercourse, coughing, constipation, Valsalva's maneuver) Pelvic pain is not affected by specific movements but gets worse toward the end of the day or after standing for a long time May be temporarily relieved by position change (e.g., getting off feet, resting or elevating the legs, putting the feet up) Pelvic pain is not reduced or eliminated by scar or soft tissue mobilization or by trigger point release of myofascial structures in the pelvic cavity Positive McBurney's, Blumberg's, or iliopsoas/obturator sign (see Chapter 8)
Associated Signs and Symptoms
• • • • • • •
Discharge from vagina or penis Urologic signs or symptoms Unreported abdominal pain Dyspareunia (painful or difficult intercourse) Constitutional symptoms Missed menses or unexplained/unexpected spotting (light staining of blood) (e.g., ectopic pregnancy) ask about shoulder pain Headache, fatigue, irritability
* Many of the histories listed here are also risk factors for pelvic pain.
groin, and rectum. Usually, pelvic disease appears as acute illness with sudden onset of severe pain accompanied by nausea and vomiting, fever, and abdominal pain. Mild to moderate back or pelvic pain that gets worse as the day progresses may be associated with gynecologic disorders. The therapist is more likely to see the atypical presentation of systemically related central lumbar and sacral pain, which is easily mistaken for mechanical pain.
Associated
Signs
and
Symptoms
While collecting pertinent personal and family history, conducting a risk factor assessment, and evaluating the client's pain pattern, the therapist listens and looks for any yellow or red flags. From there, the therapist formulates any additional questions that may be appropriate on the basis of data collected so far. Before leaving the screening task, the therapist asks a few final questions. The first is about the presence of any associated signs and symptoms.
For example, perhaps the client has pelvic pain and unreported shoulder pain. She may not think her previously unreported shoulder pain has any connection with the current pelvic pain. Or, she may not see that the presence of a vaginal discharge is linked in any way to her low back and pelvic pain. Discharge from the vagina or penis (yellow or green, with or without an odor) in the presence of low back, pelvic, or sacral pain may be a red flag. To bring this information out and make any of these connections, the therapist must ask about the presence of any associated signs and symptoms. Ask the client the following: Follow-Up Questions • Do you have any symptoms anywhere else in your body? Tell me even if you don't think they are related to your pelvic pain. If the client says "No," then ask about the presence of urologic symptoms and constitutional symp-
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toms, and look for a connection between the menstrual cycle and symptoms. If it appears that there may be a gynecologic basis for the client's symptoms, the therapist may want to ask some additional questions about missed menses, shoulder pain, and spotting or bleeding. The therapist should assess for the presence of dysmenorrhea, defined as painful cramping during menstruation. Dysmenorrhea may be primary (of unknown cause) or secondary as a result of a pelvic pathologic condition related to endometriosis, intrauterine tumors or polyps (myomas), uterine prolapse, pelvic inflammatory disease, cervical stenosis, and adenomyosis (benign invasive growths of the endometrium into the muscular layers of the uterus). Dysmenorrhea is characterized by spasmodic, cramp-like pain that comes and goes in waves and radiates over the lower abdomen and pelvis, thighs, and low back, sometimes accompanied by headache, irritability, mental depression, fatigue, and GI symptoms.
Screening for Neuromuscular and Musculoskeletal Causes of Pelvic Pain The therapist is most likely to see pelvic pain caused by a neuromuscular or musculoskeletal problem. The therapist must remember that pelvic pain or symptoms may be referred from systemic or neuromusculoskeletal origins from the hip, SI joint, sacrum, or low back. Likewise, pelvic diseases can refer pain and symptoms to the low back, groin, and thigh. When evaluating low back or pelvic pain, the therapist must assess for pelvic floor laxity or tension, psoas abscess, trigger points, history of birth or sexual trauma, and the presence of any associated signs and symptoms. Neurologic disorders (e.g., nerve entrapment, incomplete spinal cord lesion, multiple sclerosis, Parkinson's, stroke, pudendal neuralgia) can cause pelvic pain and dysfunction. Pudendal nerve entrapment is characterized by pain relief when one is sitting on a toilet seat or standing; elimination of symptoms after a pudendal nerve block is diagnostic. Pregnancy-related low back pain and pelvic pain are also common and have an impact on daily life for many women. Prevention and treatment of symptoms is an important issue for therapists who work in the area of women's health. Musculoskeletal dysfunction of the pelvic girdle and low back may manifest as dyspareunia (painful intercourse). Hypertonus of the pelvic floor and pelvic floor trigger points can contribute to
707
entrance dyspareunia. Deep thrust dyspareunia may be related to SI or low back dysfunction. Dyspareunia symptoms that are reduced in alternate positions may indicate a musculoskeletal component, especially when other signs and symptoms characteristic of musculoskeletal dysfunction are also present. One of the most common musculoskeletal sources of pelvic pain is the trigger point. Muscles most likely to refer pain to the pelvic area include the abdominals, quadratus lumborum, and iliopsoas. Typical aggravating and relieving factors for pain from a neuromuscular or musculoskeletal source include the following: • Aggravated by exercise, weight bearing • Aggravated by trunk/lumbar rotation • Relieved by rest or stretching • Pain or altered movement pattern produced by trunk and lumbar rotation • Eliminated by trigger point therapy The therapist looks for a contributing history such as a fall on the buttocks, pregnancy, or trauma. Avulsion of hamstrings from a sports injury may be reported. Trauma from physical or sexual assault may remain unreported. Screening for assault is an important part of many evaluations (see Chapter 2). The therapist also looks for muscle impairment. For therapists trained in pelvic floor palpation, external and internal palpation of the pelvic floor musculature is helpful. Examination includes observation for varicosities and assessment of muscle tone and the presence of trigger points. Many clients who experience low back, pelvic, SI, sacral, or groin pain have unrecognized pelvic floor dysfunction. Fig. 15-2 gives a simple representation of how the puborectalis muscle acts as a sling around various structures of the pelvis. The condition and position of the pelvic sling are very important in the maintenance of normal pelvic floor health. Fig. 14-1 provides a visual reminder that the muscles of the pelvic floor support the reproductive organs and the viscera in the peritoneum. Any impairment of these organs may cause dysfunction of the pelvic floor and vice versa. Any weakness or dysfunction of the pelvic floor can lead to problems with the viscera located in the abdominal or pelvic cavities. 25
26
27
26,28,29
24
Anterior
Pelvic
Pain
Anterior pelvic pain occurs most often as a result of any disorder that affects the hip joint, including inflammatory arthritis; upper lumbar vertebrae
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SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Pubic symphysis Coccyx
Puborectalis muscle -
Rectum Anal canal Anus
Fig. 15-2 • Pelvic sling. Puborectalis muscle forms a Ushaped sling encircling the posterior aspect of the rectum and returns along the opposite side of the levator hiatus to the posterior surface of the pubis. This shows how the condition and position of the pelvic sling contribute to the function of the pelvic floor and the encircled viscera. Obesity, multiparity, and prolonged pushing during labor and delivery are just a few of life's events that can disrupt the integrity of the pelvic sling and the pelvic floor. (From Myers RS: Saunders manual of physical therapy practice, Philadelphia, 1 995, WB Saunders.)
(disc disease is rare at these segments); pregnancy with separation of the symphysis pubis; local injury to the insertion of the rectus abdominis, rectus femoris, or adductor muscle; femoral neuralgia; and psoas abscess. Stress reactions of the pubis or ilium, sometimes called stress fractures, can occur during traumatic labor and delivery, but they are more common in osteomalacia and Paget's disease and produce anterior pelvic pain. Traumatic stress reactions may also occur in joggers, military personnel, athletes, and pregnant women during delivery. Symptoms may include pain in the involved areas that is aggravated by active motion of the limb or deep pressure and weight bearing during ambulation. Femoral hernia, which accounts for 20% of hernias in women, may cause lateral wall pelvic pain when the hernia strangulates. The referred pain pattern is located down the medial side of the thigh to the knee; inguinal hernias are likely to cause groin pain. Immediate surgical repair is indicated.
Posterior
Pelvic
Pain
Posterior pelvic pain originating in the lumbosacral, sacroiliac, coccydynial, and sacrococ-
cygeal regions usually appears as localized pain in the lower lumbar spine and over the sacrum, often radiating over the sacroiliac ligaments. Pain radiating from the sacroiliac joint can commonly be felt in both the buttock and the posterior thigh and is often aggravated by rotation of the lumbar spine on the pelvis. A proximal hamstring injury, including avulsion of the ischial epiphysis in the adolescent, may also cause posterior pelvic and buttock pain. Coccydynial and sacrococcygeal pain is a common presentation in women and is often associated with a fall on the buttocks or traumatic childbirth. It manifests with the person having difficulty sitting on firm surfaces and having pain in the coccygeal region on defecation or straining. Levator ani syndrome and tension myalgia may produce symptoms of pain, pressure, and discomfort in the rectum, vagina, perirectal area, or low back and can mimic a discogenic problem. Spasm and tenderness in the levator ani may occur in men and women and may be caused by birthing trauma (women), neurologic abnormalities in the lumb o s a c r a l spine, sexual assault or sexual trauma, or anal fissures from anal intercourse. Pain or rectal pressure may occur during sexual intercourse, as may throbbing pain during bowel movement with accompanying constipation and impaired bowel and bladder function.
Screening for Gynecologic Causes of Pelvic Pain Pregnancy, multiparity, and prolonged labor and delivery (especially combined with obesity) are risk factors for gynecologic conditions that can alter the normal position of the bladder, uterus, and rectum in relation to one another (Fig. 15-3), resulting in problems such as rectocele, cystocele, and prolapsed uterus with concomitant pelvic floor pain and dysfunction. Gynecologic causes of pelvic pain are most often produced by congenital anomaly, inflammatory processes (including infection), neoplasia, or trauma. In addition, pelvic pain may be associated with pregnancy, endometriosis, and altered uterine position (Fig. 15-4). Variations in the angle and position of the uterus occur from woman to woman. Many women are unaware of their uterine position. Only if the physician tells her, "You have a tipped uterus," or "You have a retroverted uterus," will she know whether any change from the normal position of the uterus has occurred. Other women experience extreme pain associated with the menstrual cycle, which may be linked with uterine position.
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SCREENING THE SACRUM, SACROILIAC, A N D PELVIS
Children younger than 14 years rarely experience pelvic pain of gynecologic origin. Infection is the most likely cause and is limited to the vulva and vagina. Theoretically, infection can ascend to involve the peritoneal cavity, causing iliopsoas abscess and pelvic, hip, or groin pain, but this rarely happens in this age group.
Peritoneum Uterus
Pregnancy
Cervix Vagina Bladder — Rectum —
Fig. 15-3 • Normal female reproductive anatomy (sagittal view). Locate the rectum, uterus, bladder, vagina, and cervix in this illustration. Note the size, shape, and orientation of each of these structures. The rectum turns away from the viewer in this sagittal section, giving it the appearance of ending with no connection to the intestines. Understanding the normal orientation of these structures will help when each of the diseases that can cause low back pain is considered.
A.
709
Pelvic pain associated with normal pregnancy is similar to low back pain, as was discussed earlier in Chapter 14. About 1% of all pregnancies take place outside the endometrium (or ectopic), with most ectopic implantations occurring in the fallopian tube (Fig. 15-5). Risk factors include tubal ligation; sexually transmitted disease; pelvic inflammatory disease; infertility or infertility treatment; previous tubal, pelvic, or abdominal surgery; or the use of an intrauterine contraceptive device (IUCD; rings, loops, coils, or Ts) (see Fig. 14-6). Symptoms of ectopic pregnancy most often include unexplained vaginal spotting, bursts of bleeding, and sudden lower abdominal and pelvic cramping shortly after the first missed menstrual period. At first, the pain may be a vague "twinge" or soreness on the affected side; later it can be sharp and severe.
B. TubalOvarian
C.
D.
Fig. 15-4 • Abnormal positions of the uterus. Variations in the angle and position of the uterus occur from woman to woman. Each illustration depicts a slightly different anatomic position of the uterus. A, Midline position. Usually, the uterus is above and parallel to the bladder. In the midline position, the uterus is more vertical. B, Anteflexed uterus. The uterus is in its proper position above the bladder, but the upper onethird to one-half of the body is flexed forward. C, Retroverted uterus. About 20% of American women have a tilted, or retroverted, uterus. The top of the uterus naturally slants toward the spine rather than toward the umbilicus. D, Retroflexed uterus. An extremely tilted uterus called retroflexion may even bend down toward the tailbone. A woman with a retroflexed uterus may be unable to use a tampon or a diaphragm. Back pain is more likely to occur with pregnancy and labor for the woman with a retroverted or retroflexed uterus.
Peritoneal
Fig. 15-5 • Ectopic pregnancy. An ectopic pregnancy can occur when the egg is fertilized and implanted outside the uterus. The ovum can be embedded inside the ovary (ovarian pregnancy), inside the fallopian tube (tubal pregnancy), or anywhere between the ovary and the uterus, including along the outside lining of the uterus (extrauterine) or inside the abdominal cavity along the peritoneum as shown. Rupture of the ovum and hemorrhage is the usual result. If this occurs early in the menstrual cycle, the woman may experience heavier bleeding than usual but remain unaware of the failed pregnancy.
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Gradual hemorrhage causes pelvic (and sometimes low back or shoulder) pain and pressure, but rapid hemorrhage results in hypotension or shock. Tubal rupture is common and requires medical attention and diagnosis. Clinical Signs and Symptoms of Ectopic Pregnancy •
Unexplained vaginal missed menses
bleeding
(spotting),
•
Sudden, unexplained lower abdominal and pelvic cramping (especially after first missed menstrual period); usually unilateral • Pain may be mild, progressing to severe over a matter of hours to days • Low back (unilateral or bilateral) or shoulder pain (unilateral) • Hypotension (low blood pressure and pulse rate), shock (tubal rupture)
Prolapsed
Conditions
Prolapse is the collapse, falling down, or downward displacement of structures such as the uterus, bladder, or rectum. A pelvic examination is performed by a physician or other trained professional, such as a physical therapist, to identify prolapse (Fig. 15-6).
Fig. 15-6 • Pelvic examination. With the woman in the lithotomy position (supine with hips and knees flexed and feet in stirrups), the examiner inserts one or two gloved fingers into the vaginal canal up to the point of the cervix or soft tissue obstruction. The examiner applies firm pressure in the lower abdomen above the bladder while the woman bears down slightly as if performing a Valsalva maneuver. The examiner evaluates the tone of the pelvic floor and the position of the uterus during this test. Integrity of the pelvic floor (e.g., muscle tone, laxity, trigger points) can also be tested.
Uterovaginal prolapse can cause low-grade and persistent pelvic pain. Prolapse may result from a combination of basic anatomic structure, effects of pregnancy and labor, postmenopausal hormone deficiency, and poor general muscular fitness. Pelvic floor tension myalgia and prolapse often occur together. Obesity combined with chronic cough, constipation, and multiparity is a common contributing factor to pelvic floor problems. U T E R I N E PROLAPSE
Uterine prolapse occurs most often after childbirth and is graded as first, second, or third degree prolapse (Fig. 15-7). Secondary prolapse may occur with prolonged pushing during labor and delivery, large intrapelvic tumors, or sacral nerve disorders, or it may follow surgical resection. The pain of prolapse is central, suprapubic, and dragging in the groin, and a sensation of a lump at the vaginal opening is noted. Pain is primarily due to stretching of the ligamentous supports and secondarily to excoriation (scratch or abrasion) of the prolapsed cervical or vaginal tissue, which may occur. Third degree prolapse is often accompanied by low back pain with or without pelvic, sacral, or abdominal cramping or heaviness. Symptoms are relieved by rest and lying down and are often aggravated by prolonged standing, walking, coughing, sexual intercourse, or straining. Urinary incontinence is commonly associated with uterine prolapse. Sexual intercourse is possible because the soft tissues of the uterus and vagina can be pushed or pressed out of the way. However, excoriation (scratching or abrasion) of the tissue may occur, accompanied by bleeding and local pain. Care must be taken when anything is inserted into the vagina. Excessive, repetitive force should be avoided. Some women use a removable device called a pessary for a prolapsed uterus or rectum. It is placed in the vagina to support the prolapsed structure. These devices are usually considered temporary and should be used in conjunction with a program to rehabilitate the pelvic floor dysfunction. Identifying the presence of uterine prolapse does not necessarily require medical referral. Conservative care such as a program of pelvic floor recovery and management of sexual intercourse can be very helpful for the woman and may be the first step in treatment. Client education about positions in which gravity is used to assist the uterus in resuming its normal position can be very helpful.
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71 1
Spine Uterus
Fig. 15-7 • Uterine prolapse. First-degree prolapse (in vagina): the uterus has dropped up to onethird of the way into the vaginal canal. Second-degree prolapse (vaginal introitus): the uterus has descended fully into the vaginal canal, right down to the vaginal opening. Third-degree prolapse (outside vagina): the uterus is displaced downward even further and bulges outside the vaginal opening.
Rectum Cervix Vagina Bladder
First degree
Normal
Third degree
Second degree
For example, supine with a pillow or wedge support under the pelvis is a helpful rest position and can be used while the patient is doing pelvic floor exercises. It is also a more comfortable position for sexual intercourse for some women. Clinical Signs and Symptoms of Uterine Prolapse •
Trauma to the pudendal or sacral nerves during birth and delivery is an additional risk factor. Decreased muscle tone due to aging, complications of pelvic surgery, or excessive straining during bowel movements may also result in prolapse. Pelvic tumors and neurologic conditions such as spina bifida and diabetic neuropathy, which interrupt the innervation of pelvic muscles, can also increase the risk of prolapse.
Lump in vaginal opening
• Pelvic discomfort, backache • Abdominal cramping • Symptoms relieved by lying down • Symptoms made worse by prolonged standing, walking, coughing, or straining • Urinary incontinence CYSTOCELE A N D RECTOCELE
Cystocele is the protrusion or herniation of the urinary bladder against the wall of the vagina. Rectocele is a protrusion or herniation of the rectum and posterior wall of the vagina into the vagina (Fig. 15-8). Similar to the prolapsed uterus, these two pelvic floor disorders occur most often after pregnancy and childbirth but may also be associated with surgery and obesity (especially obesity combined with multiple pregnancies and births). These conditions are the result of pelvic floor relaxation or structural overstretching of the pelvic musculature or ligamentous structures. Patient history may include prolonged labor, bearing down before full dilation, forceful delivery of the placenta, instrument delivery (e.g., forceps, vacuum suction), chronic cough, or lifting of heavy objects.
Cystocele
Normal
Rectocele
Fig. 15-8 • Pelvic organ prolapse. Cystocele. The arrow shows displacement of the bladder against the vaginal canal. Rectocele. The uterus and bladder are in their proper anatomic place, but the rectum has prolapsed and is compressing against the vaginal canal. Many women have both conditions at the same time as a result of pregnancy and childbirth.
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Clinical Signs and Symptoms of Cystocele •
Urinary frequency and urgency
• • •
Difficulty emptying the bladder Cystitis (bladder infection) Painful lump or bearing down sensation in the perineal area • Urinary stress incontinence
Rectocele •
Pelvic, perineal pain and difficulty with defecation
• • •
Feeling of incomplete rectal emptying Constipation Painful intercourse
• Aching or pressure after a bowel movement
Endometriosis Endometriosis (see Chapter 14) is a pathologic condition of retrograde menstruation. Tissue resembling the mucous membrane lining the uterus occurs outside the normal location in the uterus but within the pelvic cavity, including the ovaries, pelvic peritoneum, bowel, and diaphragm. It occurs most often during the reproductive years and in up to 50% of women with infertility. ' Severity of pain is related more to the site than to the extent of disease. Pelvic pain associated with endometriosis can be referred to the low back, rectum, and lower sacral or coccygeal region, starting before or after the onset of menstruation and improving after cessation of menstrual flow, with cyclic recurrence. As the condition progresses, pain continues throughout the cycle, with exacerbation at menstruation and, finally, constant severity. Other symptoms may include rectal discomfort during bowel movements, diarrhea, constipation, recurrent miscarriage, and infertility. See Box 15-5 for more information on this condition. 30 31
Gynecalgia Although a pathologic cause can be identified for most cases of chronic pelvic pain, a small percentage remains for which no physical cause can be determined, and the term gynecalgia is used. Women with gynecalgia syndrome are usually 25 to 40 years of age and have at least one child. The symptoms are of at least 2 years' duration (and often many more), with acute exacerbation from time to time. Pain associated with gynecalgia is vague and poorly localized, although it is usually confined to
the lower abdomen and pelvis, radiating to the groin and upper and inner thighs. Other symptoms include dyspareunia, menstrual changes, low back pain, urinary and bowel changes, fatigue, and obvious anxiety and depression.
Screening for Infectious Causes of Pelvic Pain Infection is the most common cause of systemically induced pelvic pain. Infection or inflammation within the pelvis from acute appendicitis, diverticulitis, Crohn's disease, osteomyelitis, septic arthritis of the SI joint, urologic disorders, sexually transmitted infection (e.g., Chlamydia trachomatis), and salpingitis (inflammation of the fallopian tube) can produce visceral and somatic pelvic pain because of the involvement of the parietal peritoneum. Secondary pelvic infection may follow surgery, septic abortion, pregnancy, or recent birth as a result of the entry of endogenous bacteria into the damaged pelvic tissues. Pelvic inflammatory disease (PID) and sexually transmitted infection are the most common causes of infection in women. All these disorders have similar signs and symptoms during the acute phase. The client may not have any pain but will report low back or pelvic "discomfort," or there may be a report of acute, sharp, severe aching on both sides of the pelvis. Accompanying groin discomfort may radiate to the inner aspects of the thigh. Keep in mind that in the older adult, the first sign of any infection might not be an elevated temperature, but rather, confusion, increased confusion, or some other change in mental status. Right-sided abdominal or pelvic inflammatory pain is often associated with appendicitis, whereas left-sided pain is more likely associated with diverticulitis. Bilateral pain may indicate infection. The pain may be aggravated by increased abdominal pressure (e.g., coughing, walking). Knowing these pain patterns helps the therapist quickly decide what questions to ask and which associated signs and symptoms to look for. The therapist should test for iliopsoas or obturator abscesses (see Chapter 8). Other red flag symptoms may be reported in response to specific questions about disturbances in urination, odorous vaginal discharge, tachycardia, dyspareunia (painful or difficult intercourse), or constitutional symptoms such as fever, general malaise, and nausea and vomiting.
Pelvic
Inflammatory
Disease
PID consists of a variety of conditions (i.e., it is not a single entity), including endometritis, salpingitis,
CHAPTER 15
B O X 15-5
SCREENING THE SACRUM, SACROILIAC, A N D PELVIS
713
Resources (1-800-994-9662) or online at: http y/w ww. 4 woman. go v/
Endometriosis* • Endometriosis Zone, a service of The Universe of Women's Health—a commercial organization directed by a board of obstetricians and gynecologists. Information is directed at medical professionals, the medical industry, and women. The Endometriosis Zone is found at both of the following Web links: http://www.endozone.org http://www.endometriosiszone.org • Endometriosis Research Center was started as a lobbying organization. The goal of the ERC is to bring science and support together through education. http://www.endocenter.org or call (800) 239-7280. • The International Endometriosis Association (IEA) The IEA was established by Mary Lou Ballweg, RN, PhD, as an advocacy organization for endometriosis; offers online support for women diagnosed with endometriosis. http ://www. endometriosis as sn. org • The National Library of Medicine offers an interactive tutorial about endometriosis in both English and Spanish at: http://www.nlm.nih.gov/medlineplus/ tutorials/endometriosis
• Centers for Disease Control and Prevention provides a PID Fact Sheet: http://www.cdc.gov/std/PID/STDFact-PID.htm • Mount Auburn Obstetrics & Gynecologic Associates, Cincinnati, Ohio, a group of obstetric and gynecologic ( 0 B G Y N ) professionals; offering online education about endometriosis and other 0 B G Y N topics: http://www.mtauburnobgyn.com/pid.html Pelvic Pain • The American College of Obstetricians and Gynecologists ( A C 0 G ) offers information, education, and publications related to a wide variety of women's health issues: http ://www. acog.org/ The A C 0 G has recently issued a new practice bulletin on chronic pelvic pain in women. The guidelines were published as: A C 0 G Practice Bulletin No. 51. Chronic Pelvic Pain in Obstetrics and Gynecology 103(3):589-605, 2004. To read more about these guidelines, go to: http://www.medscape.com/viewarticle/471545 The International Pelvic Pain Society is a professional organization with the goal to enhance and improve the treatment of diseases that cause pelvic pain in men and women. Education for health care professionals is a major focus of this organization, which can be reached at:
Pelvic Inflammatory Disease (PID) • The National Women's Health Information Center (NWHIC) offers information on all aspects of women's health, including PID;
http://www.pelvicpain.org/
* Data from Deevey S: Endometriosis: Internet resources. Med RefServ Q 24(l):67-77, Spring 2005.
tubo-ovarian abscess, and pelvic peritonitis. Any inflammatory condition that affects the female reproductive organs (uterus, fallopian tubes, ovaries, cervix) may come under the diagnostic label of PID. PID is a bacterial infection that occurs whenever the uterus is traumatized; it is often associated with sexually transmitted infection/disease (STI/STD) and may occur after birth or after an abortion. Infection can be introduced from the skin, vagina, or GI tract. It can be an acute, one-time episode or may be chronic with multiple recurrences.
burning during urination. Pelvic pain does not occur until chlamydia leads to PID. When detected and treated early, chlamydia is relatively easy to cure. A direct relationship has been observed between early age of first sexual intercourse, the number of sexual partners a woman has, and the risk of STD (especially human papillomavirus, or HPV, a risk factor for cervical c a n c e r ) . PID may occur if chlamydia is not treated; even if it is treated, damage to the pelvic cavity cannot be reversed. The more partners a woman has, the greater is the risk of PID.
It is estimated that two-thirds of all cases are caused by STIs such as chlamydia and gonorrhea. Chlamydia is a bacterial sexually transmitted infection that is acquired through vaginal, oral, or anal intercourse. It is often asymptomatic but can present with vaginal bleeding and discharge and
If it progresses to PID, scarring in the pelvic organs, including the ovaries, fallopian tubes, bowel, and bladder, may cause chronic pain. Women can be left infertile because of damage and scarring to the fallopian tubes. After a single episode of PID, a woman's risk of ectopic pregnancy
32
33,34
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increases sevenfold compared with the risk for women who have no history of P I D . ' 35
36
Clinical Signs and Symptoms of Pelvic I n f l a m m a t o r y Disease • Often asymptomatic • Vaginal discharge or bleeding • Burning on urination (dysuria) • Moderate (dull aching) to severe abdominal and/or pelvic pain; back pain is possible • • •
Painful intercourse (dyspareunia) Painful menstruation Constitutional symptoms (fever, chills, nausea, vomiting)
STIs such as chlamydia and syphilis are on the rise among America's sexually active young adult population (ages 18 to 25). In fact, chlamydia was the most commonly reported infectious disease in the United States in 2004. According to the Centers for Disease Control (CDC) annual report, the highest rates of chlamydia occur in sexually active women ages 15 to 19. Syphilis predominates in homosexual men (men having sex with men) who engage in risky sexual behavior (e.g., unprotected oral sex). " It does not happen often, but there may be times when the therapist must ask about the possibility of an STL Sexually active women with vague symptoms are the most likely group to be interviewed about STIs/STDs. See specific screening questions in Chapter 14 and Appendix B-29. Any of the red flags listed in Box 15-4 in the presence of pelvic pain raises the suspicion of a medical problem. Medical referral must be made as quickly as possible. Early medical intervention can prevent the spread of infection and septicemia, and can preserve fertility. Damage to the pelvic floor from any of these conditions can result in pelvic floor dysfunction that is within the scope of a physical therapist's practice. See Box 15-5 for resources that can provide more information on this and other conditions. 36
38
Screening for Vascular Causes of Pelvic Pain Vascular problems that affect the pelvic cavity and pelvic floor musculature have two primary causes. The first is the general condition of peripheral vascular disease (PVD); the second is a specific example of PVD called pelvic congestion syndrome from ovarian varicoceles. Other conditions such as abdominal angina and abdominal aneurysm are less common vascular causes of pelvic pain; these
conditions are Chapter 6.
Peripheral
discussed in greater
Vascular
detail in
Disease
The iliac arteries may become gradually occluded by atherosclerosis or may be obstructed by an embolus. The resultant ischemia produces pain in the affected limb but may also give rise to pelvic pain. Whether the occlusion is thrombotic or embolic, the client may report pain in the pelvis, affected limb, and possibly the buttocks. The pain is characteristically aggravated by exercise (claudication). Typically, symptoms develop 5 or 10 minutes after the client has started the activity. This lag time is characteristic of a vascular pain pattern associated with atherosclerosis or blood vessel occlusion. Musculoskeletal causes of pelvic pain are also made worse by activity and exercise, especially weight-bearing exercise, but the timing is not as predictable as with pain from vascular causes. Musculoskeletal conditions may cause pain immediately (e.g., with muscle strain or trigger points) or, more likely, after prolonged activity or exercise. The affected limb becomes colder and paler. In sudden occlusion, diminished sensation to pinprick may be observed on examination. Femoral and distal arteries should be palpated for pulsation. Thrombosis of the large iliac veins may occur spontaneously after injury to the lower limb and pelvis, or it may appear after pelvic surgical procedures. An estimated 30% of clients have asymptomatic deep vein thrombosis after major surgery. Thrombosis that occludes the iliac vein produces an enlarged, warm, and painful leg; occasionally, discomfort in the pelvis is noted. Anyone with PVD can demonstrate the same kind of symptoms in the pelvic floor structures. The most likely age group to be affected by vascular disease is adults over 60, especially women who are postmenopausal. Watch for a history of heart disease with a clinical presentation of pelvic, buttock, and leg pain that is aggravated by activity or exercise (claudication). Look for changes in skin and temperature on the affected side (arterial occlusion or venous thrombosis), especially in the presence of known heart disease or recent pelvic surgery (see Box 4-12; see Case Example 15-2).
Pelvic
Congestion
Syndrome
Varicose veins of the ovaries (varicosities) cause the blood in the veins to flow downward rather than up toward the heart. They are a manifesta-
CHAPTER 15
CASE
EXAMPLE
15-2
Pelvic and Buttock P a i n
A 34-year-old man with leukemia had a routine bone marrow biopsy near the left posterior superior iliac crest. No problems were noted at the time of biopsy, but 2 days later, the man came into physical therapy complaining of pelvic pain. He said his platelet count was 50,000/uL and international normalized ratio (INR, a measure of clotting time) was "normal." Laboratory values were recorded on the day of the biopsy. The only clinical findings were a positive Faber's (Patrick's) test on the left and tenderness to palpation over the left sciatic notch, about an inch below the biopsy site. No abnormal neurologic signs were observed. What are the red flags in this scenario? Use the screening model to find the red flags and decide what to do. History: Current history of cancer; recent history of biopsy Clinical Presentation: Reduced platelet count (normal is >100,000); new onset of painful symptoms within 48 hours of biopsy; tenderness to palpation in left buttock Associated Signs and Symptoms: None. Client had no other signs and symptoms.
tion of PVD and a potential cause of chronic pelvic pain. The condition has been called pelvic congestion syndrome (PCS) or ovarian varicocele. The specific impairment associated with PCS is an incompetent and dilated ovarian vein with retrograde blood flow (Fig. 15-9). Venous stasis produces congestion and pelvic pain. Imaging studies have verified the fact that very few venous valves are found in the blood vessels of the pelvic area. " Any compromise of the valves (or blood vessels) in the area can lead to this condition. It can also occur as the result of kidney removal or donation because the ovarian vein is cut when the kidney is removed. Varicosity of the gonadal venous plexus can occur in men and is more readily diagnosed by the presentation of observable varicosities of the scrotum. Many women are unaware that they have this problem and remain asymptomatic. Women of childbearing age are affected most often. Many have had three or four (or more) pregnancies and are 40 years old or older. 39
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SCREENING THE SACRUM, SACROILIAC, AND PELVIS
The therapist has to make a clinical judgment in a case like this. The platelet level is low, putting the client at risk for poor clotting and spontaneous bleeding, but the INR suggests that the body is able to initiate the coagulation cascade. Given the timing between the biopsy and the symptoms, it is likely that the procedure caused an intramuscular hematoma. The diagnosis can be made with a computed tomography scan. The location of biopsy needle entry indicates that the gluteus medius was punctured. No major blood vessel is located in this area, so the problem is rare. Pain after bone marrow biopsy is usually mild to moderate and gradually gets better. The use of ice, massage, and, later, moist heat is safe when properly applied. Worsening buttock pain over the next 24 to 48 hours would necessitate a medical referral. It is always a good idea to contact the primary care physician and report your findings and intended intervention. This gives the doctor the option of following up with the client immediately if he or she thinks it is warranted.
Varicose Veins of the Ovary
.Arteries
Uterus Veins
Fallopiar tube
41
Ovary
Fig. 15-9 • Ovarian varicosities associated with pelvic congestion syndrome are the cause of chronic pelvic pain for women. This form of venous insufficiency is often accompanied by prominent varicose veins elsewhere in the lower quadrant (buttocks, thighs, calves). Men may have similar varicosities of the scrotum (not shown).
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Symptoms of ovarian varicosities reflect the vascular incompetence associated with venous insufficiency These symptoms include pelvic pain that worsens toward the end of the day or after standing for a long time, pain after intercourse, sensation of heaviness in the pelvis, and prominent varicose veins elsewhere on the body, especially the buttocks and t h i g h s . 3942
Clinical Signs and Symptoms of Pelvic Congestion S y n d r o m e ( O v a r i a n varicosities) •
Lower abdominal/pelvic pain (intermittent or continuous, described as "dull aching" but can be sharp and severe) • Unilateral or bilateral • Pain that worsens with prolonged standing or at the end of the day • Pain that is worse before or during menses •
Pain or "aching" that occurs after intercourse
(dyspareunia) • Presence of varicose veins in the buttocks, thighs, or lower extremities • Low backache is a common feature, made worse by standing •
Other associated signs and symptoms (these vary; see text below)
Other associated symptoms may vary and include vaginal discharge, headache, emotional
CASE
EXAMPLE
15-3
distress, GI distress, constipation, and urinary frequency and urgency. An undetermined number of women also have endometriosis, but the relationship is unknown. Varicosities may be large enough to compress the ureter, leading to these urologic symptoms. Fatigue (loss of energy) and insomnia are common in women who experience headache with PCS (Case Example 15-3). Medical treatment for pelvic congestion syndrome is under investigation. To date, analgesics, hormone therapy, and ovarian vein ligation or embolization have been used with some success. 43
Screening for Cancer as a Cause of Pelvic Pain The female pelvis is a depository for malignant tissue after incomplete removal of a primary carcinoma within the pelvis, for recurrence of cancer after surgical resection or radiotherapy of a pelvic neoplasm, or for metastatic deposits from a primary lesion elsewhere in the abdominal cavity. Metastatic spread can occur from any primary tumor in the abdominal or pelvic cavity (see Fig. 13-2). For example, colon cancer can metastasize to the pelvic cavity by direct extension through the bowel wall to the musculoskeletal walls of the pelvic cavity or to surrounding organs. This may produce fistulas into the small intestine, bladder, or vagina. Advanced rectal tumors can become "fixed" to the sacral hollow. Deep pain within the
Pelvic Congestion S y n d r o m e
If a woman presents with chronic pelvic pain, how would you assess for a vascular problem? Or, ovarian varicosities as a possible cause? Remember, we are not trying to make a medical diagnosis, but rather, to look for clues to suggest when medical referral is required. Use the overall clues in our screening model. What kind of past medical history and risk factors would you expect to see? With a vascular cause of pelvic pain, a history of heart disease is often reported in a postmenopausal woman. With ovarian varicosities, multiparity is usually present (i.e., a woman who has had several fullterm pregnancies and deliveries). What would you expect to see in the clinical presentation? With a vascular cause of pelvic pain, the client often reports pelvic, buttock, and leg pain or "discomfort" that is aggravated by
activity or exercise. With varicosities, the client usually has a generalized dull ache in the lower abdominal/low back area that is worse after standing, after intercourse, or just at the end of the day. When you ask the client what other symptoms are present, she may not have any other symptoms, but if she does, look for a cluster of vascular signs and symptoms. These can be found in Box 4-17. With ovarian varicocele, visually observe for varicose veins in the legs. These are a prominent feature in the clinical presentation of most women with ovarian varicosities. Ask about the presence of associated signs and symptoms such as vaginal discharge, headache, gastrointestinal distress, insomnia, and urologic symptoms.
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SCREENING THE SACRUM, SACROILIAC, A N D PELVIS
pelvis may indicate spread of neoplasm into the sacral nerve plexuses. Cancer recurrence can also occur after radiotherapy or surgery to the abdominal or pelvic cavity. This happens most often when incomplete removal of the primary carcinoma has occurred.
Using the Screening Model for Cancer In the case of cancer as a cause of pelvic pain, a past history of cancer is usually present, most commonly, cancer within the pelvic or abdominal cavity (e.g., GI, renal, reproductive). A history of cancer with recent surgical removal of tumor tissue followed by back, hip, sacral, or pelvic pain within the next 6 months is a major red flag. Even if it appears to be a clear neuromuscular or musculoskeletal problem, referral is warranted for medical evaluation. A common clinical presentation of pelvic or abdominal cancer referred to the soma is one of back, sacral, or pelvic pain described as one or more of the following: deep aching, colicky, constant with crescendo waves of pain that come and go, or diffuse pain. Usually, the client cannot point to it with one finger (i.e., pain does not localize). The therapist must remember to ask whether the client is having any symptoms of any kind anywhere else in the body. This is vitally important! Signs and symptoms associated with pelvic pain can range from constitutional symptoms to symptoms more common with the GI, GU, or reproductive system. The therapist must ask about blood in the urine or stools. Once the physical therapy examination has been completed, including the history, risk factor assessment, pain patterns, and any associated signs and symptoms, it is time to step back and conduct a Review of Systems (see Chapters 1 and 4). The Review of Systems is part of the evaluation described in the Guide's Elements of Patient/ Client Management that leads to optimal outcomes (see Fig. 1-4). It is part of the dynamic process in which the therapist makes clinical judgments on the basis of data gathered during the examination. In the screening process, the therapist reviews the following: • Do any red flags in the history or clinical presentation suggest a systemic origin of symptoms? • Are any red flags associated signs and symptoms? • What additional screening tests or questions are needed (if any)?
717
• Is referral to another health care provider needed, or is the therapist clear to proceed with a planned intervention (Case Example 15-4)? Keep in mind the Clues Suggesting Systemic Pelvic Pain, which are listed at the end of this chapter. If hip or groin pain is an accompanying feature with pelvic pain, review Clues Suggesting Systemic Hip and Groin Pain (see Chapter 16); likewise for anyone with pelvic and back pain (see Clues Suggesting Systemic Back Pain [Chapter 14]). The therapist can use the Special Questions to Ask at the end of Chapter 14. It may not be necessary to ask all these questions. The therapist can use the overall clues gathered from the history, risk factor assessment, clinical presentation, and associated signs and symptoms, while reviewing the list of special questions to see whether there is anything appropriate to ask the individual client.
Gynecologic Cancers Cancers of the female genital tract account for about 12% of all new cancers diagnosed in women. Although gynecologic cancers are the fourth leading cause of death from cancer in women in the United States, most of these cancers are highly curable when detected early. The most common cancers of the female genital tract are uterine endometrial cancer, ovarian cancer, and cervical cancer. 44
E N D O M E T R I A L (UTERINE) C A N C E R
Cancer of the uterine endometrium, or lining of the uterus, is the most common gynecologic cancer, usually occurring in postmenopausal women between the ages of 50 and 70 years. Its occurrence is associated with obesity, endometrial hyperplasia, prolonged unopposed estrogen therapy (hormone replacement therapy without progesterone), and, more recently, tamoxifen used in the treatment of breast cancer. ' Clinical Signs and Symptoms Seventy-five percent of all cases of endometrial cancer occur in postmenopausal women. The most common symptom is abnormal vaginal bleeding or discharge at presentation. However, 25% of these cancers occur in premenopausal women, and 5% occur in women younger than 40 years. In a physical therapy practice, the most common presenting complaint is pelvic pain without abnormal vaginal bleeding. Abdominal pain, weight loss, and fatigue may occur but remain unreported. Unexpected or unexplained vaginal bleeding in a woman taking tamoxifen (chemoprevention for breast cancer) is a red flag sign. Tamoxifen 45
46
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CASE
EXAMPLE
15-4
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
P e r i p h e r a l N e u r o p a t h y of the Pelvic F l o o r
A 57-year-old woman presented with an unusual triad of symptoms. She reported numbness and tingling of the feet, urinary incontinence, and migrating arthralgias and myalgias of the lower body (e.g., low back or hip, sometimes hip adductor spasm or aching, a "heavy" sensation in the pelvic region). Past Medical History: Significant previous medical history included a hysterectomy 10 years ago for uncontrolled bleeding, and oophorectomy 2 years ago followed by pelvic radiation for ovarian cancer. She is a nonsmoker and a nondrinker and is in apparent good health after cancer treatment. She is not taking any medications or using any drugs or supplements. All follow-up checks have have detected no signs of cancer recurrence. She is active in a women's cancer support group and exercises 4 or 5 times a week. She has kept a journal of activities, foods, and symptoms but cannot find a pattern to explain any of her symptoms. Urinary incontinence is present continually with constant dripping and leaking. It is not made worse by exercise, the sound or feel of running water, putting the key in the door, or other triggers of urge or stress incontinence. Bowel function is reportedly "normal." The client is a widow and is not currently sexually active. Where do you go from here? What are the red flags? What questions do you ask? What tests do you perform? Is medical referral needed? Red Flags • Age • Previous history of cancer • Bilateral symptoms (numbness and tingling in both feet) Screening
Questions
Menstrual history, including pregnancies, miscarriages or abortions, births; current menstrual status (perimenopausal, postmenopausal, hormone replacement therapy) Any symptoms or other problems anywhere else in the body? Screening
Tests
Can you reproduce any of the muscle or joint pain?
Neurologic screen: Besides the usual manual muscle testing, deep tendon reflexes, and sensation, the therapist should test for lower extremity proprioception and assess feet more closely to identify the level of peripheral nerve dysfunction. • Ask about the presence of other neurologic symptoms such as headache, muscle weakness, confusion, depression, irritability, blurred vision, balance/coordination problems, memory changes, and sleepiness. • Some of these are more likely when the central nervous system is impaired; for now it looks as though we are looking at a problem in the peripheral nervous system, but paraneoplastic syndrome or metastases to the central nervous system can occur. Assess for signs of skin or soft tissues, including the presence of lymphedema Palpate the lymph nodes Assess vital signs Medical
Referral
Immediate medical referral is warranted if the patient has not been evaluated recently. It is impossible to tell whether her symptoms are radiation induced or are signs of cancer recurrence. A phone conversation between therapist and the oncologist may be all that is needed. Information gathered during the interview and examination should be summarized for the physician. Result: The client had peripheral neuropathies that affected the bladder, pelvic floor muscles, and feet because the same nerves innervate these two areas. Physical therapy intervention remained appropriate, and cancer recurrence was ruled out. Radiation therapy is well known to cause significant delayed, chronic effects on connective tissue and nervous system. Fibrosis of connective tissue can result in impairment of the soft tissues such as pelvic adhesions with subsequent functional limitations. The incidence of plexopathy after radiation therapy has been reduced significantly with improved treatment, but it still occurs in a small number of cases. Younger women seem more vulnerable to radiation-induced peripheral neuropathy.
CHAPTER 15
is a well-known carcinoma.
risk
factor
for
endometrial
47
Clinical Signs and Symptoms of Endometrial (Uterine) Cancer •
• • • •
Unexpected or unexplained vaginal bleeding or vaginal discharge after menopause (extremely significant sign) Persistent irregular or heavy bleeding between menstrual periods, especially in obese women Watery pink, white, brown, or bloody discharge from the vagina Abdominal or pelvic pain (more advanced disease) Weight loss, fatigue
OVARIAN CANCER
Ovarian cancer is the second most common reproductive cancer in women and the leading cause of death from gynecologic malignancies, accounting for more than half of all gynecologic cancer deaths in the Western world. Risk Factors Risk increases with advancing age, and the incidence of ovarian cancer peaks between the ages of 40 and 70 years. Other factors that may influence the development of ovarian cancer include the following: • Nulliparity (never being pregnant), giving birth to fewer than two children, giving birth for the first time when over age 35 • Personal or family history of breast, endometrial, or colorectal cancer • Family history of ovarian cancer (mother, sister, daughter; especially at a young age); carrying the BRCA1 or BRCA2 gene • Infertility • Early menopause • Exposure to talc, or asbestosis (remains under investigation) " Identification of the BRCA1 or BRCA2 gene and subsequent evidence for a family of genes that may play a role in the breast-ovarian syndrome and familial ovarian cancer offer the possibility of identifying women truly at risk for this disease. No reliable screening test can detect ovarian cancer in its early, most curable stages. Two diagnostic tests are used, but both lack sensitivity and specificity. The CA-125 blood test (carcinoembryonic antigen, a biologic marker) shows elevation in about half of women with early-stage disease and about 80% of those with advanced disease. Transvaginal ultrasonography helps determine whether an existing ovarian growth is benign or cancerous. 48
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SCREENING THE SACRUM, SACROILIAC, A N D PELVIS
Because early-stage symptoms are nonspecific, most women do not seek medical attention until the disease is advanced. The ovaries begin in utero, where the kidneys are located in the fully developed human, and then migrate along the pathways of the ureters. Following the viscerosomatic referral patterns discussed in Chapter 3, ovarian cancer can cause back pain at the level of the kidneys. Murphy's percussion test (see Chapter 10) would be negative; other symptoms of ovarian cancer might be present but remain unreported if the woman does not recognize their significance. Clinical Signs and Symptoms of Ovarian or Primary Peritoneal Cancer Retrospective studies indicate that more than 70% of women with ovarian cancer have symptoms for 3 months or longer before diagnosis. Early symptoms are often vague, nonspecific, and easily overlooked: • Persistent vague GI complaints • Abdominal discomfort, bloating, increase in abdominal or waist size (ascites) • Indigestion, belching • Early satiety • Mild anorexia in a woman age 40 or older 53
• •
Vaginal bleeding Changes in bowel or bladder habits, especially urinary frequency or severe urinary urgency • Pelvic discomfort or pressure; back pain •
Ascites, pain, and pelvic mass (advanced disease)
Rarely, a woman with ovarian carcinoma will present first with a paraneoplastic syndrome such as polyarthritis syndrome, carpal tunnel syndrome, myopathy, plantar fasciitis, or palmar fasciitis (swelling, digital stiffness or contractures, palmar erythema). The condition may be misdiagnosed as chronic regional pain syndrome (formerly reflex sympathetic dystrophy), Dupuytren's contracture, or a rheumatologic disorder. Hand and upper extremity manifestations often appear before the tumor is clinically evident. Treatment of the symptoms will have little effect on these conditions. Only successful treatment of the underlying neoplasm will affect symptoms favorably. The therapist should consider it a red flag whenever someone does not improve with physical therapy intervention. Failure to respond or worsening of symptoms requires a second screening 54
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examination. Progression of disease is often accompanied by a cluster of new signs and symptoms. EXTRAOVARIAN PRIMARY PERITONEAL CARCINOMA Extraovarian primary peritoneal carcinoma (EOPPC) is an abdominal cancer (peritoneal carcinomatosis) without ovarian involvement. It arises in the peritoneum and mimics the symptoms, microscopic appearance, and pattern of spread of endothelial ovarian cancer with no identifiable disease of the ovaries. EOPPC develops only in women and accounts for most extraovarian causes of symptoms with a presumed but inaccurate diagnosis of ovarian cancer. EOPPC has been reported after bilateral oophorectomy performed for benign disease or prophylaxis. The occurrence of EOPPC with the same histology as neoplasms arising within the ovary may be explained by the common origin of the peritoneum and the ovaries from the coelomic epithelium. 55
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CERVICAL CANCER Cancer of the cervix is the third most common gynecologic malignancy in the United States. It is the most common cause of death from gynecologic cancer in the world. Since the widespread introduction of the Papanicolaou (Pap) smear as a standard screening tool, the diagnosis of cervical cancer at the invasive stage has decreased significantly. Even so, nearly half of all women diagnosed with cervical cancer are diagnosed at a late stage, with locally or regionally advanced disease and a poor prognosis. At the same time that rates of invasive cervical carcinoma have been on the decline, the highly curable preinvasive carcinoma in situ (CIS) has increased. CIS is more common in women 30 to 40 years of age, and invasive carcinoma is more frequent in women over age 40 years. Risk Factors Risk factors associated with the development of cervical cancer are many and varied and include the following: • Early age at first sexual intercourse • Early age at first pregnancy • Tobacco use, including exposure to passive smoke • Low socioeconomic status (lack of screening) • History of any sexually transmitted disease (especially HPV and human immunodeficiency virus [HIV]) • History of multiple sex partners • History of childhood sexual abuse 44
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• Intimate partner abuse • Women whose mothers used the drug diethylstilbestrol (DES) during pregnancy Research into the health effects of intimate partner abuse points to a higher risk of STD and prevention of women from seeking health care; both contribute to an increased risk of cervical cancer. Women with a past history of childhood sexual abuse may avoid regular gynecologic care because being examined triggers painful memories. A history of childhood sexual abuse also increases a woman's risk of exposure to STIs that may contribute to the development of cervical cancer. The American Cancer Society (ACS) has issued updated recommendations for the early detection of cervical cancer. The ACS advises all women to start cervical cancer screening 3 years after beginning to have vaginal intercourse, but no later than age 21. Pap smears should be done regularly, usually every year. After a total hysterectomy (including removal of the cervix) or after age 70, the Pap smear is discontinued. In the normal healthy adult female age 30 years or older, after three negative annual examinations, the Pap may be performed less frequently at the advice of the physician. Women with certain risk factors for cervical cancer (e.g., HIV infection, longterm steroid use, immunocompromised status, DES exposure before birth) should be advised to have an annual Pap smear. Clinical Signs and Symptoms Early cervical cancer has no symptoms. Clinical symptoms related to advanced disease include painful intercourse; postcoital, coital, or intermenstrual bleeding; and a watery, foul-smelling vaginal discharge. Disease usually spreads by local extension and through the lymphatics to the retroperitoneal lymph nodes (see Table 13-5). Metastases to the central nervous system can occur hematogenously late in the course of the disease and are generally rare. Clinical presentation of brain metastases depends on the site of the metastasized lesion; hemiparesis and headache are the most commonly reported signs and symptoms. 59
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Clinical Signs and Symptoms of Cervical Cancer • May be asymptomatic (early stages) • Painful intercourse or pain after intercourse • Unexplained or unexpected bleeding • Watery, foul-smelling vaginal discharge • Hemiparesis, headache (cancer recurrence with brain metastases)
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SCREENING THE SACRUM, SACROILAC, A N D PELVIS
Screening for Gastrointestinal Causes of Pelvic Pain Gastrointestinal conditions can cause pelvic pain. The most common causes of pelvic pain referred from the GI system are the following: • Acute appendicitis • Inflammatory bowel disease (IBD; Crohn's disease or regional enteritis, ulcerative colitis) • Diverticulitis • Irritable bowel syndrome (IBS) The small bowel, sigmoid, and rectum can be affected by gynecologic disease; low back or pelvic pain may result from pressure or displacement of these organs. Swelling, reaction to an adjacent infection, or reaction to the spilling of blood, menstrual fluid, or infected material into the abdominal cavity can cause pressure or displacement. Bowel function is usually altered, but sometimes, the client experiences periods of normal bowel function alternating with intermittent bowel symptoms, and the client does not see a pattern or relationship until asked about current (or recent) changes in bowel function. For all of these conditions, the symptoms as seen or reported in a physical therapy practice are usually the same. The client may present with one or more of the following: • GI symptoms (see Box 4-17) • Symptoms aggravated by increased abdominal pressure (coughing, straining, lifting, bending) • Iliopsoas abscess (see Figs. 8-3 through 8-6; a positive test is indicative of an inflammatory/ infectious process) • Positive McBurney's point (see Figs. 8-8 and 89; appendicitis) • Rebound tenderness or Blumberg's sign (see Fig. 8-10; appendicitis or peritonitis) Appendicitis can cause peritoneal inflammation with psoas abscess, resulting in referred pain to the low back, hip, pelvis, or groin area (Case Example 15-5). The position of the vermiform appendix in the abdominal cavity is variable (see Fig. 8-9). Negative tests for appendicitis that use McBurney's point may occur when the appendix is located somewhere other than at the end of the cecum. See Fig. 8-10 for an alternate test (Blumberg's sign). Clinical signs and symptoms of appendicitis are listed in Chapter 8. Blumberg's sign, a test for rebound tenderness, is usually positive in the presence of peritonitis, appendicitis, PID, or any other infection or inflammation associated with abdominal or pelvic conditions. Acute appendicitis is rare in older adults, but half of all those who die from a ruptured appendix are over 6 5 . 63
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The test for rebound tenderness can be very painful for the client. The therapist is advised to do this test last. Some clinicians prefer to start out with this test (the only screening test used for abdominal or pelvic inflammation or infection) and to make a medical referral immediately when it is positive. This is really a matter of professional preference based on experience and clinical judgment. In our experience, the iliopsoas and obturator tests are useful tools. If back pain (rather than abdominal quadrant pain) is the response, the therapist is alerted to the need to assess these muscles further and to consider their role in low back pain. If the iliopsoas test is negative for lower quadrant pain, the therapist can palpate the integrity of the iliopsoas muscle and assess for trigger points (see Fig. 8-5). If the tests are negative (i.e., they do not cause abdominal pain), then the therapist can palpate McBurney's point for the appendix. If McBurney's is negative but an infectious cause of symptoms is suspected, the test for rebound tenderness can be conducted last. Clients with symptoms of a possible inflammatory or infectious origin usually have a history of the conditions mentioned earlier (e.g., appendicitis, IBD or IBS, other GI disease). PID is another common cause of pelvic pain that can cause psoas abscess and a subsequent positive iliopsoas or obturator test. In this case, it is most likely a young woman with multiple sexual partners who has a known or unknown case of untreated chlamydia. Crohn's disease, chronic inflammation of all layers of the bowel wall (see Chapter 8), may affect the terminal ileum and cecum or the rectum and sigmoid colon in the pelvis. In addition to pelvic and low back pain, systemic manifestations of Crohn's disease may include intermittent fever with sweats, malaise, anemia, arthralgias, and bowel symptoms. Diverticular disease of the colon (diverticulosis), an acquired condition most common in the fifth to seventh decades, appears with intermittent symptoms. Moderate to severe pain in the left lower abdomen and the left side of the pelvis may be accompanied by a feeling of bowel distention and bowel symptoms such as hard stools, alternating diarrhea and constipation, mucus in the stools, and rectal bleeding. IBS produces persistent, colicky lower abdominal and pelvic pain associated with anorexia, belching, abdominal distention, and bowel changes. Symptoms are produced by excessive colonic motility and spasm of the bowel (spastic colon).
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CASE
S E C T I O N III
EXAMPLE
15-5
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Appendicitis
Background: A 23-year-old woman who was training for a marathon developed groin and pelvic pain—first just on the right side, but then on both sides. She reported that the symptoms came on gradually over a period of 2 weeks. She could not point to a particular spot as the source of the pain, but rather, indicated a generalized lower abdominal, pelvic, and inner thigh area. She denied ever being sexually active and had never been diagnosed with a sexually transmitted disease. She was on a rigorous training schedule for the marathon, did not appear anorexic, and seemed in overall good health. No signs of swelling, inflammation, or temperature change were noted in the area. Running made the pain worse, rest made it better. Range of motion of the hip and back was full and painless. A neurologic screening examination was normal. Resisted hip abduction was "uncomfortable" but did not exactly reproduce the symptoms. What are the red flags here? What do you ask about or do next? Not very many red flags are present: the bilateral presentation and overall size and location of the symptoms are the first two to be considered. Aggravating and relieving factors seem consistent with a musculoskeletal problem, but objective findings to support an impairment of the movement system are significantly lacking. What do you ask about or do next? Take the client's vital signs, including body temperature, blood pressure, respiratory rate, and heart rate. If you are pressed for time, at least take the body temperature and blood pressure.
See Chapter 8 for additional details about the referred pain patterns and most common associated signs and symptoms for each of these diseases.
Screening for Urogenital Causes of Pelvic Pain Infection of the bladder or kidney, kidney stones, renal failure (chronic kidney disease), spasm of the
Perform one or more of the tests for abdominal or pelvic infection/inflammation. You can go right to the rebound (Blumberg's) test, or you can assess the soft tissues one at a time as discussed in the text. If this is negative, consider trigger points as a possible source of painful symptoms. Ask the client about constitutional symptoms or other symptoms anywhere else in the body. Your next step or steps in interviewing or assessing the client will depend on the results of your evaluation so far. Once you have compiled the clinical presentation, step back and conduct a Review of Systems. If a cluster of signs and symptoms is associated with a particular visceral system, look over the Special Questions to Ask at the end of the chapter that address that system. Check the Special Questions for Men and Women. Have you left out or missed any that might be appropriate to this case? Results: The client had normal vital signs but reported "night and day sweats" from time to time. The iliopsoas and obturator tests caused some general discomfort but were considered negative. McBurney's point was positive, eliciting extreme pain. Blumberg's test for rebound was not performed. The client was referred to the emergency department immediately because she did not have a primary care physician. It turned out that this client had peritonitis from a ruptured appendix. The doctors think she was in such good shape with a high pain threshold that she presented with minimal symptoms (and survived). Her white blood count was almost 100,000 at the time that laboratory work was finally ordered.
urethral smooth muscle, and tumors in any of the urogenital organs can refer pain to the lower lumbar and pelvic regions, mimicking musculoskeletal dysfunction. Pelvic floor tension myalgia can develop in response to these conditions and create pelvic pain. The primary pain pattern may radiate around the flanks to the lower abdominal region, the genitalia, and the anterior/medial thighs (see Figs. 10-7 to 10-10).
CHAPTER 15
SCREENING THE SACRUM, SACROILIAC, A N D PELVIS
Usually, the most common diseases of this system appear as obvious medical problems. In the physical therapy setting, past medical history, risk factors, and associated signs and symptoms provide important red-flag clues. The therapist needs to ask the client about the presence of painful urination or changes in urination and constitutional symptoms such as fever, chills, sweats, and nausea or vomiting. Deep, aching pelvic pain that is worse on weight-bearing or is accompanied by sciatica or numbness and tingling in the groin or lower extremity may be associated with cancer recurrence or cancer metastases.
Screening for Other Conditions as a Cause of Pelvic Pain Psychogenic pain is often ill defined, and its anatomic distribution depends more on the person's concepts than on clinical disease processes. Pelvic pain may co-evolve with relational dysfunction. Such pain does not usually radiate; commonly, the client has multiple unrelated symptoms, and fluctuations in the course of symptoms are determined more by crises in the person's psychosocial life than by physical changes. (See also Screening for Emotional and Psychologic Overlay in Chapter 3.) A history of sexual abuse in childhood or adulthood (men and women) may contribute to chronic pelvic pain or symptoms of a vague and diffuse nature. In some cases, the link between abuse and pelvic pain may be psychologic or neurologic, or may result from biophysical changes that heighten a person's physical sensitivity to pain. Taking a history of sexual abuse may be warranted. Occasionally, a woman has been told there is no organic cause for her distressing pelvic pain. Chronic vascular pelvic congestion, enhanced by physical or emotional stress, may be the underlying problem. The therapist may be instrumental in assessing for this condition and providing some additional clues to the medical community that can lead to a medical diagnosis. Surgery, in particular hysterectomy, is associated with varying amounts of pain from problems such as nerve damage, scar formation, or hematoma formation with infection, which can cause backache and pelvic pain. Lower abdominal discomfort, vaginal discharge, and fatigue may accompany pelvic pain or discomfort months after gynecologic surgery. Other types of abdominal, pelvic, or tubal surgery, such as laparotomy, tubal ligation, or 64
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laminectomy, can also be followed by pelvic pain, usually associated with low back pain. During the client interview, the therapist must include questions about recent surgical procedures.
PHYSICIAN REFERRAL Guidelines for Immediate Medical Attention Immediate medical attention is required anytime the therapist identifies signs and symptoms that point to fracture, infection, or neoplasm. For example, a positive rebound test for appendicitis or peritonitis requires immediate medical referral. Likewise, severe sacral pain in the presence of a previous history of uterine, abdominal, prostate, rectal, or anal cancer requires immediate medical referral. Suspicion of any infection (e.g., STD, PID) requires immediate medical referral. Early medical intervention can prevent the spread of infection and septicemia and preserve fertility. A sexually active female with shoulder or back pain of unknown cause may need to be screened for ectopic pregnancy. Onset of symptoms after a missed menstrual cycle or in association with unexplained or unexpected vaginal bleeding requires immediate medical attention. Hemorrhage from ectopic pregnancy can be a lifethreatening condition.
Guidelines for Physician Referral Blood in the toilet after a bowel movement may be a sign of anal fissures or hemorrhoids but can also signal colorectal cancer. A medical differential diagnosis is needed to make the distinction. History of an unrepaired hernia or suspected undiagnosed hernia requires medical referral. Lateral wall pelvic pain referred down the anteromedial side of the thigh to the knee can occur with femoral hernias; inguinal hernias are more likely to cause groin pain. A history of cancer with recent surgical removal of tumor tissue followed by back, hip, sacral, or pelvic pain within 6 months of surgery is a red flag for possible cancer recurrence. Even in the presence of apparent movement system impairment, referral for medical evaluation is warranted. All adolescent females and adult women who are sexually active or over the age of 21 should be asked when their last Pap smear was done and what the results were. The therapist can play an important part in client education and disease prevention by teaching women about the importance
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SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
of an annual Pap smear and encouraging them to schedule one, if appropriate. Women with conditions such as endometriosis, pelvic congestion syndrome, STI, and PID can be helped with medical treatment. Medical referral is advised anytime a therapist identifies signs and symptoms that suggest any of these conditions. Failure to respond to physical therapy intervention is usually followed by reevaluation that includes a second screening and a Review of Systems. Any red flags or cluster of suspicious signs and symptoms must be reported. Depending on the therapist's findings, medical evaluation may be the next step.
Clues to Screening the Sacrum/Sacroiliac Past
Medical
History
• Previous history of Crohn's disease; presence of skin rash with new onset of sacral, hip, or leg pain • Previous history of other GI disease • Previous history of rheumatic disease • Previous history of conjunctivitis or venereal disease (Reiter's syndrome) • History of heart disease or PVD; the therapist should ask about the effect of activity on symptoms • Remember to consider unreported assaults or anal intercourse (partnered rape, teens, homosexual men with men). Please note that many of today's teens are resorting to anal intercourse and oral sex in an effort to prevent pregnancy. These forms of sexual contact do not prevent STD. In addition, they can result in sacral pain and other lesions (e.g., rectal fissures) caused by trauma.
Clinical
Presentation
• Constant (usually intense) pain; pain with a "catch" or "click" (sacral fracture) • Sacral pain occurs when the rectum is stimulated (pain occurs when passing gas or having a bowel movement) • Pain relief occurs after passing gas or having a bowel movement • Sacral or SI pain in the absence of a (remembered) history of trauma or overuse • Assess for trigger points, a common musculoskeletal (not systemic) cause of sacral pain. If trigger point therapy relieves, reduces, or eliminates the pain, further screening may not be necessary
• Lack of objective findings; special tests (e.g., Patrick's, Gaenslen maneuver, Yeoman test, central posterior-anterior overpressure or spring test on the sacrum) are negative. Soft tissue and contractile tissue can usually be provoked during a physical examination by palpation, resistance, overpressure, compression, distraction, or motion • Look for other pelvic floor dysfunction
Associated
Signs
and
Symptoms
• Presence of urologic or GI symptoms along with sacral pain (the therapist must ask to find out)
Clues to Screening the Pelvis Frequently, pelvic and low back pain occur together or alternately. Whenever pelvic pain is listed, the reader should consider this as pelvic pain with or without low back or sacral pain.
Past
Medical
History/Risk
Factors
• History of dysmenorrhea, ovarian cysts, inflammatory disease, STD, fibromyalgia, sexual assault/incest/trauma, chronic yeast/vaginal infection, chronic bladder or urinary tract infection, chronic IBS • History of abdominal, pelvic, or bladder surgery • History of pelvic or abdominal radiation • Recent therapeutic or spontaneous abortion • Recent IUCD in the presence of PID or in women with a history of PID • History of previous gynecologic, colon, or breast cancer • History of prolonged labor, use of forceps or vacuum extraction, and/or multiple births • Obesity, chronic cough
Clinical
Presentation
• Pelvic pain that is described as "achy" or "comes and goes in waves" and is poorly localized (person cannot point to one spot) • Pelvic pain that is aggravated by walking, sexual intercourse, coughing, or straining • Pain that is not clearly affected by position changes or specific movements, especially when accompanied by night pain unrelieved by change in position • Pelvic pain that is not reduced or eliminated by scar tissue mobilization, soft tissue mobilization, or release of trigger points of the myofascial structures in the pelvic cavity
CHAPTER 15
Associated Signs
SCREENING THE SACRUM, SACROILIAC, A N D PELVIS
and Symptoms
• Pelvic pain in the presence of yellow, odorous vaginal discharge • Positive McBurney's or iliopsoas/obturator tests (see Chapter 6) • Pelvic pain with constitutional symptoms, especially nausea and vomiting, GI symptoms (possible enteropathic origin) • Presence of painful urination; urinary incontinence, urgency, or frequency; nocturia; blood in the urine; or other urologic changes
Gynecologic • Pelvic pain that is relieved by rest, placing a pillow or support under the hips and buttocks in the supine position, or "getting off your feet" • Pelvic pain that is correlated with menses or sexual intercourse • Pelvic pain that occurs after the first menstrual cycle is missed, especially if the woman is using an IUCD or has had a tubal ligation (see text for
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other risk factors), with shoulder pain also present (ruptured ectopic pregnancy); assess for low blood pressure • Presence of unexplained or unexpected vaginal bleeding, especially after menopause • Presence of pregnancy
Vascular • History of heart disease with a clinical presentation of pelvic, buttock, and leg pain that is aggravated by activity or exercise (claudication) • Pelvic pain accompanied by buttock and leg pain with changes in skin and temperature on the affected side (arterial occlusion or venous thrombosis), especially in the presence of known heart disease or recent pelvic surgery • Pain that worsens toward the end of the day, accompanied by pain after intercourse and in the presence of varicose veins elsewhere in the body (ovarian varicosities)
KEY POINTS TO REMEMBER Many of the Key Points to Remember in Chapter 14 also apply to the sacrum and sacroiliac joints. These will not be repeated here.
Sacrum/Sacroiliac Joint / Sacral pain, in the absence of a history of trauma or overuse, that is not reproduced with anterior-posterior overpressure (spring test) on the sacrum is a red flag presentation that indicates a possible systemic cause of symptoms. / Pain above the 15 spinous process is not likely from the sacrum or SI joint. / Midline lumbar pain, especially if present when rising from sitting, more often comes from a discogenic source; clients with unilateral pain below 15 when rising from sitting are more likely to have a painful SI joint / Insufficiency fractures of the spine are not uncommon with individuals who have osteoporosis or who are
taking corticosteroids; apparent insidious onset or minor trauma is common. / The most common cause of noninfected, inflammatory sacral/SI pain is ankylosing spondylitis; other causes may include Reiter's syndrome, psoriatic arthritis, and arthritis associated with IBD. / Infection can seed itself to the joints, including the SI joint. Watch for a history of recent dental surgery (endocarditis), intravenous drug use, trauma (including surgery), and chronic immunosuppression. / Anyone with joint pain of unknown cause should be asked about a recent history of skin rash (delayed allergic reaction, Crohn's disease)
Pelvis / Pelvic and low back pain often occur together; either may be accompanied by unreported abdominal pain, discomfort, or other symptoms. The therapist must ask about the presence of any unreported pain or symptoms.
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KEY POINTS TO REMEMBER—cont'd / Yellow or green discharge from the vagina or penis (with or without an odor) in the presence of low back, pelvic, or sacral pain may be a red flag. The therapist must ask additional questions to determine the need for medical evaluation. / The first sign of pelvic infection in the older adult might not be an elevated temperature, but rather, confusion, increased confusion, or some other change in mental status
rator abscess, appendicitis, or peritonitis (see discussion, Chapter 8). / Pelvic pain that is aggravated by exercise and starts 5 or more minutes after exercise begins may be vascularly induced / A history of sexual abuse at any time in the person's past may contribute to chronic pelvic pain or nonspecific symptoms. Taking a history of sexual abuse may be needed.
/ Bilateral anterior pelvic pain may be a symptom of inflammation; the therapist can test for iliopsoas or obtu-
SUBJECTIVE
EXAMINATION
Special Q u e s t i o n s t o A s k : S a c r u m , Sacroiliac, a n d Pelvis See Special Questions to Ask: Back, and Special Questions to Ask Men/Women Experiencing Back, Hip, Pelvic, Groin, Sacroiliac, or Sacral Pain, Chapter 14. Not all the special questions listed in Chapter 14 will have to be asked. Use your professional judgment to decide what to ask based on what the client has told you and what you've observed during the examination.
Remember to consider unreported assault, anal intercourse (partnered rape; adolescents may use anal intercourse to prevent pregnancy, homosexual men with men). Please note that many of today's teens are resorting to anal intercourse and oral sex in an effort to prevent pregnancy. These forms of sexual contact do not prevent STD. In addition, they can result in sacral pain and other lesions (e.g., rectal fissures) resulting from trauma. Pelvic Pain
Sacral/SI Pain • Have you ever been diagnosed with ulcerative colitis, Crohn's disease, IBS, or colon cancer? • Are you taking any antibiotics? (long-term use of antibiotics can result in colitis) • Have you ever been diagnosed or treated for cancer of any kind? (metastases to the bone, especially common with breast, lung, or prostate cancer, but also with pelvic or abdominal cancer) • Do you have any abdominal pain or GI symptoms? (assess for lower abdominal or suprapubic pain at the same level as the sacral pain; if the client denies GI symptoms, follow up with a quick list: Any nausea? Vomiting? Diarrhea? Change in stool color or shape? Ever have blood in the toilet?) • If sacral pain occurs when the rectum is stimulated: Is your pain relieved by passing gas or by having a bowel movement? • Sacral or SI pain without a history of trauma or overuse
• Have you ever been diagnosed or treated for cancer of any kind? • Have you had recent abdominal or pelvic surgery (including hysterectomy, bladder reconstruction, prostatectomy)? • Have you ever been told that you have (or do you have) varicose veins? (pelvic congestion syndrome) • Do you ever have blood in the toilet? For women with low back, sacral, or pelvic pain: See Special Questions to Ask: Women Experiencing Back, Hip, Pelvic, Groin, Sacroiliac (SI), or Sacral Pain, Chapter 14. For anyone with low back, sacral, or pelvic pain of unknown cause: It may be necessary to conduct a sexual history as part of the screening process (see Chapter 14 or Appendix B-29). For men with sciatica, pelvic, sacral, or low back pain: See Special Questions to Ask: Men Experiencing Back, Hip, Pelvic, Groin, or Sacroiliac Pain (Chapter 14 or Appendix B-21).
CHAPTER 15
CASE
SCREENING THE SACRUM, SACROILIAC, AND PELVIS
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STUDY
STEPS IN THE SCREENING PROCESS
When a client presents with pelvic pain, how do you get started with the screening process? First, review the possible causes of pelvic pain (see Table 15-2). • Was there anything in the history or presentation to suggest one of the categories in this table? • From looking at the table, do additional questions come to mind? • Review Special Questions to Ask: Sacrum, SI, or Pelvis, presented in this chapter. Are any of these questions appropriate or needed? • Did you ask about associated signs and symptoms? • Remember to ask the client the following: • Is there anything else about your general health that concerns you? • What other symptoms are you having that may or may not be connected to your current problem? Next, review Clues Suggesting Systemic Pelvic Pain. Is there anything here to raise your suspicion of a systemic disorder? • If necessary, conduct a general health screening examination: • Have you had any recent infections or illnesses? • Have you had any fevers, sweats, or chills? • Any unusual discharge from the vagina or penis? • Any unusual skin rashes or muscle/joint pain? • Any unusual fatigue, irritability, or difficulty sleeping? • Is there anything to suggest a pelvic floor dysfunction as the source of symptoms? Look for the following: • Pain that comes and goes and changes location • Pain that is not predictably reproducible • Pain that is alleviated by heat to the lower abdomen, groin, or front of the upper thighs • Pain made worse by William Flexion Exercises (WFEs; single or double knee to chest) but relieved by hamstring stretching • Rectal pain or discomfort that is worse during intercourse or penetration
• Pain or discomfort (better or worse) before, during, or after menstrual cycle • Mentally conduct a Review of Systems • Did the past medical history, age, medications, or associated signs and symptoms point to anything? • Use your Review of Systems table (see Box 417) to look for possible clusters of symptoms, or to remind you what to look for • If you identify a specific system in question, ask additional questions for that system: • For example, if a significant past medical history or current signs and symptoms of GI involvement are reported, review the Special Questions to Ask in Chapter 8. Would any questions listed be appropriate to ask, given your client's clinical presentation? Or, if you suspected a renal/urologic cause of symptoms, look at the questions posed in Chapter 10. Sometimes, the initial screening process does not raise any suspicious history or red flag symptoms. As discussed in Chapter 1, screening can take place anywhere in the Guide's patient/client management model (see Box 1-5). The therapist may begin to carry out the intervention without seeing any red flags that suggest a systemic disorder and may then find that the client does not improve with physical therapy. This in itself is a red flag. If someone is not improving with physical therapy intervention, the therapist reviews the findings (i.e., what you are doing and why you are doing it), while evaluating the need to repeat some steps in the screening process. Because systemic disease progresses over time, new signs and symptoms may have developed since the time of the first interview and client history taking. The therapist may want to have someone else review the case. Often, this can provide some clarity and add insight to the evaluation process. Asking a few screening questions may bring to light some new information to be included in the ongoing evaluation. Now may be the time to repeat (or perform for the first time) specific and appropriate screening tests and measures.
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PRACTICE QUESTIONS 1. Which of the following signs and symptoms does not describe pelvic pain of systemic origin? a. Pain that is made worse after 5 to 10 minutes of physical activity or exertion but goes away with rest or cessation of the activity b. Pain that is relieved by placing a pillow or support under the hips and buttocks c. Pain that is worse in the morning but decreases with movement or stretching d. Pain that is not reduced or eliminated by trigger point release or soft tissue mobilization 2. A positive Blumberg sign indicates: a. Pelvic infection b. Ovarian varicosities c. Arthritis associated with IBD d. Sacral neoplasm 3. A 33-year-old pharmaceutical sales representative reports pain over the mid-sacrum radiating to the right posterior superior iliac spine (PSIS). Overpressure on the sacrum does not reproduce symptoms. This signifies: a. Neoplasm is present b. Red flag sign of sacral insufficiency fracture c. A lack of objective findings d. Coccygodynia 4. A 67-year-old man was seen by a physical therapist for low back pain rated 7 out of 10 on the visual analog scale. He was evaluated, and a diagnosis was made by the physical therapist. The client attained immediate relief of symptoms, but after 3 weeks of therapy, the symptoms returned. What is the next step from a screening perspective? a. The client can be discharged. Maximum benefit from physical therapy has been achieved. b. The client should be screened for systemic disease even if you have already included screening during the initial evaluation. c. The client should be sent back to the physician for further medical follow-up. d. The client should receive an additional modality to help break the pain-spasm cycle. 5. McBurney's point for appendicitis is located: a. Approximately one-third the distance from the anterior superior iliac spine [ASIS] toward the umbilicus, usually on the left side
6.
7.
8.
9.
10.
b. Approximately one-half the distance from the ASIS toward the umbilicus, usually on the left side c. Approximately one-third the distance from the ASIS toward the umbilicus, usually on the right side d. Approximately one-half the distance from the ASIS toward the umbilicus, usually on the right side e. Impossible to tell because the appendix can be located anywhere in the abdomen Which of the following is NOT a red flag finding? a. Sacral pain occurs when the client is passing gas or having a bowel movement. b. Sacral pain is relieved after the client passes gas or has a bowel movement. c. Sacral pain occurs without a history of trauma or overuse. d. Sacral pain is reduced or relieved by release of trigger points. Cancer as a cause of sacral or pelvic pain is usually characterized by: a. A previous history of reproductive cancer b. Constant pain c. Blood in the urine or stools d. Constitutional symptoms e. All of the above Reproduced or increased abdominal or pelvic pain when the iliopsoas muscle test is performed suggests: a. Iliopsoas trigger point b. Inflammation or abscess of the muscle from an inflamed appendix or peritoneum c. Abdominal aortic aneurysm d. Neoplasm A 75-year-old woman with a known history of osteoporosis has pain over the sacrum radiating to the right posterior superior iliac spine and right buttock. How do you rule out an insufficiency fracture? a. Perform Blumberg's test. b. Conduct a sacral spring test (posterioranterior overpressure of the sacrum). c. Perform Murphy's percussion test. d. Diagnostic imaging is the only way to know for sure. What is the importance of the pelvic floor musculature in relation to the abdominal and pelvic viscera?
CHAPTER 15
SCREENING THE SACRUM, SACROILIAC, A N D PELVIS
REFERENCES 1. Buchowski JC, Kebaish KM, Sinkov V, et al: Functional and radiographic outcome of sacroiliac arthrodesis for the disorders of the sacroiliac joint. The Spine Journal 5(5):520528, 2005. 2. Haanpaa M, Paavonen J: Transient urinary retention and chronic neuropathic pain associated with genital herpes simplex virus infection. Acta Obstet Gynecol Scand 83(10):946-949, 2004. 3. Blake SP, Connors AM: Sacral insufficiency fracture. Br J Radiol 77(922):891-896, 2004. 4. Fortin J, April C, Dwyer A, et al: Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. I: Asymptomatic volunteers. Spine 19(13):1475-1482, 1994. 5. Fortin JD, Aprill CN, Ponthieux B, et al: Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part II: Clinical evaluation. Spine 19(13):1483-1489, 1994. 6. Young S, Aprill C, Laslett M: Correlation of clinical examination characteristics with three sources of low back pain. The Spine Journal 3(6):460-465, 2003. 7. Slipman CW, Patel RK, Whyte WS, et al: Diagnosing and managing sacroiliac pain. J Muse Med 18(6):325-332, 2001. 8. Dreyfuss P, Dreyer SJ, Cole A, et al: Sacroiliac joint pain. J Am Acad Orthop Surg 13(4):255-265, July/August 2004. 9. Schumacher HR Jr, Klippel JH, Koopman WJ, editors: Primer on the rheumatic diseases, 12th edition, Atlanta, Georgia, 2001, Arthritis Foundation. 10. Betancourt-Albrecht M, Roman F, Marcelli M: Grand rounds in endocrinology, diabetes, and metabolism from Baylor College of Medicine: a man with pain in his bones. Medscape Diabetes Endocrinol 5(l):2003.Available on-line (free service but requires login and password): http://www.medscape.com/viewarticle/445158. Accessed November 10, 2005. 11. White JH, Hague C, Nicolaou S, et al: Imaging of sacral fractures. Clin Radiol 58:914-921, 2003. 12. Lin JT, Lane JM: Sacral stress fractures. J Womens Health (Larchmt) 12(9):879-888, November 2003. 13. Leroux JL, Denat B, Thomas E, et al: Sacral insufficiency fractures presenting as acute low-back-pain-biomechanical aspects. Spine 18(16):2502-2506, 1993. 14. Boissonnault WG, Thein-Nissenbaum JM: Differential diagnosis of a sacral stress fracture. J Orthop Sports Phys Ther 12(32):613-621, December 2002. 15. Ahovuo JA, Kiuru MJ, Visuri T: Fatigue stress fractures of the sacrum: diagnosis with MR imaging. Eur Radiol 14(3):500-505, March 2004. 16. Khan MH, Smith PN, Kang JD: Sacral insufficiency fractures following multilevel instrumented spinal fusion. Spine 30(16):E484-488, August 15, 2005. 17. Parikh VA, Edlund JW: Sacral insufficiency fractures—rare complication of pelvic radiation for rectal carcinoma. Dis Colon Rectum 41(2):254-257, February 1998. 18. Zileli M, Hoscoskun C, Brastiano P, et al: Surgical treatment of primary sacral tumors: complications with sacrectomy. Neurosurg Focus 15(5):E9, November 15, 2003. 19. Randall RL: Giant cell tumor of the sacrum. Neurosurg Focus 15(2):E 13, August 15, 2003. 20. Payer M: Neurological manifestation of sacral tumors. Neurosurg Focus 15(2):E1, August 15, 2003. 21. Perkins R, Schofferman J, Reynolds J: Coccygectomy for severe refractory sacrococcygeal joint pain. J Spinal Disord Tech 16(1):100-103, 2003. 22. Howard FM, El-Minawi AM, Sanchez RA: Conscious pain mapping by laparoscopy in women with chronic pelvic pain. Obstet Gynecol 96(6):934-939, December 2000. 23. Howard FM: Chronic pelvic pain. Obstet Gynecol 101(3): 594-611, March 2003.
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24. Stuge B, Hilde G, Vollestad N: Physical therapy for pregnancy-related low back and pelvic pain: a systematic review. Acta Obstet Gynecol Scand 82(ll):983-990. 25. Baker PK: Musculoskeletal problems. In Steege JF, Metzger DA, Levy BS: Chronic pelvic pain: an integrated approach, Philadelphia, 1998, WB Saunders, pp. 215-240. 26. Simons DG, Travell JG: Travell & Simons' myofascial pain and dysfunction: the trigger point manual, vol 2, Baltimore, 1993, Williams & Wilkins, 1993. [Myopain Seminars: www.painpoints.com/seminars.htm]. 27. B0 K, Sherburn M: Evaluation of female pelvic-floor muscle function and strength. Phys Ther 85(3):269-282, March 2005. 28. Headley B: When movement hurts: a self-help manual for treating trigger points, Boulder, Colorado, 1997, Innovative Systems. 29. Kostopoulos D, Rizopoulos K: The manual of trigger point and myofascial therapy, Thorofare, NJ, 2001, Slack, Inc. 30. Giudice LC: Status of current research on endometriosis. J Reprod Med 43(3 suppl):252-262, 1998. 31. Giudice LC, Kao LC: Endometriosis. Lancet 364(9447):1789-1799, November 2004. 32. Jossens MOR: Risk factors associated with pelvic inflammatory disease of differing microbial etiologies. Sexually Trans Dis 23:239-247, 1996. 33. Kahn JA, Kaplowitz RA, Goodman E, et al: The association between impulsiveness and sexual risk behaviors in adolescent and young adult women. J Adolesc Health 30(4):229-232, April 2002. 34. Kahn JA, Rosenthal SL, Succop PA, et al: Mediators of the association between age of first sexual intercourse and subsequent papillomavirus infection. Pediatrics 109(1):E5, January 2002. 35. Centers for Disease Control and Prevention (CDC): Policy guidelines for prevention and management of pelvic inflammatory disease (PID), Washington, DC, 1991, U.S. Department of Health and Human Services. Available at: www.cdc.gov. Accessed November 15, 2005. 36. Centers for Disease Control and Prevention: Sexually transmitted disease surveillance: 2004, Washington, DC, 2005, U.S. Department of Health and Human Services. 37. Anderton JP, Valdiserri RO: Combating syphilis and HIV among users of internet chatrooms. J Health Commun 10(7):665-771, October-November 2005. 38. Douglas JM Jr, Peterman TA, Fenton KA: Syphilis among men who have sex with men: challenges to syphilis elimination in the United States. Sex Transm Dis 32(10 suppl):S80-S83, October 2005. 39. Tarazov PG, Prozorovskij KV, Ryzhkov VK: Pelvic pain syndrome caused by ovarian varices. Acta Radiol 38(6): 10231025, 1997. 40. El-Minawi AM: Pelvic varicosities and pelvic congestion syndrome. In Howard FM, et al: Pelvic pain diagnosis and management, Philadelphia, 2000, Lippincott, Williams & Wilkins, pp. 171-183. 41. Hobbs JT: Varicose veins arising from the pelvis due to ovarian vein incompetence. Int J Clin Pract 59(10): 11951203, October 2005. 42. Gasparini D, Geatti O, Orsolon PG, et al: Female "varicocele." Clin Nucl Med 23(7):420-422, 1998. 43. Hartung O, Grisoli D, Boufi M, et al: Endovascular stenting in the treatment of pelvic vein congestion cause nutcracker syndrome: lessons learned from the first five cases. J Vase Surg 42(2):275-280, August 2005. 44. Jemal A, Murray T, Ward E, et al: Cancer statistics, 2005. Cancer J Clin 55(1):10-31, January/February 2005. 45. Ferguson SE, Soslow RA, Amsterdam A, et al: Comparison of uterine malignancies that develop during and following tamoxifen therapy. Gynecol Oncol December 9, 2005; Epub ahead of print. 46. Carter J, Pather S: An overview of uterine cancer and its management. Expert Rev Anticancer Ther 6(l):33-42, January 2006.
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47. Varras M, Polyzos D, Akrivis C: Effects of tamoxifen on the human female genital tract: review of the literature. Eur J Gynaecol Oncol 24(3-4):258-268, 2003. 48. Eltabbakh GH: Recent advances in the management of women with ovarian cancer. Minerva Ginecol 56(l):81-89, February 2004. 49. Huncharek M, Geschwind JF, Kupelnick B: Perineal application of cosmetic talc and risk of invasive epithelial ovarian cancer: a meta-analysis of 11,933 subjects from sixteen observational studies. Anticancer Res 23(2C):19551960, March-April 2003. 50. Langseth H, Kjaerheim K: Ovarian cancer and occupational exposure among pulp and paper employees in Norway. Scand J Work Environ Health 30(5):356-361, 2004. 51. Mills PK, Riordan DG, Cress RD, et al: Perineal talc exposure and epithelial ovarian cancer risk in the Central Valley of California. Int J Cancer 112(3):458-464, November 2004. 52. Study questions ovary removal during hysterectomy: what factors affect ovarian cancer risk? Harvard Women's Health Watch 13(2):7, October 2005. 53. Goff BA, Mandel LS, Melancon CH, et al: Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. JAMA 291(22):2705-2712, June 2004. 54. Martorell EA, Murray PM, Peterson JJ, et al: Palmar fasciitis and arthritis syndrome associated with metastatic ovarian carcinoma: a report of four cases. J Hand Surg 29A(4):654-660, 2004. 55. Roffers SD, WU XC, Johnson CH, et al: Incidence of extraovarian primary cancers in the United States, 1992-1997. Cancer 97(10 suppl):2643-2647, May 15, 2003.
56. Eltabbakh GH, Piver MS: Extraovarian primary peritoneal carcinoma. Oncology (Williston Park) 12(6):813-819, June 1998. 57. Kunz J, Rondez R: Correlation between serous ovarian tumors and extra-ovarian peritoneal tumors of the same histology. Schweiz Rundsch Med Prax 87(6):191-198, February 1998. 58. Trimble CL, Genkinger JM, Burke AE, et al: Active and passive cigarette smoking and the risk of cervical neoplasia. Obstet Gynecol 105(1):174-181, January 2005. 59. Shinn SE: Taking a stand against cervical cancer. Nursing 2004 34(5):36-42, May 2004. 60. Saslow D, Runowicz CD, Solomon D, et al: American Cancer Society guideline for the early detection of cervical neoplasia and cancer. Cancer J Clin 52(6):342-362, November/ December 2002. 61. American Cancer Society (ACS): ACS cancer detection guidelines, Atlanta, Georgia. Available on-line: http://www. cancer.org. Accessed February 16, 2006. 62. Amita M, Sudeep G, Rekha W, et al: Brain metastasis from cervical carcinoma. Medscape Gen Med 7(1):2005. 63. Storm-Dickerson TL, Horattas MC: What have we learned over the past 20 years about appendicitis in the elderly? Am J Surg 185(3):198-201, March 2003. 64. Mathias SD, Kuppermann M, Liberman RF, et al: Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol 87(3):321-327, 1996. 65. Hilden M, Schei B, Swahnberg K, et al: A history of sexual abuse and health: a Nordic multicentre study. BJOG 111(10):1121-1127, October 2004.
Screening the Lower Quadrant: Buttock, Hip, Groin, Thigh, and Leg
T
he causes of lower quadrant pain or dysfunction vary widely; presentation of symptoms is equally wide ranging. Vascular conditions (e.g., arterial insufficiency, abdominal aneurysm), infectious or inflammatory conditions, gastrointestinal (GI) disease, and gynecologic and male reproductive systems may cause symptoms in the lower quadrant and lower extremity, including the pelvis, buttock, hip, groin, thigh, and knee. Some overlap may occur, but unique differences exist. Cancer may present as primary hip, groin, or leg pain or symptoms. Primary cancer can metastasize to the low back, pelvis, and sacrum, thus referring pain to the hip and groin. Primary cancer may also metastasize to the hip, causing hip or groin pain and symptoms. Pain may be referred from other locations such as the scrotum, kidneys, abdominal wall, abdomen, peritoneum, or retroperitoneal region. Lower quadrant pain may be referred through conditions that affect nearby anatomic structures, such as the spine, spinal nerve roots or peripheral nerves, and overlying soft tissue structures (e.g., hernia, bursitis, fasciitis). One of the keys to accurate and quick screening is knowledge of the types of conditions, illnesses, and systemic disorders that can refer pain to the lower quadrant, especially the hip and groin. Much of the information related to screening of the back (see Chapter 14), sacrum, sacroiliac (SI), and pelvis (see Chapter 15) also applies to the hip and groin.
USING THE SCREENING MODEL TO EVALUATE THE LOWER QUADRANT When screening is called for, the therapist looks at the client's personal and family history, clinical presentation, and associated signs and symptoms. Knowledge of problems that can affect the lower quadrant, along with the likely history, pain patterns, and associated signs and symptoms, shows us the steps to follow in screening. Most often, the screening process takes place through a series of special questions. A few special tests may be used as well. Recognition of red flag signs and symptoms of systemic or viscerogenic problems can direct the client toward the necessary medical attention early in the disease process. In many cases, early detection and treatment may result in improved outcomes.
Past Medical History Some of the more common histories associated with lower extremity, hip, or groin pain of a visceral nature are listed in Box 16-1. A previous history of cancer such as prostate cancer (men), any reproductive cancers (women), 731
SECTION III
732
BOX
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Red Flag Histories Associated W i t h the Lower Extremity
16-1
• Previous history of cancer history of renal or urologic disease • Previous such as kidney stones and urinary tract • •
• • • • • •
infections (UTIs) Trauma/assault (fall, blow, lifting) History of infectious or inflammatory condition • Crohn's disease (regional enteritis) or ulcerative colitis • Diverticulitis • Pelvic inflammatory disease (PID) • Reiter's syndrome • Appendicitis History of gynecologic condition(s): • Recent pregnancy, childbirth, or abortion • Multiple births (multiparity) • Other gynecologic conditions History of alcoholism (e.g., hip osteonecrosis) Long-term use of immunosuppressants (e.g., Crohn's disease, sarcoidosis, cancer treatment, organ transplant, autoimmune disorders) History of heart disease (e.g., arterial insufficiency, peripheral vascular disease) History of AIDS (acquired immunodeficiency syndrome)-related tuberculosis History of hematologic disease, such as sickle cells anemia or hemophilia
as a cause of hip, groin, or lower extremity pain are presented in Chapter 13. Many conditions with overlap symptoms (e.g., back and hip pain, pelvic and groin pain) are presented throughout this third text section (Systemic Origins of Neuromusculoskeletal Pain and Dysfunction) as part of the discussion of back pain (see Chapter 14) or pelvic pain (see Chapter 15). Awareness of risk factors for various problems can help alert the therapist early to the need for medical intervention, as well as for direct education and prevention efforts. Many risk factors for disease are modifiable. Exercise often plays a key role in prevention and treatment of pathologic conditions. Recognizing red flags in the history and clinical presentation and knowing when to refer versus when to treat are topics of focus in this chapter.
Clinical Presentation If no neuromuscular or musculoskeletal cause of the client's symptoms can be identified, then the therapist must consider the following: Follow-Up
Questions
• Are red flags suggestive of a viscerogenic cause of pain or symptoms? (see Box 14-1); the lack of diagnostic testing or imaging studies may be an additional red flag • What kind of pain patterns do we expect to see with each of the viscerogenic causes? • Are any associated signs and symptoms suggestive of a particular organ system? 2
or breast cancer is a red flag as these cancers may be associated with metastases to the hip. Past history of joint replacement (especially hip arthroplasty) combined with recent infection of any kind and new onset of hip, groin, or knee pain is suspicious. Postoperatively, orthopedic pins may migrate, referring pain from the hip to the back, tibia, or ankle. Loose components, improper implant size, muscular imbalance, and infection that occurs any time after joint arthroplasty may cause lower quadrant pain or symptoms (Case Example 16-1). 1
Risk Factors Each condition, illness, or disease that can cause referred pain to the buttock, hip, thigh, groin, or lower extremity has its own unique risk factors. Most known risk factors for systemically induced problems have been discussed in the individual chapters on each specific condition. For example, arterial insufficiency as a cause of low back, hip, buttock, or leg pain is presented as part of the discussion of peripheral vascular disease in Chapter 6 and again in Chapter 14 because it relates just to low back pain. Likewise, known risk factors for bone cancer or metastases
Hip
and
Buttock
The physical therapist is well acquainted with hip or buttock pain (Table 16-1) as a result of regional neuromuscular or musculoskeletal disorders. The therapist must be aware that disorders affecting the organs within the pelvic and abdominal cavities can also refer pain to the hip region, mimicking a primary musculoskeletal lesion. A careful history and physical examination usually differentiate these entities from true hip disease. PAIN PATTERN
True hip pain, whether from a neuromusculoskeletal or systemic cause (Table 16-2), is usually felt posteriorly deep within the buttock or anteriorly in the groin, sometimes with radiating pain down the anterior thigh. Pain perceived on the outer (lateral) side of the hip is usually not caused by an intra-articular problem, but more likely results from a trigger point, bursitis, SI, or back problem.
CHAPTER 16
CASE EXAMPLE
1 6 - 1
Medical Screening After
A 74-year-old retired homemaker had a total hip replacement (THR) 2 days ago. She remains as an inpatient with complications related to congestive heart failure. She has a previous medical history of gallbladder removal 20 years ago, total hysterectomy 30 years ago, and surgically induced menopause with subsequent onset of hypertension. Her medications include intravenous furosemide (Lasix), digoxin, and potassium replacement. During the initial physical therapy intervention, the client reported muscle cramping and headache but was able to complete the entire exercise protocol. Blood pressure was 100/76 mm Hg (measured in the right arm while lying in bed). Systolic measurement dropped to 90 mm Hg when the client moved from supine to standing. Pulse rate was 56bpm with a pattern of irregular beats. Pulse rate did not change with postural change. Platelet count was 98,000 cells/mm when it was measured yesterday. 3
How Would You Screen a Client with This History and Current Comorbidities? Neuromusculoskeletal
SCREENING THE LOWER QUADRANT
Systemic
Assess orthopedic complications such as signs of infection, increased skin temperature, localized swelling, pain.
Monitor all vital signs.
Observe patient's adherence to hip precautions; note surgical technique and approach used, type of implant, and location of incision.
Monitor platelet levels, international normalized ratio: If low, observe for bruising, joint bleeds, deep venous thrombosis; follow precautions and exercise guidelines.
Be aware that orthostatic hypotension can cause dizziness, loss of balance, falls—a very dangerous situation with a recent THR.
Watch for signs and symptoms of cardiovascular/ pulmonary impairments such as: • Fatigue and muscle weakness
1
Total
Hip
Neuromusculoskeletal This can be compounded by osteoporosis, if present as a result of surgical menopause.
733
Replacement
Systemic • Tachycardia • Fluid migration from the legs to the lungs during the supine position • Dyspnea, orthopnea,* spasmodic cough (check sputum) • Peripheral edema; check jugular distention (see Fig. 4-42) • Check nail beds for signs of decreased perfusion Observe for side effects of medications or drug interactions: • Diuresis from Lasix (loop diuretic) can result in potassium depletion and lead to increased sensitivity of myocardium to digoxin (digitalis); monitor serum electrolytes, and observe for signs/symptoms of potassium imbalance; observe for urinary frequency and headache. • Common adverse effects of Lasix include: Dehydration, muscle cramping, fatigue, weakness, headache, paresthesias, nausea, confusion, orthostatic hypotension, blurred vision, rash • Digoxin: Headache, drowsiness, other central nervous system disturbance, bradycardia, arrhythmia, gastrointestinal upset, blurred vision, halos "Ask if the patient must use pillows and sit up or have the head of the bed elevated; often described as "1-pillow orthopnea" or "2-pillow orthopnea"
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SECTION III
CASE
EXAMPLE
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
1 6 - 1
M e d i c a l
Screening
What Signs and Symptoms Should Reported to the Medical Staff?
Be
Nurses will be closely monitoring the patient's signs and symptoms. Read the medical record to stay up with what everyone else knows or has observed about the patient. Read the physician's notes to see whether medical intervention has been ordered. Report anything observed, but not already recorded in the chart, such as muscle cramping, headache, irregular heartbeat with bradycardia, low pulse, and orthostatic hypotension. Bradycardia is one of the first signs of digitalis toxicity. In some hospitals, a pulse less than 60 bpm in an adult would indicate that the next dose of digoxin should be withheld and the physician contacted. The protocol may be different from institution to institution.
TABLE
16-1
After
Total
Hip
R e p l a c e m e n t — c o n t ' d
The therapist is advised to report the following: • Irregular heartbeat with bradycardia (a possible sign of digoxin/digitalis toxicity) • Muscle cramping (possible adverse effect of Lasix) and headache (possible adverse effect of digoxin) • Charting of vital signs; her blood pressure was not too unusual and pulse rate did not change with position change (probably because of medications), so she does not have medically defined orthostatic hypotension. • Monitor vital signs throughout intervention; record the time it takes for vital signs to return to normal after exercise or treatment for your own documentation of measurable outcomes.
Causes of Buttock Pain
Systemic
Neuromusculoskeletal
Sciatica from tumor, infection, endometriosis (see Table 16-6) Neoplasm (primary or regional metastases via lymph nodes) Osteomyelitis of the upper femur Fracture (sacrum, ilium, pubic ramus) Septic arthritis (hip, sacroiliac) Abscess from aseptic necrosis, Crohn's disease, or other retroperitoneal infection Ischemia (e.g., claudication from peripheral vascular disease, peripheral arterial aneurysm)
Sciatica (nerve compression from surrounding soft tissues; see Table 16-6) Hip joint disease Disc disease (thoracic or lumbar) Bursitis (psoas, gluteal) Trigger points
With true hip joint disease, pain will occur with active or passive motion of the hip joint; this pain increases with weight bearing. Often, an antalgic gait pattern is observed as the individual leans away from the affected hip and shortens the swing phase to avoid weight bearing. When the underlying problem is related to soft tissue (e.g., abductor weakness) rather than to the joint as the source of symptoms, the client may lean toward the affected side to compensate for the downward rotation of the pelvis. With soft tissue involvement of the bursa or tendons (e.g., gluteus medius, gluteus minimus) pain may radiate down the leg to the level of insertion of the iliotibial tract on the proximal tibia.
Pain with medial rotation and decreased hip medial range of motion is associated with hip osteoarthritis. Cyriax's "Sign of the Buttock" (Box 16-2) can help differentiate between hip and lumbar spine disease.
3
4
5
6
7,8
NEUROMUSCULOSKELETAL PRESENTATION
Identifying the hip as the source of a client's symptoms may be difficult because pain originating in the hip may not localize to the hip but rather may present as low back, buttock, groin, SI, anterior thigh, or even knee or ankle pain (Fig. 16-1). On the other hand, regional pain from the low back, SI, sacrum, or knee can be referred to the hip. SI pain that localizes to the base of the spine may
CHAPTER 16
TABLE
16-2
SCREENING THE LOWER QUADRANT
735
Causes of H i p Pain
Systemic
Neuromusculoskeletal*
Cancer Metastasis Bone tumors Osteoid osteoma Chrondrosarcoma Giant cell tumor Ewing's sarcoma Vascular Arterial insufficiency Abdominal aortic aneurysm Avascular necrosis Urogenital Kidney (renal) impairment Testicular cancer Infectious/inflammatory conditions Abdominal or peritoneal inflammation (psoas abscess; see Box 16-3) Crohn's disease; ulcerative colitis Diverticulitis Appendicitis Pelvic inflammatory disease Ankylosing spondylitis Reiter's syndrome Rheumatoid arthritis Tuberculosis Metabolic disease Osteoporosis Gaucher's disease Paget's disease Ochronosis Hemochromatosis Other Sickle cell anemia Hemophilia Ectopic pregnancy
Low back, sacroiliac joint, sacral, or knee dysfunction Osteoarthritis Synovitis Femoral or inguinal hernia Bursitis (trochanteric, iliopectineal, iliopsoas, ischial) Fasciitis Muscle impairment (weakness, loss of flexibility, hypertonus, hypotonus sprain/strain/tear/avulsion) Piriformis syndrome Stress reactions/fractures Peripheral nerve injury or entrapment; meralgia paresthetica Total hip arthroplasty Acetabular labral or cartilage tear Developmental hip dysplasia; hip dislocation Legg-Calve-Perthes disease Slipped capital femoral epiphysis (SCFE) Osteitis pubis (pubic pain radiates to anterior hip)
* This is not an exhaustive, all-inclusive list, but rather, it includes the most commonly encountered adult neuromuscular or musculoskeletal causes of hip pain.
BOX
16-2
Sign of the Buttock
James Cyriax, M.D., was the first to write about the "Sign of the Buttock," which is actually made up of seven signs that indicate serious disease posterior to the axis of flexion and extension of the hip. These signs of neural tension deficit suggest severe central nervous system compromise, requiring medical referral. When positive, this test may help the therapist to identify serious extracapsular hip or pelvic disease. • Primary sign of the buttock: Passive hip flexion more limited and more painful than the straight leg raise
• Limited straight leg raise • Trunk flexion limited to the same extent as hip flexion • Painful weakness of hip extension • Noncapsular pattern of restriction (hip); capsular pattern: Marked limitation of hip flexion and medial rotation with some limitation of abduction and little or no limitation of adduction and lateral rotation • Swelling in the buttocks region • Empty end feel with hip flexion
Data from: Cyriax J: Textbook of Orthopaedic Medicine. Diagnosis of Soft Tissue Lesions, 8th edition, Philadelphia, 1983, WB Saunders.
SECTION III
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SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
F i g . 1 6 - 1 • Pain referred from the hip to other structures and anatomic locations. Pain from a pathologic condition of the hip can be referred to the low back, sacroiliac or sacral area, groin, anterior thigh, knee, or ankle.
be accompanied by radicular pain extending across the buttock and down the leg. It can also cross the lateral hip area. Additionally, SI joint dysfunction can cause groin pain and, with referred pain to the hip, may be accompanied by an ipsilateral decrease in hip joint internal rotation of 15 degrees or more, thereby confusing the clinical picture even further. Overlying soft tissue structure disorders such as femoral hernia, bursitis, or fasciitis; muscle impairments such as weakness, loss of flexibility, hypertonus or hypotonus, strain, sprain, or tears; and peripheral nerve injury or entrapment, including meralgia paresthetica can also cause localized hip pain. Hip pain referred from the upper lumbar vertebrae can radiate into the anterior aspect of the thigh, whereas hip pain from the lower lumbar vertebrae and sacrum is usually felt in the gluteal 9
F i g . 1 6 - 2 • Pain referred to the hip from other structures and anatomic locations. A, Hip pain referred from the upper lumbar vertebrae can radiate into the anterior aspect of the thigh. B, Hip pain from the lower lumbar vertebrae and sacrum is usually felt in the gluteal region, with radiation down the back or outer aspect of the thigh.
region, with radiation down the back or outer aspect of the thigh (Fig. 16-2). The client with pain caused by component instability following total hip arthroplasty may report hip or groin pain with activity, pain at rest, or both. Clinically, a history of "start up" pain may indicate a loose component. After 5 or 10 steps, the groin pain subsides. Pain may increase again after a moderate amount of walking. Groin or thigh pain is most common with micromotion at the bone-prosthesis interface or other loose component, periosteal irritation, or an undersized femoral stem. " The client reports a dull aching pain in the thigh with no history of systemic illness or recent trauma. Often, the pain is localized to the site of the prosthetic stem tip. The client points to a spe10
12
CHAPTER 16
CASE
EXAMPLE
1 6 - 2
N o n c a p s u l a r
SCREENING THE LOWER QUADRANT
737
Hip Pattern
A 46-year-old male long-distance runner developed sudden onset of right hip pain. He was given a diagnosis of trochanteric bursitis by an orthopedic physician and was referred to physical therapy. Objective Findings - For tenderness on palpation over the greater trochanter - Trigger points of the hip and low back region + Noncapsular pattern of restriction of the hip (capsular pattern in the hip is flexion, abduction, and medial rotation); client was limited in extension and lateral rotation + Heel strike test The major criteria for a medical diagnosis of trochanteric bursitis consist of marked tenderness to deep palpation of the greater trochanter and relief of pain after peritrochanteric injection with a local anesthetic and corticosteroid. The absence of greater trochanter tenderness and the presence of a noncapsular pattern of restriction of the hip were not consistent with the given diagnosis. Local injection was not administered. If an injection had been given, trochanteric bursitis may have been eliminated from the list of possible diagnoses. Objective findings are not consistent with trochanteric bursitis. What do you do now? More tests, of course, and more questions! Is there any history of cancer or prostate problems? Take his vital signs. Can he squat? Clear the hip. Conduct a review of systems to look for a pattern in the past medical history, clinical presentation, and any associated signs and symptoms.
Look for a pattern of symptoms that suggests a particular visceral system. Hip pain can be caused by gastrointestinal, vascular, infectious, or cancerous causes. Ask a few screening questions directed at each of these systems. For example: Gastrointestinal: Are you having any nausea? Vomiting? Abdominal pain? Changes in bowel function? Blood in the stool? Test for psoas abscess. Vascular: Any throbbing pain? Presence of varicose veins? Trophic changes? History of heart disease? Infectious: Any history of inflammatory bowel conditions such as Crohn's disease, ulcerative colitis, or diverticulitis? Ever have appendicitis? Any recent skin rashes in the legs? Cancerous: Previous history of cancer? Bone pain at night? Night sweats? Palpate the lymph nodes in the inguinal and popliteal regions. Result: Red flags included: • Age • Past history of prostate cancer at age 44 • Positive heel strike test • Noncapsular hip pattern • Inconsistent symptoms with diagnosis The results of the physical therapy examination warranted further medical evaluation, and the client was returned to the physician with a recommendation for imaging studies. Magnetic resonance imaging (MRI) results indicated a nondisplaced, complete fracture of the femoral neck from prostate cancer that had metastasized to the bone.
Data from Jones DL, Erhard RE: Differential diagnosis with serious pathology: A case report. Phys Ther 76:S89-S90, 1996.
cific spot along the anterolateral thigh. Pain on initiation of activity that resolves with continued activity should raise suspicion of a loose prosthesis. Persistent pain that is not relieved with rest and continues through the night suggests infection, requiring medical referral. 10
SYSTEMIC PRESENTATION A noncapsular pattern of restricted hip motion (e.g., limited hip extension, adduction, lateral rotation) may be a sign of serious underlying disease
(Case Example 16-2). The pattern of movement restriction most common with a capsular pattern for the hip is limitation of flexion, abduction, medial rotation and, sometimes, slight limitation of hip extension. Empty end feel can be an indicator of potentially serious disease such as infection or neoplasm. Empty end feel is described as limiting pain before the end range of motion is reached but with no resistance perceived by the examiner. Whenever assessing hip joint pain for a systemic or viscerogenic cause, the therapist should look at 8
738
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
hip rotation in the neutral position and perform the log-rolling test. With the client in the supine position, the examiner supports the client's heels in the examiner's hands and passively rolls the feet in and out. Decreased range of motion (usually accompanied by pain) is positive for an intraarticular source of symptoms. If normal hip rotation is present in this position but the motion reproduces hip pain, then an extra-articular cause should be considered. Log-rolling of the hip back and forth is generally considered to be the most specific examination maneuver for intra-articular hip disease because it rotates the femoral head back and forth in relation to the acetabulum and capsule, not stressing any of the surrounding extra-articular structures. The test does not identify the specific disease present but identifies the source of the symptoms as intra-articular. Keep in mind that if normal rotations are present but painful, the problem may still be musculoskeletal in origin (e.g., SI, early sign of arthritic changes in the hip joint). Full motion is also possible in the early stages of avascular necrosis and sickle cell anemia. The log-rolling test should be combined with Patrick's or Faber's (flexion, abduction, and external rotation) test and the scour (quadrant) test to determine whether the hip is a possible source of symptoms. 13
Groin The physical therapist may see a client with an isolated groin problem (Case Example 16-3), but more often, the individual has low back, pelvic, hip, or SI problems with a secondary complaint of groin pain. Possible systemic causes of groin pain are wide ranging, whether it appears as an isolated symptom or in combination with pelvic, hip, low back, or thigh pain (Table 16-3) (Case Example 16-4). Palpating the groin area is usually necessary in making a differential diagnosis. This can be a sensitive issue, and the therapist is advised to have a third person in the examination area. This person should be the same gender as the client. The therapist should explain the examination procedure and obtain the client's permission. During examination of the groin, the physical therapist may palpate enlarged lymph nodes, or the client may indicate these nodes to the examiner. Painless, progressive enlargements of lymph nodes or lymph nodes that are aberrant or suspicious for any reason, especially if present in more than one area or in the presence of a past medical
history of cancer, are an indication of the need for medical referral. Changes in lymph nodes without a previous history of cancer continue to represent a yellow or red flag. Tender, movable inguinal lymph nodes may be a sign of food intolerance or allergies or an indication that the body is fighting off an infectious process. The therapist should use his or her best clinical judgment in deciding what to do but should always err on the side of caution. When doubt arises, one should contact the physician and communicate any concerns, observations, or questions. NEUROMUSCULOSKELETAL PRESENTATION
Neuromuscular or musculoskeletal causes of groin pain should also be considered (Case Example 16-5). Groin pain is a common complaint in sports that involve kicking and rapid change of direction (e.g., soccer, hockey). The most common musculoskeletal cause of groin pain is strain of the adductor muscles, most often involving the adductor longus. The history includes a specific trauma or injury, which occurs primarily at the junction of the muscle fibers and the extended tendon of origin. Acutely, this injury causes pain with passive stretching or active contraction; eccentric activation may be even more painful. Acute injury may be followed in several days by ecchymosis. Another common problem in the young athlete or long distance runner is acute muscle strain or stress reaction (stress fracture). Chronic, unresolved groin pain in the athletic population also has been linked with altered neuromotor control. The therapist may need to evaluate groin pain from a motor control point of view. Older adults are more likely to experience hip, buttock, or groin pain associated with arthritis, lumbar stenosis, or hip arthroplasty. Arthritis is characterized by radiating pain to the knee, but not below, with decreased hip range of motion. Gait disturbances may be seen as arthritis progresses. Hip and groin pain secondary to lumbar stenosis can manifest as low back pain that radiates to the lower extremities. The pain begins and gets worse with ambulation. Standing and walking may also increase symptoms when the lumbar spine assumes a more lordotic position and the ligamentum flavus folds in on itself, pinching the foramina closed. The client who has stenosis bends forward or sits to avoid painful symptoms. Clients who have a total hip arthroplasty for hip pain may have continued groin and buttock pain, secondary to sciatica or lumbar spinal stenosis. 14
15
11
11
CHAPTER 16
CASE
EXAMPLE
1 6 - 3
G r o i n
Pain
in
SCREENING THE LOWER QUADRANT
a
Referral: A 13-year-old boy presented with a 2-week history of left groin pain. He reported a skateboarding accident as the cause of the symptoms. He was coming down a flight of stairs, hit the last step by mistake, and caught his foot on the stair railing. His leg was forced into wide abduction and external rotation. No (heard or felt) pop or snap was perceived at the time of injury. The client continued skateboarding but experienced increasing pain 2 hours later. At that time, he could "hardly walk" and has had trouble walking without limping ever since. He tried getting back to skateboarding but was stopped by sharp pain in the groin. No other symptoms were reported (no saddle anesthesia, no numbness and tingling, no bladder changes, no constitutional symptoms). Clinical Presentation: An antalgic gait was observed as the boy avoided putting full weight through the hip during the stance phase. Trendelenburg gait or Trendelenburg test was not positive. He could not do a squat test because of pain. He could not put enough weight on the left leg to try heel walking or toe walking. Generalized pain occurred along the inner thigh and was described as "tenderness." The child cannot internally rotate the hip past midline. Abduction was limited to 30 degrees with painful empty end feel. During active hip flexion, the hip automatically flexes, abducts, and externally rotates. Pain increases with active assisted or passive hip flexion when one is trying to keep the hip in neutral alignment.
13-Year-Old
739
S k a t e b o a r d e r
Associated Signs and Symptoms: When asked about symptoms of any kind anywhere else in his body, the boy replied, "No." When offered a list of possible symptoms, these were all negative. He did admit to being slightly constipated because of the pain. Vital signs were all within normal limits. Is medical referral indicated in the absence of any signs or symptoms of viscerogenic or systemic disease? Some red flags are identified here, even though they do not point to a viscerogenic or systemic origin. Trauma, young age, and failure to complete a squat screening test for orthopedic clearance of the hip, knee, and ankle all suggest the need for medical referral before physical therapy intervention is initiated. Turn to Table 16-3. As you look at the left column of Systemic Causes, what clinical presentation and signs and symptoms might be expected with each of these conditions? Does the current clinical presentation fit any of these? Now look at the musculoskeletal causes of groin pain (right column, Table 16-3). Are past medical history, risk factors, or clinical presentation consistent for any of these problems? For example, pain in the hip or groin area in anyone who is not skeletally mature raises the suspicion of an orthopedic injury. Abduction and external rotation forces on the hip can produce a slipped capital femoral epiphysis (SCFE). This is the case here, which required imaging studies for diagnosis. Anteroposterior x-rays were negative, but a lateral view showed slippage to confirm SCFE.
Data from Learch T, Resnick D: Groin pain in a 13-year-old skateboarder. J Musculoskel Med 20:513-515, 2003.
SYSTEMIC PRESENTATION
The clinical presentation of groin pain from a systemic source does not vary from musculoskeletally induced groin pain. Once again, the key is to look at the client's age (e.g., atherosclerotically induced vascular problems in the older adult), past medical history (e.g., previous history of cancer, liver disease, hemophilia), and gender (e.g., ectopic pregnancy, prostate or testicular problems). In addition, asking about the presence of other symptoms and conducting a Review of Systems
may help the therapist identify any one of the systemic causes listed in Table 16-3.
Thigh Once again, we cannot emphasize enough the importance of conducting a thorough physical examination to rule out systemic or viscerogenic disease as the source of thigh pain; client history and lower quadrant screening examination should be performed (see Box 4-15).
740
TABLE
SECTION III
16-3
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Cause of G r o i n Pain
Systemic causes
Neuromusculoskeletal causes
Cancer • Spinal cord tumors • Hodgkin's disease/lymphoma • Leukemia • Testicular • Prostate Upper urinary tract problems affecting the kidneys or ureters (inflammation, infection, obstruction) Fluid in peritoneal cavity • Ascites (cirrhosis) • Congestive heart failure • Cancer • Hyperaldosteronism Hemophilia • Gastrointestinal bleeding Abdominal aortic aneurysm, peripheral arterial aneurysm Gynecologic conditions • Cancer • Endometriosis • Ectopic pregnancy (not common) • Sexually transmitted infection • Pelvic inflammatory disease (PID) Infection, usually intra-abdominal or intraperitoneal infection (see Box 16-3) Prostate impairment (prostatitis, benign prostatic hyperplasia or BPH, prostate cancer)
CASE
EXAMPLE
1 6 - 4
Soft
Tissue
Musculotendinous strain (adductors, hamstrings, iliopsoas, abdominals) Internal oblique avulsion Nerve compression (ilioinguinal, obturator, lateral femoral cutaneous, sciatic nerves) Stress reaction or fracture Bursitis (iliopectineal) Pubalgia Osteitis pubis (most common in distant runners; insidious onset of midline pain that radiates to the groin; pain reproduced by palpation of the pubis [anterior], passive hip abduction, and resisted hip adduction) Trauma (physical, sexual, birth) Inguinal or femoral hernia (abdominal wall abnormality) Hip joint impairment • Subluxation, dislocation, dysplasia • Avascular necrosis (osteonecrosis) • Total hip arthroplasty (loosening, infection, bone loss, subsidence) • Slipped capital femoral epiphysis (SCFE) • Arthritis, arthrosis Sacroiliac joint (SIJ) impairment Lumbar spine impairment (spinal stenosis, disc disease) Trigger points Thoracic disc disease (lower thoracic spine)
S a r c o rn o
A 38-year-old female patient was referred to physical therapy by a primary care clinic physician assistant with a diagnosis of "groin strain." The client denied any injury or trauma. Little to no pain was reported, but a feeling of "fullness" in the left proximal thigh was described. She was unable to cross her legs when sitting because of this fullness. No other constitutional symptoms or associated symptoms were noted. When asked, "How long have you had this?" the client thought it had been present for the past 3 months. When asked, "Has it changed since you first noticed it?" she stated that she thought it was getting larger.
Examination: There was an obvious area of edema or tissue mass was identified in the proximal medial left thigh. No tenderness, bruising, erythema, or skin temperature changes were reported. The area in question had a boggy feel on palpation. Lower extremity range of motion and manual muscle testing were within normal limits. Screening and Differential Diagnosis: Look at Table 16-3. As you review the possible systemic and musculoskeletal causes of groin pain, what additional questions and tests or measures must be asked/carried out to complete your screening examination?
CHAPTER 16
CASE
EXAMPLE
1 6 - 4
Soft
Tissue
SCREENING THE LOWER QUADRANT
741
S a r c o rn a — c o n t ' d
On the Systemic Side • Spinal cord tumors—no temperature changes, dermatomal changes, or associated bowel and bladder changes; no further testing required at this time • Hodgkin's disease/lymphoma/leukemia—Ask about previous history of cancer, family history of cancer; palpate lymph nodes (quick screen of lymph nodes above and below the groin and careful examination of inguinal lymph nodes) • Urinary tract involvement—no history of recent fever, chills, difficulty urinating, or urinary tract infection; no blood in the urine; no further questions at this time • Ascites—No apparent abdominal ascites, no history of alcoholism; check for asterixis, liver palms (palmar erythema); ask about symptoms of carpal tunnel syndrome, look for spider angiomas during inspection, and observe nail beds for any changes (nails of Terry) • Hemophilia—It is a long shot, but ask about personal/family history • Abdominal aortic aneurysm—Ask about bounding pulse sensation in the abdomen; palpate aortic pulse width (see Fig. 4-51); ask about the presence of chest or back pain at any time, but especially with exertion • Gynecologic—Ask about a history of pelvic pain, pelvic inflammatory disease, or sexually transmitted infection McBurney's test, • Appendicitis—Perform Blumberg's sign, and iliopsoas and obturator tests (see Chapter 8 for descriptions) On the Musculoskeletal Side • Muscle strain—As already tested, no loss of motion or strength; no pain with resisted movement; no history of trauma or overuse; red flag: Clinical presentation is not consistent with the medical diagnosis • Internal oblique avulsion/stress reaction or fracture—As above
• Pubalgia—As above; no painful symptoms reported, no pain on palpation • Sexual assault/domestic violence—Even though the client denies trauma, consider a screening interview for nonaccidental trauma (see Chapter 2 or Appendix B-3); absence of erythema, skin bruising, or other skin changes makes this type of trauma unlikely • Total hip arthropathy—Negative history • Avascular necrosis—Not likely, given the clinical presentation; ask about a history of long-term use of immunosuppressants (corticosteroids for Crohn's disease, sarcoidosis, autoimmune disorders) • Trigger points—Atypical presentation for a trigger point; check for latent trigger points of the adductors, iliopsoas, vastus medialis, and sartorius Special Questions to Ask: Take a final look at Special Questions to Ask in this chapter. Have you missed anything? Left anything out? Result: On the basis of lack of objective findings and red flags of mass increasing in size and clinical presentation inconsistent with medical diagnosis, the therapist consulted with an orthopedic surgeon in the same health care facility. The orthopedic surgeon ordered x-rays, which were normal, and advised a short period of observation before ordering magnetic resonance imaging (MRI). After 3 weeks, no changes were observed, and an MRI was ordered. The MRI showed a soft tissue tumor, later diagnosed on biopsy as a stage IIIB high-grade soft tissue sarcoma. The client underwent multiple surgical procedures, including removal of the medial compartment musculature and limb salvage with an eventual hemiarthroplasty. Physical therapy included gait training, regaining safe hip active range of motion, an aquatic rehabilitation program, use of an underwater treadmill, and both open and closed kinetic chain strengthening.
Adapted from Baxter RE: Identification of neoplasm mimicking musculoskeletal pathology: A case report involving groin symptoms. Poster presented at: Combined Sections Meeting, 2004, New Orleans, LA. Used with permission.
742
CASE
SECTION III
EXAMPLE
1 6 - 5
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Groin
P a i n — M u s c u l o s k e l e t a l
A 44-year-old male patient came to physical therapy with a 7-year history of right groin pain. X-rays, bone scan, and arthrogram of the hip were negative. At the time of initial examination, the client was taking morphine for pain that was described as constant, severe, and sharp, and that was rated 8 out of 10 on the numeric rating scale (NRS; see Chapter 3). Sitting and driving made the symptoms worse, and he was unable to work as a mechanic because prolonged squatting was required. Lying supine relieved the pain. Physical examination revealed extreme hip medial rotation associated with active hip flexion, abduction, and knee extension; each of these movements reproduced his symptoms. Passive range of motion of the right hip was painful and was limited to 95 degrees of flexion and 0 degrees of lateral rotation. Visual inspection during movement and palpation of the greater trochanter indicated that the proximal femur had medially rotated and moved anteriorly during hip flexion. Through application of a posteroinferior glide over the proximal femur during hip flexion, groin pain was decreased and motion increased. The client was able to moderate his symptoms by avoiding hip medial rotation during hip and knee movements. Consider: Are any red flags present? Is further screening indicated to rule out systemic origin of symptoms? If yes, what questions or tests might you consider carrying out? Red Flags: Age (over 40); constant, intense pain Further Screening Required: The length of time that symptoms have been present without accompanying signs and symptoms of a urologic or gastrointestinal nature (7 years) is not typical of systemic origin of musculoskeletal symptoms.
Cause
The fact that no aggravating and relieving factors are known further rules out a viscerogenic cause of pain. It would be appropriate to ask the Special Questions for Men at the end of this chapter (see also Appendix B-21). It is always a good idea to ask one final question: Are any other symptoms of any kind anywhere else in your body? Special tests might include the heel strike test (fracture), translational rotation tests for stress reaction (fracture), iliopsoas and obturator tests (abscess; see Chapter 8), and trigger point assessment. Result: The client was treated for femoral anterior glide with medial rotation (movement impairment diagnosis). Training to teach the client to modify hip medial rotation during sustained postures and functional activities was a key component of the intervention. Exercises were given to strengthen the right iliopsoas muscle, hip lateral rotator muscles, and posterior gluteus medius muscle. The client was pain-free and off pain medications 2 months later, after 6 treatment sessions. He was able to return to full-time work. Comment: Knowledge of red flag signs and symptoms, risk factors for various systemic conditions and illnesses, associated signs and symptoms of viscerogenic pain, and typical clinical presentations for neuromuscular and musculoskeletal problems can guide the therapist in quickly sizing up a situation and deciding whether or not further screening is warranted. In this case, the therapist can see that only a few screening questions are in order. The application of any additional special tests depends on the client's answers to screening questions. The client's immediate response to intervention is another way to verify a correct physical therapy diagnosis. Failure to progress with intervention is a red flag that indicates the need for reevaluation. 14
Data from Bloom NJ, Sahrmann SA: Groin pain caused by movement system impairments: A case report. Poster presented at: Combined Sections Meeting, 2004, New Orleans, LA. Submitted for publication. Used with permission.
CHAPTER 16
Anterior thigh pain is more common (Table 16-4), but posterior thigh pain may occur, with ruptured abdominal aortic aneurysm. Local anterior or posterior thigh pain of systemic origin generally occurs as a deep aching generated by soft tissue irritation or bone involvement. Radicular pain is usually a sharp, stabbing pain that projects in dermatomal distributions caused by compression of the dorsal nerve roots. NEUROMUSCULOSKELETAL PRESENTATION The lower lumbar vertebrae and sacrum can refer pain to the gluteal and hip region, with pain radiating down the posterior or posterolateral thigh. Pain down the lateral aspect of the thigh to the knee may also be caused by inflammation of the tensor fascia lata with iliotibial band syndrome. Anterior thigh pain is commonly disc related, resulting from L3-L4 disc herniation, and occurring most often in older clients with a previous history of lumbar spine surgery. The clinical presentation varies among affected individuals, but thigh pain alone is most common (Case Example 16-6). Back and thigh pain, a positive reverse straight leg raising test, and depressed knee reflex are described more often in clients with disc herniation at the L3-L4 level than in clients with L4-L5 and L5-S1 l e v e l s . A positive reverse straight leg raise is defined as pain traveling down the ipsilat3
1617
TABLE
16-4
SCREENING THE LOWER QUADRANT
743
eral leg when the person is prone and the leg is extended at the hip and the knee. A positive test is caused by tension on the femoral nerve and its roots. Objective neurologic findings such as hyperreflexia or hyporefiexia, decreased sensation to light touch or pinprick, and decreased motor strength can occur with soft tissue problems such as bursitis. However, clients with true nerve root irritation experience pain extending into the lower leg and foot. Clients with bursitis exhibit a positive "jump" sign when pressure is applied over the greater trochanter; no jump sign is seen with nerve root irritation. A common neuromuscular cause of anterior or anterolateral thigh pain is lateral femoral cutaneous nerve (LFCN) neuralgia. Entrapment or compression of the LFCN causes pain or dysesthesia, or both, in the anterolateral thigh—a condition called meralgia paresthetica. Compression of the LFCN may occur at the level of the L2 and L3 roots through upper lumbar disc herniation or tumor in the second lumbar vertebra. LFCN neuropathy may occur after spine surgery to repair nerve damage that occurred during harvesting of the iliac bone graft or that resulted from pressure on the pelvis with use of the Relton-Hall frame. Other causes of injury to the LFCN include abnormal posture, chronic muscle spasm, tightfitting braces, corsets or pants, and thigh injury. 5
18
Causes of Anterior Thigh Pain
Systemic Retroperitoneal or intra-abdominal tumor or abscess (see Box 16-3) Kidney stones (nephrolithiasis, ureteral or renal colic) Peripheral neuropathy (bilateral, symmetric) • Diabetes mellitus • Neoplasm • Chronic alcohol use Thrombosis (femoral artery, great saphenous vein) Bone tumor (primary or metastases)
Neuromusculoskeletal Musculotendinous strains (e.g., adductor, abductor, quadriceps) Iliopectineal bursitis (anterior and medial thigh pain); trochanteric bursitis (lateral thigh) Peripheral neuropathy (unilateral, asymmetric) Contusions (collisions with balls, hockey pucks, the ground, other athletes) Nerve compression (e.g., meralgia paresthetica from compression of the lateral femoral cutaneous nerve) Myositis ossificans (injury with contusion and hematoma formation) Femoral shaft stress reaction or fracture; insufficiency fracture/ stress reaction Hip disease (osteoarthritis, labral tear) Total hip arthroplasty (loose component, undersized/oversized femoral stem, periosteal irritation) Sacroiliac joint dysfunction Upper lumbar spine dysfunction; spondylolisthesis, herniated disc, previous surgery Trigger points Inguinal hernia
744
CASE
SECTION III
EXAMPLE
1 6 - 6
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Buttock
Pain
Post Prostatectomy
A 62-year-old male patient was examined by a physical therapist for a chief complaint of severe left buttock and lateral thigh pain. No injury or trauma was reported; the client noticed low back pain 3 days ago. He lifted a couple of sand bags but did not think that was the cause of his pain. He has seen the chiropractor twice this week and felt that the electrical stimulation he had on one visit "usually does it" (helped relieve the pain). Pain relief was of a very short-term nature and had no lasting effects. Past Medical History: Prostatectomy 4 years ago for cancer followed by 36 radiation treatments. The bowel was resected, and the patient received a stoma at that time. Current Health Report: Prostate-specific antigen has increased from 0 to 0.4 in a stepwise fashion over the past year. The patient has not seen his oncologist for any follow-up "for quite some time." At this time, the client is not taking any medications except for over-the-counter pain relievers. Supplements include calcium and fish oil. Clinical Presentation Pain Pattern: Pain is reported as "constant," but it "has its highs and lows." The client prefers lying on his left (involved) side. He cannot sit for longer than 1 minute without onset of radicular symptoms. Physical Examination: Visual inspection showed flattened lumbar spine. What appeared to be atrophy was seen in the right gluteal; this was confirmed with comparative palpation. Pelvic landmarks were slightly elevated (L higher than R). Lumbar range of motion was limited in all planes with remarkably minimal flexion, which the patient said was normal for him. No centralization of pain occurred with side glides or with repeated extension in standing. Vascular Examination: No signs of peripheral vascular disease were noted in the lower extremities. Blood pressure was not assessed. Neurologic Screening Examination: Hyperreflexive patellar deep tendon reflexes on the right (L3); this was difficult to assess: He may have been notably hyporeflexive on the left. Achilles deep tendon reflexes (SI) appeared
equal, with grading of 2/4 bilaterally. Clonus, Babinski's, and Openheim's were negative. Manual muscle testing (MMT) showed fatiguing weakness on the left at L2 (hip flexors), L3 (quadriceps), L5 (extensor hallucis longus and gluteus medius), and SI (hamstring). No loss of light touch sensation was observed. Associated Signs and Symptoms: No nausea or vomiting was reported. No recent significant weight loss or gain occurred. No changes in bowel or bladder function were described. The patient reported feeling chills of late, intermittently, which he says are caused by the bouts of severe pain. He showed no diaphoresis during the physical therapist's examination. Red Flags • Insidious onset of radicular pain in a 62-yearold with a previous history of cancer • Constitutional symptom (chills) • Constant, intense pain • Notable proximal muscle weakness; multisegmental weakness on the left • No improvement with chiropractic care or physical therapy Result: The therapist applied some direct intervention for pain relief (positioning, Pain Reflex Release Technique™ (PRRT), trigger point release) with no immediate relief of painful symptoms. The therapist explained his concerns regarding the red flag symptoms and advised the client to make an appointment with his oncologist for further evaluation. The client was instructed to call the therapist with the name and number for the oncologist, so his findings could be relayed to her. The client left a message on the therapist's answering machine (received the next morning) that he was "going to the ER: I've got to do something about the pain." The client followed up midday to state that he had gone to the emergency department. Diagnostic tests were ordered, and MRI revealed a herniated nucleus pulposus (HNP) of the L3/4 disc with effacement on the L3 nerve root. The L5/S1 disc was also reportedly herniated, although this did not affect the adjacent nerve root. The client is to see a neurosurgeon next week.
CHAPTER 16
For clients with hip arthroplasty, both passive and active range of motion should be evaluated to assess implant stability. X-rays are needed to look at component position, bone-prosthesis interface, and signs of fracture or infection. 10
SYSTEMIC PRESENTATION
The pain pattern for anterior thigh pain produced by systemic causes is often the same as that presented for pain resulting from neuromusculoskeletal causes. The therapist must rely on clues from the history and the presence of associated signs and symptoms to help guide the decision-making process. For example, obstruction, infection, inflammation, or compression of the ureters may cause a pattern of low back and flank pain that radiates anteriorly to the ipsilateral lower abdomen and upper thigh. The client usually has a past history of similar problems or additional urologic symptoms such as pain with urination, urinary frequency, low-grade fever, sweats, or blood in the urine. Murphy's percussion test (Fig. 4-51) may be positive when the kidney is involved. The same pain pattern can occur with lower thoracic disc herniation. However, instead of urologic signs and symptoms, the therapist should look for a history of back pain and trauma, and the presence of neurologic signs and symptoms accompanying discogenic lesions. Retroperitoneal or intra-abdominal tumor or abscess may also cause anterior thigh pain. A past history of reproductive or abdominal cancer, or the presence of any condition listed in Box 16-3 is a red flag.
Knee and Lower Leg Pain in the lower leg is most often caused by injury, inflammation, tumor (malignant or benign), altered peripheral circulation, deep vein thrombosis (DVT), or neurologic impairment (Table 16-5). Assessment of limb pain follows the series of pain-related questions presented in Figure 3-6. The therapist can use the information in Boxes 4-12 and 4-15 to conduct a screening examination. In addition to screening for medical problems, the therapist must remember to clear the joint above and below the area of symptoms or dysfunction. True knee pain or symptoms are often described as mechanical (local pain and tenderness with locking or giving way of the lower leg) or loading (poorly localized pain with weight bearing). Assessment of trigger points (TrPs) is also essen-
SCREENING THE LOWER QUADRANT
745
tial as pain referral to the knee from TrPs in the lower quadrant is well recognized but sometimes forgotten. Many therapists over the years have shared with us stories of clients treated for knee pain with a total knee replacement only to discover later (when the knee pain was unchanged) that the problem was really coming from the hip. On the flip side, it is not as likely but is still possible that hip pain can be caused by knee disease. Individual case reports of hip fracture presenting as isolated knee pain have been published (Case Example 16-7). Leg cramps, especially those occurring in the lower leg and calf, are common in the adult population. The history and physical examination are key elements in identifying the cause. The most common causes of leg cramps include dehydration, arterial occlusion from peripheral vascular disease, neurogenic claudication from spinal stenosis, neuropathy, medications, metabolic disturbances, nutritional (vitamin, calcium) deficiency, and anterior compartment syndrome from trauma, hemophilia, burns, casts, snakebites, or revascular perfusion injury. Athletes often experience leg cramps preceded by muscle fatigue or twitching. Fractures and ligament tears can mimic a cramp. Cramping associated with severe dehydration may be a precursor to heat stroke. Burning and pain in the legs and feet at night are common in older adults. The exact cause is often unknown; many factors should be considered, including allergic response to the fabric in clothing and socks, poorly fitting shoes, long-term alcohol use, adverse effects of medications, diabetes, pernicious anemia, and restless legs syndrome. 19
20
21
22
Associated Signs and Symptoms Asking about the presence of other signs and symptoms, conducting a review of systems, and identifying red flag symptoms will help the therapist in the clinical decision-making process. The therapist can use the Red Flags (see Appendix A-2) to guide screening questions. Always ask every client the following: Follow-Up
Questions
• Are there any other symptoms of any kind anywhere else in your body? If the client says, "No," the therapist may want to ask some general screening questions, including questions about constitutional symptoms.
TABLE
16-5
Neurogenic claudication
Peripheral n e u r o p a t h y
Restless legs s y n d r o m e
Pain* is usually bilateral
Pain is usually bilateral but may be unilateral Burning and dysesthesia in the back, buttocks, and/or legs
Pain, aching, and numbness of feet (and hands)
Crawling, creeping sensation in legs; involuntary Involuntary contractions of calf muscles, occurring especially at night Painf can be mild to severe, lasting seconds, minutes, or hours
No burning or dysesthesia
Decreased or absent pulses Color and skin changes in feet Normal deep tendon reflexes; may be absent in people older than 60 Sciatica possible (ischemia)
Normal pulses Good skin nutrition Depressed or absent ankle jerks Positive straight-leg raise Sciatica
Pulses may be affected, depending on underlying pathologic condition (e.g., diabetes) Deep tendon reflexes diminished or absent May have positive straight-leg raise May have sciatica
Sleep disturbance, paresthesias
Location
Usually calf first but may occur in the buttock, hip, thigh, or foot
Low back, buttock, thighs, calves, feet
Feet and hands in stocking-glove pattern
Feet, calves, legs
Aggravating factors
Pain is consistent in all spinal positions; brought on by physical exertion (e.g., walking); increased by climbing stairs or walking uphill
Increased in spinal extension Increased with walking; less painful when walking uphill
Depends on underlying cause (e.g., uncontrolled glucose levels with diabetes; progressive alcoholism)
Caffeine, pregnancy, iron deficiency
Relieving factors
Relieved promptly by standing still, sitting down, or resting (1-5 minutes)
Pain decreased by sitting, lying down, bending forward, or flexion exercises (may persist for hours)
Relieved by pain medications and relaxation techniques; treatment of underlying cause
Eliminate caffeine; increase iron intake, movement, walking, moderate exercise; medications; stretching; maintain hydration; heat or cold
Ages affected 40-60+
40-60+
Varies depending on underlying cause
Variable
Cause
Neoplasm or abscess Disc protrusion Osteophyte formation Ligamentous thickening
More than 100 causes: diabetes; medications; accidents; nerve compression; metal toxicity; nutritional deficiency; diseases such as rheumatoid arthritis, systemic lupus erythematosus, AIDS; cancer, hypothyroidism, alcoholism
Cause unknown; may be a sleep disorder, arterial disorder, or dysautonomic disorder of the autonomic nervous system; may occur with dehydration or as a side effect of many medications
Atherosclerosis in peripheral arteries
* "Pain" associated with vascular claudication may also be described as an "aching," "cramping," or "tired" feeling. t "Pain" associated with restless legs syndrome may not be painful but may be described as a "frantic," "unbearable," or "compelling" need to move the legs.
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
Associated signs and symptoms
Motor, sensory, and autonomic changes: burning, prickling, or tingling may be present; extreme sensitivity to touch (or numbness); weakness, falling (foot drop), muscle atrophy; infection, ulcers, gangrene
SECTION III
Vascular claudication
746
Description
Symptoms a n d Differentiation of Leg Pain
CHAPTER 16
CASE
EXAMPLE
1 6 - 7
Total
Knee
SCREENING THE LOWER QUADRANT
747
A r t hr o p l a s t y
A 78-year-old woman went to the emergency department over a weekend for knee pain. She reported a knee joint replacement 6 months ago because of arthritis. X-ray examination showed that the knee implant was intact with no complications (i.e., no infection, fracture, or loose components). She was advised to contact her orthopedic surgeon the following Monday for a follow-up visit. The woman decided instead to see the physical therapist who was involved with her postoperative rehabilitation. The physical therapist's interview and examination revealed the following information. No pain was perceived or reported anywhere except in the knee. The pain pattern was constant (always present) but was made worse by weightbearing activities. The knee was not warm, red, or swollen. No other associated signs and symptoms or constitutional symptoms were present, and vital signs were within normal limits for her age range. Range of motion was better than at the time of previous discharge, but painful symptoms were elicited with a gross manual muscle screening examination. After a test of muscle strength, the woman was experiencing intense pain and was unable to put any weight on the painful leg.
Failure to improve with physical therapy intervention may be part of the medical differential diagnosis and should be reported within a reasonable length of time, given the particular circumstances of each client.
TRAUMA AS A CAUSE OF HIP, GROIN, OR LOWER QUADRANT PAIN Trauma, including accidents, injuries, physical or sexual assault, or birth trauma, can be the underlying cause of buttock, hip, groin, or lower extremity pain.
Birth Trauma Birth trauma is one possible cause of low back, pelvic, hip, or groin pain, with pain radiating down
The physical therapist insisted that the woman contact her physician immediately and arranged by phone for an emergency appointment that same day. R e s u l t : Orthopedic examination and pelvic and hip x-ray films showed a hip fracture that required immediate total hip replacement the same day. The knee can be a site for referred pain from other areas of the musculoskeletal system, especially when symptoms are monoarticular. Systemic origin of symptoms is more likely when multiple joints are involved or migrating arthralgias are present. No history or accompanying signs and symptoms suggested a systemic origin of knee pain, but the pain on weight bearing made worse after muscle testing was a red flag symptom for bone involvement. Hip fractures or other hip disease can masquerade as knee pain. Prompt diagnosis of hip fracture is important in preventing complications. This therapist chose the conservative approach with medical referral rather than proceeding with physical therapy intervention. Sometimes, the "treatand-see" approach to symptom assessment works well, but if any identifiable red flags are identified, a physician referral is advised.
the leg in some cases. Multiple births, prolonged labor and delivery, forceps/vacuum delivery, and postepidural complications are just a few of the more common birth-related causes of hip, groin, and lower extremity pain. Gynecologic conditions are discussed more completely in Chapter 15.
Stress Reaction or Fracture An undiagnosed stress reaction or stress fracture is a possible cause of hip, thigh, or groin pain. A stress reaction or fracture is a microscopic disruption, or break, in a bone that is not displaced; it is not seen initially on regular x-rays. Exercise-induced groin pain is the most common presentation. The client is often a distance runner or military recruit (pubic ramus stress reaction) or an older adult (hip fracture). Depending on the age of the client, the therapist should look for a history of
748
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
high-energy trauma, prolonged activity, or abrupt increase in training intensity. Other risk factors include changes in running surface, use of inadequately cushioned footwear, and the presence of the female athlete triad of disordered eating, osteoporosis, and amenorrhea. ' Femoral shaft stress fractures are rare in the general population but are not uncommon among distance runners and military recruits involved in repetitive loading activities such as running and marching. Vague anterior thigh pain that radiates to the hip or knee with activity or exercise is the most common clinical presentation. The affected individual usually has full but painful active hip motion. The fulcrum test (Fig. 16-3) has high clinical correlation with femoral shaft stress injury. Osteopenia or osteoporosis, especially in the postmenopausal woman or older adult with arthritis, can result in injury and fracture or fracture and injury (Case Example 16-8). The client has a small 23
24
25
26
mishap, perhaps losing her footing on a slippery surface or tripping over an object. As she tries to "catch herself," a torsional force occurs through the hip, causing a fracture and then a fall. This is a case of fracture then fall, rather than the other way around. Often, but not always, the client is unable to get up because of pain and instability of the fracture site. ' Pain on weight bearing is a red flag symptom for stress reaction or fracture in any individual. In the case of bone pain (deep pain, pain on weight bearing), the therapist can perform a heel strike test. This is done by applying a percussive force with the heel of the examiner's hand through the heel of the client's foot in a non-weight-bearing (supine) position. Reproduction of painful symptoms with axial loading is positive and highly suggestive of a bone fracture or stress reaction. The therapist can ask a physically capable client to hop on the uninvolved side and to do a full squat to clear the hip, knee, and ankle. These tests are used to screen for pubic ramus or hip stress fracture (reaction). Palpation over the injured bone may reproduce the painful symptoms, but when the stressed bone lies deep within the tissue, the therapist may be able to reproduce the pain by stressing the bone with translational (resisted active adduction) or rotational force (resisted active adduction combined with hip external rotation). Swelling is not usually evident early in the course of a stress reaction or fracture, but it does develop if the person continues athletic activity. Look for the following clues suggestive of hip, groin, or thigh pain caused by a stress reaction or stress fracture. 27
29
Clinical Stress
• • • • • • F i g . 1 6 - 3 • Fulcrum test for femoral shaft stress reaction or fracture. With the client in a sitting position, the examiner places his or her forearm under the client's thigh and applies downward pressure over the anterior aspect of the distal femur. A positive test is characterized by reproduction of thigh pain often described as "sharp," with considerable apprehension on the part of the client. 26
28
•
•
Signs
and
Symptoms
Reaction/Stress
of Fracture
Pain described as aching or deep aching Pain increases with activity and improves with rest Compensatory gluteus medius gait Pain localizing to a specific area of bone (localized tenderness) Positive Patrick's or Faber's test Pain reproduced by weight bearing, heel strike, or hopping test Pain reproduced by translational/rotational stress (exquisite pain in response to active resistance to hip adduction/hip adduction combined with external rotation) Thigh pain reproduced by the fulcrum test (femoral shaft fracture)
CHAPTER 16
• • •
SCREENING THE LOWER QUADRANT
test is positive, communication with the physician may be warranted.
Possible local swelling Increased tone of hip adductor muscles; limited hip abduction Night pain (femoral neck stress fracture)
Assault
The therapist should keep in mind that some fractures of the intertrochanteric region do not show up on standard anteroposterior or lateral xray. An oblique view may be needed. If an x-ray has been ruled negative for hip fracture but the client cannot put weight on that side, and a heel strike
CASE
EXAMPLE
1 6 - 8
Insufficiency
749
The client may not report assault as the underlying cause, or he or she may not remember any specific trauma or accident. It may be necessary to take a sexual history (see Appendix B-29) that includes specific questions about sexual activity (e.g., incest, partner assault or rape) or the presence of sexually transmitted infection. Appropriate
Fracture
A 50-year-old Caucasian woman was referred to physical therapy with a 4-year history of rheumatoid arthritis (RA). She had been taking prednisone (5 to 30mg/day) and sulfasalazine ( l g twice a day). She has a history of hypertension, smokes a pack of cigarettes a day, and drinks a six-pack of beer every night. She lives alone and no longer works outside the home. She admits to very poor nutrition and does not take a multivitamin or calcium. Clinical Presentation: Symmetric arthritis with tenderness and swelling of bilateral metacarpophalangeal (MCP) joints, proximal interphalangeal joints (PIPs), wrists, elbows, and metatarsophalangeal joints (MTPs). The patient reported "hip pain," which started unexpectedly 2 weeks ago in the right groin area. The pain went down her right leg to the knee but did not cross the knee. Any type of movement made it hurt more, especially on walking. Hip range of motion was limited because of pain; formal range of motion (active, passive, accessory motions) and strength testing were not possible. What are the red flags in this case? • Age • Insidious onset with no known or reported trauma • Cigarette smoking • Alcohol use • Poor diet • Corticosteroid therapy
Result: The client was showing multiple risk factors for osteoporosis. Further questioning revealed that surgical menopause took place 10 years ago; this is another risk factor. The patient was unable to stand on the right leg unsupported. She could not squat because of her arthritic symptoms. Heel strike test was negative. Patrick's (Faber's test) could not be performed because of the acuteness of her symptoms. The patient was referred to her rheumatologist with a request for a hip x-ray before any further physical therapy was provided. The therapist pointed out the risk factors present for osteoporosis and briefly summarized the client's current clinical presentation. The client was given a diagnosis of insufficiency fracture of the right inferior and superior pubic rami. An insufficiency fracture differs from a stress fracture in that it occurs when a normal amount of stress is placed on abnormal bone. A stress fracture occurs when an unusual amount of stress is placed on normal bone. Conservative treatment was recommended with physical therapy, pain medications, and treatment of the underlying osteoporosis. Weight bearing as tolerated, a general conditioning program, and an osteoporosis exercise program were prescribed by the physical therapist. Client education about managing active rheumatoid arthritis and synovitis was also included.
Data from Kimpel DL: Hip pain in a 50-year-old woman with RA. J Musculoskel Med 16:651-652, 1999.
750
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
screening questions for assault or domestic violence are included in Chapter 2; see also Appendix B-3.
SCREENING FOR SYSTEMIC CAUSES OF SCIATICA Sciatica, described as pain radiating down the leg below the knee along the distribution of the sciatic nerve, is usually related to mechanical pressure or inflammation of lumbosacral nerve roots (Fig. 16-4). Sciatica is the term commonly used to describe pain in a sciatic distribution without overt signs of radiculopathy.
Radiculopathy denotes objective signs of nerve (or nerve root) irritation or dysfunction, usually resulting from involvement of the spine. Symptoms of radiculopathy may include weakness, numbness, or reflex changes. Sciatic neuropathy suggests damage to the peripheral nerve beyond the effects of compression, often resulting from a lesion outside the spine that affects the sciatic nerve (e.g., ischemia, direct trauma to the nerve, compression by neoplasm or piriformis muscle). The terms radiculopathy and neuropathy are often used interchangeably, although a pathologic difference is described here. Electrodiagnostic studies, including nerve conduction studies (NCS), electromyography (EMG), and somatosensory evoked potential studies (SSEPs), are used to make the differentiation. Sciatica has many neuromuscular causes, both discogenic and nondiscogenic; systemic or extraspinal conditions can produce or mimic sciatica (Table 16-6). Risk factors for a mechanical cause of sciatica include previous trauma to the low back, taller height, tobacco use, pregnancy, and work and occupational-related posture or movement. 30
Risk Factors Risk factors for systemic or extraspinal causes vary with each condition (Table 16-7). For example, clients with arterial insufficiency are more likely to be heavy smokers and to have a history of atherosclerosis. Increasing age, past history of cancer, and comorbidities such as diabetes mellitus, endometriosis, or intraperitoneal inflammatory disease (e.g., diverticulitis, Crohn's disease, pelvic inflammatory disease) are risk factors associated with sciatic-like symptoms (Case Example 16-9). Total hip arthroplasty is a common cause of sciatica because of the proximity of the nerve to the hip joint. Possible mechanisms for nerve injury include stretching, direct trauma from retractors, infarction, hemorrhage, hip dislocation, and compression. Sciatica referred to as sciatic nerve "burn" has been reported as a complication of hip arthroplasty caused by cement extrusion. The incidence of this complication has decreased with its increased recognition, but even small amounts of cement can cause heat production or direct irritation of the sciatic nerve. Propionibacterium acnes, a cause of spinal infection, has been linked to sciatica. Bacterial wound contamination during spinal surgery has been traced to this pathogen on the patient's skin. Minor trauma to the disc with a breach to the 31
F i g . 1 6 - 4 • Sciatica pain pattern. Perceived or reported pain associated with compression, stretch, injury, entrapment, or scarring of the sciatic nerve depends on the location of the lesion in relation to the nerve root. The sciatic nerve is innervated by L4, L5, SI, S2, and sometimes S3 with several divisions (e.g., common fibular (peroneal) nerve, sural nerve, tibial nerve).
32
CHAPTER 16
TABLE
16-6
751
SCREENING THE LOWER QUADRANT
Causes of Sciatica Systemic/extraspinal causes*
Neuromuscular causes
Disorders
Disorder Discogenic Disc herniation
Symptoms
Lateral entrapment syndrome (spinal stenosis)
Buttock and leg pain with radiculopathy; pain often relieved by sitting, aggravated by extension of the spine
Similar to disc herniation
Low back and buttock pain
Tender sacroiliac joint; rjositivp latpral I J I ' . ^ l l 1 * & J i l l l J 111 compression test; positive Patrick's test Pain and weakness on resisted abduction/external rotation of the thigh
Nondiscogenic Sacroiliitis
Piriformis syndrome
Iliolumbar syndrome Trochanteric bursitis
Physical Signs
Low back pain with Restricted spinal movement; Vascular • Ischemia of sciatic nerve radiculopathy and restricted spinal segment; • Peripheral vascular disease paravertebral muscle positive Laseque's sign or restricted straight leg raise (PVD) spasm; Valsalva's maneuver • Intrapelvic aneurysm (internal and sciatic stretch reproduce (SLR) symptoms iliac artery)
Low back and buttock pain with referred pain down the leg to the ankle or midfoot Pain in iliolumbar ligament area (posterior iliac crest); referred leg pain Buttock and lateral thigh pain; worse at night and with activity
Greater trochanteric pain syndrome (GTPS)
Mimics lumbar nerve root compression
Ischiogluteal bursitis
Buttock and posterior thigh pain; worse with sitting
Posterior facet syndrome
Low back pain
Fibromyalgia
Back pain, difficulty sleeping, anxiety, depression
Tender iliac crest and increased pain with lateral or side bending Tender greater trochanter; rule out associated leglength discrepancy; positive "jump sign" when pressure is applied over the greater trochanter
Neoplasm (primary or metastatic) Diabetes mellitus (diabetic neuropathy) Megacolon Pregnancy; vaginal delivery Infection • Bacterial endocarditis • Wound contamination • Herpes zoster (shingles)
33,34
• Psoas muscle abscess (see Box 16-3) • Reiter's syndrome Total hip arthroplasty Endometriosis Deep venous thrombosis (DVT; blood clot)
Low back, buttock, or lateral thigh pain; may radiate down the leg to the iliotibial tract insertion on the proximal tibia; inability to sleep on the involved side Tender ischial tuberosity; positive SLR and Patrick's tests; rule out associated leg-length discrepancy Lateral bending in spinal extension increases pain; side bending and rotation to the opposite side are restricted at the involved level Multiple tender points (see Fig. 12-2) 5
Data from Namey TC, An HC: Sorting out the causes of sciatica, Mod Med 52:132, 1984. * Clinical symptoms of systemic/extraspinal sciatica can be very similar to those of sciatica associated with disc protrusion.
752
TABLE
SECTION III
16-7
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Risk Factors for Sciatica
Musculoskeletal or neuromuscular factors Previous low back injury or trauma; direct fall on buttock(s); gunshot wound Total hip arthroplasty Pregnancy Work- or occupation-related postures or movements Fibromyalgia Leg-length discrepancy Congenital hip dysplasia; hip dislocation Degenerative disc disease Piriformis syndrome Spinal stenosis
CASE
EXAMPLE
1 6 - 9
L o w
Back
Systemically induced factors Tobacco use History of diabetes mellitus Atherosclerosis Previous history of cancer (metastases) Presence of intra-abdominal or peritoneal inflammatory disease (abscess): • Crohn's disease • Pelvic inflammatory disease • Diverticulitis Endometriosis of the sciatic nerve Radiation therapy (delayed effects; rare) Recent spinal surgery, especially with instrumentation
Pain W i t h
A 52-year-old man with low back pain and sciatica on the left side has been referred to you by his family physician. He underwent discectomy and laminectomy on two separate occasions about 5 to 7 years ago. No imaging studies have been done since that time. What follow-up questions would you ask to screen for systemic disease? 1. The first question should always be, Did you actually see your doctor? [Of course, communication with the physician is the key here in understanding the physician's intended goal with physical therapy and his or her thinking about the underlying cause of the sciatica.] 2. Assess for the presence of constitutional symptoms. For example, after paraphrasing what the client has told you, ask, "Are you having any other symptoms of any kind in your body that you haven't mentioned?" If no, ask more specifically about the presence of associated signs and symptoms; name constitutional symptoms one by one. 3. Follow-up with Special Questions for Men (see Appendix B-21). Include questions about past history of prostate health problems, cancer of any kind, and current bladder function. 4. Take a look at Table 16-6. By reviewing the possible systemic/extraspinal causes of sciatica, we can decide what additional questions might be appropriate for this man.
Sciatica
Vascular ischemia of the sciatic nerve can occur at any age as a result of biomechanical obstruction. It can also result from peripheral vascular disease. Check for skin changes associated with ischemia of the lower extremities. Ask about the presence of known heart disease or atherosclerosis. Intrapelvic Aneurysm: Palpate aortic pulse width and listen for femoral bruits. Neoplasm (primary or metastatic): Consider this more strongly if the client has a previous history of cancer, especially cancer that might metastasize to the spine. We know from Chapter 13 that the three primary sites of cancer most likely to metastasize to the bone are lung, breast, and prostate. Other cancers that metastasize to the bone include thyroid, kidney, melanoma (skin), and lymphoma. A previous history of any of these cancers is a red flag finding. Primary bone cancer is not as likely in a middle-aged male as in a younger age group. Cancer metastasized to the bone is more likely and is most often characterized by pain on weight bearing that is deep and does not respond to treatment modalities. Diabetes (diabetic neuropathy): Ask about a personal history of diabetes. If the client has diabetes, assess further for associated neuropathy. If not, assess for symptoms of
CHAPTER 16
CASE
EXAMPLE
1 6 - 9
L o w
Bock
Pain W i t h
possible new-onset, but as yet undiagnosed, diabetes. Megacolon: An unlikely cause unless the client is much older or has recently undergone major surgery of some kind. Pregnancy: Not a consideration in this case. Infection: Ask about a recent history of infection (most likely bacterial endocarditis, urinary tract infection, or sexually transmitted infection, but any infection can seed itself to the joints or soft tissues). Ask about any other signs or symptoms of infection (e.g., flulike symptoms such as fever and chills or skin rash in the last few weeks). Remember from Chapter 3 to ask the following: Follow-Up
SCREENING THE LOWER QUADRANT
Questions
• Are you having any pain anywhere else in your body? • Are you having symptoms of any other kind that may or may not be related to your main problem? • Have you recently (last 6 weeks) had any of the following: • Fractures • Bites (human, animal) • Antibiotics or other medications • Infections (you may have to prompt with specific infections such as strep throat, mononucleosis, urinary tract, upper respiratory [cold or flu], gastrointestinal, hepatitis, STDs)
mechanical integrity of the disc may also allow access by low virulent microorganisms, thereby initiating or stimulating a chronic inflammatory response. These microorganisms may cause prosthetic hip infection but also may be associated with the inflammation seen in sciatica; they may even be a primary cause of sciatica. ' Anyone with pain radiating from the back down the leg as far as the ankle has a greater chance that disc herniation is the cause of low back pain. This is true with or without neurologic findings. Unremitting, severe pain and increasing neurologic deficit are red flag findings. Sciatica caused by extraspinal bone and soft tissue tumors is rare but may occur when a mass is present in the pelvis, thigh, popliteal fossa, and calf.
Sciatica—cont'd
Total Hip Arthroplasty: Has the client had a recent (cemented) total hip replacement (e.g., cement extrusion, infection, implant fracture, loose component)? Result: The client had testicular cancer that had already metastasized to the pelvis and femur. By asking additional questions, the physical therapist found out that the client was having swelling and hardness of the scrotum on the same side as the sciatica. He was unable to maintain an erection or to ejaculate. The physician was unaware of these symptoms because the client did not mention them during the medical examination. Testicular carcinoma is relatively rare, especially in a man in his 50s. It is most common in the 15- to 39-year-old male group. Metastasis usually occurs via the lymphatics, with the possibility of abdominal mass, psoas invasion, lymphadenopathy, and back pain. Palpation revealed a dominant mass (hard and painless) in the ipsilateral groin area. Sending a client back to the referring physician in a case like this may require tact and diplomacy. In this case, the therapist made telephone contact to express concerns about the reported sexual dysfunction and palpable groin lymphadenopathy. By alerting the physician to these additional symptoms, further medical evaluation was scheduled, and the diagnosis was made quickly.
Clinical
Signs
and
Sciatica/Sciatic
Symptoms
of
Radiculopathy
Symptoms are variable and following:
may include the
•
Pain along the sciatic nerve anywhere from the spine to the foot (see Fig. 16-4)
•
Numbness or tingling in the groin, rectum, leg, calf, foot, or toes
• •
Diminished or absent deep tendon reflexes Weakness in the L4, L5, S I , S2 (and sometimes S3) myotomes (distal motor deficits more prominent than proximal)
•
Diminished or absent deep tendon reflexes (especially of the ankle)
•
Ache in the calf
33 34
35
753
Continued on p. 754
754
SECTION III
Sciatic
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Neuropathy
• •
Symptoms of sciatica as described above Dysesthetic* pain described as constant burning or sharp, jabbing pain
•
Foot drop (tibialis anterior weakness) with gait disturbance Flail lower leg (severe motor neuropathy)
•
• Dysesthesia is the distortion of any sense, especially touch; it is an unpleasant sensation produced by normal stimuli.
The therapist can conduct an examination to look for signs and symptoms associated with systemically induced sciatica. Box 4-12 offers guidelines on conducting an assessment for peripheral vascular disease. Box 4-15 provides a checklist for the therapist to use when examining the extremities. These tools can help the therapist define the clinical presentation more accurately. The straight leg raise (SLR) and other neurodynamic tests are widely used but do not identify the underlying cause of sciatica. For example, a positive SLR test does not differentiate between discogenic disease and neoplasm. Without a combination of imaging and laboratory studies, the clinical picture of sciatica is difficult to distinguish from that of conditions such as neoplasm and infection. Erythrocyte sedimentation rate (ESR, or sed rate) is the rate at which red blood cells settle out of unclotted blood plasma within 1 hour. A high sed rate is an indication of infection or inflammation (see Table A, inside front cover). Elevated sed rate and abnormal imaging are effective tools to use in screening for occult neoplasm and other systemic disease. Imaging studies are an essential part of the medical diagnosis, but even with these diagnostic tests, errors in conducting and interpreting imaging studies may occur. Symptoms can also result from involvement outside the area captured on computed tomography (CT) scan or magnetic resonance imaging (MRI). 36
SCREENING FOR ONCOLOGIC CAUSES OF LOWER QUADRANT PAIN Many clients with orthopedic or neurologic problems have a previous history of cancer. The therapist must recognize signs and symptoms of cancer recurrence and those associated with cancer treatment such as radiation therapy or chemotherapy. The effects of these may be delayed by as long as
10 to 20 years or more (see Table 13-10) (Case Example 16-10). Until now, the emphasis has been on advancing age as a key red flag for cancer. Anyone older than 50 years of age may need to be screened for systemic origin of symptoms. With cancer and, specifically, musculoskeletal pain caused by primary cancer or metastases to the bone, young age is a red flag as well. Primary bone cancer occurs most often in adolescents and young adults, hence the new red flag: age younger than 20 years, or bone pain in an adolescent or young adult.
Cancer Recurrence The therapist is far more likely to encounter clinical manifestations of metastases from cancer recurrence than from primary cancer. Breast cancer often affects the shoulder, thoracic vertebrae, and hip first, before other areas. Recurrence of colon (colorectal) cancer is possible with referred pain to the hip and/or groin area. Beware of any client with a past history of colorectal cancer and recent (past 6 months) treatment by surgical removal. Reseeding the abdominal cavity is possible. Every effort is made to shrink the tumor with radiation or chemotherapy before attempts are made to remove the tumor. Even a small number of tumor cells left behind or introduced into a nearby (new) area can result in cancer recurrence.
Hodgkin's Disease Hodgkin's disease arises in the lymph glands, most commonly on a single side of the neck or groin, but lymph nodes also enlarge in response to infection throughout the body. Lymph nodes in the groin area can become enlarged specifically as a result of sexually transmitted disease. The presence of painless, hard lymph nodes that are also similarly present at other sites (e.g., popliteal space) is always a red flag symptom. As always, the therapist must question the client further regarding the onset of symptoms and the presence of any associated symptoms, such as fever, weight loss, bleeding, and skin lesions. The client must seek a medical diagnosis to be certain of the cause of enlarged lymph nodes.
Spinal Cord Tumors Spinal cord tumors (primary or metastasized) present as dull, aching discomfort or sharp pain in the thoracolumbar area in a beltlike distribution, with pain extending to the groin or legs. Depending on the location of the lesion, symptoms may be unilateral or bilateral with or without radicular
CHAPTER 16
CASE EXAMPLE
1 6 - 1 0
Evaluating
a
Referral: A 54-year-old man is self-referred to physical therapy on the recommendation of his personal trainer who is a friend of yours. He is experiencing leg weakness (greater on the right), with occasional pain radiating into the groin area on both sides. He reports a twisting back injury 5 years ago when he was shoveling snow. At that time, he saw a physical therapist but did not get any better until he started working out at the YMCA. Leg weakness has been present about 2 weeks. Last weekend, he went to the emergency department because his leg was numb and he could not lift his ankle. He was told to rest. The leg was better the next day. Past Medical History: Renal calculi, surgery for parathyroid and thyroid cancer 10 years ago, pneumonia 20 years ago. Currently seeing a counselor for emotional problems. Objective Findings: Neurologic Screen • Alert; oriented to time, place, person • Pupils equal and equally reactive to light; eye movements in all directions without difficulty • No tremor, upper extremity weakness, or changes in deep tendon reflexes (DTRs) • Straight leg raise (SLR) was mobile and pain free to 90 degrees bilaterally • Iliopsoas, gluteal, hamstring manual muscle testing (MMT) = 3/5 on the right side. MMT within normal limits on the left side. • Tibialis anterior, plantar evertors and flexors: MMT = 2/5 (right); 3+ to 4 on the left • No ankle clonus, no Babinski's, no changes in DTRs of LEs • Increased muscle tone in both lower extremities No pain was reported with any movements performed during the examination. Name 3 red flag symptoms in this case. Age is the first red flag: A man over 40 (and especially over 50 years of age) with a previous history of cancer (second red flag) and new onset of painless neurologic deficit (third red flag) is significant.
SCREENING THE LOWER QUADRANT
Client
for
Cancer
755
Recurrence
Now that we have identified three red flags, what is next? Does this signify an automatic referral to the physician? We do not think so: The need for physician referral may depend on the specific red flags that are present. For example, in the case just presented, the three red flags are pretty significant. Take a closer look, and gather as much information as possible. In this case, it appears likely that an immediate referral is warranted. Can we tell whether this is a recurrence of his previous cancer now metastasized or the presence of prostate cancer? No, but we can ask some additional questions to look for clusters of associated signs and symptoms that might point to prostate involvement. First, ask about bladder function, urination, and finally, sexual function. Remember, you may have to explain the need to ask a few personal questions. • Have you ever had prostate problems or been told you have prostate problems? • Have you had any changes in urination recently? • Can you easily start a flow of urine? • Can you keep a steady stream without stopping and starting? • When you are finished urinating, does it feel as though your bladder is empty? Or, do you feel like you still have to go, but you can't get any more out? • Do you ever dribble urine? • Do you have trouble getting an erection? • Do you have trouble keeping an erection? • Do you have trouble ejaculating? Because the patient is seeing a counselor for emotional problems, you may wish to screen him for emotional overlay. You can use the three tools discussed in Chapter 3 (Symptom Magnification, McGill's Pain Questionnaire, Waddell's nonorganic tests). After you have completed your examination, step back and put all the pieces together. Is there a cluster of signs and symptoms that point to any particular system? The answer to this question may lead you to ask some additional questions or to confirm the need for medical attention.
756
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
symptoms. The therapist should look for and ask about associated signs and symptoms (e.g., constitutional symptoms, bleeding or discharge, lymphadenopathy). Symptoms of thoracic disc herniation can mimic spinal cord tumor. In isolated cases, thoracic disc extrusion has been reported to cause groin pain and lower extremity weakness that gets progressively worse over time. A tumor is suspected if the client has painless neurologic deficit, night pain, or pain that increases when supine. Testing the cremasteric reflex may help the therapist identify neurologic impairment in any male with suspicious back, pelvic, groin (including testicular), or anterior thigh pain. The cremasteric reflex is elicited by stroking the thigh downward with a cotton-tipped applicator (or handle of the reflex hammer). A normal response in males is upward movement of the testicle (scrotum) on the same side. The absence of a cremasteric reflex is an indication of disruption at the T12-L1 level. Additionally, groin pain associated with spinal cord tumor is disproportionate to that normally expected with disc disease. No change in symptoms occurs after successful surgery for herniated disc. Age is an important factor: teenagers with symptoms of disc herniation should be examined closely for tumor. Spinal metastases to the femur or lower pelvis may appear as hip pain. With the exception of myeloma and rare lymphoma, metastasis to the synovium is unusual. Therefore, joint motion is not compromised by these bone lesions. Although any tumor of the bone may appear at the hip, some 37,38
CASE EXAMPLE
1 6 - 1 1
benign and malignant neoplasms have a propensity to occur at this location.
Bone Tumors Osteoid osteoma, a small, benign but painful tumor, is relatively common, with 20% of lesions occurring in the proximal femur and 10% in the pelvis. The client is usually in the second decade of life and complains of chronic dull hip, thigh, or knee pain that is worse at night and is alleviated by activity and aspirin. Usually, an antalgic gait is present, along with point tenderness over the lesion with restriction of hip motion. A great many varieties of benign and malignant tumors may appear differently, depending on the age of the client and the site and duration of the lesion (Case Example 16-11). Malignant lesions compressing the lateral femoral cutaneous nerve can cause symptoms of meralgia paresthetica, delaying diagnosis of the underlying neoplasm. Other bone tumors that cause hip pain, such as chondroblastoma, chondrosarcoma, giant cell tumor, and Ewing's sarcoma, are discussed in greater detail in Chapter 13. 39,40
Clinical
Signs
Buttock, Extremity with
• • •
and
Hip,
Symptoms Groin,
Pain
or
of Lower
Associated
Cancer
Bone pain, especially on weight bearing; positive heel strike test Antalgic gait Local tenderness Continued on p. 758
Ischial Bursitis
Referral: A 30-year-old dentist was referred to physical therapy by an orthopedic surgeon for ischial bursitis, sometimes referred to as "Weaver's bottom." He reported left buttock pain and "soreness" that was intermittent and work related. As a dentist, he was often leaning to the left, putting pressure on the left ischium. Background: Magnetic resonance imaging (MRI) showed local inflammation on the ischial tuberosity to confirm the medical diagnosis. He was given a steroid injection and was placed on an antiinflammatory (Celebrex) before he went to physical therapy.
The client reported a mild loss of hip motion, especially of hip flexion, but no other symptoms of any kind. The pain did not radiate down the leg. No significant past medical history and no history of tobacco use were reported; only an occasional beer in social situations was described. The client described himself as being "in good shape" and working out at the local gym 4 to 5 times/week. Intervention/Follow-TJp: Physical therapy intervention included deep friction massage, iontophoresis, and stretching. The client modified his dentist's chair with padding to take pressure off the buttock. Symptoms did not improve
CHAPTER 16
CASE EXAMPLE 1 6 - 1 1
SCREENING THE LOWER QUADRANT
757
I s c h i a l B u r s i t i s -- c o n t ' d
after 10 treatment sessions over the next 6 to 8 weeks; in fact, the pain became worse and was now described as "burning." The client went back to the orthopedic surgeon for a follow-up visit. A second MRI was done with a diagnosis of "benign inflammatory mass." He was given a second steroid injection and was sent back to physical therapy. He was seen at a different clinic location by a second physical therapist. The physical therapist palpated a lump over the ischial tuberosity, described as "swelling"; this was the only new physical finding since his previous visits with the first physical therapist. Treatment concentrated deep friction massage in that area. The therapist thought the lump was getting better, but it did not resolve. The client reported increased painful symptoms, including pain at work and pain at night. No position was comfortable; even lying down without pressure on the buttocks was painful. He modified every seat he used, including the one in his car. Result: The orthopedic surgeon did a bursectomy, and the pathology report came back with a diagnosis of epithelioid sarcoma. The diagnosis was made 2\ years after the initial painful symptoms. A second surgery was required because the first excision did not have clear margins. It is often easier to see the red flags in hindsight. As this case is presented here with the final outcome, what are the red flags? Red Flags • No improvement with physical therapy • Progression of symptoms (pain went from "sore" to "burning," and intermittent to constant) • Young age Clinical signs of all types of bursitis are similar and include local tenderness, warmth, and erythema. The latter two signs may not be obvious when the inflamed bursa is located deep beneath soft tissues or muscles, as in this case. The presence of a "lump" or swelling as presented in this case caused a delay in medical 39
referral and diagnosis because MRI findings were consistent with a diagnosis of inflammatory mass. In this case, symptoms progressed and did not fit the typical pattern for bursitis (e.g., pain at night, no position comfortable). Other Tests When a client is sent back a second time, the therapist's reevaluation is essential for documenting any changes from the original baseline and discharge findings. Reevaluation should include the following: • Recheck levels above and below for possible involvement, including lumbar spine, sacroiliac joint, hip, and knee; perform range of motion and special tests, and conduct a neurologic screening examination (see Chapter 4). • Test for the sign of the buttock to look for serious disease posterior to the axis of flexion and extension of the hip (see Box 16-2). A positive sign may be an indication of abscess, fracture, neoplasm, septic bursitis, or osteomyelitis. A noncapsular pattern is typical with bursitis and by itself is not a red flag. A capsular pattern with a diagnosis of bursitis would be more suspicious. Limited straight leg raise with no further hip flexion after bending the knee is a typical positive buttock sign seen with ischial bursitis. The absence of this sign would raise clinical suspicion that the diagnosis of bursitis was not accurate. With an ischial bursitis, expect to see equal leg length, negative Trendelenburg test, and normal sensation, reflexes, and joint play movements. Anything outside these parameters should be considered a yellow (caution) flag. • Assess for trigger points that may cause buttock pain, especially quadratus lumborum, gluteus maximus, and hamstrings, but also, gluteus medius and piriformis. • Reassess for the presence of constitutional symptoms or any associated signs and symptoms of any kind anywhere in the body.
Case Report courtesy of Jason Taitch, DDS, Spokane, Washington, 2005.
8
8
40
SECTION III
758
• • • • •
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Night pain (constant, intense; unrelieved by change in position) Pain relieved disproportionately by aspirin Fever, weight loss, bleeding, skin lesions Vaginal/penile discharge Painless, progressive enlargement of inguinal a n d / o r popliteal lymph nodes
SCREENING FOR UROLOGIC CAUSES OF BUTTOCK, HIP, GROIN, OR THIGH PAIN Ureteral pain usually begins posteriorly in the costovertebral angle but may radiate anteriorly to the upper thigh and groin (see Fig. 16-6), or it may be felt just in the groin and genital area. These pain patterns represent the pathway that genitals take as they migrate during fetal development from their original position, where the kidneys are located in the adult, down the pathways of the ureters to their final location. Pain is referred to a site where the organ was located during fetal development. A kidney stone down the pathway of the ureters causes pain in the flank that radiates to the scrotum (male) or labia (female). The lower thoracic and upper lumbar vertebrae and the SI joint can refer pain to the groin and anterior thigh in the same pain pattern as occurs with renal disease. Irritation of the T10-L1 sensory nerve roots (genitofemoral and ilioinguinal nerves) from any cause, but especially from discogenic disease, may cause labial (women), testicular (men), or buttock pain. The therapist can evaluate these conditions by conducting a neurologic screening examination and using the medical screening model. Referred symptoms from ureteral colic can be distinguished from musculoskeletal hip pain by the history, the presence of urologic symptoms, and the pattern of pain. Is there any history of urinary tract impairment? Is there a recent history of other infection? Are any signs and symptoms noted that are associated with the renal system? Active trigger points along the upper rim of the pubis and the lateral half of the inguinal ligament may lie in the lower internal oblique muscle and possibly in the lower rectus abdominis. These trigger points can cause increased irritability and spasm of the detrusor and urinary sphincter muscles, producing urinary frequency, retention of urine, and groin pain. The therapist can perform Murphy's percussion test to rule out kidney involvement (see Chapter 10; see also Fig. 4-51). A positive Murphy's percus41
20
sion test (pain is reproduced with percussive vibration of the kidney) points to the possibility of kidney infection or inflammation. When this test is positive, ask about a recent history of fever, chills, unexplained perspiration ("sweats"), or other constitutional symptoms.
SCREENING FOR MALE REPRODUCTIVE CAUSES OF GROIN PAIN Men can experience groin pain caused by disease of the male reproductive system such as prostate cancer, testicular cancer, benign prostatic hyperplasia (BPH), or prostatitis. Isolated groin pain is not as common as groin pain that is accompanied by low back, buttock, or pelvic pain. Risk factors, clinical presentation, and associated signs and symptoms for these conditions are discussed in Chapter 14.
SCREENING FOR INFECTIOUS AND INFLAMMATORY CAUSES OF LOWER QUADRANT PAIN Anyone with joint pain of unknown cause who presents with current (or recent, i.e., within the past 6 weeks) skin rash or recent history of infection (e.g., hepatitis, mononucleosis, urinary tract infection, upper respiratory infection, sexually transmitted infection, streptococcus, dental infection) ' must be referred to a health care clinic or medical doctor for further evaluation. Conditions affecting the entire peritoneal cavity such as pelvic inflammatory disease (PID) or appendicitis may cause hip or groin pain in the young, healthy adult. Widespread inflammation or infection may be well tolerated by athletes, sometimes for up to several weeks (Case Example 16-12). 42
43
Clinical Presentation The clinical presentation can be deceptive in young people. The fever is not dramatic and may come and go. The athlete may dismiss excessive or unusual perspiration ("sweats") as part of a good workout. Loss of appetite associated with systemic disease is often welcomed by teenagers and young adults and is not recognized as a sign of physiologic distress. With an infectious or inflammatory process, laboratory tests may reveal an elevated ESR. Questions about the presence of any other symptoms may reveal constitutional symptoms such as ele-
CHAPTER 16
CASE
EXAMPLE
1 6 - 1 2
Dancer
W i t h
A 21-year-old dance major was referred to the physical therapy clinic by the sports medicine clinic on campus with a medical diagnosis of "strained abdominal muscle." She described her symptoms as pain with hip flexion when shifting the gears in her car. Some dance moves involving hip flexion also reproduced the pain, but this was not consistent. The pain was described as "deep," "aching," and "sometimes sharp, sometimes dull." Past medical history was significant for Crohn's disease, but the client was having no gastrointestinal symptoms at this time. On examination, no evidence of abdominal trigger points (TrPs) or muscle involvement was found. The pain was not reproduced with superficial palpation of the abdominal muscles on the day of initial examination. Intervention with stretching exercises did not change the clinical picture during the first week. Result: The client was a no-show for her Monday afternoon appointment, and the physical therapy clinic receptionist received a phone call from the campus clinic with information that the client had been hospitalized over the weekend with acute appendicitis and peritonitis. The surgeon's report noted massive peritonitis of several weeks' duration. The client had a burst appendix that was fairly asymptomatic until peritonitis developed with subsequent symptoms. Her white blood cells were in excess of 100,000 at the time of hospitalization. In retrospect, the client did relate some "sweats" occurring off and on during the last 2 weeks and possibly a low-grade fever. What additional screening could have been conducted with this client? 1. Ask the client whether she is having any symptoms of any kind anywhere in her body. If she answers, "No," be prepared to offer some suggestions such as: • Any headaches? Fatigue? • Any change in vision? • Any fevers or sweats, day or night? • Any blood in your urine or stools? • Burning with urination?
SCREENING THE LOWER QUADRANT
759
Appendicitis
2.
3.
4.
5.
6.
• Any tingling or numbness in the groin area? • Any trouble sleeping at night? Even though she has denied having any gastrointestinal symptoms associated with her Crohn's disease, it is important to follow up with questions to confirm this: • Any nausea? Vomiting? • Diarrhea or constipation? • Any change in your pattern of bowel movements? • Any blood in your stools? Change in color of your bowel movements? • Any foods or smells you can't tolerate? • Any change in your symptoms when you eat or don't eat? • Unexpected weight gain or loss? • Is your pain any better or worse during or after a bowel movement? As part of the past medical history, it is important with hip pain of unknown cause to know whether the client has had any recent infections, sexually transmitted diseases, use of antibiotics or other medications, or skin rashes. In a woman of reproductive years, it may be important to take a gynecologic history: • Have you been examined by a gynecologist since this problem started? • Is there any chance you could be pregnant? • Are you using an IUD (or IUCD)? • Have you had an abortion or miscarriage in the last 6 weeks? • Are you having any unusual vaginal discharge? Check vital signs. The presence of a fever (even low-grade) is a red flag when the cause of symptoms is unknown. With a burst appendix, she may have had altered pulse and blood pressure that could alert the therapist of a systemic cause of symptoms. Test for McBurney's point (Fig. 8-9), rebound tenderness or Blumberg's sign (Fig. 8-10), and the obturator or iliopsoas sign (Figs. 8-4 to 86). Check for Murphy's percussion (Fig. 4-51; kidney involvement).
760
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
vated nocturnal temperature, sweats, and chills, suggestive of an inflammatory process (Case Example 16-13).
Psoas
Abscess
Any infectious or inflammatory process affecting the abdominal or pelvic region can lead to psoas abscess and irritation of the psoas muscle. For example, lesions outside the ureter, such as infection, abscess, or tumor, or abdominal or peritoneal inflammation, may cause pain on movement of the adjacent iliopsoas muscle that presents as hip or groin pain. (See discussion of Psoas Abscess in Chapter 10.) Pelvic inflammatory disease (PID) is another common cause of pelvic, groin, or hip pain that can cause psoas abscess and a subsequent positive iliopsoas or obturator test. In this case, it is most likely a young woman with multiple sexual part-
CASE
EXAMPLE
1 6 - 1 3
Limp
After
ners who has a known or unknown case of untreated Chlamydia. The psoas muscle is not separated from the abdominal or pelvic cavity. Figure 8-3 shows how most of the viscera in the abdominal and pelvic cavities can come into contact with the iliopsoas muscle. Any infectious or inflammatory process (Box 16-3) can seed itself to the psoas muscle by direct extension, resulting in a psoas abscess—a localized collection of pus. Hip pain associated with such an abscess may involve the medial aspect of the thigh and femoral triangle areas (Fig. 16-5). Soft tissue abscess may cause pain and tenderness to palpation without movement. Once the abscess has formed, muscular spasm may be provoked, producing hip flexion and even contracture. The leg also may be pulled into internal rotation. Pain that increases with passive and active motion can
Total Hip
A 70-year-old man was referred to physical therapy by his doctor 1 year after a right total hip replacement (THR) for osteoarthritis. The client reports that he is in good general health without pain. His primary problem is a persistent limp, despite completion of a THR rehabilitation protocol. How can you tell whether this is an infectious versus biomechanical problem? First of all, laboratory tests such as erythrocyte sedimentation rate (sed rate) and Creactive protein level can be done to screen for infection. The therapist can request this information from the medical record. The absence of pain usually rules out infection or implant loosening. An x-ray may be needed to rule out implant loosening. Again, check the record to see whether this was part of the medical diagnostic workup. Besides infection, a limp after THR may have many possible causes. Loosening of the prosthesis, neurologic dysfunction, altered joint biomechanics, and muscle weakness or dysfunction (e.g., hip abductors) are a few potential causes. As always, in an orthopedic examination, check the joints above (low back, sacrum, sacroiliac) and below (knee) the level of impairment. In the
A r t h r o p l a s t y
case of joint replacement, evaluate the contralateral hip as well. Test for abdominal muscle weakness. This can be confirmed with manual muscle testing or a Trendelenburg test. An anterolateral approach to THR is more likely to cause partial or complete abductor muscle disruption than is a posterior approach. With either approach, the superior gluteal nerve can be damaged by stretching or by cutting one of its branches. The therapist may be able to get some clues to this by looking at the incision site. Disruption of the nerve is more likely when the gluteus medius is split more than 5 cm proximal to the tip of the greater trochanter. If nerve damage has occurred, the client may not regain full strength. Electromyography (EMG) testing may be needed to document muscle denervation. Physical therapy may be a diagnostic step for the physician. If muscle strengthening does not recondition the remaining intact muscle, a revision operation to repair the muscle may be needed. It may be helpful to communicate with the physician to see what his or her thinking is on this client.
Data from Farrell CM, Berry DJ: Persistent limping after primary total hip replacement. J Musculoskel Med 19:484-486, 2002.
CHAPTER 16
BOX
Causes of Psoas Abscess
16-3
•
Diverticulitis
•
Crohn's disease
• Appendicitis •
Pelvic inflammatory disease
•
Diabetes mellitus
• Any other source of infection, including dental •
43
Renal infection
•
Infective spondylitis (vertebra)
•
Osteomyelitis
•
Sacroiliac joint infection
F i g . 1 6 - 5 • Femoral triangle: referred pain pattern from psoas abscess. Hip pain associated with such an abscess may involve the medial aspect of the thigh and femoral triangle areas. The femoral triangle is the name given to the anterior aspect of the thigh formed as different muscles and ligaments cross each other, producing an inverted triangular shape.
SCREENING THE LOWER QUADRANT
761
Leg pulled into internal rotation Positive psoas sign, i.e., pain elicited by stretching the psoas muscle by extending the hip Fever up and down (hectic fever pattern) Sweats Loss of appetite or other Gl symptoms Palpable mass in the inguinal area (present with distal extension of the abscess) Positive iliopsoas or obturator test (see Figs. 84 through 8-6)
A positive response for any of these tests is indicative of an infectious or inflammatory process. Direct back, pelvic, or hip pain that results from these palpations is more likely to have a musculoskeletal cause. Besides the iliopsoas and obturator tests, another test for rebound tenderness used more often by nurses is called Blumberg's sign (see Fig. 8-10). It may be appropriate to conduct these tests with a variety of clinical presentations involving the pelvic area, sacrum, hip, or groin. Psoas abscess must be differentiated from trigger points of the psoas muscle, causing the psoas minor syndrome, which is easily mistaken for appendicitis. Hemorrhage within the psoas muscle, either spontaneous or associated with anticoagulation therapy for hemophilia, can cause a painful compression syndrome of the femoral nerve. Systemic causes of hip pain from psoas abscess are usually associated with loss of appetite or other GI symptoms, fever, and sweats. Symptoms from an iliopsoas trigger point are aggravated by weight-bearing activities and are relieved by recumbency or rest. Relief is greater when the hip is flexed. 20
occur when infected tissue is irritated. Pain elicited by stretching the psoas muscle through extension of the hip, called the positive psoas sign, may be present. Clinical Psoas
Signs
and
Symptoms
of
Abscess
•
Pain that is usually confined to the psoas fascia but that may extend to the buttock, hip, groin, upper thigh, or knee
•
Pain located in the anterior hip in the area of the medial thigh or femoral triangle, often accompanied by or alternating with abdominal pain Psoas spasm causing functional hip flexion contracture
•
SCREENING FOR GASTROINTESTINAL CAUSES OF LOWER QUADRANT PAIN The relationship of the gut to the joint is well known but poorly understood. Intestinal bypass syndrome, inflammatory bowel disease, ankylosing spondylitis, celiac disease, postdysenteric reactive arthritis, and antibiotic-associated colitis all share the fact that some "interface" exists between the bowel and the hip articular surface. It is possible that the clinical expression of immune-mediated joint disease results from an immunologic response to an antigen that crosses the gut mucosa with an autoimmune response against self. " For the client with hip pain of unknown cause or suspicious presentation, ask whether any 44
48
762
SECTION III
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
back pain or abdominal pain is ever present. Alternating abdominal pain with low back pain at the same level, or alternating abdominal pain with hip pain is a red flag that requires medical referral. The therapist may treat a patient with joint or back pain with an underlying enteric cause before he or she realizes what the underlying problem is. Palliative intervention can make a difference in the short term but does not affect the final outcome. Symptoms that are unrelieved by physical therapy intervention are always a red flag. Symptoms that improve after physical therapy but then get worse again are also a red flag, revealing the need for further screening. In the case of enterically induced joint pain, the client will get worse without medical intervention. Without early identification and referral, the client will eventually return to his or her gastroenterologist or primary care physician. Medical treatment for the underlying disease is essential in affecting the musculoskeletal component. Physical therapy intervention does not alter or improve the underlying enteric disease. It is better for the client if the therapist recognizes as soon as possible the need for medical intervention.
Crohn's Disease In anyone with hip or groin pain of unknown cause, look for a known history of PID, Crohn's disease (regional enteritis), ulcerative colitis, irritable bowel syndrome, diverticulitis, or bowel obstruction. It is possible that new onset of low back, sacral, or hip pain is merely a new symptom of an already established enteric (GI) disease. Twenty-five percent of those with inflammatory enteric disease (particularly Crohn's disease) have concomitant back or joint pain. A skin rash that comes and goes can accompany enterically induced arthritis. A flat rash or raised skin lesion of the lower extremities is possible; it usually precedes joint or back pain. Be sure to ask the client whether he or she has had skin rashes of any kind over the past few weeks. Several tests can be done to assess for hip pain resulting from psoas abscess caused by abdominal or intraperitoneal infection or inflammation. These were discussed in the previous section. A positive response for each of these tests is NOT reproduction of the client's hip or groin pain, but rather, lower quadrant abdominal pain on the side of the test. This is a symptom of an infectious or inflammatory process. Hip or back pain in response to these tests is more likely muscu-
loskeletal in origin such as a trigger point of the iliopsoas or muscular tightness.
Reactive
Arthritis
In the case of reactive arthritis, joint symptoms occur 1 to 4 weeks after an infection, usually GI (gastrointestinal) or GU (genitourinary). The joint is not septic (infected), but rather, it is aseptic (without infection). Affected joints often occur at a site that is remote from the primary infection. Prosthetic joints are not immune to this type of infection and may become infected years after the joint is implanted. Whether the infection occurs in the natural joint or in the prosthetic implant, the client is unable to bear weight on the joint. An acute arthritic presentation may occur, and the client often has a fever (commonly of low grade in older adults or in anyone who is immunosuppressed). Screening questions for clients with joint pain are listed in Box 3-5 and in the Appendix B-16. These questions may be helpful for the client with joint pain of unknown cause or with an unusual presentation/history that does not fit the expected pattern for injury, overuse, or aging.
SCREENING FOR VASCULAR CAUSES OF LOWER QUADRANT PAIN Vascular pain is often throbbing in nature and exacerbated by activity. With atherosclerosis, a lag time of 5 to 10 minutes occurs between when the body asks for increased oxygenated blood and when symptoms occur because of arterial occlusion. The client is older, often with a personal or family history of heart disease. Other risk factors include hyperlipidemia, tobacco use, and diabetes.
Peripheral Vascular Disease Peripheral vascular disease (PVD) (peripheral arterial disease (PAD); arterial insufficiency) in which the arteries are occluded by atherosclerosis can cause unilateral or bilateral low back, hip, buttock, groin, or leg pain, along with intermittent claudication and trophic changes of the affected lower extremities. Intermittent claudication of vascular origin may begin in the calf and may gradually make its way up the lower extremity. The client may report the pain or discomfort as "burning," "cramping," or "sharp." Pain or other symptoms begin several minutes after the start of physical activity and resolve almost immediately with rest. As discussed in Chapter 14, the site of symptoms is determined
CHAPTER 16
SCREENING THE LOWER QUADRANT
by the location of the pathology (see Fig. 14-3) (Case Example 16-14). PVD is a rare cause of lower quadrant pain in anyone under the age of 65, but leg pain in recreational athletes caused by isolated areas of arterial stenosis have been reported. The therapist must include assessment of vital signs and must look for trophic skin changes so often present with chronic arterial insufficiency. Pulse oximetry may be helpful when thrombosis is not clinically obvious; for example, pulses can 49
CASE
EXAMPLE
1 6 - 1 4
Intermittent
be present in both feet with oxygen saturation ( S a 0 ) levels at 90% or less. When assessing for PAD as a possible cause of back, buttock, hip, groin, or leg pain, look for other signs of PAD. See further discussion of this topic in Chapters 4, 6, and 14. Deep venous thrombosis (DVT) as a cause of leg pain may present as swelling of the calf or ankle, with calf tenderness and erythema. Further discussion and information on assessment of DVT are presented in Chapters 4 and 6. 50
2
C Ia u d i c a t i o n
Referral: A 41-year-old woman who was referred by her primary care physician with a medical diagnosis of sciatica reported bilateral lower extremity weakness with pain in the left buttock and left sacroiliac (SI) area. She also noted that she had numbness in her left leg after walking more than half a block. She said both her legs felt like they were going to "collapse" after she walked a short distance and that her left would go "hot and cold" during walking. She also experienced cramping in her right calf muscle after walking more than half a block. Symptoms are made worse by walking and better after resting or by standing still. Symptoms have been present for the last 2 months and came on suddenly without trauma or injury of any kind. No night pain was reported. No medical tests or imaging studies have been done at this time. Past Medical History: Significant positive for family history of heart disease (both sides of the family); smoking history: 1 pack of cigarettes/day for the past 26 years. Clinical Presentation Neurologic Screening Examination: Negative/within normal limits (WNL) Neural Tissue Mobility: Tests were all negative; tissue tension WNL Complete Lumbar Spine Examination: Unremarkable; ruled out as a source of client's symptoms Diminished dorsalis pedis pulse on the left side
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W i t h
Sciatica
Bike Test (reviewed in Chapter 14; this test can be used to stress the integrity of the vascular supply to the lower extremities): Cycling in a position of lumbar forward flexion reproduced leg weakness and eliminated dorsalis pedis pulse on the left; no change was noted on the right. Associated Signs and Symptoms None. What are the red flags in this case? • LE weakness without pain accompanied by "giving out" sensation • Symptoms brought on by specific activity, relieved by rest or standing still • Significant family history of heart disease • No known cause; onset of symptoms without trauma or injury • Temperature changes in lower extremities (LEs) • Positive smoking history Result: Given the severity of her family history of heart disease (sudden death at a young age was very common), she was sent back to the doctor immediately. The therapist briefly outlined the red flags and asked the physician to reevaluate for a possible vascular cause of symptoms. Medical testing revealed a high-grade circumferential stenosis (narrowing) of the distal aorta at the bifurcation. The client underwent surgery for placement of a stent in the occluded artery. After the operation, the client reported complete relief from all symptoms, including buttock and SI pain.
Data from Gray JC: Diagnosis of intermittent vascular claudication in a patient with a diagnosis of sciatica: Case report. Phys Ther 79:582-590, 1999.
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Abdominal Aortic Aneurysm
Avascular Osteonecrosis
Abdominal aortic aneurysm (AAA) may be asymptomatic; discovery occurs on physical or x-ray examination of the abdomen or lower spine for some other reason. The most common symptom is awareness of a pulsating mass in the abdomen, with or without pain, followed by abdominal and back pain. Groin pain and flank pain may occur because of increasing pressure on other structures. For more detailed information, see Chapter 6. Be aware of the client's age. The client with an AAA can be of any age because this may be a congenital condition, but usually, he or she is over age 50 and, more likely, is 65 or older. The condition remains asymptomatic until the wall of the aorta grows large enough to rupture. If that happens, blood in the abdomen causes searing pain accompanied by a sudden drop in blood pressure. Other symptoms of impending rupture or actual rupture of the aortic aneurysm include the following: • Rapid onset of severe groin pain (usually accompanied by abdominal or back pain) • Radiation of pain to the abdomen or to posterior thighs • Pain not relieved by change in position • Pain described as "tearing" or "ripping" • Other signs, such as cold, pulseless lower extremities An increasingly prevalent risk factor in the aging adult population is initiation of a weightlifting program without prior medical evaluation or approval. The presence of atherosclerosis, elevated blood pressure, or an unknown aneurysm during weight training can precipitate rupture. The therapist can palpate the aortic pulse to identify a widening pulse width, which is suggestive of an aneurysm (see Fig. 4-51). Place one hand or one finger on either side of the aorta as shown. Press firmly deep into the upper abdomen just to the left of midline. You should feel aortic pulsations. These pulsations are easier to appreciate in a thin person and are more difficult to feel in someone with a thick abdominal wall or a large anteroposterior diameter of the abdomen. Obesity and abdominal ascites or distention make this more difficult. For therapists who are trained in auscultation, listen for bruits. Bruits are abnormal blowing or swishing sounds heard on auscultation of the arteries. Bruits with both systolic and diastolic components suggest the turbulent blood flow of partial arterial occlusion. If the renal artery is occluded as well, the client will be hypertensive.
Avascular osteonecrosis (also known as osteonecrosis or septic necrosis) can occur without known cause but is often associated with various risk factors. Chronic use and abuse of alcohol is a common risk factor for this condition. Screening for alcohol or drug use and abuse is discussed in Chapter 2 (see also Appendices B-l and B-2). Osteonecrosis is also associated with many other conditions such as systemic lupus erythematosus, pancreatitis, kidney disease, blood disorders (e.g., sickle cell disease, coagulopathies), diabetes mellitus, Cushing's disease, and gout. Long-term use of corticosteroids or immunosuppressants, or any condition that causes immune deficiency, can also result in osteonecrosis. Individuals who are taking immunosuppressants include organ transplant recipients, clients with cancer, and those with rheumatoid arthritis or another chronic autoimmune disease. The femoral head is the most common site of this disorder. Bones with limited blood supply are at enhanced risk for this condition. Hip dislocation or fracture of the neck of the femur may compromise the already precarious vascular supply to the head of the femur. Ischemia leads to poor repair processes and delayed healing. Necrosis and deformation of the bone occur next. The client may be asymptomatic during the early stages of osteonecrosis. Hip pain is the first symptom. At first, it may be mild, lasting for weeks. As the condition progresses, symptoms become more severe, with pain on weight bearing, antalgic gait, and limited motion (especially, internal rotation, flexion, and abduction). The client may report a distinct click in the hip when moving from the sitting position and increased stiffness in the hip as time goes by.
Clinical
Signs
and
Symptoms
of
Osteonecrosis
•
M a y be asymptomatic at first
•
Hip pain (mild at first, progressively worse over time) Groin or anteromedial thigh pain possible Pain worse on weight bearing Antalgic gait with a gluteus minimus limp Limited hip range of motion (internal rotation, flexion, abduction) Tenderness to palpation over the hip joint Hip joint stiffness Hip dislocation
• • • • • • •
CHAPTER 16
SCREENING FOR OTHER CAUSES OF LOWER QUADRANT PAIN Osteoporosis Osteoporosis may result in hip fracture and accompanying hip pain, especially in postmenopausal women who are not taking hormone replacement. Osteoporosis accompanying the postmenopausal period—when combined with circulatory impairment, postural hypotension, or some medications—may increase a person's risk of falling and incurring hip fracture. Transient osteoporosis of the hip can occur during pregnancy, although the incidence is fairly low. Symptoms include progressive hip pain, sometimes referred to the lateral thigh. The pain develops shortly before or during the last trimester and is aggravated by weight bearing. The pain subsides, and the x-ray appearance returns to normal within several months after delivery. Any evaluation procedures that produce significant shear through the femoral head of a pregnant woman must be performed by the physical therapist with extreme caution. The transient osteoporosis of pregnancy is not limited to the hip, and vertebral compression may also occur. 51
Extrapulmonary Tuberculosis Tubercular disease of the hip or spine is rare in developed countries, but it may occur as an opportunistic disease associated with acquired immunodeficiency syndrome (AIDS) that causes hip or back pain. Usually, the diagnosis of AIDS and tuberculosis is known, which alerts the therapist about the underlying systemic cause. With hip involvement, the client usually appears with a chronic limp and describes pain in the hip that persists at rest. Approximately 60% of affected individuals do not have constitutional symptoms, although the tuberculin skin test is usually positive, and radiographs are similar to those for septic arthritis.
Sickle Cell Anemia Sickle cell anemia resulting in avascular necrosis (death of cells caused by lack of blood supply) of the hip and hemarthrosis (blood in the joint) associated with hemophilia are two of the most common hematologic diseases that cause pain in the hip, groin, knee, or leg. Hemophilia may involve GI bleeding accompanied by low abdominal, hip, or groin pain caused by bleeding into the wall of the large intestine or the iliopsoas muscle. This retroperitoneal hemorrhage produces a muscle spasm of the iliopsoas
SCREENING THE LOWER QUADRANT
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muscle. The subsequent bleeding-spasm cycle produces increased hip pain and hip flexion spasm or contracture. Other symptoms may include melena, hematemesis, and fever. Clinical Hip
• • •
Signs
and
Symptoms
of
Hemarthrosis
Pain in the groin and thigh Fullness in the hip joint, both anterior in the groin and over the greater trochanter Limited motion in hip flexion, abduction, and external rotation (allows most room for the blood in the joint capsule)
Liver Disease Ascites is an abnormal accumulation of serous (edematous) fluid in the peritoneal cavity; this fluid contains large quantities of protein and electrolytes as the result of portal backup and loss of proteins (see Fig. 9-8). This condition is associated with liver disease and alcoholism. For the physical therapist, the distended abdomen, abdominal hernias, and lumbar lordosis observed in clients with ascites may present musculoskeletal symptoms, such as groin or low back pain. The presence of ascites as it is linked with groin pain would be physically evident. If abdominal distention is present, then the therapist should ask about a past medical history of liver impairment, chronic alcohol use, and the presence of carpal or tarsal tunnel syndrome associated with liver impairment. The therapist can carry out the four screening tests for liver impairment discussed in Chapter 9, including the following: • Liver flap (Asterixis; see Fig. 9-7) • Palmar erythema (Liver Palms; see Fig. 9-5) • Scan for angiomas (Upper Body and Abdomen; see Fig. 9-3) • Assessment of nail beds for change in color (Nail beds of Terry; see Fig. 9-6)
PHYSICIAN REFERRAL Guidelines for Immediate Medical Attention • Painless, progressive enlargement of lymph nodes, or lymph nodes that are suspicious for any reason and that persist or that involve more than one area (groin and popliteal areas); immediate medical referral is required for a client with a past medical history of cancer • Hip or groin pain alternating or occurring simultaneously with abdominal pain at the same level (aneurysm, colorectal cancer)
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• Hip or leg pain on weight bearing with positive tests for stress reaction or fracture
Guidelines for Physician Referral • Hip, thigh, or buttock pain in a client with a total hip arthroplasty that is brought on by activity but resolves with continued activity (loose prosthesis), or who has persistent pain that is unrelieved by rest (implant infection) • Sciatica accompanied by extreme motor weakness, numbness in the groin or rectum, or difficulty controlling bowel or bladder function • One or more of Cyriax's Signs of the Buttock (see Box 16-2) • New onset of joint pain in a client with a known history of Crohn's disease, requiring careful screening and possible referral based on examination results
Clues to Screening Lower Quadrant Pain • See also Clues Suggesting Systemic Back Pain; general concepts from the back also apply to the hip and the groin (see especially Cardiovascular discussion) • Client does not respond to physical therapy intervention or gets worse, especially in the presence of a past medical history of cancer or an unknown cause of symptoms
Past
Medical
History
• History of AIDS-related tuberculosis, sickle cell anemia, or hemophilia • Hip or groin pain in a client who has a long-term history of use of nonsteroidal antiinflammatory drugs (NSAIDs) or corticosteroids (osteonecrosis)
Clinical
Presentation
• Limited passive hip range of motion with empty end feel, especially in someone with a previous
• • • •
•
history of cancer, insidious onset, or an unknown cause of painful symptoms Palpable soft tissue mass in the anterior hip or groin (psoas abscess, hernia) Presence of rebound tenderness, positive McBurney's, iliopsoas, or obturator test (see Chapter 8) Abnormal cremasteric response in male with groin or anterior thigh pain Hip pain in a young adult that is worse at night and is alleviated by activity and aspirin (osteoid osteoma) Sciatica in the presence of night pain and an atypical pattern of restricted hip range of motion No change in symptoms of sciatica with trigger point release, neural gliding techniques, soft tissue stretching, or postural changes Painless neurologic deficit (spinal cord tumor) Insidious onset of groin or anterior thigh pain with a recent history of increased activity (e.g., runners who increase their mileage) 52
•
• •
Associated
Signs
and
Symptoms
• Hip or groin pain accompanied by or alternating with signs and symptoms associated with the GI, urologic/renal, hematologic, or cardiovascular system, or with constitutional symptoms, especially fever and night sweats • Groin pain in the presence of fever, sweats, weight loss, bleeding, skin lesions, or vaginal/penile discharge • Hip or groin pain, with any clues suggestive of cancer (see Chapter 13), especially anyone with a previous history of cancer and men between the ages of 18 and 24 years who experience hip or groin pain of unknown cause (testicular cancer) • Buttock, hip, thigh, or groin pain accompanied by fever, weight loss, bleeding or other vaginal/penis discharge, skin lesions, or other discharge
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A.
B. Right renal artery
C. Left renal artery Kidney Abdominal aortic aneurysm /
D. F i g . 1 6 - 6 • Overview: Composite figure. A, Ureteral pain may begin posteriorly in the costovertebral angle, radiating anteriorly to the ipsilateral lower abdomen, upper thigh, or groin area. Isolated anterior thigh pain is possible, but uncommon. B, Pain pattern associated with sciatica from any cause. C, Pain pattern associated with psoas abscess from any cause. D, Abdominal aortic aneurysm can cause low back pain that radiates into the buttock unilaterally or bilaterally (not shown), depending on the underlying location and size of the aneurysm.
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KEY POINTS TO REMEMBER / See also Key Points to Remember: Neck and Back Pain, Chapter 14. / Identifying the hip as the source of a client's symptoms may be difficult in that pain originating in the hip may not localize to the hip, but rather, may present as low back, buttock, groin, SI, anterior thigh, or even knee or ankle pain. / Hip pain can be referred from other locations, such as the scrotum, kidneys, abdominal wall, abdomen, peritoneum, or retroperitoneal region. / In addition to screening for medical problems, the therapist must remember to clear the joint above and below the area of symptoms or dysfunction / True hip pain from any cause is usually felt in the groin or deep buttock, sometimes with pain radiating down the anterior thigh. Pain perceived on the outer (lateral) side of the hip is usually not caused by an intra-articular problem, but likely results from a trigger point, or from bursitis, SI, or back problems. / Hip pain referred from the upper lumbar vertebrae can radiate into the anterior aspect of the thigh, whereas hip pain from the lower lumbar vertebrae and sacrum is usually felt in the gluteal region, with radiation down the back or outer aspect of the thigh. / Systemic or viscerogenic causes of lower quadrant pain or symptoms mimic a neuromuscular or musculoskeletal cause, but usually, a red flag history, risk factors, or associated signs and symptoms are identified during the screening process; this facilitates identification of the underlying problem. / Cancer recurrence most likely to metastasize to the hip includes breast, bone, and prostate. / Changes in lymph nodes with or without a previous history of cancer are a yellow or red flag. / Normal but painful hip rotations (log-rolling test) present when the client is tested in the supine position with the hips in neutral extension (zero degrees of hip flexion) may be a yellow warning flag.
/ Cyriax's "Sign of the Buttock" can help differentiate between hip and lumbar spine disease. / Anyone with lower quadrant pain and a past history of hip or knee arthroplasty must be evaluated for component problems (e.g., infection, subsidence, looseness), regardless of the client's perceived cause of the problem. Watch for pain on initiation of activity that gets better with continued activity (loose prosthesis); also watch for signs of infection (recent history of infection anywhere else in the body, fever, chills, sweats, pain that is not relieved with rest, night pain, pain on weight bearing). / A noncapsular pattern of restricted hip motion (e.g., limited hip extension, adduction, lateral rotation) may be a sign of serious underlying disease. / Anyone with pain radiating from the back down the leg as far as the ankle has a greater chance for disc herniation to be the cause of low back pain; this is true with or without neurologic findings. / The straight leg raise (SLR) and other neurodynamic tests are widely used but do not identify the underlying cause of sciatica. A positive SLR test does not differentiate between discogenic disease and neoplasm; imaging studies may be needed. / Tests for the presence of hip pain caused by psoas abscess are advised whenever an infectious or inflammatory process is suspected on the basis of past medical history, clinical presentation, and associated signs and symptoms. / New onset of low back or hip pain in a client with a previous history of Crohn's disease, especially in the presence of a recent history of skin rash, requires screening for GI signs and symptoms. / Long-term use of corticosteroids or immunosuppressants, or any condition that causes immune deficiency may also result in hip pain from osteonecrosis. As the condition progresses, symptoms become more severe with pain on weight bearing, antalgic gait, and limited motion.
CHAPTER 16
SUBJECTIVE Special Lower
Questions
to
SCREENING THE LOWER QUADRANT
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EXAMINATION Ask:
Quadrant
It is not necessary to ask every client every question listed. Sometimes, we ask some general screening questions because of something the client has told us. At other times, we screen because of something we saw in the clinical presentation. We may need to ask some specific questions based on gender. Finally, sometimes, the review of systems has pinpointed a particular system (e.g., GI, GU, vascular, pulmonary, gynecologic), and we go right to the end of the chapter dealing with that system and look for any screening questions that may be pertinent to the client. The more often the therapist conducts screening interviews, the faster the process will get, and the easier it will become to remember which questions make the most sense to ask. The beginner may ask more questions than are really needed, but with practice and experience, the screening process will smooth out. Generally it takes about 3 to 5 minutes to conduct a screening interview and another 5 minutes to carry out any special tests. Because hip pain may be caused by referred pain from disorders of the low back, abdomen, and reproductive and urologic structures, special questions should include consideration of the following: • Special Questions for Women Experiencing Back, Hip, Pelvic, Groin, or Sacroiliac Pain (see Appendix B-32) • Special Questions to Ask: Men Experiencing Back, Hip, Pelvic, Groin, or Sacroiliac Pain (see Appendix B-21) • Special questions for clients (see Chapter 14: Special Questions to Ask: Neck or Back): • General systemic questions • Pain assessment • Gastrointestinal questions • Urologic questions
• For anyone with lower quadrant pain of unknown cause: It may be necessary to conduct a sexual history as part of the screening process. See Chapter 14 or Appendix B-29 • A quick screening interview and additional questions may include the following: Pain
Assessment
See Appendix C-4 for a complete pain assessment. • Have you had a recent injury? If yes, tell me what happened. Did you hear any popping, snapping, or cracking when the injury occurred? • How is the pain affected by putting weight on it? • Does your leg "give out" on you? (or feel like it is going to give out)? • Does your pain feel better, same, or worse after walking on it for awhile? (With joint arthroplasty, pain improves after walking with loose components) Past Medical
History
• Have you ever been told (or have you known) that you have a sexually transmitted infection or disease? • Have you been treated with cortisone, prednisone, other corticosteroids, or any other drug of that type? • Do you have a known history of Crohn's disease, diverticulitis, or pelvic inflammatory disease? • Have you ever had cancer of any kind? If no, Have you ever been treated with chemotherapy or radiation therapy? Have you ever had a bone tumor? Associated
Signs
and
Symptoms
• Do you have any other symptoms anywhere else in your body? Any fatigue? Fever? Chills? Swollen joints?
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STUDY
STEPS IN THE SCREENING PROCESS A 34-year-old woman was referred to physical therapy for pelvic pain from a nonrelaxing puborectalis muscle. She reported bilateral groin pain that was superficial and affected the skin area. She also said the area feels "warm." The pain was worse when sitting, better when standing, and had lasted longer than a month. The physician ruled out shingles and sent her to physical therapy for further evaluation. What Are Some Steps You Can Take to Start the Screening Process? Have the client complete a past medical history form, and review it for any clues that might help direct the screening process. Ask the usual questions about bowel and bladder function (see Appendices B-5 and B-6). Superficial skin changes are usually a sudomotor response; messages arrive via the spinal cord, but the system has no way to know the specific source of the problem (i.e., viscerogenic vs. somatic), so it sends out a "distress" signal that something is wrong at the S2-S3 level. The therapist must consider what could be involved. Using Table 16-3 as a guide, the therapist can assess the likelihood of each condition listed on the basis of age, gender, past medical history, and associated signs and symptoms. Screening tests may be conducted, as appropriate. For example, a neurologic screening examination may help identify discogenic disease or possible spinal cord tumor.
The client is young to have developed an AAA from atherosclerosis, but a congenital aneurysm may be present. Palpating the abdomen and the aortic pulse and listening with a stethoscope for femoral bruits may be helpful. A stress fracture would likely have a suspicious history such as prolonged activity requiring axial loading or trauma of some kind. It may be necessary to ask about physical or sexual assault. Conduct screening tests such as heel strike, rotational/translational stress test of the pubis, hop on one leg, and full squat. Assess for trigger points. Ureteral problems are usually accompanied by bladder changes (e.g., dysuria, hematuria, frequency) and constitutional symptoms such as fever, sweats, or chills. Take vital signs. Gynecologic causes of low back, pelvic, groin, hip, or sacroiliac pain are usually accompanied by a significant history of gynecologic conditions or traumatic or multiple birth/delivery history. Some additional questions along these lines may be needed if the past medical history form is not sufficient. Sexually transmitted infection or ectopic pregnancy is possible, although rare causes of groin pain may occur in sexually active women. Appendicitis or another infectious process can cause a wide range of symptoms outside of the typical or expected right lower abdominal quadrant pain, including isolated groin pain or combined hip and groin pain. McBurney's test (see Fig. 8-8) or Blumberg's sign for rebound tenderness (see Fig. 8-10) can help the therapist to recognize when medical referral is required.
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771
PRACTICE QUESTIONS 1. The screening model used to help identify viscerogenic or systemic origins of hip, groin, and lower extremity pain and symptoms is made up of: a. Past medical history, risk factors, clinical presentation, and associated signs and symptoms b. Risk factors, risk reduction, and primary prevention c. Enteric disease, systemic disease, neuromusculoskeletal dysfunction d. Physical therapy diagnosis, review of systems, physician referral 2. When would you use the iliopsoas, obturator, or Blumberg test? 3. Hip and groin pain can be referred from a. Low back b. Abdomen c. Retroperitoneum d. All of the above 4. Screening for cancer may be necessary in anyone with hip pain who: a. Is younger than 20 or older than 50 b. Has a past medical history of diabetes mellitus c. Reports fever and chills d. Has a total hip arthroplasty (THA) 5. Pain on weight bearing may be a sign of hip fracture, even when x-rays are negative. Follow-up clinical tests may include: a. McBurney's, Blumberg's, Murphy's test b. Squat test, hop test, translational/rotational tests c. Psoas and obturator tests d. Patrick's or FABER's test 6. Abscess of the abdominal muscles from intraabdominal infection or inflammation can cause
7.
8.
9.
10.
hip and/or groin pain. Clinical tests to differentiate the cause of hip pain resulting from psoas abscess include: a. McBurney's, Blumberg's, or Murphy's test b. Squat test, hop test, translational/rotational tests c. Iliopsoas and obturator tests d. Patrick's or FABER's test Anyone with hip pain of unknown cause must be asked about: a. Previous history of cancer or Crohn's disease b. Recent infection c. Presence of skin rash d. All of the above Vascular diseases that may cause referred hip pain include: a. Coronary artery disease b. Intermittent claudication c. Aortic aneurysm d. All of the above True hip pain is characterized by: a. Testicular (male) or labial (female) pain b. Groin or deep buttock pain with active or passive range of motion c. Positive McBurney's test d. All of the above Hip pain associated with primary or metastasized cancer is characterized by: a. Bone pain on weight bearing; may not be able to stand on that leg b. Night pain that is relieved by aspirin c. Positive heel strike test with palpable local tenderness d. All of the above
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REFERENCES 1. Goodman CC, Snyder TEK: Laboratory tests and values. In Goodman CC, Boissonnault WG, Fuller K, eds: Pathology: Implications for the Physical Therapist, 2nd edition, Philadelphia, 2003, WB Saunders, pp. 1174-1200. 2. Browder DA, Erhard RE: Decision making for a painful hip: A case requiring referral, J Orthop Sports Phys Ther 35:738-744, 2005. 3. Kimpel DL: Hip pain in a 50-year-old woman with RA, J Musculoskel Med 16:651-652, 1999. 4. Bertot AJ, Jarmain SJ, Cosgarea AJ: Hip pain in active adults: 20 clinical pearls, J Muscloskel Med 20:35-55, 2003. 5. Tortolani PJ, Carbone JJ, Quartararo LG: Greater trochanteric pain syndrome in patients referred to orthopedic spine specialists, Spine J 2:251-254, 2002. 6. Lyle MA, Manes S, McGuinness M, et al: Relationship of physical examination findings and self-reported symptom severity and physical function in patients with degenerative lumbar conditions, Phys Ther 85:120-133, 2005. 7. Greenwood MJ, Erhard RE, Jones DL: Differential diagnosis of the hip vs. lumbar spine: Five case reports, J Orthop Sports Phys Ther 27:308-315, 1998. 8. Cyriax J: Textbook of Orthopaedic Medicine, 8th edition, London, UK, 1982, Bailliere Tindall. 9. Cibulka MT, Sinacore DR, Cromer GS, et al: Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional, Spine 23:1009-1015, 1998. 10. Brown TE, Larson B, Shen F, et al: Thigh pain after cementless total hip arthroplasty: Evaluation and management, J Am Acad Orthop Surg 10:385-392, 2002. 11. Fogel GR, Esses SI: Hip spine syndrome: Management of coexisting radiculopathy and arthritis of the lower extremity, Spine J 3:238-241, 2003. 12. Kim YH, Oh SH, Kim JS, et al: Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head, J Bone Joint Surg 85:675-681, 2003. 13. Byrd JWT: Investigation of the symptomatic hip: Physical examination. In Byrd JWT, editor: Operative Hip Arthroscopy, New York, 1998, Thieme, pp. 25-41. 14. Sahrmann SA: Diagnosis and Treatment of Movement Impairment Syndromes, St. Louis, 2002, Mosby. 15. Cowan SM, Schache P, Brukner KL, et al: Onset of transversus abdominus in long-standing groin pain, Med Sci Sports Exerc 36:2040-2045, 2004. 16. Tamir E, Anekshtein Y, Melamed E, et al: Clinical presentation and anatomic position of L3-L4 disc herniation, J Spinal Disord Tech 17:467-469, 2004. 17. Reverse straight leg raise test. Available on-line at: http://courses.washington.edu/hubio553/glossary/reverse. html. Accessed December 24, 2005. 18. Yang SH, Wu CC, Chen PQ: Postoperative meralgia paresthetica after posterior spine surgery, Spine 30:E547-E550, 2005. 19. Cummings M: Referred knee pain treated with electroacupuncture to iliopsoas, Aupunct Med 21:32-35, 2003. 20. Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Lower Extremities, vol 2, Baltimore, 1992, Williams and Wilkins. 21. Guss DA: Hip fracture presenting as isolated knee pain, Ann Emerg Med 29:418-420, 1997. 22. Steele MK: Relieving cramps in high school athletes, J Musuloskel Med 20:210, 2003. 23. Brukner P, Bennell KM, Matheson G: Stress Fractures, Australia, 1999, Blackwell Publishing. 24. Seidenberg PH, Childress MA: Managing hip pain in athletes, J Musculoskel Med 22:246-254, 2005.
25. Weishaar MD, McMillian DJ, Moore JH: Identification and management of 2 femoral shaft stress injuries, J Orthop Sports Phys Ther 35:665-673, 2005. 26. Johnson AW, Weiss CB Jr, Wheeler DL: Stress fractures of the femoral shaft in athletes—more common than expected: A new clinical test, Am J Sports Med 22:248-256, 1994. 27. Salter RB: Textbook of Disorders and Injuries of the Musculoskeletal System, 3rd edition, Baltimore, 1999, Williams and Wilkins. 28. Hoppenfeld S, Murthy VL: Treatment and Rehabilitation of Fractures, Philadelphia, 2000, Lippincott Williams & Wilkins. 29. Ozburn MS, Nichols JW: Pubic ramus and adductor insertion stress fractures in female basic trainees, Milit Med 146:332-334, 1981. 30. Jewell DV, Riddle DL: Interventions that increase or decrease the likelihood of a meaningful improvement in physical health in patients with sciatica, Phys Ther 85(11):1139-1150, 2005. 31. Yuen EC, So YT: Sciatic neuropathy, Neurol Clin 17:617631, 1999. 32. Martin WN, Dixon JH, Sandhu H: The incidence of cement extrusion from the acetabulum in total hip arthroplasty, J Arthroplasty 18:338-341, 2003. 33. Stirling A, Worthington T, Rafiq M, et al: Association between sciatica and Propionibacterium acnes, Lancet 357:2024-2025, 2001. 34. McLorinn GC, Glenn JV, McMullan MG, et al: Propionibacterium acnes wound contamination at the time of spinal surgery, Clin Orthop Rel Res 437:67-73, 2005. 35. Bickels J, Kahanvitz N, Rubert CK, et al: Extraspinal bone and soft-tissue tumors as a cause of sciatica: Clinical diagnosis and recommendations: Analysis of 32 cases, Spine 24:1611, 1999. 36. Deyo RA, Diehl AK: Cancer as a cause of back pain: Frequency, clinical presentation, and diagnostic strategies, J Gen Intern Med 3:230-238, 1988. 37. Guyer RD, Collier RR, Ohnmeiss DD, et al: Extraosseous spinal lesions mimicking disc disease, Spine 13:328-331, 1988. 38. Bose B: Thoracic extruded disc mimicking spinal cord tumor, Spine J 3:82-86, 2003. 39. Arromdee E, Matteson EL: Bursitis: Common condition, uncommon challenge, J Musculoskel Med 18:213-224, 2001. 40. Magee DJ: Orthopedic Physical Assessment, 4th edition, Philadelphia, 2002, WB Saunders. 41. Doubleday KL, Kulig K, Landel R: Treatment of testicular pain using conservative management of the thoracolumbar spine: A case report, Arch Phys Med Rehabil 84:1903-1905, 2003. 42. Keulers BJ, Roumen RH, Keulers MJ, et al: Bilateral groin pain from a rotten molar. The Lancet 366:94, 2005. 43. Todkar M: Case report: Psoas abscess—Unusual etiology of groin pain, Medscape Gen Med 7. Available at: http:// www.medscape.com/viewarticle/507610_print. Accessed on-line December 22, 2005. 44. Inman RD: Arthritis and enteritis—An interface of protean manifestations, J Rheumatol 14:406-410, 1987. 45. Inman RD: Antigens, the gastrointestinal tract, and arthritis, Rheum Dis Clin North Am 17:309-321, 1991. 46. Gran JT, Husby G: Joint manifestations in gastrointestinal diseases. 1. Pathophysiological aspects, ulcerative colitis and Crohn's disease, Dig Dis 10:274-294, 1992. 47. Gran JT, Husby G: Joint manifestations in gastrointestinal diseases. 2. Whipple's disease, enteric infections, intestinal bypass operations, gluten-sensitive enteropathy, pseudomembranous colitis and collagenous colitis, Dig Dis 10:295-312, 1992. 48. Keating RM, Vyas AS: Reactive arthritis following Clostridium difficile colitis, West J Med 162:61-63, 1995.
CHAPTER 16 49. Lundgren JM, Davis BA: End artery stenosis of the popliteal artery mimicking gastrocnemius strain, Arch Phys Med Rehabil 85:1548-1551, 2004. 50. Brau SA, Delamarter RB, Schiffman ML, et al: Vascular injury during anterior lumbar surgery, Spine J 4:409-441, 2004.
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51. Boissonnault WB, Boissonnault JS: Transient osteoporosis of the hip associated with pregnancy, J Orthop Sports Phys Ther 31:359-367, 2001. 52. Ross MD, Bayer E: Cancer as a cause of low back pain in a patient seen in a direct access physical therapy setting, J Orthop Sports Phys Ther 35:651-658, 2005.
Screening the Chest, Breasts, and Ribs
C
lients do not present in a physical therapy clinic with chest or breast pain as the primary symptom very often. The therapist is more likely to see the individual with an orthopedic or neurologic impairment who experiences chest or breast pain during exercise or during other intervention by the therapist. In other situations, the client reports chest or breast pain as an additional symptom during the screening interview. The pain may occur along with (or alternating with) the presenting symptoms of jaw, neck, upper back, shoulder, breast, or arm pain. When chest pain is the primary complaint, it is often an atypical pain pattern that has misled the client and/or the physician. On the other hand, it is also possible for clients to have primary chest pain from a movement system impairment. Symptoms persist or recur, often with months in between when the client is free of any symptoms. Countless medical tests are performed and repeated with referral to numerous specialists before a physical therapist is consulted (see Case Example 1-7). Finally, so many of today's aging adults with movement system impairments have multiple medical comorbidities that the therapists must be able to identify signs and symptoms of systemic disease that can mimic neuromuscular or musculoskeletal dysfunction. Systemic or viscerogenic pain or symptoms that can be referred to the chest or breast include the cardiovascular, pulmonary, and upper gastrointestinal systems, as well as other causes such as anxiety, steroid use, and cocaine use (Table 17-1). Various neuromusculoskeletal conditions such as thoracic outlet syndrome, costochondritis, trigger points, and cervical spine disorders can also affect the chest and breast. When faced with chest pain, the therapist must know how to assess the situation quickly and decide if medical referral is required and whether medical attention is needed immediately. We must be able to differentiate neuromusculoskeletal from systemic origins of symptoms. The therapist must especially know how and what to look for to screen for cancer, cancer recurrence, and/or the delayed effects of cancer treatment. Cancer can present as primary chest pain with or without accompanying neck, shoulder, and/or upper back pain/symptoms. Basic principles of cancer screening are presented in Chapter 13; specific clues related to the chest, breast, and ribs will be discussed in this chapter. Breast cancer is always a consideration with upper quadrant pain or dysfunction.
USING THE SCREENING MODEL TO EVALUATE THE CHEST, BREASTS, OR RIBS There are many causes of chest pain, both cardiac and noncardiac in origin (see Table 17-1). Two conditions may be present at the same time, each contributing to chest pain. For example, someone with cervicodorsal 774
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Causes of Chest Pain
Systemic causes
Cancer Mediastinal tumors
Cardiac Myocardial ischemia (angina) Myocarditis Pericarditis Myocardial infarct Dissecting aortic aneurysm Aortic aneurysm Aortic stenosis or regurgitation Mitral valve prolapse*
Pleuropulmonary Pulmonary embolism Pneumothorax Pulmonary hypertension* Cor pulmonale Pneumonia with pleurisy Mediastinitis
N e u r o m u s c u l o s k e l e t a l causes
Tietze's syndrome Costochondritis Hypersensitive xiphoid, xiphodynia Slipping rib syndrome Trigger points (see Table 17-4) Myalgia Rib fracture, costochondral dislocations Cervical spine disorders, arthritis Neurologic Nerve root, intercostal neuritis Dorsal nerve root irritation Thoracic outlet syndrome Thoracic disc disease Postoperative pain Breast Mastodynia Trigger points Trauma (including motor vehicle accident, assault)
Epigastric/Upper Gastrointestinal Esophagitis* Esophageal spasm* Upper gastrointestinal ulcer Cholecystitis Pancreatitis
Breast (see Table 17-2) Other Anemia Rheumatic diseases Anxiety, panic attack* Cocaine use Anabolic steroids Fibromyalgia Dialysis (first-use syndrome) Type III hypersensitivity reaction Herpes zoster (shingles) Sickle cell anemia Psychogenic * Relieved by nitroglycerin because it relaxes smooth muscle.
arthritis could also experience reflux esophagitis or coronary disease. Either or both of these conditions can contribute to chest pain. Chest pain can be evaluated in one of two ways: cardiac versus noncardiac or systemic versus neuromusculoskeletal (NMS). Physicians and nurses assess chest pain from the first paradigm: cardiac versus noncardiac. The therapist must understand the basis for this screening method while also viewing each problem as potentially systemic versus NMS. Throughout the screening process, it is important to remember we are not medical cardiac specialists; we are just screening for sys-
temic disease masquerading as NMS symptoms or dysfunction. Paying attention to past medical history, recognizing unusual clinical presentation for a neuromuscular or musculoskeletal condition, and keeping in mind the clues to differentiating chest pain will help the therapist evaluate difficult cases. Additionally, the woman with chest, breast, axillary, or shoulder pain of unknown origin at presentation must be questioned regarding breast self-examinations. Any recently discovered lumps or nodules must be examined by a physician. The client may need education regarding breast self-
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examination, and the physical therapist can provide this valuable information. Techniques of breast self-examination are commonly available in written form for the physical therapist or the client who is unfamiliar with these methods (see Appendix D-6). 1,2
Past Medical History Although the past medical history (PMH) is important, it cannot be relied upon to confirm or rule out medical causes of chest pain. PMH does alert the therapist to an increased risk of systemic conditions that can masquerade as NMS disorders. Like risk factors, PMH varies according to each system affected or condition present and is reviewed individually in each section of this chapter.
Risk Factors Any suspicious findings should be checked by a physician, especially in the case of the client with identified risk factors for cancer or heart disease. Identifying red-flag risk factors and PMH and then correlating this information with objective findings are important steps in the screening process. Risk for cardiac-caused symptoms increases with advancing age, tobacco use, menopause (women), family history of hypertension or premature coronary artery disease, and high cholesterol. Risk factors associated with noncardiac conditions vary with each individual condition.
Clinical Presentation When the clinical presentation suggests further screening is needed, the therapist can follow the guide to physical assessment for the upper quadrant as presented in Table 4-13. The client's general appearance, along with vital sign assessment, will offer some idea of the severity of the condition. Watch for uneven pulses from side to side, diminished or absent pulses, elevated blood pressure, or extreme hypotension. Auscultation for breath or lung sounds and chest percussion may provide additional cardiopulmonary clues.
Chest Pain
Patterns
From the previous discussion in Chapter 3, we know that there are at least three possible mechanisms for referred pain patterns to the soma from the viscera (embryologic development, multisegmental innervations, direct pressure on the diaphragm). Pain in the chest may be derived from the chest wall (dermatomes Tl-12), the pleura, the trachea and main airways, the mediastinum
(including the heart and esophagus), and the abdominal viscera. From an embryologic point of view, the lungs are derived from the same tissue as the gut, so problems can occur in both areas (lung or gut), causing chest pain and other related symptoms. Certain chest pain patterns are more likely to point to a medical rather than musculoskeletal cause. For example, pain that is positional or reproduced by palpation is not as suspicious as pain that radiates to one or both shoulders or arms or that is precipitated by exertion. Physicians agree that the chest pain history by itself is not enough to rule out cardiac or other systemic origin of symptoms. In most cases, some diagnostic testing is needed. Chest pain associated with increased activity is a red flag for possible cardiovascular involvement. In such cases, the onset of pain is not immediate but rather occurs 5 to 10 minutes after activity begins. This is referred to as the "lag time" and is a screening clue used by the physical therapist to assess when chest pain may be caused by musculoskeletal dysfunction (immediate chest pain occurs with use) or by possible vascular compromise (chest pain occurs 5 to 10 minutes after activity begins). Parietal pain may appear as unilateral chest pain (rather than midline only) because at any given point the parietal peritoneum obtains innervation from only one side of the nervous system. It is usually not reproduced by palpation. Thoracic disc disease can also present as unilateral chest pain, requiring careful screening. The four types of pain discussed in Chapter 3 (cutaneous, deep somatic or parietal, visceral, and referred) also apply to the chest. Parietal (somatic) chest pain is the most common systemic chest discomfort encountered in a physical therapy practice. Parietal pain refers to pain generating from the wall of any cavity, such as the chest or pelvic cavity (see Fig. 6-5). Although the visceral pleura are insensitive to pain, the parietal pleura are well supplied with pain nerve endings. It is usually associated with infectious diseases but is also seen in pneumothorax, rib fractures, pulmonary embolism with infarction, and other systemic conditions. Pain fibers, originating in the parietal pleura, are conveyed through the chest wall as fine twigs of the intercostal nerves. Irritation of these nerve fibers results in pain in the chest wall that is usually described as knifelike and is sharply localized close to the chest wall, occurring cutaneously (in the skin). 3
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Pain from the thoracic viscera and true chest wall pain are both felt in the chest wall, but visceral pain is referred to the area supplied by the upper four thoracic nerve roots. Report of pain in the lower chest usually indicates local disease, but upper chest pain may be caused by disease located deeper in the chest. There are few nerve endings (if any) in the visceral pleurae (linings of the various organs), such as the heart or lungs. The exception to this statement is in the area of the pericardium (sac enclosed around the entire heart), which is adjacent to the diaphragm (see Fig. 6-5). Extensive disease may develop within the body cavities without the occurrence of pain until the process extends to the parietal pleura. Neuritis (constant irritation of nerve endings) in the parietal pleura then produces the pain described in this section. Pleural pain may be aggravated by any respiratory movement involving the diaphragm, such as sighing, deep breathing, coughing, sneezing, laughing, or the hiccups. It may be referred along the costal margins or into the upper abdominal quadrants. Palpation usually does not reproduce pleural pain; change in position does not relieve or exacerbate the pain. In some cases of pleurisy, the individual can point to the painful spot but deep breathing (not palpation) reproduces it.
Associated Signs and Symptoms If the client has an underlying infectious or inflammatory process causing chest or breast pain or symptoms, there may be changes in vital signs and/or constitutional symptoms such as chills, night sweats, fever, upper respiratory symptoms, or gastrointestinal (GI) distress. Signs and symptoms associated with noncardiac causes of chest pain vary according to the underlying system involved. For example, cough, sputum production, and a recent history of upper respiratory infection may point to a pleuropulmonary origin of chest or breast pain. Anyone with persistent coughing or asthma can experience chest pain related to the strain of the chest wall muscles. Chest or breast pain associated with GI disease is often food related in the presence of a history of peptic ulcer, gastroesophageal reflux disease (GERD), or gallbladder problems. Blood in the stool or vomitus, along with a history of chronic nonsteroidal antiinflammatory drug (NSAID) use, may point to a GI problem and so on. Many of the conditions affecting the breast are not accompanied by other systemic signs and symptoms. Risk factors, client history, and clinical presentation provide the major clues as to a vis-
777
cerogenic, systemic, or cancerous origin of chest and/or breast pain or symptoms.
SCREENING FOR ONCOLOGIC CAUSES OF CHEST OR RIB PAIN Cancer can present as primary chest, neck, shoulder, and/or upper back pain and symptoms. A previous history of cancer of any kind is a major red flag (Case Example 17-1). Primary cancer affecting the chest with referred pain to the breast is not as common as cancer metastasized to the pulmonary system with subsequent pulmonary and chest/ breast symptoms.
Clinical Presentation The most common symptoms associated with metastases to the pulmonary system are pleural pain, dyspnea, and persistent cough. As with any visceral system, symptoms may not occur until the neoplasm is quite large or invasive because the lining surrounding the lungs has no pain perception. Symptoms first appear when the tumor is large enough to press on other nearby structures or against the chest wall. The presence of any skin changes, lesions, or masses should be documented using the information presented in Box 4-10.
Skin
Changes
Ask the client about any recent or current skin changes. Metastatic carcinoma can present with a cellulitic appearance on the anterior chest wall as a result of carcinoma of the lung (see Fig. 4-24). The skin lesion may be flat or raised and any color from brown to red or purple. Liver impairment from cancer or any liver disease can also cause other skin changes, such as angiomas over the chest wall. An angioma is a benign tumor with blood (or lymph, as in lymphangioma) vessels. Spider angioma (also called spider nevus) is a form of telangiectasis, a permanently dilated group of superficial capillaries (or venules; see Fig. 9-3). In the presence of skin lesions, ask about a recent history of infection of any kind, use of prescription drugs within the last 6 weeks, and previous history of cancer of any kind. Look for lymph node changes. Report all of these findings to the physician.
Palpable
Mass
Occasionally, the therapist may palpate a painless sternal or chest wall mass when evaluating the head and neck region. Most mediastinal tumors are the result of a metastatic focus from a distant
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CASE E X A M P L E
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R i b M e t a s t a s e s A s s o c i a t e d W i t h O v a r i a n Cancer
Referral: A 53-year-old university professor came to the physical therapy clinic with complaints of severe left shoulder pain radiating across her chest and down her arm. She rated the pain a 10 on the numeric rating scale (see explanation in Chapter 3). Past Medical History: She had a significant personal and social history, including ovarian cancer 10 years ago, death of a parent last year, filing for personal bankruptcy this year, and a divorce after 30 years of marriage. Clinical Presentation: First Visit: During the screening examination for vital signs, the client's blood pressure was 220/125 mm Hg. Pulse was 88 beats per minute. Pulse oximeter measured 98%. Oral temperature: 98.0°F. She denied any previous history of cardiovascular problems or current feelings of stress. Intervention: She was referred for medical attention immediately on the basis of her blood pressure readings but returned a week later with a medical diagnosis of "rib bruise." Electrocardiography (EKG) and heart catheterization ruled out a cardiac cause of symptoms. She was put on Prilosec for gastroesophageal reflux disease (GERD) and an antiinflammatory for her rib pain. Clinical Presentation: Second Visit: The therapist was able to reproduce the symptoms
primary tumor and remain asymptomatic unless they compress mediastinal structures or invade the chest wall. The primary tumor is usually a lymphoma (Hodgkin's lymphoma in a young adult or nonHodgkin's lymphoma in a child or older adult; see Fig. 4-27), multiple myeloma (primarily observed in people over 60 years of age), or carcinoma of the breast, kidney, or thyroid. When involvement of the chest wall and nerve roots results in pain, the pattern is more diffuse, with radiation of pain to the affected nerve roots (Case Example 17-2). Irritation of an intercostal nerve from rib metastasis produces burning pain that is unilateral and segmental in distribution. Sensory loss or hyperesthesia over the affected dermatomes may be noted.
described above with moderate palpation of the eighth rib on the left side and sidebending motion to the left side. The client described the symptoms as constant, sharp, burning, and intense. She had pain at night if she slept too long on either side. Sidelying on the involved side and slump sitting did not reproduce the symptoms. There was no obvious mechanical cause for the painful symptoms (e.g., intercostal tear, costovertebral dysfunction, neuritis from nerve entrapment). The therapist considered the possibility of a somato-visceral reflex responses (e.g., a biomechanical dysfunction of the tenth rib can cause gallbladder changes), but there were no accompanying associated signs and symptoms and the tenth rib was not painful. Result: The therapist decided to contact the referring physician to discuss the client's clinical presentation before initiating treatment, especially given the constancy and intensity of the pain in the presence of a past medical history of cancer. The physician directed the therapist to have the client return for further testing. A bone scan revealed metastases to the ribs and thoracic spine. Physical therapy intervention was not appropriate at this time.
SCREENING FOR CARDIOVASCULAR CAUSES OF CHEST, BREAST, OR RIB PAIN Cardiac-related chest pain may arise secondary to angina, myocardial infarction, pericarditis, endocarditis, mitral valve prolapse, or aortic aneurysm. Despite diagnostic advances, acute coronary syndromes and myocardial infarctions are missed in 2% to 10% of patients. There is no single element of chest pain history powerful enough to predict who is or who is not having a coronary-related incident. Medical referral is advised whenever there is any doubt; medical diagnostic testing is almost always required. Cardiac-related chest pain also can occur when there is normal coronary circulation, as in the case 3
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779
Lymphoma Masquerading as Nerve Entrapment
Referral: A 72-year-old woman was referred to physical therapy for a postural exercise program and home traction by her neurologist with a diagnosis of "nerve entrapment." She was experiencing symptoms of left shoulder pain with numbness and tingling in the ulnar nerve distribution. She had a moderate forward head posture with slumped shoulders and loss of height from known osteoporosis. Past Medical History: The woman's past medical history was significant for right breast cancer treated with a radical mastectomy and chemotherapy 20 years ago. She had a second cancer (uterine) 10 years ago that was considered separate from her previous breast cancer. Clinical Presentation: The physical therapy examination was consistent with the physician's diagnosis of nerve entrapment in a classic presentation. There were significant postural components to account for the development of symptoms. However, the therapist palpated several large masses in the axillary and supraclavicular fossa on both the right and left sides. There was no local warmth, redness, or tenderness associated with these lesions. The therapist requested permission to palpate the client's groin and popliteal spaces for any other suspicious lymph nodes. The rest of the examination findings were within normal limits. Associated Signs and Symptoms: Further questioning about the presence of associated signs and symptoms revealed a significant disturbance in sleep pattern over the last 6 months
of clients with pernicious anemia. Affected clients may have chest pain or angina on physical exertion because of the lack of nutrition to the myocardium.
Risk Factors Gender and age are nonmodifiable risk factors for chest pain caused by heart disease. The rate of coronary artery disease (CAD) is rising among women and falling among men. Men develop CAD at a younger age than women, but women make up for it after menopause. Many women know about the risk of breast cancer, but in truth, they are 10 times more likely to die of cardiovascular
with unrelenting shoulder and neck pain. There were no other reported constitutional symptoms, skin changes, or noted lumps anywhere. Vital signs were unremarkable at the time of the physical therapy evaluation. Result: Returning this client to her referring physician was a difficult decision to make given that the therapist did not have the benefit of the medical records or results of neurologic examination and testing. Given the significant past medical history for cancer, the woman's age, presence of progressive night pain, and palpable masses, no other reasonable choice remained. When asked if the physician had seen or felt the masses, the client responded with a definite "no." There are several ways to approach handling a situation like this one, depending on the physical therapist's relationship with the physician. In this case, the therapist had never communicated with this physician before. It is possible that the physician was aware of the masses, knew from medical testing that there was extensive cancer, and chose to treat the client palliatively. Because there was no indication of such, the therapist notified the physician's staff of the decision to return the client to the physician. A brief (one-page) written report summarizing the findings was given to the client to hand-carry to the physician's office. Further medical testing was performed, and a medical diagnosis of lymphoma was made.
disease. While one in 30 women's deaths is from breast cancer, one in 2.5 deaths is from heart disease. Women do not seem to do as well as men after taking medications to dissolve blood clots or after undergoing heart-related medical procedures. Of the women who survive a heart attack, 46% will be disabled by heart failure within 6 years. AfricanAmerican women have a 70% higher death rate from CAD compared with Caucasian women. Whenever screening individuals who have chest pain, keep in mind that older men and women, menopausal women, and African-American women are at greatest risk for cardiovascular causes. 5
6
5
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A common treatment for CAD after heart attack is angioplasty with insertion of a stent. A stent is a wire mesh tube that props open narrowed coronary arteries. Sometimes, the stent malfunctions or gets scarred over. Cardiologists have realized that such treatments, while effective at alleviating chest pain, do not reduce the risk of heart attacks for most people with stable angina. When the client presents with chest pain, he or she often does not think it can be from the heart because there is a stent in place, but this may not be true. Anyone with a history of stent insertion presenting with chest pain should be screened carefully. Take vital signs, and ask about associated signs and symptoms. Assess the effect of exercise on symptoms. For example, does the chest, neck, shoulder, or jaw pain start 3 to 5 minutes after exercise or activity? What is the effect on pain in the upper body when the individual is using just the lower extremities, such as walking on a treadmill or up a flight of stairs? Other risk factors for CAD are listed in Table 6-3. The therapist can help clients assess their 10-year risk for heart attack using a risk assessment tool from the National Cholesterol Education program. 7
Clinical Presentation There are some well-known pain patterns specific to the heart and cardiac system. Sudden death can be the first sign of heart disease. In fact according to the American Heart Association, 63% of women who died suddenly of cardiovascular disease had no previous symptoms. Sudden death is the first symptom for half of all men who have a heart attack. Cardiac arrest strikes immediately and without warning. Clinical Signs and Symptoms of Cardiac A r r e s t •
Sudden loss of responsiveness; no response to gentle shaking • No normal breathing; client does not take a normal breath when you check for several seconds. • No signs of circulation; no movement or coughing
Cardiac
Pain
Patterns
Doctors and nurses often use "the three Ps" when screening for chest pain of a cardiac nature. The presence of any or all of these Ps suggests the client's pain or symptoms are not caused by a myocardial infarction (MI):
• Pleuritic pain (exacerbation by deep breathing is more likely pulmonary in nature) • Pain on palpation (musculoskeletal cause) • Pain with changes in position (musculoskeletal cause) Cardiac pain patterns may differ for men and women. For many men, the most common report is a feeling of pressure or discomfort under the sternum (substernal), in the midchest region or across the entire upper chest. It can feel like uncomfortable pressure, squeezing, fullness, or pain. Pain may occur just in the jaw, upper neck, midback, or down the arm without chest pain or discomfort. Pain may also radiate from the chest to the neck, jaw, midback, or down the arm(s). Pain down the arm(s) affects the left arm most often in the pattern of the ulnar nerve distribution. Radiating pain down both arms is also possible. For women, symptoms can be more subtle or atypical (Box 17-1). Chest pain or discomfort is less common in women but still a key feature for some. They often have prodromal symptoms up to 1 month before having a heart attack (see Table 6-4). Fatigue, nausea, and lower abdominal pain may signal a heart attack. Many women pass these off 8
9
B O X 17-1
• • • • • • • • • • • • •
T
Signs and Symptoms of Myocardial Ischemia in Women
Heart pain in women does not always follow classic patterns. Many women do experience classic chest discomfort. In older women, mental status change or confusion may be common. Dyspnea (at rest or with exertion) Weakness and lethargy (unusual fatigue; fatigue that interferes with ability to perform activities of daily living) Indigestion or heart burn; mistakenly diagnosed or assumed to have gastroesophageal reflux disease (GERD) Lower abdominal pain Anxiety or depression Sleep disturbance (woman awakens with any of the symptoms listed here) Sensation similar to inhaling cold air; unable to talk or breathe Isolated midthoracic back pain Isolated right biceps aching Symptoms may be relieved by antacids (sometimes antacids work better than nitroglycerin).
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as the flu or food poisoning. Other symptoms for women include a feeling of intense anxiety, isolated right biceps pain, or midthoracic pain. Heartburn; sudden shortness of breath or the inability to talk, move, or breathe; shoulder or arm pain; or ankle swelling or rapid weight gain are also common symptoms with MI.
Chest Pain Associated with Angina The therapist should keep in mind that coronary disease may go unnoticed because the client has no anginal or infarct pain associated with ischemia. This situation occurs when collateral circulation is established to counteract the obstruction of the blood flow to the heart muscle. Anastomoses (connecting channels) between the branches of the right and left coronary arteries eliminate the person's perception of pain until challenged by physical exertion or exercise in the physical therapy setting. Chest pain caused by angina is often confused with heartburn or indigestion, hiatal hernia, esophageal spasm, or gallbladder disease, but the pain of these other conditions is not described as sharp or knifelike. The client often says the pain feels like "gas" or "heartburn" or "indigestion." Referred pain from a trigger point in the external oblique abdominal muscle can cause a sensation of heartburn in the anterior chest wall (see Fig. 17-7). Episodes of stable angina usually develop slowly and last 2 to 5 minutes. Discomfort may radiate to the neck, shoulders, or back (Case Example 17-3). Shortness of breath is common. Symptoms of angina may be similar to the pattern associated with a heart attack. One primary difference is duration. Angina lasts a limited time (a few minutes up to a half hour) and can be relieved by rest or nitroglycerin. When screening for angina, a
CASE E X A M P L E
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781
lack of objective musculoskeletal findings is always a red flag: • Active range of motion (AROM) such as trunk rotation, side bending, shoulder motions does not reproduce symptoms. • Resisted motion does not reproduce symptoms (horizontal shoulder abduction/adduction). • Heat and stretching do not reduce or eliminate symptoms. The therapist should also watch for unstable angina in a client with known angina. Unlike stable angina, rest or nitroglycerin does not relieve symptoms associated with an MI, unless administered intravenously. Without intervention, symptoms of an MI may continue without stopping. A sudden change in the client's typical anginal pain pattern suggests unstable angina. Pain that occurs without exertion, lasts longer than 10 minutes, or is not relieved by rest or nitroglycerin signals a higher risk for a heart attack. Immediate medical referral is required under these circumstances.
SCREENING FOR PLEUROPULMONARY CAUSES OF CHEST, BREAST, OR RIB PAIN Pulmonary chest pain usually results from obstruction, restriction, dilation, or distention of the large airways or large pulmonary artery walls. Specific diagnoses include pulmonary artery hypertension, pulmonary embolism, mediastinal emphysema, pleurisy, pneumonia, and pneumothorax. Pleuropulmonary disorders are discussed in detail in Chapter 7.
Past Medical History A previous history of cancer of any kind, recent history of pulmonary infection, or recent accident or hospitalization may be significant. Look for
Adhesive Capsulitis
Referral: A 56-year-old man returned to the same physical therapist with his third recurrence of left shoulder adhesive capsulitis of unknown cause. Past Medical History: There was no reported injury, trauma, or repetitive motion as a precipitating factor in this case. The client was a car salesman with a fairly sedentary job. He reported a past history of prostatitis, peptic ulcers, and a broken collarbone as a teenager.
He reported being a "social" drinker at workrelated functions but did not smoke or use tobacco products. He was taking ibuprofen for his shoulder but no other over-the-counter or prescription medications or supplements. The two previous episodes of shoulder problems resolved with physical therapy intervention. The client had a home program to follow to maintain range of motion and normal movement. At the time of his most recent discharge 6
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Adhesive Capsulit s—cont'd
months ago, he had attained 80% of motion available on the uninvolved side with some continued restricted glenohumeral movement and altered scapulohumeral rhythm. The client reported that he did not continue with his exercise routine at home, and "that's why I got worse again." Clinical Presentation Shoulder flexion and abduction Shoulder medial (internal) rotation Shoulder lateral (external) rotation
Left: 105/100 Right: 170/165 0-70
0-90
0-45
0-80
Accessory motions: Reduced inferior and anterior glide on the left; within normal limits on the right. The client reports pain during glenohumeral flexion, abduction and medial and lateral rotations. Clinical impression: Decreased physiologic motion with capsular pattern of restriction and compensatory movements of the shoulder girdle; humeral superior glide syndrome. Associated Signs and Symptoms: When asked if there were any symptoms of any kind anywhere else in the body, the client reported "chest tightness" whenever he tried to use his arm for more than a few minutes. Previously, he was used to "working through the pain," but he can't seem to do that anymore. He also reported "a few bouts of nausea and sweating" when his shoulder started aching. He denied any shortness of breath or constitutional symptoms such as fever or sweats. There were no other gastrointestinal-related symptoms. What are the red flags in this case? How would you screen further? • Age over 50 • Nausea and sweating concomitant with shoulder pain; chest tightness • Insidious onset • Recurring pattern of symptoms Screening can begin with something as simple as vital sign assessment. The therapist can consult Box 4-17 for a list of other associated signs and symptoms and look for a cluster or pattern associated with a particular system. Given his age, sedentary lifestyle, and particular clinical presentation, a cardiovascular screening examination seems most appropriate.
The therapist can also consult the Special Questions to Ask box at the end of Chapter 6 for any additional pertinent questions based on the client's responses to questions and examination results. A short (3- to 5-minute) bike test also can be used to assess the effect of lower extremity exertion on the client's symptoms. Result: The client's blood pressure was alarmingly high at 185/120 mm Hg. Although this is an isolated (one time) reading, he was under no apparent stress, and he revealed that he had a history of elevated blood pressure in the past. The bike test was administered while his heart rate and blood pressure were being monitored. Symptoms of chest and/or shoulder pain were not reproduced by the test, but the therapist was unwilling to stress the client without a medical evaluation first. Referral was made to his primary care physician with a phone call, fax, and report of the therapist's findings and concerns. Although there is a known viscerosomatic effect between heart and chest and heart and shoulder, there is no reported direct cause and effect link between heart disease and adhesive capsulitis. Comorbid factors such as diabetes or heart disease have been shown to affect pain levels and function. Likewise, adhesive capsulitis is known to occur in some people following immobility associated with intensive care, coronary artery bypass graft, or pacemaker complications/ revisions. The physician considered this an emergency situation and admitted the client to the cardiology unit for immediate workup. The electrocardiogram results were abnormal during the exercise stress test. Further testing confirmed the need for a triple bypass procedure. Following the operation and phase 1 cardiac rehab in the cardiac rehab unit, the client returned to the original outpatient physical therapist for his phase 2 cardiac rehab program. Shoulder symptoms were gone, and range of motion was unimproved but regained rapidly as the rehab program progressed. The therapist shared this information with the cardiologist, who agreed that there may have been a connection between the chest/shoulder symptoms before surgery, although he could not say for sure. 10
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other risk factors, such as age, smoking, prolonged immobility, immune system suppression (e.g., cancer chemotherapy, corticosteroids), and eating disorders (or malnutrition from some other cause).
Clinical Presentation Pulmonary pain patterns differ slightly depending on the underlying pathology and the location of the disease. For example, tracheobronchial pain is referred to the anterior neck or chest at the same levels as the points of irritation in the air passages. Chest pain that tends to be sharply localized or that worsens with coughing, deep breathing, other respiratory movements or motion of the chest wall and that is relieved by maneuvers that limit the expansion of a particular part of the chest (e.g., auto-splinting) is likely to be pleuritic in origin. Symptoms that increase with deep breathing and activity or the presence of a productive cough with bloody or rust-colored sputum are red flags. The therapist should ask about new onset of wheezing at any time or difficulty breathing at night. Be careful when asking clients about changes in breathing patterns. It is not uncommon for the client to deny any shortness of breath. Often, the reason for this is because the client has stopped doing anything that will bring on the symptoms. It may be necessary to ask what activities he or she can no longer do that were possible 6 weeks or 6 months ago. Symptoms that are relieved by sitting up are indicative of pulmonary impairment and must be evaluated more carefully.
SCREENING FOR GASTROINTESTINAL CAUSES OF CHEST, BREAST, OR RIB PAIN GI causes of upper thorax pain are a result of epigastric or upper GI conditions. GERD ("heartburn" or esonhaeitis) accounts for a significant number of
cases of noncardiac chest pain. Stomach acid or gastric juices from the stomach enter the esophagus, causing irritation to the protective lining of the lower esophagus. Whether the client is experiencing GERD or some other cause of chest pain, there is usually a telltale history or associated signs and symptoms to red flag the case.
Past Medical History Watch for a history of alcoholism, cirrhosis, esophageal varices, and esophageal cancer or peptic ulcers. Any risk factors associated with these conditions are also red flags such as longterm use of NSAIDs as a cause of peptic ulcers or chronic alcohol use associated with cirrhosis of the liver.
Clinical Presentation The GI system has a broad range of referred pain patterns based on embryologic development and multisegmental innervations, as discussed in Chapter 3. Upper GI and pancreatic problems are more likely than lower GI disease to cause chest pain. Chest pain referred from the upper GI tract can radiate from the chest posteriorly to the upper back or interscapular or subscapular regions from T10 to L2 (Fig. 17-1).
Esophagus Esophageal dysfunction will present with symptoms such as anterior neck and/or anterior chest pain, pain during swallowing (odynophagia), or difficulty swallowing (dysphagia) at the level of the lesion. Symptoms occur anywhere a lesion is present along the length of the esophagus. Early satiety, often with weight loss, is a common symptom with esophageal carcinoma. Lesions of the upper esophagus may cause pain in the (anterior) neck, whereas lesions of the lower esophagus are more likely to be character-
Pancreas F i g . 1 7 - 1 • Chest pain caused by gastrointestinal (GI) disease with referred pain to the shoulder and back. Upper GI problems can refer pain to the anterior chest with radiating pain to the thoracic spine at the same level. Look for accompanying GI symptoms and red flag history.
783
Esophagus Gallbladder
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ized by pain originating from the xiphoid process, radiating around the thorax to the middle of the back. Chest pain with or without accompanying or alternating midthoracic back pain from an esophageal or other upper GI problem is usually red nagged by a suspicious history or cluster of associated signs and symptoms. The pain pattern associated with thoracic disc disease can be the same as for esophageal pathology. In the case of disc disease, there may be bowel and/or bladder changes and sometimes numbness and tingling in the upper extremities. The therapist should ask about a traumatic injury to the upper back region and conduct a neurologic screening examination to assess for this possibility as a cause of the symptoms.
Epigastric
Pain
Epigastric pain is typically characterized by substernal or upper abdominal (just below the xiphoid process) discomfort (see Fig. 17-1). This may occur with radiation posteriorly to the back secondary to long-standing duodenal ulcers. Gastric duodenal peptic ulcer may occasionally cause pain in the lower chest rather than in the upper abdomen. Antacid and food often immediately relieve pain caused by an ulcer. Ulcer pain is not produced by effort and lasts longer than angina pectoris. The therapist will not be able to provoke or eliminate the client's symptoms. Likewise, physical therapy intervention will not have any long-lasting effects unless the symptoms were caused by trigger points (TrPs). Pain in the lower substernal area may arise as a result of reflux esophagitis (regurgitation of gastroduodenal secretions), a condition known as gastroesophageal reflux disease, or GERD. It may be gripping, squeezing, or burning, described as "heartburn" or "indigestion." Like that of angina pectoris, the discomfort of reflux esophagitis may be precipitated by recumbency or by meals; however, unlike angina, it is not precipitated by exercise and is relieved by antacids.
Hepatic
and Pancreatic
Systems
Epigastric pain or discomfort may occur in association with disorders of the liver, gallbladder, common bile duct, and pancreas, with referral of pain to the interscapular, subscapular, or middle/low back regions. This type of pain pattern can be mistaken for angina pectoris or myocardial infarction (e.g., hypotension occurring with pancreatitis produces a reduction of coronary blood flow with the production of angina pectoris).
Hepatic disorders may cause chest pain with radiation of pain to the shoulders and back. Cholecystitis (gallbladder inflammation) appears as discrete attacks of epigastric or right upper quadrant pain, usually associated with nausea, vomiting, and fever and chills. Dark urine and jaundice indicate that a stone has obstructed the common duct. The pain has an abrupt onset, is either steady or intermittent, and is associated with tenderness to palpation in the right upper quadrant. The pain may be referred to the back and right scapular areas. A gallbladder problem can result in a sore tenth rib tip (right side anteriorly) as described in Chapter 9 (Case Example 17-4). Rarely, pain in the left upper quadrant and anterior chest can occur. Acute pancreatitis causes pain in the upper part of the abdomen that radiates to the back (usually anywhere from T10 to L2) and may spread out over the lower chest. Fever and abdominal tenderness may develop. Clinical Signs and Symptoms of Gastrointestinal D i s o r d e r s •
Chest pain (may radiate to back)
• Nausea • Vomiting • Blood in stools • Pain on swallowing or associated with meals • Jaundice • Heartburn or indigestion • Dark urine
SCREENING FOR BREAST CONDITIONS THAT CAUSE CHEST OR BREAST PAIN Occasionally, a client may present with breast pain as the primary complaint, but most often the description is of shoulder or arm or neck or upper back pain. When asked if any symptoms occur elsewhere in the body, the client may mention breast pain (Case Example 17-5). During examination of the upper quadrant, the therapist may observe suspicious or aberrant changes in the integument, breast, or surrounding soft tissues. The client may report discharge from the nipple. Discharge from both nipples is more likely to be from a benign condition; discharge from one nipple can be a sign of a precancerous or malignant condition. Asking the client about history, risk factors, and the presence of other signs and symptoms is the next step (see Box 4-16). Knowing possible causes
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CASE E X A M P L E
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SCREENING T H E CHEST, BREASTS, A N D RIBS
785
Chest Pain D u r i n g Pregnancy
Referral: A 33-year-old woman in her twenty-ninth week of gestation with her first pregnancy was referred to a physical therapist by her gynecologist. Her abdominal sonogram and lab tests were normal. A chest x-ray was read as negative. Past Medical History: None. The client had the usual childhood illnesses but had never broken any bones and denied use of tobacco, alcohol, or substances of any kind. There was no recent history of infections, colds, viruses, coughs, trauma or accidents, and changes in gastrointestinal function and no history of cancer. Clinical Presentation: Although there were no signs and symptom associated with the respiratory system, the client's symptoms were reproduced when she was asked to take a deep breath. Palpation of the upper chest, thorax, and ribs revealed pain on palpation of the right tenth rib (anterior). Thinking about the role of the gallbladder causing tenth rib pain, the therapist asked further questions about past history and current gastrointestinal symptoms. The client had no red flag symptoms or history in this regard.
of breast pain can help guide the therapist during the screening interview (see Table 17-2).
Past Medical History A past history of breast cancer, heart disease, recent birth, recent upper respiratory infection (URI), overuse, or trauma (including assault) may be significant for the client presenting with breast pain or symptoms. Any component of heart disease, such as hypertension, angina, myocardial infarction, and/or any heart procedure such as angioplasty, stent, or coronary artery bypass, is considered a red flag. Any woman experiencing chest or breast pain should be asked about a personal history of previous breast surgeries, including mastectomy, breast reconstruction, or breast implantation or augmentation. A past history of breast cancer is a red flag even if the client has completed all treatment and has been cancer free for 5 years or more. Breast cancer and cysts develop more frequently in individuals who have a family history of breast
Knowing that transient osteoporosis can be associated with pregnancy, " the therapist gave the client the Osteoporosis Screening Evaluation (see Appendix C-3). The client replied "yes" to three questions (Caucasian or Asian, mother diagnosed with osteoporosis, physically inactive), suggesting the possibility of rib fracture. Result: The therapist initiated a telephone consultation with the physician to review her findings. Although the original x-ray was read as negative, the physician ordered a different view (rib series) and identified a fracture of the tenth rib. The physician explained that the mechanical forces of the enlarging uterus on the ribs pull the lower ribs into a more horizontal position. Any downward stress from above (e.g., forceful cough or pull from the external oblique muscles) or upward force from the serratus anterior and latissimus dorsi muscles can increase the bending stress on the lower ribs. An aquatics therapy program was initiated and continued throughout the remaining weeks of this client's pregnancy. 11
16
1214
12
disease. A previous history of cancer is always cause to question the client further regarding the onset and pattern of current symptoms. This is especially true when a woman with a previous history of breast cancer or cancer of the reproductive system appears with shoulder, chest, hip, or sacroiliac pain of unknown cause. If a client denies a previous history of cancer, the therapist should still ask whether that person has ever received chemotherapy or radiation therapy. It is surprising how often the answer to the question about a previous history of cancer is "no" but the answer to the question about prior treatment for cancer is "yes."
Clinical Presentation For the most part, breast pain (mastalgia), tenderness, and swelling are the result of monthly hormone fluctuations. Cyclical pain may get worse during perimenopause when hormone levels change erratically. These same symptoms may continue after menopause, especially in women who
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CASE E X A M P L E
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SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
Breast Pain and Trigger Points
Referral: A 67-year-old woman came to physical therapy after seeing her primary care physician with a report of decreased functional left shoulder motion. She was unable to reach the top shelf of her kitchen cabinets or closets. She felt that at 5 feet 7 inches this is something she should be able to do. Past Medical History: During the Past Medical History portion of the interview, she mentioned that she had had a stroke 10 years ago. Her referring physician was unaware of this information. She had recently moved here to be closer to her daughter, and no medical records have been transferred. There was no other significant history. At the end of the interview, when asked, "Is there anything else you think I should know about your health or current situation that we haven't discussed?" she replied, "Well, actually the reason I really went to see the doctor was for pain in my left breast." She had not reported this information to the physician. Clinical Presentation: Examination revealed mild loss of strength in the left upper extremity accompanied by mild sensory and proprioceptive losses. Palpation of the shoulder and pectoral muscles produced breast pain. The client had been aware of this pain, but she had attributed it to a separate medical problem. She was reluctant to report her breast pain to her physician. Objectively, there were positive trigger points of the left pectoral muscles and loss of accessory motions of the left shoulder (see Fig 17-7). • Active trigger point of the left pectoralis major with pain centered in the left breast • Decreased left shoulder accessory motions (caudal glide, posterior glide and lateral
use hormone replacement therapy (HRT). Noncyclical breast pain is not linked to menstruation or hormonal fluctuations. It is unpredictable and may be constant or intermittent, affecting one or both breasts in a small area or the entire breast. The typical referral pattern for breast pain is around the chest into the axilla, to the back at the level of the breast, and occasionally into the neck and posterior aspect of the shoulder girdle (Fig. 17-
•
• • •
traction); no shoulder pain or discomfort reported Range of motion limited by 20% compared with the right shoulder in flexion, external rotation, and abduction Mild strength deficit Mild sensory and proprioceptive losses Vital signs:
Blood pressure (sitting, left arm) Heart rate
142/108 mm Hg 72bpm
Pulse oximeter Oral temperature
98% 98.0 degrees
Intervention: Physical therapy treatment to eliminate trigger points and restore shoulder motion resolved the breast pain during the first week. Should you make a medical referral for this client? If so, on what basis? Despite this woman's positive response to physical therapy treatment, given the age of this client, her significant past medical history for cerebrovascular injury (reportedly unknown to the referring physician), current blood pressure (although an isolated measurement), report of breast pain (also unreported to her physician), and the residual paresis, medical referral was still indicated. At the first follow-up visit, a letter was sent with the client that briefly summarized the initial objective findings, her progress to date, and the current concerns. She returned for an additional week of physical therapy to complete the home program for her shoulder. A medical evaluation ruled out breast disease, but medical treatment (medication) was indicated to address cardiovascular issues.
2). The pain may continue along the medial aspect of the ipsilateral arm to the fourth and fifth digits, mimicking pain of the ulnar nerve distribution. Jarring or movement of the breasts and movement of the arms may aggravate this pain pattern. Pain in the upper inner arm may arise from outer quadrant breast tumors, but pain in the local chest wall may point to any pathologic condition of the breast.
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787
F i g . 1 7 - 2 • Pain arising from the breast (mastalgia) can be referred into the axilla along the medial aspect of the arm. Referral pattern can also extend to the supraclavicular level and into the neck. Breast pain may be diffuse around the thorax through the intercostal nerves. Pain may be referred to the back and the posterior shoulder. Ask the client about the presence of lumps, nipple discharge, distended veins, or puckered or red skin (or any other skin changes).
Nipple discharge in women is common, especially in pregnant or lactating women, and does not always signal a serious underlying condition. It may occur as a result of some medications (e.g., estrogen-based drugs, tricyclic antidepressants, benzodiazepines, and others). The fluid may be thin to thick in consistency and various colors (e.g., milky white, green, yellow, brown, or bloody). Any unusual nipple discharge should be evaluated by a medical doctor. Injury, hormonal imbalance, underactive thyroid, infection or abscess, or tumors are just a few possible causes of nipple discharge. Clinical Signs and Symptoms of Breast Pathology •
Family history of breast disease
•
Palpable breast nodules or lumps and previous history of chronic mastitis May be painless Breast pain with possible radiation to inner aspect of arm(s) Skin surface over a tumor may be red, warm, edematous, firm, and painful. Firm, painful site under the skin surface
• • • •
•
Skin dimpling over the lesion with attachment of the mass to surrounding tissues, preventing normal mobilization of skin, fascia, and muscle
•
Unusual nipple discharge or bleeding from the nipple(s) • Pain aggravated by jarring or movement of the breasts • Pain that is not aggravated by resistance to isometric movement of the upper extremities
Causes of Breast Pain There is a wide range of possible causes of breast pain, including both systemic or viscerogenic and neuromusculoskeletal etiologies (Table 17-2). Not all conditions are life threatening or even require medical attention. Although it is more typical in women, both men and women can have chest, back, scapular, and shoulder pain referred by a pathologic condition of the breast. Only those conditions most likely to be seen in a physical therapist's practice are included in this discussion.
Mastodynia Mastodynia (irritation of the upper dorsal intercostal nerve) that causes chest pain is almost
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TABLE
S E C T I O N III
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SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
Causes of Breast Pain
S y s t e m i c causes
Infection • Mastitis (lactating women) • Abscess Paget's disease Tumors, cysts, fibrocystic changes Lymph disease Premenstrual syndrome (PMS), menstrual or hormonal influences Shingles (herpes zoster) Cancer (rare cause of breast pain) Pleuritis Gastroesophageal reflux disease (GERD) Medications (e.g., some hormone, cardiovascular, psychiatric drugs)
N e u r o m u s c u l o s k e l e t a l causes
Pectoral myalgia or other conditions affecting the pectoralis muscles Trigger points (TrPs) Mastodynia (mammary neuralgia) Breast implants, augmentation, reduction • Scar tissue Trauma or injury (e.g., assault, breast biopsy, or surgery) Thoracic outlet syndrome Costochondritis Connective tissue disorders Heavy, pendulous breasts
always associated with ovulatory cycles, especially premenstrually. The association between symptoms and menses may be discovered during the physical therapist's interview when the client responds to Special Questions to Ask: Breast (see end of this chapter or Appendix B-7). The presentation is usually unilateral breast or chest pain and occurs initially at the premenstrual period and later more persistently throughout the menstrual cycle.
Mastitis Mastitis is an inflammatory condition associated with lactation (breast feeding). Mammary duct obstruction causes the duct to become clogged. The breast becomes red, swollen, and painful. The involved breast area is often warm or even hot. Constitutional symptoms such as fever, chills, and flulike symptoms are common. Acute mastitis can occur in males (e.g., nipple chafing from jogging); the presentation is the same as for females. Risk factors include previous history of mastitis; cracked, bleeding, painful nipples; and stress or fatigue. Bacteria can enter the breast through cracks in the nipple during trauma or nursing. Subsequent infection may lead to abscess formation. Obstructive and infectious mastitis are considered as two conditions on a continuum. Mastitis is often treated symptomatically, but the client should be encouraged to let her doctor know about any breast signs and symptoms present. Antibiotics may be needed in the case of a developing infection.
Benign
Tumors and Cysts
Benign tumors and cysts were once lumped together and called "fibrocystic breast disease." With additional research over the years, scientists have come to realize that a single label is not adequate for the variety of benign conditions possible, including fibroadenomas, cysts, and calcifications that can occur in the breast. An unchanged lump of long duration (years) is more likely to be benign. Many lumps are hormonally induced cysts and resolve within 2 or 3 menstrual cycles. Cyclical breast cysts are less common after menopause. Other conditions can include intraductal papillomas (wartlike growth inside the breast), fat necrosis (fat breaks down and clumps together), and mammary duct ectasia (ducts near the nipple become thin-walled and accumulate secretions). Some of these breast changes are a variation of the norm, and others are pathologic but nonmalignant. A medical diagnosis is needed to differentiate between these changes.
Paget's
Disease
Paget's disease of the breast is a rare form of ductal carcinoma arising in the ducts near the nipple. The woman experiences itching, redness, and flaking of the nipple with occasional bleeding (Fig. 17-3). Paget's disease of the breast is not related to Paget's disease of the bone, except that the same physician (Dr. James Paget, a contemporary of Florence Nightingale, 1877) named both conditions after himself.
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TABLE
F i g . 1 7 - 3 • Paget's disease of the breast is a rare form of breast cancer affecting the nipple. It is characterized by a red (sometimes scaly) rash on the breast that often surrounds the nipple and areola, as seen in this photograph. Other presentations are possible, such as a red pimple or sore on the nipple that does not heal. Symptoms are unilateral, and the breast may be sore, itch, or burn. Diagnosis is often delayed because the symptoms seem harmless or the condition is misdiagnosed as dermatitis. (From Callen JP, Jorizzo J, Greer KE, et al: Dermatological signs of internal disease, Philadelphia, 1988, Saunders.)
Breast Cancer The breast is the second most common site of cancer in women (the skin is first). Cancer of the breast is second only to lung cancer as a cause of death from cancer among women. Male breast cancer is possible but rare, accounting for 1% of all breast cancers (400 cases in 2005 compared with 30,000 for women). Although the frequency of breast cancer in men is strikingly less than that in women, the disease in both sexes is remarkably similar in epidemiology, natural history, and response to treatment. Men with breast cancer are 5 to 10 years older than women at the time of diagnosis, with mean or median ages between 60 and 66 years. This apparent difference may occur because symptoms in men are ignored for a longer period and the disease is diagnosed at a more advanced state. 17
RISK F A C T O R S
Despite the discovery of a breast cancer gene (BRCA-1 and BRCA-2), researchers estimate that only 5% to 10% of breast cancers are a result of inherited genetic susceptibility. Normally, BRCA-1 and BRCA-2 help prevent cancer by making pro-
17-3
Factors Associated W i t h Breast Cancer
Gender
Women > men
Race
White
Age
Advancing age; >60 years Peak incidence: 45-70 Mean and median age: 60-61 (women) 60-66 (men)
Genetic
BRCA1/BRCA2 gene mutations
Family history
First-degree relative with breast cancer Premenopausal Bilateral Mother, daughter, or sister
Previous medical history
Previous personal history of cancer Breast Uterine Ovarian Colon Number of previous breast biopsies (positive or negative)
Exposure to estrogen
Age at menarche 55 Nulliparous (never pregnant) First live birth after age 35 Environmental estrogens (esters)
For a more detailed guide to risk factors for breast cancer, see the American Cancer Society's document "What are the risk factors for breast cancer?" Available at http://www.cancer.org/docroot/CRI/content/CRI_2_4_2x_ what_are_the_risk_factors_for_breast_cancer_5.asp
teins that keep cells from growing abnormally. Inheriting either mutated gene from a parent increases the risk of breast cancer. A large proportion of cases are attributed to other factors, such as age, race, smoking, physical activity, alcohol intake, exposure to ionizing radiation, and exposure to estrogens (Table 17-3). Women who received multiple fluoroscopies for tuberculosis or radiation treatment for mastitis during their adolescent or childbearing years are at increased risk for breast cancer as a result of exposure to ionizing radiation. In the past, irradiation was used for a variety of other medical conditions, including gynecomastia, thymic enlargement, eczema of the chest, chest burns, pulmonary tuberculosis, mediastinal lymphoma, and other cancers. Most of these clients are in their 70s now and at risk for cancer because of advancing age as well. As a general principle, the risk of breast cancer is linked to a woman's total lifelong exposure to 18
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SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
estrogen. The increased incidence of estrogenresponsive tumors (tumors that are rich in estrogen receptors proliferate when exposed to estrogen) has been postulated to occur as a result of a variety of factors, such as prenatal and lifelong exposure to synthetic chemicals and environmental toxins, earlier age of menarche (first menstruation), improved nutrition in the United States, delayed and decreased childbearing, and longer average lifespan. At the same time, it should be remembered that many women diagnosed with breast cancer have no identified risk factors. More than 70% of breast cancer cases are not explained by established risk factors. There is no history of breast cancer among female relatives in more than 90% of clients with breast cancer. However, first-degree relatives (mother, daughters, or sisters) of women with breast cancer have two to three times the risk of developing breast cancer than the general female population, and relatives of women with bilateral breast cancer have five times the normal risk. Risk factors for men are similar to those for women, but at least half of all cases do not have an identifiable risk factor. Risk factors for men include heredity, obesity, infertility, late onset of puberty, frequent chest x-ray examinations, history of testicular disorders (e.g., infection, injury, or undescended testes), and increasing age. Men who have several female relatives with breast cancer and those in families who have the BRCA-2 mutation have a greater risk potential. The presence of any of these factors may become evident during the interview with the client and should alert the physical therapist to the potential for neuromusculoskeletal complaints from a systemic origin that would require a medical referral. There are several easy-to-use screening tools available. In addition to screening for current risk, clients should be given this information for future use (Box 17-2). 19
18
CLINICAL P R E S E N T A T I O N
Breast cancer may be asymptomatic in the early stages. The discovery of a breast lump with or without pain or tenderness is significant and must be investigated. Physical signs associated with advanced breast cancer have been summarized using the acronym BREAST: Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, and Tender breast. Less common symptoms are breast pain; nipple discharge; nipple erosion, enlargement, itching, or redness; and generalized hardness, enlargement, or shrinking of the breast. Watery, serous, or bloody discharge from the nipple 20
BOX
17-2
Resources for Assessing Breast Cancer Risk
National Cancer Institute http://bcra.nci.nih. go v/br c/ The National Cancer Institute (NCI) offers a Breast Cancer Risk Assessment, an interactive tool to measure the risk of invasive breast cancer. This tool was designed to assist health care professionals in guiding individual clients to estimate the risk of invasive breast cancer. It is only part of a woman's options for assessing risk and screening for breast cancer. More information is available by calling the Cancer Information Service (CIS) at 1-800-4CANCER.
Breast Cancer Risk Calculator http://www.halls.md/breast/risk.htm This calculator uses the Gail model but with some added risk modifier questions. The author of the web-site (Steven B. Halls, MD) notes that the methods on the website have been gathered from peer-reviewed journals but have not been peer reviewed. Results provided are estimates.
Oncolink http://www. oncolink .com/ Abramson Cancer Center of the University of Pennsylvania offers a comprehensive website with information about various types of cancers, risk factors, cancer treatment, and cancer resources. Click on Cancer Types>Breast Cancer.
The Harvard Center for Cancer Prevention http://www.yourdiseaserisk.harvard.edu/ The Harvard Center for Cancer Prevention offers an easy-to-use tool to assess risk factors for a variety of diseases, including breast cancer.
is an occasional early sign but is more often associated with benign disease. Breast cancer usually consists of a nontender, firm, or hard lump with poorly delineated margins that is caused by local infiltration. Breast cancer in women has a predilection for the outer upper quadrant of the breast and the areola (nipple) area (Fig. 17-4) involving the breast tissue overlying the pectoral muscle. During palpation, breast tissue lumps move easily over the pectoral muscle, compared with a lump within the muscle tissue itself. Later signs of malignancy include fixation of the tumor to the skin or underlying muscle fascia. Male breast cancer begins as a painless induration, retraction of the nipple, and an attached mass progressing to include lymphadenopathy and skin and chest wall lesions. A tumor of any size in male
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(CBE) and mammography. CBE alone detects 3% to 45% of diagnosed breast cancers that screening mammography misses. Studies show the sensitivity of CBE is 54% (test's ability to determine a true positive) and specificity is 94% (test's ability to determine a true negative). The previous edition of this text (Differential Diagnosis in Physical Therapy, ed 3) specifically stated, "breast examination is not within the scope of a physical therapist's practice." This practice is changing. As the number of cancer survivors increases in the United States, physical therapists treating postmastectomy women and clients of both genders with lymphedema are on the rise. With direct and unrestricted access of consumers to physical therapists in many states, advanced skills have become necessary. For some clients, performing a CBE is an appropriate assessment tool in the screening process. The American Cancer Society and National Cancer Institute support the provision of cancer screening procedures by qualified health specialists. With additional training, physical therapists can qualify. ' Guidelines for CBE are provided in Appendix D-7. Therapists who are trained to perform CBEs must make sure this examination is allowed according the state practice act. In some states, it is allowed by exclusion, meaning it is not mentioned and therefore included. Discussion of the role of the physical therapist in primary care and cancer screening as it relates to integrating CBE into an upper quarter examination is available. A form for recording findings from the CBE is provided in Fig. 4-45 and Appendix C-7. The physical therapist does not diagnose any kind of cancer, including breast cancer; only the pathologist diagnoses cancer. The therapist can identify aberrant soft tissue and refer the client for further evaluation. Early detection and intervention can reduce morbidity and mortality. For the therapist who is not trained in CBE, the client should be questioned about the presence of any changes in breast tissue (e.g., lumps, distended veins, skin rash, open sores or lesions, or other skin changes) and nipple (e.g., rash or other skin changes, discharge, distortion). Visual inspection is also possible and may be very important postmastectomy (Fig. 17-5). Ask the client if he or she has noticed any changes in the scar. Continue by asking: 21
22
F i g . 1 7 - 4 • Most breast cancer presents in the upper outer quadrant of the breast (45%) or around the nipple (25%). Metastases occur via the lymphatic system at the axillary lymph nodes to the bones (shoulder, hip, ribs, vertebrae) or central nervous system (brain, spinal cord). Breast cancer can also metastasize hematogenously to the lungs, pleural cavity, and liver.
breast tissue is associated with skin fixation and ulceration and deep pectoral fixation more often than a tumor of similar size in female breast tissue is because of the small size of male breasts. Clinical Signs and Symptoms of B r e a s t Cancer •
Nontender, firm, or hard lump
• •
Unusual discharge from nipple Skin or nipple retraction dimpling; erosion, retraction, itching of nipple Redness or skin rash over the breast or nipple Generalized hardness, enlargement, shrinking, or distortion of the breast or nipple Unusual prominence of veins over the breast Enlarged rubbery lymph nodes Axillary mass Swelling of arm
• • • • • •
• Bone or back pain • Weight loss CLINICAL B R E A S T E X A M I N A T I O N
Breast cancer mortality is reduced when women are screened by both clinical breast examination
22 23
22
Follow-Up Questions • Would you have any objections if I looked at (or examined) the scar tissue?
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F i g . 1 7 - 5 • This photo shows the chest of a woman who has had a right radical mastectomy. There is a metastatic nodule in the mastectomy scar as a result of local cancer recurrence. Breast cancer can occur (recur) if a mastectomy has been done. A closer look at the lesion suggests that the skin changes have been present for quite some time. Even in this black and white photo, the change in skin coloration is obvious in a large patch around the nodule. Anytime a woman with a past medical history of cancer develops neck, back, upper trapezius, shoulder pain, or other symptoms, examining the site of the original cancer removal is a good idea. (From Callen JP, Jorizzo J, Greer KE, et al: Dermatological signs of internal disease, Philadelphia, 1988, Saunders.)
If the client declines or refuses, the therapist should follow up with counsel to perform selfinspection, emphasizing the need for continued CBEs and the importance of reporting any changes to the physician immediately. Therapists have an important role in primary prevention and client education. The American Cancer Society offers recommendations for breast cancer screening. The therapist can encourage women (and men) to follow these guidelines (Box 17-3). LYMPH N O D E A S S E S S M E N T
Palpation of the underlying soft tissues (chest wall, axilla) and lymph nodes in the supraclavicular and axillary regions should be part of a screening exam in any client with chest pain (see Chapter 4 for description of lymph node palpation). Any report of palpable breast nodules, lumps, or changes in the appearance of the breast requires medical followup, especially when there is a personal or family history of breast disease. "Normal" lymph nodes are not palpable or visible, but not all palpable or visible lymph nodes 24
are a sign of cancer. Infections, viruses, bacteria, allergies, and food intolerances can cause changes in the lymph nodes. Lymph nodes that are hard, immovable, irregular, and nontender raise the suspicion of cancer, especially in the presence of a previous history of cancer. The skin surface over a tumor may be red, warm, edematous, firm, and painful. There may be skin dimpling over the lesion, with attachment of the mass to surrounding tissues preventing normal mobilization of skin, fascia, and muscle. In the past, therapists were taught that any changes in lymph nodes present for more than 1 month in more than one region were a red flag. This has changed with the increased understanding of cancer metastases via the lymphatic system and the potential for cancer recurrence. A physician must evaluate all suspicious lymph nodes. METASTASES
Metastases have been known to occur up to 25 years after the initial diagnosis of breast cancer. On the other hand, breast cancer can be a rapidly progressing, terminal disease. Approximately 40% of clients with stage II tumors experience relapse. Knowledge of the usual metastatic patterns of breast cancer and the common complications can aid in early recognition and effective treatment. Because bone is the most frequent site of metastases from breast cancer in men and women, a past medical history of breast cancer is a major red flag in anyone presenting with new onset or persistent findings of NMS pain or dysfunction. All distant visceral sites are potential sites of metastases. Other primary sites of involvement are lymph nodes, remaining breast tissue, lung, brain, central nervous system (CNS), and liver. Women with metastases to the liver or CNS have a poorer prognosis. Spinal cord compression, usually from extradural metastases, may appear as back pain, leg weakness, and bowel/bladder symptoms. Rarely, an axillary mass, swelling of the arm, or bone pain from metastases may be the first symptom. Back or bone pain, jaundice, or weight loss may be the result of systemic metastases, but these symptoms are rarely seen on initial presentation. Medical referral is advised before initiating treatment for anyone with a past history of cancer presenting with symptoms of unknown cause, especially without an identifiable movement system impairment. A medical evaluation is still needed in light of new findings even if the client has been rechecked
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SCREENING THE CHEST, BREASTS, A N D RIBS
793
A C S Recommendations for Breast Cancer Screening
Summary Recommendation
Older Women
The American Cancer Society (ACS) recommendations for breast cancer screening are presented below in abbreviated form. Readers should refer to the original full text guideline document to see the complete recommendations, along with the rationale and summary of the evidence.
Screening decisions in older women should be individualized by considering the potential benefits and risks of mammography in the context of current health status and estimated life expectancy. As long as a woman is in reasonably good health and would be a candidate for treatment, she should continue to be screened with mammography.
Women at Average Risk
Women at Increased Risk
• Begin mammography at age 40. • For women in their 20s and 30s, it is recommended that clinical breast examination (CBE) be part of a periodic health examination, preferably at least every 3 years. Asymptomatic women aged 40 and over should continue to receive a CBE as part of a periodic health examination, preferably annually. • Beginning in their 20s, women should be told about the benefits and limitations of breast selfexamination (BSE). The importance of prompt reporting of any new breast symptoms to a health professional should be emphasized. Women who choose to perform BSE should receive instruction and have their technique reviewed on the occasion of a periodic health examination. It is acceptable for women to choose not to do BSE or to do BSE irregularly. • Women should have an opportunity to become informed about the benefits, limitations, and potential harms associated with regular screening.
Women at increased risk of breast cancer might benefit from additional screening strategies beyond those offered to women of average risk, such as earlier initiation of screening, shorter screening intervals, or the addition of screening modalities other than mammography and physical examination, such as ultrasound or magnetic resonance imaging. However, the evidence currently available is insufficient to justify recommendations for any of these screening approaches. Summary of New ACS Guidelines • CBE every 3 years for women ages 20 to 39 • Annual CBE every year for asymptomatic women ages 40+ • SBE occasionally or not at all • Women ages 20+ should be educated about the benefits and limitations of the SBE. • Mammogram annually from age 40
Data from American Cancer Society: ACS News Center: Updated breast cancer screening guidelines http://www.cancer.org/docroot/NWS/content/NWS_l_lx_Updated_Breast_Cancer_Screening_Guidelines_Released.asp, May 2003. Accessed January 24, 2006.
by a medical oncologist recently. It is better to err on the side of caution. Failure to recognize the need for medical referral can result in possible severe and irreversible consequences of any delay in diagnosis and therapy. 25
Clinical Signs and Symptoms of M e t a s t a s i z e d B r e a s t Cancer •
Palpable mass in supraclavicular, chest, or axillary regions • Unilateral upper extremity numbness and • • • •
tingling Back, hip, or shoulder pain Pain on weight bearing Leg weakness or paresis Bowel/bladder symptoms
• Jaundice
SCREENING FOR OTHER CONDITIONS AS A CAUSE OF CHEST, BREAST, OR RIB PAIN Breast Implants Scar tissue or fibrosis from a previous breast surgery, such as reconstruction following mastectomy for breast cancer or augmentation or reduction mammoplasty for cosmetic reasons, is an important history to consider when assessing chest, breast, neck, or shoulder symptoms. Likewise, the client should be asked about a history of radiation to the chest, breast, or thorax. Women who have implants for reconstruction following mastectomy for breast cancer are nearly three times more likely to have complications (e.g., pain, capsular contracture, infection, seroma) than those who receive implants for cosmetic reasons
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only. The rate of capsular contracture is significantly higher for irradiated breasts than for nonirradiated breasts. Clinical outcomes from the Danish Cancer Society report that ruptures are rare, but thick, tight scarring and infection occur in up to 20% of women who have breast implants after mastectomy. Rates of early local complications in American women undergoing mastectomy with immediate breast implants are much higher. Other complications of breast implantation may include gel bleed, implant leaking or rupture, infection, calcifications around the implant, chronic breast pain, prolonged wound healing, and formation of granulation tissue. 26
27
28
29
Anxiety An anxiety state or, in its extreme form, panic attack can cause chest or breast pain typical of a heart attack. The client experiences shortness of breath, perspiration, and pallor. It is the most common noncardiac cause of chest pain, accounting for half of all emergency department admissions each year for chest or breast pain (just ahead of chest pain caused by cocaine use).
Risk
Factors
The first panic attack often follows a period of extreme stress, sometimes associated with being the victim of a crime or the loss of a job, partner, or close family member. The presence of another mental health disorder, such as depression or substance abuse (drugs or alcohol), increases the risk of developing panic disorder. There may be a familial component, but it is not clear if this is hereditary or environmental (learned behavior). Drugs such as over-the-counter decongestants and cold remedies can trigger panic attacks. Excessive use of caffeine and stimulants such as amphetamines and cocaine combined with a lack of sleep can also trigger an attack. Menopause, quitting smoking, or caffeine withdrawal can also bring on new onset of panic attacks in someone who has never experienced this problem before. See Chapter 3 for further discussion. 30
Clinical
Presentation
There are several types of chest or breast discomfort caused by anxiety. The pain may be sharp, intermittent, or stabbing and located in the region of the left breast. The area of pain is usually no larger than the tip of the finger but may be as large as the client's hand. It is often associated with a local area of hyperesthesia of the chest wall. The
client can point to it with one finger. It is not reproduced with palpation or activity. It is not changed or altered by a change in position. Anxiety-related pain may be located precordially (region over the heart and lower part of the thorax) or retrosternally (behind the sternum). It may be of variable duration, lasting no longer than a second or for hours or days. This type of pain is unrelated to effort or exercise. Distinguishing this sensation from myocardial ischemia requires medical evaluation. Discomfort in the upper portion of the chest, neck, and left arm, again unrelated to effort, may occur. There may be a sense of persistent weakness and unpleasant awareness of the heartbeat. In the past, radiation of chest discomfort to the neck or left arm was considered to be diagnostic of atherosclerotic coronary heart disease. More recently, stress testing and coronary arteriography have shown that chest discomfort of this type can occur in clients with normal coronary arteriograms. Some individuals with anxiety-related chest pain may have a choking sensation in the throat caused by hysteria. There may be associated hyperventilation. Palpitation, claustrophobia, and occurrence of symptoms in crowded places are common. Hyperventilation occurs in persons with and without heart disease and may be misleading. Such clients have numbness and tingling of the hands and lips and feel as if they are going to "pass out." For a more detailed explanation of anxiety and its accompanying symptoms (e.g., hyperventilation), see Chapter 3. Clinical Signs and Symptoms of Chest P a i n Caused by A n x i e t y •
Dull, aching discomfort in the substernal region and in the anterior chest
• • • • • • • •
Sinus tachycardia Fatigue Fear of closed-in places Diaphoresis Dyspnea Dizziness Choking sensation Hyperventilation: numbness of hands and lips
and
tingling
Cocaine Cocaine use (also methamphetamine, known as crank and phencyclidine or PCP) has cardiotoxic effects, including cocaine dilated cardiomyopathy, angina, and left ventricular dysfunction, and can
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precipitate myocardial infarction, cardiac arrhythmias, and even sudden cardiac death. Chronic use of cocaine or any of its derivatives is the number-one cause of stroke in young people today. The incidence of stroke associated with substance use and abuse is increasing. Use of these stimulants also has an effect on anyone with a congenital cerebral aneurysm and can lead to rupture. The physiologic stress of cocaine use on the heart accounts for an increasing number of heart transplants. Acute effects of cocaine include increased heart rate, blood pressure, and vasomotor tone. Cocaine remains the most common of illicit drug-related cause of severe chest pain bringing the person to the emergency department. In fact, chest pain is the most common cocaine-related medical complaint. Many people with chest pain have used cocaine within the last week but deny its use. The use of these substances is not uncommon in middle-aged and older adults of all socioeconomic backgrounds. The therapist should not neglect to ask clients about their use of substances because of preconceived ideas that only teenagers and young adults use drugs. Careful questioning (see Chapter 2; see also Appendix B-31) may assist the physical therapist in identifying a possible correlation between chest pain and cocaine use. Always end this portion of the interview by asking: 31
32
31,33
F o l l o w - U p Questions • Are there any drugs or substances you take that you haven't mentioned?
Anabolic-Androgenic Steroids Anabolic steroids are synthetic derivatives of testosterone used to enhance athletic performance or cosmetically shape the body. Used in supraphysiologic doses (more than the body produces naturally), these drugs have a potent effect on the musculoskeletal system, including the heart, potentially altering cardiac cellular and physiologic function. Effects persist long after their use has been discontinued. The use of self-administered anabolicandrogenic steroids (AASs) is illegal but continues to increase dramatically among both athletes and nonathletes. It is used among preteens who do not compete in sports for cosmetic reasons. The goal is to advance to a more mature body build and enhance their looks. AASs do have medical uses and were added to prescribed controlled substances in 1990 under the control of the Drug Enforcement Administration. 34
35
795
In spite of stricter control of the manufacture and distribution of AASs, illegal supplies come from unlicensed sources all over the world. When dispensed without a regulating agency, the purity and processing of chemicals is unknown. The quality of black market supplies is a major concern. There is no guarantee that the products obtained are correctly labeled. Contents and dosage may be inaccurate. Some athletes are using injectable anabolic steroids intended for veterinary use only.
Clinical
Presentation
Any young adult with chest pain of unknown cause, possibly accompanied by dyspnea and elevated blood pressure and without clinical evidence of NMS involvement, may have a history of anabolic steroid use. Consider anabolic steroid use as a possibility in men and women presenting with chest pain in their early 20s who have used this type of steroid since age 11 or 12. In the pediatric population, there is a risk of decreased or delayed bone growth. Tendon and muscle strains are common and take longer than normal to heal. Injuries that take longer than the expected physiologic time to heal are an important red flag. Delayed healing occurs because the soft tissues are working under the added strain of extra body mass. The alert therapist may recognize the associated signs and symptoms accompanying chronic use of these steroids. Changes in personality are the most dramatic signs of steroid use. The user may become more aggressive or experience mood swings and psychologic delusions (e.g., believe he or she is indestructible; sometimes referred to as "steroid psychosis"). "Roid rages," characterized by sudden outbursts of uncontrolled emotion, may be observed. Severe depression leading to suicide can occur with AAS withdrawal. Clinical Signs and Symptoms of Anabolic S t e r o i d U s e • • • • • • •
Chest pain Elevated blood pressure Ventricular tachycardia Weight gain (10 to 15 pounds in 2 to 3 weeks) Peripheral edema Acne on the face, upper back, chest Altered body composition with marked development of the upper torso • Stretch marks around the back, upper arms, and chest • Needle marks in large muscle groups (e.g., buttocks, thighs, deltoids) Continued on p. 796
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•
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Development of male pattern baldness
•
Gynecomastia (breast tissue development in males); breast tissue atrophy in females • Frequent hematoma or bruising •
Personality changes called "steroid psychosis" (rapid mood swings, sudden increased aggressive tendencies) • Females: secondary male characteristics (deeper voice, breast atrophy, abnormal facial and body hair); menstrual irregularities • Jaundice (chronic use)
The therapist who suspects a client may be using anabolic steroids should report findings to the physician or coach if one is involved. The therapist can begin by asking about the use of nutritional supplements or performance-enhancing agents. In the well-muscled male athlete, observe for common side effects of AAS such as acne, gynecomastia, and cutaneous striae in the deltopectoral region. Women who use AAS may exhibit muscular hypertrophy; male pattern baldness; excess hair growth on the face, breasts, and arms; and breast tissue atrophy. Asking about the presence of common side effects of AAS and testing for elevated blood pressure may provide an opportunity to ask if the client is using these chemicals. 34
SCREENING FOR MUSCULOSKELETAL CAUSES OF CHEST, BREAST, OR RIB PAIN It is estimated that 20% to 25% of noncardiac chest pain has a musculoskeletal basis. Musculoskeletal causes of chest (wall) pain must be differentiated from pain of cardiac, pulmonary, epigastric, and breast origin (see Table 17-1) before physical therapy treatment begins. Careful history taking to identify red flag conditions differentiates those who require further investigation. Movement system impairment is most often characterized by pain during specific postures, motion, or physical activities. Reproducing the pain by movement or palpation often directs the therapist in understanding the underlying problem. Chest pain can occur as a result of cervical spine disorders because nerves originating as high as C3 and C4 can extend as far down as the nipple line. Pectoral, suprascapular, dorsal scapular, and long thoracic nerves originate in the lower cervical spine, and impingement of these nerves can cause chest pain. Musculoskeletal disorders such as myalgia associated with muscle exertion, myofascial TrPs, cos36
tochondritis, or xiphoiditis can produce pain in the chest and arms. Compared with angina pectoris, the pain associated with these conditions may last for seconds or hours, and prompt relief does not occur with the ingestion of nitroglycerin. Tietze's syndrome, costochondritis, a hypersensitive xiphoid, and the slipping rib syndrome must be differentiated from problems involving the thoracic viscera, particularly those of the heart, great vessels, and mediastinum, as well as from illness originating in the head, neck, or abdomen. Rib pain (with or without neck, back, or chest pain or symptoms) must be evaluated for systemic versus musculoskeletal origins (Box 17-4). The same screening model used for all conditions can be applied.
Costochondritis Costochondritis, also known as anterior chest wall syndrome, costosternal syndrome, and parasternal chondrodynia (pain in a cartilage), is used interchangeably with Tietze's syndrome, although these two conditions are not the same. Costochondritis is more common than Tietze's syndrome. Although both disorders are characterized by inflammation of one or more costal cartilages (costochondral joints), costochondritis refers to pain in the costochondral articulations without swelling. This disorder can occur at almost any age but is observed most often in people older than 40. It tends to affect the second, third, fourth, and fifth costochondral joints; women are affected in 70% of all cases (Fig. 17-6). Other risk factors include trauma (e.g., driver striking steering wheel with chest during a motor vehicle accident, upper chest surgery, helmet tackle in sports, or other sports injury to the chest) or repetitive motion (e.g., grocery-store clerk lifting and scanning items). 37
BOX
17-4
Causes of Rib Pain
Systemic • • • • •
Gallbladder disease (tenth rib) Shingles (herpes zoster) Pleurisy Osteoporosis Cancer (metastasized to the bone)
Musculoskeletal • • • • •
Trauma (e.g., bruise, fracture) Slipping rib syndrome Tietze's syndrome or costochondritis Trigger points Thoracic outlet syndrome
CHAPTER 17
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Costochondral joints
Sternum
F i g . 1 7 - 6 • Costochondritis is an inflammation of any of the costochondral joints (also called costal cartilages) where the rib joins the sternum. Sharp, stabbing, or aching pain can occur on either side of the sternum but tends to affect the left more often, even radiating down the left arm sometimes or to upper back. Many people mistake the symptoms for a heart attack. In most cases, symptoms occur at a single site involving the second or third costochondral joint, although any of the joints can be affected as shown.
Costochondritis is characterized by a sharp pain along the front edges of the sternum, especially on the left side, often misinterpreted as a heart attack. The pain may radiate widely, stimulating intrathoracic or intraabdominal disease. It differs from a myocardial infarction because during a heart attack, the initial pain is usually in the center of the chest, under the sternum, not along the edges. Costochondritis can be similar to muscular pain and is elicited by pressure over the costochondral junctions. Occasionally, the affected individual will report a burning sensation in the breast(s) associated with this condition. Costochondritis may follow trauma or may be associated with systemic rheumatic disease. It can come and go or persist for months. Inflammation of upper costal cartilages may cause chest pain, whereas inflammation of lower costal cartilages is more likely to cause abdominal or low back discomfort.
Tietze's Syndrome Tietze's syndrome (inflammation of a rib and its cartilage; costal chondritis) may be one possible cause of anterior chest wall pain, manifested by painful swelling of one or more costochondral articulations. In most cases, the cause of Tietze's syndrome is unknown. Other causes of sternal swelling may include an infectious process in the immunocom-
797
promised person resulting from tuberculosis, aspergillosis, brucellosis, staphylococcal infection, or pseudomonal disease producing sternal osteomyelitis. Onset is usually before 40 years of age, with a predilection for the second and third decades. However, it can occur in children. Approximately 80% of clients have only single sites of involvement, most commonly the second or third costal cartilage (costochondral joint). Anterior chest pain may begin suddenly or gradually and may be associated with increased blood pressure, increased heart rate, and pain radiating down the left arm. Pain is aggravated by sneezing, coughing, deep inspirations, twisting motions of the trunk, horizontal shoulder abduction and adduction, or the "crowing rooster" movement of the upper extremities. These symptoms may seem similar to those of a heart attack, but the raised blood pressure, reproduction of painful symptoms with palpation or pressure, and aggravating factors differentiate Tietze's syndrome from myocardial infarction (Case Example 17-6). In rare cases, the individual has been diagnosed with Tietze's syndrome only to find out later the precipitating cause was cancer (e.g., lymphoma, squamous cell carcinoma of the mediastinum). ' Tietze's syndrome can also be confused with TrPs (pectoralis major, internal intercostalis), an often overlooked cause of the same symptoms. 38
39
40
Clinical Signs and Symptoms of Tietze's S y n d r o m e o r Costochondritis •
Sudden or gradual onset of upper anterior chest pain
• •
Pain/tenderness of costochondral joint(s) Bulbous swelling of the involved costal cartilage (Tietze's syndrome) • Mild-to-severe chest pain that may radiate to the left shoulder and arm • Pain aggravated by deep breathing, sneezing, coughing, inspiration, bending, recumbency, or exertion (e.g., push-ups, lifting grocery items)
Hypersensitive Xiphoid The hypersensitive xiphoid (xiphodynia) is tender to palpation, and local pressure may cause nausea and vomiting. This syndrome is manifested as epigastric pain, nausea, and vomiting.
Slipping Rib Syndrome The slipping, or painful, rib syndrome (sometimes also referred to as the clicking rib syndrome)
S E C T I O N III
798
CASE EXAMPLE
17-6
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
Tietze's Syndrome
Referral: A 53-year-old woman was referred by her physician with a diagnosis of left anterior chest pain. The woman is employed at a sawmill and performs tasks that require repetitive shoulder flexion and extension in using a hydraulic apparatus on a sliding track. Lifting (including overhead lifting) is required occasionally but is limited to items less than 20 pounds. Past Medical History: Her past medical history was significant for a hysterectomy 10 years ago for prolonged bleeding. She has been a four- to five-pack/day smoker for 30 years but has cut down to one half pack/day for the last 2 months. Clinical Presentation Pain Pattern: The woman described the onset of her pain as sudden, crushing chest pain radiating down the left arm, occurring for the first time 6 weeks ago. She was transported to the emergency department, but tests were negative for cardiac incident. Blood pressure at the time of the emergency admittance was 195/110 mm Hg. She was released from the hospital with a diagnosis of "stress-induced chest pain." The client experienced the same type of episode of chest pain 10 days ago but described radiating pain around the chest and under the armpit to the upper back. Today, her symptoms include extreme tenderness and pain in the left chest with deep pain described as penetrating straight through her chest to her back. There is no numbness or tingling and no pain down the arm but a residual soreness in the left arm.
The client believes that her symptoms may be "stress-induced" but expresses some doubts about this because her symptoms persist and no known cause has been found. She relates that because of divorce proceedings and child custody hearings, she is under extreme stress at this time. Examination: The neurologic screen was negative. The deep tendon reflexes were within normal limits; strength testing was limited by pain but with a strong initial response elicited; and there were no changes in sensation, twopoint discrimination, or proprioception observed. There was exquisite pain on palpation of the left pectoral muscle with tenderness and swelling noted at the second, third, and fourth costochondral joints. Painful and radiating symptoms were reproduced with resisted shoulder horizontal adduction. Active shoulder range of motion was full but with a positive painful arc on the left. There was also painful reproduction of the radiating symptoms down the arm with palpation of the left supraspinatus and biceps tendons. The painful chest/arm/upper back symptoms were not altered by respiratory movements (deep breathing or coughing), but the client was unable to lie down without extreme pain. Result: The physical therapy assessment was suggestive of Tietze's syndrome secondary to repetitive motion and exacerbated by emotional stress* with concomitant shoulder dysfunction. Physical therapy intervention resulted in initial rapid improvement of symptoms with full return to work 6 weeks later.
* It should be noted that although the physical therapist's assessment recognized emotional stress as a factor in the client's symptoms, it may not be in the client's best interests to include this information in the documentation. Although the medical community is increasingly aware of the research surrounding the mind-body connection, worker's compensation and other third-party payers may use this information to deny payment.
occurs most often when there is hypermobility of the lower ribs. In this condition, inadequacy or rupture of the interchondral fibrous attachments of the anterior ribs allows the costal cartilage tips to sublux, impinging on the intercostal nerves. This condition can occur alone or can be associated with a broader phenomenon such as myofascial pain syndrome. 41
Rib syndrome can occur at any age, including during childhood, but most commonly occurs during the middle-aged years. The physical therapist is usually able to identify readily a rib syndrome as the cause of chest pain after a careful musculoskeletal examination. In some cases, persistent upper abdominal and/or low thoracic pain occurs, leaving physicians, chiropractors, and ther42
CHAPTER 17
TABLE
17-4
SCREENING THE CHEST, BREASTS, AND RIBS
Trigger Point Pain Guide
Location
P o t e n t i a l muscles i n v o l v e d
Front of chest pain
Pectoralis major Pectoralis minor Scaleni Sternocleidomastoid (sternal) Sternalis Iliocostalis cervicis Subclavius External abdominal oblique
Side of chest pain
Serratus anterior Lattissimus dorsi
Upper abdominal/ lower chest pain
Rectus abdominis Abdominal obliques Transversus abdominis
Modified from Travell JG, Simons DG: Myofascial pain and dysfunction: the trigger point manual, Baltimore, 1983, Williams & Wilkins, p574.
apists puzzled. ' A sonogram may be needed to make the diagnosis. Pain is made worse by slump sitting or side bending to the affected side. Reduction or elimination of symptoms following rib mobilization helps confirm the differential diagnosis. Gallbladder impairment can also cause tenderness or soreness of the tip of the tenth rib on the right side. The affected individual may or may not have gallbladder symptoms. Because visceral and cutaneous fibers enter the spinal cord at the same level for the ribs and gallbladder, the nervous system may respond to the afferent input with sudomotor changes such as pruritus (itching of the skin) or a sore rib instead of gallbladder symptoms. The clinical presentation appears as a biomechanical problem such as a rib dysfunction instead of nausea and food intolerances normally associated with gallbladder dysfunction. Symptoms will not be alleviated by physical therapy intervention, eventually sending the client back to his or her physician. 43
44
Trigger Points The most common musculoskeletal cause of chest pain is TrPs, sometimes referred to as myofascial trigger points (MTrPs). TrPs (hypersensitive spots in the skeletal musculature or fascia) involving a variety of muscles (Table 17-4) may produce precordial pain (Fig. 17-7). Abdominal muscles have multiple referred pain patterns that may reach up into the chest or midback and produce heartburn or deep epigastric pain. Although these patterns strongly mimic cardiac pain, myofascial TrP pain shows a much wider variation in its
799
response to daily activity than does angina pectoris to activity. In addition to mimicking pain of a cardiac nature, TrPs can occur in response to cardiac disorders. A visceral-somatic response can occur when biochemical changes associated with visceral disease affect somatic structures innervated by the same spinal nerves. In such cases, the individual has a past history of visceral disease. TrPs accompanied by symptoms such as vertigo, headache, visual changes, nausea, and syncope are yellow flags warning of autonomic involvement not usually present with TrPs strictly from a somatic origin. Chest pain that persists long after an acute myocardial infarction may be due to myofascial TrPs. In acute myocardial infarction, pain is commonly referred from the heart to the midregion of the pectoralis major and minor muscles (see discussion of viscerosomatic sources of pain, Chapter 3). The injury to the heart muscle initiates a viscerosomatic process that activates TrPs in the pectoral muscles. After recovery from the infarction, these selfperpetuating TrPs tend to persist in the chest wall. As with all myofascial syndromes, inactivation of the TrPs eliminates the client's symptoms of chest pain. If the client's symptoms are eliminated with TrP release, medical referral may not be required. However, communication with the physician is essential; the therapist is advised to document all findings and report them to the client's primary care physician. 40
40
Past
Medical
History
There may be a history of upper respiratory infection with repeated forceful coughing. There is often a history of immobility (e.g., cast immobilization after fracture or injury). The therapist should also ask about muscle strain from lifting weights overhead, from pushups, and from prolonged, vigorous activity that requires forceful abdominal breathing, such as severe coughing, running a marathon, or repetitive bending and lifting.
Clinical
Presentation
TrPs are reproduced with palpation or resisted motions. On examination, the physical therapist should palpate for tender points and taut bands of muscle tissue, squeeze the involved muscle, observe for increased pain with palpation, test for increased pain with resisted motion, and correlate symptoms with respiratory movements. Chest pain from serratus anterior TrPs may occur at rest in severe cases. Clients with this
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A
F i g . 1 7 - 7 • A, Referred pain pattern from the left serratus anterior muscle. B, Left pectoralis major muscle: referred pain pattern in a woman and a man. C, Referred pain pattern from the left sternalis muscle. D, Referred pain from the external oblique abdominal muscle can cause "heartburn" in the anterior chest wall. Marathon runners may report chest pain mimicking a heart attack from this trigger point.
B
C
myofascial syndrome may report that they are "short of breath" or that they are in pain when they take a deep breath. Serratus anterior TrPs on the left side of the chest can contribute to the pain associated with myocardial infarction. This pain is rarely aggravated by the usual tests for range of motion at the shoulder but may result from a strong effort to protract the scapula. Palpation reveals tender points that increase symptoms, and there is usually a palpable taut band present within the involved muscles.
D
One of the most extensive patterns of pain from irritable TrPs is the complex pattern from the anterior scalene muscle. This may produce ipsilateral sternal pain, anterior chest wall pain, breast pain, or pain along the vertebral border of the scapula, shoulder, and arm, radiating to the thumb and index finger. Breast pain may be differentiated from the aching pain arising from the scalene or pectoral muscles by a history of upper extremity overuse usually associated with myalgia. Resistance to
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isometric movement of the upper extremities reproduces the symptoms of a myalgia but does not usually aggravate pain associated with breast tissue. Additionally, palpation of the underlying muscle reproduces the painful symptoms. When active TrPs occur in the left pectoralis major muscle, the referred pain (anterior chest to the precordium and down the inner aspect of the arm) is easily confused with that of coronary insufficiency. Pacemakers placed superficially can cause pectoral trigger points. In the case of pacemaker-induced TrPs, the physical therapist can teach the client TrP self-treatment to carry out at home.
Myalgia Myalgia, or muscular pain, can cause chest pain separate from TrP pain but with a similar etiologic basis of prolonged or repeated movement. As mentioned earlier, the physical therapy interview must include questions about recent upper respiratory infection with repeated forceful coughing and recent activities of a repetitive nature that could cause sore muscles (e.g., painting or washing walls; calisthenics, including push-ups; or lifting heavy objects or weights). Three tests must be used to confirm or rule out muscle as the source of symptoms: (1) palpation, (2) stretch, and (3) contraction. If the muscle is not sore or tender on palpation, stretch, or contraction, the source of the problem most likely lies somewhere else. With true myalgia, squeezing the muscle belly will reproduce painful chest symptoms. The discomfort of myalgia is almost always described as aching and may range from mild to intense. Diaphragmatic irritation may be referred to the ipsilateral neck and shoulder, lower thorax, lumbar region, or upper abdomen as a muscular aching pain. Myalgia in the respiratory muscles is well localized, reproducible by palpation, and exacerbated by movement of the chest wall.
Rib Fractures Periosteal (bone) pain associated with fractured ribs can cause sharp, localized pain at the level of the fracture with an increase in symptoms associated with trunk motions and respiratory movements, such as deep inspiration, laughing, sneezing, or coughing. The pain may be accompanied by a grating sensation during breathing. This localized pain pattern differs from bone pain associated with chronic disease affecting bone marrow and endosteum, which may result in poorly localized pain of varying degrees of severity.
801
Occult (hidden) rib fractures may occur, especially in a client with a chronic cough or someone who has had an explosive sneeze. Fractures may occur as a result of trauma (e.g., motor vehicle accident, assault), but painful symptoms may not be perceived at first if other injuries are more significant. A history of long-term steroid use in the presence of rib pain of unknown cause should raise a red flag. Rib fractures must be confirmed by x-ray diagnosis. Rib pain without fracture may indicate bone tumor or disease affecting bone, such as multiple myeloma.
Cervical Spine Disorders Cervicodorsal arthritis may produce chest pain that is seldom similar to that of angina pectoris. It is usually sharp and piercing but may be described as a deep, boring, dull discomfort. There is usually unilateral or bilateral chest pain with flexion or hyperextension of the upper spine or neck. The chest pain may radiate to the shoulder girdle and down the arms and is not related to exertion or exercise. Rest may not alleviate the symptoms, and prolonged recumbency makes the pain worse. Discogenic disease can also cause referred pain to the chest, but there is usually evidence of disc involvement observed with diagnostic imaging and the presence of neurologic symptoms.
SCREENING FOR NEUROMUSCULAR OR NEUROLOGIC CAUSES OF CHEST, BREAST, OR RIB PAIN There are several possible neurologic disorders that can cause chest and/or breast pain, including nerve root impingement or inflammation, herpes zoster (shingles), thoracic disc disease, postoperative neuralgia, and thoracic outlet syndrome (TOS; see Table 17-1). Neurologic disorders such as intercostal neuritis and dorsal nerve root radiculitis or a neurovascular disorder such as thoracic outlet syndrome also can cause chest pain. The two most commonly recognized noncardiac causes of chest pain seen in the physical therapy clinic are herpes zoster (shingles) and TOS.
Intercostal Neuritis Intercostal neuritis, such as herpes zoster or shingles produced by a viral infection of a dorsal nerve root, can cause neuritic chest wall pain, which can be differentiated from coronary pain.
802
Risk
S E C T I O N III
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
Factors
Shingles may occur or recur at any age, but there has been a recent increase in the number of cases in two distinct age groups: college-aged young adults and older adults (over 70 years). Health care experts suggest that stress is the key factor in the first group, and immune system failure is the key factor in the second group. Anyone who is immunocompromised as a result of advancing age, underlying malignancy, organ transplantation, or AIDS is at risk for shingles. There is an increased incidence of herpes zoster in clients with lymphoma, tuberculosis, and leukemia, but it can be triggered by trauma or injection drugs or occur with no known cause. Anyone in good health who had the chickenpox as a child is not at great risk for shingles. The risk of developing shingles increases for anyone who is immunocompromised for any reason or who has never had the chicken pox. Herpes zoster is a communicable disease and requires some type of isolation. Anyone in contact with the client before the outbreak of the skin lesions has already been exposed. Specific precautions depend on whether the disease is localized or disseminated and the condition of the client. Persons susceptible to chickenpox should avoid contact with the affected client and stay out of the client's room.
Clinical
Presentation
Herpes zoster is characterized by raised fluid-filled clusters of grouped vesicles that appear unilaterally along cranial or spinal nerve dermatomes 3 to 5 days after transmission of the virus (see Figs. 4-21 and 4-22). The affected individual experiences 1 to 2 days of pain, itching, and hyperesthesia before the outbreak of skin lesions. The skin changes are referred to as "shingles" and are easily recognizable as they follow a dermatome anywhere on the body. The lesions do not cross the body midline as they follow nerve pathways, although nerves of both sides may be involved. The skin eruptions evolve into crusts on the skin and clear in about 2 weeks, unless the period between the pain and the eruption is longer than 2 days. Postherpetic neuralgia, with its burning and paroxysmal stabbing pain, may persist for long periods. Neuritic pain occurs unrelated to effort and lasts longer (weeks, months, or years) than angina. The pain may be constant or intermittent and can vary from light burning to a deep visceral sensation. It may be associated with chills, fever, headache, and
malaise. Symptoms are confined to the somatic distribution of the involved spinal nerve(s). Clinical Signs and Symptoms of Herpes Z o s t e r (Shingles) •
Fever, chills
• •
Headache and malaise 1 to 2 days of pain, itching, and hyperesthesia before skin lesions develop • Skin eruptions (vesicles) that appear along dermatomes 4 or 5 days after the other symptoms
Dorsal Nerve Root Irritation Dorsal nerve root irritation of the thoracic spine is another neuritic condition that can refer pain to the chest wall. This condition can be caused by infectious processes (e.g., radiculitis or inflammation of the spinal nerve root dural sheath; shingles can also fit in this category). However, the pain is more likely to be the result of mechanical irritation caused by spinal disease or deformity (e.g., bone spurs secondary to osteoarthritis or the presence of cervical ribs placing pressure on the brachial plexus). The pain of dorsal nerve root irritation can appear as lateral or anterior chest wall pain with referral to one or both arms through the brachial plexus. Although it mimics the pain pattern of coronary heart disease, such pain is more superficial than cardiac pain. Like cardiac pain, dorsal nerve root irritation can be aggravated by exertion of only the upper extremities. However, unlike cardiac pain, exertion of the lower extremities has no exacerbating effect. It is usually accompanied by other neurologic signs, such as muscle atrophy and numbness or tingling. Clinical Signs and Symptoms of D o r s a l N e r v e Root I r r i t a t i o n •
Lateral or anterior chest wall pain
• •
History of back pain Pain that is aggravated by exertion of only the upper body • May be accompanied by neurologic signs • Numbness • Tingling • Muscle atrophy
Thoracic Outlet Syndrome Thoracic outlet syndrome (TOS) refers to compression of the neural and/or vascular structures that leave or pass over the superior rim of the thoracic cage (see Fig. 17-10). Various names have been
CHAPTER 17
SCREENING THE CHEST, BREASTS, A N D RIBS
given to this condition according to the presumed site of major neurovascular compression: first thoracic rib, cervical rib, scalenus anticus, costoclavicular, and hyperabduction syndromes.
Past
Medical
History
History of associated back pain may be the only significant past medical history. The presence of anatomic anomalies such as an extra rib or unusual sternoclavicular and/or acromioclavicular angle may be the only known history linked to the development of TOS.
Risk
Factors
Symptoms may be related to occupational activities (e.g., carrying heavy loads, working with arms overhead), poor posture, sleeping with arms elevated over the head, or acute injuries such as cervical flexion/extension (whiplash). Athletes such as swimmers, volleyball players, tennis players, and baseball pitchers are also at increased risk for compression of the neurovascular structures. Most people become symptomatic in the third or fourth decade, and women (especially during pregnancy) are affected three times more often than are men.
Clinical
Presentation
Chest/breast pain can occur (and may be the only symptom of TOS) as a result of cervical spine disorders, an underlying etiology in TOS. This is because spinal nerves originating as high as C34 can extend down as low as the nipple line. The compressive forces associated with this problem usually affect the upper extremities in the ulnar nerve distribution but can result in episodic chest pain mimicking coronary heart disease. Neu-
TABLE
17-5
803
rogenic pain associated with TOS may be described as stabbing, cutting, burning, or electric. The pain is often unrelated to effort and lasts hours to days. There may be radiating pain to the neck, shoulder, scapula, or axilla, but usually the superficial nature of the pain and associated changes in sensation and neurologic findings point to chest pain with an underlying neurologic cause (Table 17-5). Paresthesias (burning, pricking sensation) and hypoesthesia (abnormal decrease in sensitivity to stimulation) are common. Anesthesia and motor weakness are reported in about 10% of the cases. When a vascular compressive component is involved, there may be more diffuse pain in the limb, with associated fatigue and weakness. With more severe arterial compromise, the client may describe coolness, pallor, cyanosis, or symptoms of Raynaud's phenomenon. Although vascular in origin, these symptoms are differentiated from CAD by the local or regional presentation, affecting only a single extremity or only the upper extremities. Palpation of the supraclavicular space may elicit tenderness or may define a prominence indicative of a cervical rib. The effect on pulse of the Adson or Halstead maneuvers (Fig. 17-8), the hyperabduction or Wright test (Fig. 17-9), and the costoclavicular test (exaggerated military attention posture) should be compared in both arms. Despite the widespread use of these tests, the reliability remains unknown. Specificity reported ranges from 18% to 87%, but sensitivity has been documented at 9 4 % . During assessment for vascular origin of symptoms, a change in pulse rate or rhythm is a positive test; however, because more than 50% of normal, asymptomatic individuals 45
Assessing Symptoms of Thoracic Outlet Syndrome"
Vascular component
3-minute elevated test Addison's test Swelling (arm/hand) Discoloration of hand Costoclavicular test Hyperabduction test Upper extremity claudication Differences in blood pressure Skin temperature changes Cold intolerance
Neural Upper plexus
Lower plexus
Point tenderness of C5-C6 Pressure over lateral neck elicits pain and/or numbness. Pain with head turned and/or tilted to opposite side Weak biceps Weak triceps Weak wrist Hypoesthesia in radial nerve distribution 3-minute abduction stress test
Pressure above clavicle elicits pain. Ulnar nerve tenderness when palpated under axilla or along inner arm Tinel's sign for ulnar nerve in axilla Hypoesthesia in ulnar nerve distribution Serratus anterior weakness Weak hand grip
* With the use of special tests, patterns of positive objective findings may help characterize thoracic outlet syndrome.
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A
F i g . 1 7 - 9 • Modified Wright test, also known as the Allen test or maneuver. The hyperabduction test can help screen for vascular compromise in TOS. Start with the client's arm resting at his or her side. Take the client's resting radial pulse for a full minute. Make note of any irregular or skipped beats. Raise the client's arm as shown with the client's face turned away, and recheck the pulse. This test is used to detect compression in the costoclavicular space. Diminished or thready pulse or absence of the pulse is a positive sign for (vascular) TOS. In the standard test, the examiner waits up to 3 minutes before palpating to give time for an accurate assessment. In our experience, clients with a positive hyperabduction test almost always demonstrate early changes in symptoms, skin color, and skin temperature. Having the client take a breath and hold it may have an additional effect. Tests for other aspects of neurologic or vascular compromise are available. (From Magee D: Orthopedic physical assessment, ed 4, Philadelphia, 2002, Saunders.) 45,47
B F i g . 1 7 - 8 • Adson maneuver. The client begins in the sitting position with arms at his or her sides and face forward. The examiner takes a baseline, resting radial pulse rate for 1 minute. A, The client then turns his or her head toward the test arm. The head and neck are extended slightly while the examiner laterally rotates and extends the shoulder. The client is asked to take a deep breath and hold it. Reproduction of the symptoms is the best indication of TOS, but a disappearance of the pulse is considered a positive test. B, Halstead maneuver. Baseline radial pulse is obtained before the client hyperextends and rotates his head to the opposite side. The examiner applies a downward, traction force on the involved side. Once again, the test is considered positive for a vascular component of a TOS when there is an change in pulse rate or rhythm. (From Magee D: Orthopedic physical assessment, ed 4, Philadelphia, 2002, Saunders.)
have pulse rate changes, it is better to reproduce the client's symptoms as a true indicator of TOS ' Other tests are described in orthopedic assessment t e x t s . With the use of special tests, patterns of positive objective findings may help characterize TOS as vascular, neural, or a combination of both (neurovascular). Knowing what the tests are and how they function is very helpful in guiding intervention. For example, Fig. 17-10 gives a visual representation of the effect of the hyperabduction test. A positive hyperabduction test may point to the need to restore normal function and movement of the pectoralis minor muscle. Likewise, if there is a neural component, assess for location (upper plexus versus lower plexus). Table 17-5 will help guide the therapist. 4 5
4 6
45,47
TOS should be considered when persistent chest pain occurs in the presence of a normal coronary angiogram and normal esophageal function tests.
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Scalene muscles First rib Brachial plexus Clavicle Axillary artery
Pectoralis minor
F i g . 1 7 - 1 0 • The neurovascular bundle associated with TOS can become compressed by nearby soft tissue structures such as the pectoralis minor. This illustration shows why the hyperabduction test can alter the client's pulse or reproduce symptoms. Effecting a change in the pectoralis minor may result in a change in the client's symptoms and can be measured by a return of the normal pulse rate and rhythm in the hyperabducted position.
Clinical Signs and Symptoms of
805
A vascular component to TOS may present with significant differences in blood pressure from side to side (a change of 10 mm Hg or more in diastolic is most likely). This does not mean that a medical referral is required immediately. Assess client age, past medical history, and presence of comorbidities (e.g., known hypertension), and ask about any associated signs and symptoms that might point to heart disease as a cause of the underlying symptoms. Physical therapy intervention can bring about a change in the soft tissue structures, putting pressure on the blood vessels in this area. In fact, blood pressure can be used as an outcome measure to document the effectiveness of the intervention. If blood pressure does not normalize and equalize from side to side, then medical referral may be required. If there is a cluster of cardiac symptoms, especially in the presence of a significant history of hypertension or heart disease, medical referral may be required before initiating treatment. If the Review of Systems does not provide cause for concern, documentation and communication with the physician are still important while initiating a plan of care.
Thoracic Outlet S y n d r o m e
Postoperative
Vascular
Postoperative chest pain following cardiac transplantation or other open heart procedures is usually due to the sternal incision and musculoskeletal manipulation during surgery. Coronary insufficiency does not appear as chest pain because of cardiac denervation.
•
Swelling, sometimes described as "puffiness," of the supraclavicular fossa, axilla, arm and/or hand
•
Cyanotic (blue or white) appearance of the hand; especially notable when the arm is elevated over head; sometimes referred to as the white hand sign • Subjective report of "heaviness" in arm or hand •
Chest, neck, and/or arm pain described as "throbbing" or deep aching • Upper extremity fatigue and weakness • Difference in blood pressure from side to side (more than 10-mm Hg difference in diastolic)
Neurologic •
Numbness and/or tingling, usually ulnar nerve distribution • Atrophy of the hand; difficulty with fine motor skills Pain in the upper extremity (proximal to distal); described as stabbing, cutting, burning, or electric • Numbness and tingling down the inner aspect of the arm (ulnar nerve distribution) •
Pain
PHYSICIAN REFERRAL Never dismiss chest pain as insignificant. Chest pain that falls into any of the categories in Table 6-5 requires medical evaluation. This table offers some helpful clues in matching client's clinical presentation with the need for medical referral. It may be impossible for a physician to differentiate anxiety from myocardial ischemia without further testing; such a differentiation is outside the scope of a physical therapist's practice. The therapist must confine himself or herself to a medical screening process before conducting a differential diagnosis of movement system impairments. The therapist is not making the differential diagnosis between angina, MI, mitral valve prolapse, or pericarditis. The therapist is screening for systemic or viscerogenic causes of chest, breast, shoulder or arm, jaw, or neck or upper back symptoms.
S E C T I O N III
806
SYSTEMIC ORIGINS OF PAIN A N D DYSFUNCTION
Knowing the chest and breast pain patterns and associated signs and symptoms of conditions that masquerade as NMS dysfunction will help the therapist recognize a condition requiring medical attention. Likewise, quickly recognizing red flag signs and symptoms is important in providing early medical referral and intervention, preferably with improved outcomes for the client.
Guidelines for Immediate Medical Attention • Sudden onset of acute chest pain with sudden dyspnea could be a life-threatening condition (e.g., pulmonary embolism, myocardial infarction, ruptured abdominal aneurysm), especially in the presence of red flag risk factors, personal medical history, and vital signs. • A sudden change in the client's typical anginal pain pattern suggests unstable angina. For the client with known angina, pain that occurs without exertion, lasts longer than 10 minutes, or is not relieved by rest or nitroglycerin signals a higher risk for a heart attack. • The woman with chest, breast, axillary, or shoulder pain of unknown origin at presentation must be questioned regarding breast selfexaminations. Any recently discovered breast lumps or nodules or lymph node changes must be examined by a physician.
Guidelines for Physician Referral • No change is noted in uneven blood pressure from one arm to the other after intervention for a vascular TOS component. • The therapist who suspects a client may be using anabolic steroids should report findings to the physician or coach if one is involved. • Symptoms are unrelieved or unchanged by physical therapy intervention. • Medical referral is advised before initiating treatment for anyone with a past history of cancer presenting with symptoms of unknown cause, especially without an identifiable movement system impairment.
Clues to Screening Chest, Breast, or Rib Pain Past
Medical
History
• History of repetitive motion; overuse; prolonged activity (e.g., marathon); long-term use of steroids, assault, or other trauma • History of flu, trauma, upper respiratory infection, shingles (herpes zoster), recurrent pneumonia, chronic bronchitis, or emphysema
• History of breast cancer or any other cancer; history of chemotherapy or radiation therapy • History of heart disease, hypertension, previous myocardial infarction, heart transplantation, bypass surgery, or any other procedure affecting the chest/thorax (including breast reconstruction, implantation, or reduction) • Prolonged use of cocaine or anabolic steroids • Nocturnal pain, pain without precise movement aggravation, or pain that fails to respond to treatment • Weight loss in the presence of immobility when weight gain would otherwise be expected • Recent childbirth and/or lactation (breast feeding) (pectoral myalgia, mastitis) Risk Factors (see also Table 6-3) • Age • Tobacco use • Obesity • Sedentary lifestyle, prolonged immobilization
Clinical
Presentation
• Range of motion (e.g., trunk rotation of side bending, shoulder motions) does not reproduce symptoms (exception: intercostal tear caused by forceful coughing associated with diaphragmatic pleurisy). • There is a lack of musculoskeletal objective findings; squeezing the underlying pectoral muscles does not reproduce symptoms; resisted motion (e.g., horizontal shoulder abduction or adduction) does not reproduce symptoms; heat and stretching do not reduce or eliminate the symptoms; pain or symptoms are not altered or eliminated with TrP therapy or other physical therapy intervention. • Chest pain relieved by antacid (reflux esophagitis), rest from exertion or taking nitroglycerin (angina), recumbency (mitral valve prolapse), squatting (hypertrophic cardiomyopathy), passing gas (gas entrapment syndrome) • Presence of painless sternal or chest wall mass or painless, hard lymph nodes • Unusual vital signs; changes in breathing CARDIOVASCULAR
• Timing of symptoms in relation to physical or sexual activity (immediate, 5 to 10 minutes after engaging in activity, after activity ends (lag time is associated with angina; symptoms occurring immediately or after an activity may be a sign of TOS, asthma, myalgias, or TrPs)
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• Assess the effect of exertion; reproduction of chest, shoulder, or neck symptoms with exertion of only the lower extremities may be cardiovascular. • Chest, neck, or shoulder pain that is aggravated by physical exertion, exposure to temperature changes, strong emotional reactions, or a large meal (coronary artery disease) • Atypical chest pain associated with dyspnea, arrhythmias, and light-headedness or syncope • Other signs and symptoms such as pallor, unexplained profuse perspiration, inability to talk, nausea, vomiting, sense of impending doom, or extreme anxiety • Symptoms can be precipitated by working with arms overhead; the client becomes weak or short of breath 3 to 5 minutes after raising the arms above the heart. PLEUROPULMONARY (see also Clues to Screening in Chapter 7) • Autosplinting (lying on the involved side) quiets chest wall movements and reduces or eliminates chest or rib pain; symptoms are worse with recumbency (supine position). • Pain is not reproduced by palpation. • Assess for the three ps: pleural pain, palpation, position (pleuritic pain exacerbated by respiratory movements, pain on palpation associated with musculoskeletal condition, pain with changes in neck, trunk, or shoulder position indicating musculoskeletal origin). • Musculoskeletal: Symptoms do not increase with pulmonary movements (unless there is an intercostal tear or rib dysfunction associated with forceful coughing from a concomitant pulmonary problem) but can be reproduced with palpation. • Pleuropulmonary: Symptoms increase with pulmonary movements and cannot be reproduced with palpation (unless there is an intercostal tear or rib dysfunction associated with forceful coughing). • Increased symptoms occur with recumbency (abdominal contents push up against diaphragm and in turn push against the parietal pleura). • Increased chest pain with exercise or increased movement can also be a sign of asthma; ask about a personal or family history of asthma or allergies. • Presence of associated signs and symptoms such as persistent cough, dyspnea (rest or exertional), or constitutional symptoms • Chest pain with sudden drop in blood pressure or symptoms such as dizziness, dyspnea, vomiting, or unexplained sweating while standing or
807
ambulating for the first time after surgery, an invasive medical procedure, assault, or accident involving the chest or thorax (pneumothorax) GASTROINTESTINAL (Upper GI/Epigastric; see also Clues to Screening in Chapter 8) • Effect of food on symptoms (better or worse); presence of GI symptoms, simultaneously or alternately with somatic symptoms • Pain on swallowing • Symptoms are relieved by antacids, food, passing gas, or assuming the upright position. • Supine position aggravates symptoms (upper GI problem); symptoms are relieved by assuming an upright position. • Symptoms radiate from the chest posteriorly to the upper back, interscapular, subscapular, or T10 to L2 areas. • Symptoms are not reproduced or aggravated by effort or exertion. • Presence of associated signs and symptoms such as nausea, vomiting, dark urine, jaundice, flatulence, indigestion, abdominal fullness or bloating, blood in stool, pain on swallowing BREAST (Alone or In Combination with Chest, Neck, or Shoulder Symptoms) • Appearance (or report) of lump, nodule, discharge, skin puckering, or distended veins • Jarring or movement of the breast tissue increases or reproduces the pain. • Pain is palpable within the breast tissue. • Assess for TrPs (sternalis, serratus anterior, pectoralis major; see Fig. 17-7); breast pain in the absence of TrPs or failure to respond to TrP therapy must be investigated further. • Resisted isometric shoulder horizontal adduction or abduction does not reproduce breast pain. • Breast pain is reproduced by exertion of the lower extremities (cardiac). • Association between painful symptoms and menstrual cycle (ovulation or menses) • Presence of aberrant or suspicious axillary or supraclavicular lymph nodes (e.g., large, firm, hard, or fixed) • Skin dimpling especially with adherence of underlying tissue; ask about or visually inspect for: • Lump or nodule • Red, warm, edematous, firm, and painful area over or under skin • Changes in size or shape or color of either breast or surrounding area • Unusual rash or other skin changes (e.g., puckering, dimpling, peau d'orange)
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• Distended veins • Unusual sensations in nipple or breast • Unusual nipple ulceration or discharge ANXIETY (see Table 3-9) • Pain Pattern: • Sharp, stabbing pain: left breast region • Dull aching: substernal • Discomfort: upper chest, neck, left arm • Fingertip size; does not radiate • Unable to palpate locally • Lasts seconds to hours to days • Not aggravated by respiratory or other (shoulder, arm, back) movements • Unchanged by rest or change in position • Unrelated to effort or exertion • Associated Signs and Symptoms • Local hyperesthesia of chest wall • Choking sensation (hysteria/panic) • Claustrophobia • Sense of persistent weakness • Unpleasant awareness of heartbeat • Hyperventilation (can also occur with heart attack; watch for sighing respirations and numbness/tingling of face and fingertips) NEUROMUSCULOSKELETAL • Symptoms described using words typical of NMS origin (e.g., aching, burning, hot, scalding, searing, cutting, electric shock) • Pain is superficial compared with pain of a cardiac or pleuropulmonary origin. • Symptoms are confined to somatic or spinal nerve root distribution.
• History of associated back pain • Positive hyperabduction test or other tests for TOS • Presence of TrPs; elimination of TrP(s) reduces or eliminates symptoms (see Table 17-4 and Fig. 17-7) • Symptoms are elicited easily by palpation (e.g., squeezing the pectoral muscle belly, palpating the chest wall, intercostal spaces, or costochondral junction). • Symptoms are reproduced by resisted horizontal shoulder abduction, adduction, or other shoulder movements. • Symptoms are relieved by heat and stretching. • Soft tissues (tendon and muscle) take longer than the expected time to heal (anabolic steroids). • Costochondritis or Tietze's syndrome may be accompanied by an increase in blood pressure but is usually palpable and aggravated by trunk movements. • Presence of neurologic involvement (e.g., numbness, tingling, muscle atrophy); consider age and history of trauma or injury (degenerative disc disease) • Pain referred along peripheral nerve pathway (dorsal nerve root irritation) • Pain is unrelated to effort and lasts hours or weeks to months. • Associated signs and symptoms: numbness and tingling, muscle atrophy (neurologic); rash, fever, chills, headache, malaise (constitutional symptoms; neuritis or shingles)
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SCREENING THE CHEST, BREASTS, A N D RIBS
809
Costochondral joints-
Sternum
Angina
Costochondritis
Breast
Pancreas
Esophagus Gallbladder
Myocardial Infarction
Pleuropulmonary
Esophagus
Left renal
Right renal artery
artery
Kidney
Abdominal aortic aneurysm
Aortic Aneurysm F i g , 1 7 - 1 1 • Composite picture of referred chest, breast, and rib pain patterns. Not shown: trigger point patterns (see Fig. 17-7).
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KEY POINTS TO REMEMBER / When faced with chest pain, the therapist must know how to assess the situation quickly and decide if medical referral is required and whether medical attention is needed immediately. Therapists must be able to differentiate neuromusculoskeletal from systemic origins of symptoms. / Although the past medical history (PMH) is important, it cannot be relied upon to confirm or rule out medical causes of chest pain. PMH does alert the therapist to an increased ri sk of systemic conditions that can masquerade as neuromusculoskeletal disorders. / Likewise, chest pain history by itself is not enough to rule out cardiac or other systemic origin of symptoms; in most cases, some diagnostic testing is needed. The physical therapist can offer valuable information from the screening process to aid in the medical differential diagnosis. / Chest pain associated with increased activity is a red flag for possible cardiovascular involvement. The physical therapist can assess when chest pain may be caused by musculoskeletal dysfunction (immediate chest pain occurs with use) or by possible vascular compromise (chest pain occurs 5 to 10 minutes after activity begins). / Anyone with a history of stent insertion presenting with chest pain should be screened carefully. The stent can get scarred over and/or malfunction. Stents are effective at alleviating chest pain but do not reduce the risk of heart attacks for most people with stable angina. / Cardiac pain patterns may differ for men and women; the therapist should be familiar with known pain patterns for both genders. / Trigger points can cause chest, breast, or rib pain, even mimicking cardiac pain patterns; a visceral-somatic response can also occur following a myocardial infarction, causing persisting symptoms of myocardial ischemia (angina); releasing the trigger point relieves the symptoms. / The therapist must especially know how and what to look for to screen for cancer, cancer recurrence, and/or the delayed effects of cancer treatment. Cancer can present
as primary chest pain with or without accompanying neck, shoulder, and/or upper back pain/symptoms. / When a woman with a PMH of cancer develops neck, back, upper trapezius or shoulder pain, or other symptoms, examining the site of the original cancer removal is a good idea. / The American Cancer Society (ACS) and the National Cancer Institute (NCI) support breast cancer screening by qualified health care specialists. With adequate training, the physical therapist can incorporate clinical breast examination (CBE) as a screening tool in the upper quarter examination for appropriate clients (e.g., individuals with neck, shoulder, upper back, chest, and/or breast signs or symptoms of unknown cause or insidious onset). / A physical therapist conducting a CBE could miss a lump (false negative), but this will most certainly happen if the therapist does not conduct a CBE at all to assess skin integrity and surrounding soft tissues of the breast or axilla. 2
2
/ The physical therapist does not diagnose any kind of cancer, including breast cancer; only the pathologist diagnoses cancer. The therapist can identify aberrant soft tissue and refer the client for further evaluation. Early detection and intervention can reduce morbidity and mortality. / Thoracic disc disease can also present as unilateral chest pain and requires careful screening. / Chest pain of unknown cause in the adolescent or young adult athlete may be the result of anabolic steroid use. Watch for injuries that take longer than expected to heal, personality changes, and any of the physical signs listed in the text. / A history of long-term steroid use in the presence of rib pain of unknown cause raises a red flag for rib fracture. / Many people with chest pain have used cocaine within the last week but deny its use; the therapist should not neglect asking clients of all ages about their use of substances.
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Special Q u e s t i o n s t o A s k ; C h e s t / T h o r a x Musculoskeletal • Have you strained a muscle from (repeated, forceful) coughing? • Have you ever injured your chest? • Does it hurt to touch your chest or to take a deep breath (e.g., coughing, sneezing, sighing, or laughing)? (Myalgia, fractured rib, costochondritis, myofascial trigger point) • Do you have frequent attacks of heartburn, or do you take antacids to relieve heartburn or acid indigestion? (Noncardiac cause of chest pain, abdominal muscle trigger point, gastrointestinal disorder) • Does chest movement or body/arm position make the pain better or worse? Neurologic • Do you have any trouble taking a deep breath? (Weak chest muscles secondary to polymyositis, dermatomyositis, myasthenia gravis) • Does your chest pain ever travel into your armpit, arm, neck, or wing bone (scapula)? (Thoracic outlet syndrome, trigger points) —If yes, do you ever feel burning, prickling, numbness, or any other unusual sensation in any of these areas? Pulmonary • Have you ever been treated for a lung problem? —If yes, describe what this problem was, when it occurred, and how it was treated. • Do you think your chest or thoracic (upper back) pain is caused by a lung problem? • Have you ever had trouble with breathing? • Are you having difficulty with breathing now? • Do you ever have shortness of breath, breathlessness, or can't quite catch your breath? —If yes, does this happen when you rest, lie flat, walk on level ground, walk up stairs, or when you are under stress or tension? —How long does it last? —What do you do to get your breathing back to normal? • How far can you walk before you feel breathless? • What symptom stops your walking (e.g., shortness of breath, heart pounding, or weak legs)? • Do you have any breathing aids (e.g., oxygen, nebulizer, humidifier, or ventilation devices)? • Do you have a cough? (Note whether the person smokes, for how long, and how much.) Do you have a smoker's hack?
• •
• •
•
•
•
•
—If yes to having a cough, distinguish it from a smoker's cough. Ask when it started. —Does coughing increase or bring on your symptoms? —Do you cough anything up? If yes, please describe the color, amount, and frequency. —Are you taking anything for this cough? If yes, does it seem to help? Do you have periods when you can't seem to stop coughing? Do you ever cough up blood? —If yes, what color is it? (Bright red: fresh; brown or black: older) —If yes, has this been treated? Have you ever had a blood clot in your lungs? If yes, when and how was it treated? Have you had a chest x-ray film taken during the last 5 years? If yes, when and where did it occur? What were the results? Do you work around asbestos, coal, dust, chemicals, or fumes? If yes, describe. —Do you wear a mask at work? If yes, approximately how much of the time do you wear a mask? If the person is a farmer, ask what kind of farming (because some agricultural products may cause respiratory irritation). Have you ever had tuberculosis or a positive skin test for tuberculosis? —If yes, when did it occur and how was it treated? What is your current status? When was your last test for tuberculosis? Was the result normal?
Cardiac • Has a physician ever told you that you have heart trouble? • Have you recently (or ever) had a heart attack? If yes, when? Describe. —If yes, to either question: Do you think your current symptoms are related to your heart problems? —Do you have angina (pectoris)? —If yes, describe the symptoms, and tell me when it occurs. —If no, pursue further with the following questions. • Do you ever have discomfort or tightness in your chest? (Angina) • Have you ever had a crushing sensation in your chest with or without pain down your left arm?
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EXAMINATION —cont'd
• Do you have pain in your jaw, either alone or in combination with chest pain? • If you climb a few nights of stairs fairly rapidly, do you have tightness or pressing pain in your chest? • Do you get pressure or pain or tightness in the chest if you walk in the cold wind or face a cold blast of air? • Have you ever had pain or pressure or a squeezing feeling in the chest that occurred during exercise, walking, or any other physical or sexual activity? • Do you ever have bouts of rapid heart action, irregular heartbeats, or palpitations of your heart? —If yes, did this occur after a visit to the dentist? (Endocarditis) • Have you noticed any skin rash or dots under the skin on your chest in the last 3 weeks? (Rheumatic fever, endocarditis) • Have you noticed any other symptoms (e.g., shortness of breath, sudden and unexplained perspiration, nausea, vomiting, dizziness or fainting)? • Have you used cocaine, crack, or any other recreational drug in the last 6 weeks? • Does your pain wake you up at night? (Therapist: distinguish between awakening from pain and awakening with pain; awakening from pain is more likely with cardiac ischemia, whereas awakening with pain is characteristic of sleep disturbances and more common with psychogenic or stress-induced chest pain; this information will help in deciding whether referral is needed immediately or at the next followup appointment) Epigastric • Have you ever been told that you have an ulcer? • Does the pain under your breast bone radiate (travel) around to your back, or do you ever have back pain at the same time that your chest hurts? • Have you ever had heartburn or acid indigestion? —If yes, how is this pain different? —If no, have you noticed any association between when you eat and when this pain starts?
Special Questions to Ask; Breast • Have you ever had any breast surgery (implants, lumpectomy, mastectomy, reconstructive surgery, or augmentation)? If yes, has there been any change in the incision line, nipple, or breast tissue? May I look at the incision during my exam? • Do you have a history of cystic or lumpy breasts? If yes, do the lumps come and go or change with your periods? • Is there a family history of breast disease? If yes, ask about type of disease, age of onset, treatment, and outcome. • Have you ever had a mammogram or ultrasound? If yes, when was your last test? What were the results? • Have you ever had a lump or cyst drained or biopsied? If yes, what was the diagnosis? • Have you ever been treated for cancer of any kind? If yes, when? What? • Have you examined yourself for any lumps or nodules and found any thickening or lump in the breast or armpit area? If yes, has your physician examined/treated this? If no, do you examine your own breasts? (Follow-up questions regarding last breast examination by self or other health care professional) • Do you have any discharge from your breasts or nipples? If yes, do you know what is causing this discharge? Have you received medical treatment for this problem? • Are you nursing or breastfeeding an infant (lactating)? If yes, are your nipples sore or cracked? Is your breast painful or hot? Are there any areas of redness? Have you had a fever? (Mastitis) • Have you noticed any other changes in your breast(s)? For example, are there any noticeable bulging or distended veins, puckering, swelling, tenderness, rash, or any other skin changes? • Do you have any pain in your breasts? If yes, does the pain come and go with your period? (Hormone-related)
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•
• • •
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EXAMINATION —cont'd
Does squeezing the breast tissue cause the pain? Does using your arms in any way cause the pain? Have you been involved in any activities of a repetitive nature that could cause sore muscles (e.g., painting, washing walls, push-ups or other calisthenics, heavy lifting or pushing, overhead movements, prolonged running, or fast walking)? Have you recently been coughing excessively? (Pectoral myalgia) Have you ever had angina (chest pain) or a heart attack? (Residual trigger points) Have you been in a fight or hit, punched, or pushed against any object that injured your chest or breast? (Assault)
Special Q u e s t i o n s t o A s k ; L y m p h N o d e s Use the lymph node assessment form (Fig. 4-45) to record and report baseline findings. • [General screening question:] Have you examined yourself for any lumps or nodules and found any thickening or lump? If yes, has your physician examined/treated this? If any suspicious or aberrant lymph nodes are observed during palpation, ask the following questions. • Have you recently had any skin rashes anywhere on your face or body? • Have you recently had a cold, upper respiratory infection, the flu, or other illness? (Enlarged lymph nodes) • Have you ever had: Cancer of any kind? If no, have you ever been treated with radiation or chemotherapy for any reason? Breast implants
Mastectomy or prostatectomy Mononucleosis Chronic fatigue syndrome Allergic rhinitis Food intolerances, food allergies, or celiac sprue Recent dental work Infection of any kind Recent cut, insect bite, or infection in the hand or arm A sexually transmitted disease of any kind Sores or lesions of any kind anywhere on the body (including genitals) Special Q u e s t i o n s t o A s k : S o f t T i s s u e Lumps or Skin Lesions • • • • • • • •
• • • •
How long have you had this? Has it changed in the last 6 weeks to 6 months? Has your doctor seen it? Does it itch, hurt, feel sore, or burn? Does anyone else in your household have anything like this? Have you taken any new medications (prescribed or over-the-counter) in the last 6 weeks? Have you traveled somewhere new in the last month? Have you been exposed to anything in the last month that could cause this? (consider exposure due to occupational, environmental, and hobby interests) Do you have any other skin changes anywhere else on your body? Have you had a fever or sweats in the last 2 weeks? Are you having any trouble breathing or swallowing? Have you had any other symptoms of any kind anywhere else in your body?
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STUDY
STEPS IN THE SCREENING PROCESS
Could It Be Pulmonary?
If a client comes to you with chest pain, breast pain, or rib pain (either alone or in combination with neck, back, or shoulder pain), start by looking at Tables 17-1 and 17-2 and Box 17-4. As you look down these lists, does your client have any red flag histories, unusual clinical presentation, or associated signs and symptoms to point to any particular category? Just by looking at these lists, you may be prompted to ask some additional questions that have not been asked yet.
• Consider the age of the client and any recent history of pneumonia or other upper respiratory infections. Again, consider the 3 Ps. • Have you observed or heard any reports from the client to suggest changes in the breathing pattern? Are there other pulmonary symptoms present (e.g., dry or productive cough, symptoms aggravated by respiratory movements)? • Are the symptoms made better by sitting up, worse by lying down, or better in sidelying on the affected side (autosplinting)? If yes, further screening may be warranted.
Could It Be Cancer?
The therapist does not make a determination as to whether or not a client has cancer; only the pathologist makes this kind of determination. The therapist's assessment determines whether the client has a true neuromuscular or musculoskeletal problem that is within the scope of our practice. However, knowing red flags for the possibility of cancer helps the therapist know what questions to ask and what red flags to look for. Early detection often means reduced morbidity and mortality for many people. Watch for the following: • Previous history of cancer (any kind, but especially breast or lung cancer). • Be sure to assess for trigger points (TrPs). Reassess after trigger point therapy (e.g., Were the symptoms alleviated? Did the movement pattern change?). • Conduct a neurologic screening exam. • Look for skin changes or other trophic changes, and ask about recent rashes or lesions (see Examining a Skin Lesion or Mass in Box 4-10). Could It Be Vascular?
• Consider the client's age, menopausal status (women), past medical history, and the presence of any cardiac risk factors. Do any of these components suggest the need to screen further for a vascular cause? • Are there any reported associated signs and symptoms (e.g., unexplained perspiration without physical activity, nausea, pallor, unexplained fatigue, palpitations; see Box 4-17)? • Is there a significant difference in blood pressure from one arm to the other? Have you checked? Do the symptoms suggest the need to conduct this assessment? • Have you assessed for the 3 Ps? (pleuritic pain, palpation, position)
Could It Be Upper GI?
• Follow the same line of thinking in terms of mentally reviewing the client's past medical history (e.g., chronic NSAID use, GERD, gallbladder, or liver problems) and the presence of any GI signs or symptoms. Is there anything here to suggest a potential GI cause of the current symptoms? If yes, then review the Special Questions to Ask box for any further screening questions. • Have you asked the client about the effect of eating or drinking on the symptoms? It is a quick and simple screening question to help identify any GI component. • Be sure and assess for trigger points as a potential cause of what might appear to be Gl-induced symptoms. Could It Be Breast Pathology?
• Consider red flag histories, risk factors, and pain pattern for men and women when considering breast tissue as a possible cause of upper quadrant pain. • Is there any cyclical aspect to the symptoms linked to menstruation or hormonal fluctuations? • Ask if jarring or squeezing the breast reproduces the pain. • Ask if there have been any obvious changes in the breast tissue or nipple. • Have you palpated the axillary or supraclavicular lymph nodes? This is a quick and easy screening test that can easily be incorporated into your examination. Could It Be Trauma or Other Causes?
• Remember to consider trauma (including assault) as a possible cause of symptoms.
CHAPTER 17
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STUDY —cont'd
• Is there any reason to suspect drug use (e.g., cocaine, anabolic steroids)? • Should you consider screening for emotional overlay or psychogenic source of symptoms (see Chapter 3; see Appendix B-28)? • Consider anemia as a possible cause; without a laboratory test, this is impossible to know for certain. In the screening process, the therapist can ask some questions to help formulate a referral decision. For example, has the client complained of fatigue, a hallmark finding in anemia? Some additional questions may include the following: • Have you experienced any unusual or prolonged bleeding from any part of your body? • Have you noticed any blood in your urine or stools? Have you noticed any changes in the color of your stools? (Dark, tarry, sticky stools may signal melena from blood loss in the GI tract.)
• Have you been taking any over-the-counter or prescribed antiinflammatory drugs (NSAIDs and peptic ulcer with GI bleeding)? • Have you ever been told you have rheumatoid arthritis, lupus, HIV/AIDs, or anemia? • Rheumatoid arthritis is a systemic condition that can cause chest pain; osteoarthritis of the cervical spine, fibromyalgia, and anxiety can also cause chest pain. When completing the Review of Systems, look for a cluster of associated signs and symptoms that might suggest any of these conditions. • Do not forget to consider screening for anabolic steroid use, cocaine or other substance use, and domestic violence or assault. Finally, review the clues to differentiating chest, breast, or rib pain, and then scan the Special Questions to Ask: Chest/Thorax or Special Questions to Ask: Breast in this chapter (depending on the chief complaint and presenting symptoms). Have you left anything out?
PRACTICE QUESTIONS 1. Chest pain can be caused by trigger points of the: a. Sternocleidomastoid b. Rectus abdominis c. Upper trapezius d. Iliocostalis thoracis 2. During examination of a 42-year-old woman's right axilla, you palpate a lump. Which characteristics most suggest the lump may be malignant? a. Soft, mobile, tender b. Hard, immovable, nontender 3. A client complains of throbbing pain at the base of the anterior neck that radiates into the chest and interscapular areas and increases with exertion. What should you do first?
a. Monitor vital signs, and palpate pulses b. Call the physician or 911 immediately c. Continue with the exam; find out what relieves the pain d. Ask about past medical history and associated signs and symptoms 4. A 55-year old grocery store manager reports becoming extremely weak and breathless whenever stocking groceries on overhead shelves. What is the possible significance of this complaint? a. Thoracic outlet syndrome b. Myocardial ischemia c. Trigger Point d. All of the above
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PRACTICE QUESTIONS—cont'd 5. Chest pain of a pleuritic nature can be distinguished by: a. Increases with autosplinting (lying on the involved side) b. Reproduced with palpation c. Exacerbated by deep breathing d. All of the above 6. A 66-year-old woman has been referred to you by her physiatrist for preprosthetic training after an above-knee amputation. Her past medical history is significant for chronic diabetes mellitus (insulin dependent), coronary artery disease, and peripheral vascular disease. About 6 weeks ago, she had an angioplasty with stent placement. During the physical therapy examination, the client reported anterior neck pain radiating down the left arm. Which test will help you differentiate a musculoskeletal cause from a cardiac cause of neck and arm pain? a. Stair climbing or stationary bike test b. Using arms overhead for 3 to 5 minutes c. Trigger point assessment d. All of the above 7. You are evaluating a 30-year-old woman with left chest pain that starts just below the clavicle and extends down to the nipple line. The majority of test results point to thoracic outlet syndrome. Her blood pressure is 120/78 mm Hg on the right (sitting) and 125/100 on the left (sitting). She is in apparent good health with no history of surgeries or significant health problems. What plan of action would you recommend? a. Refer her to a physician before initiating treatment. b. Carry out a plan of care, and reassess after three sessions or 1 week, whichever comes first. c. Document your findings, and contact the physician by phone or by fax while initiating treatment. d. Eliminate trigger points, and then reassess symptoms.
8. A 60-year-old woman with a history of left breast cancer (10 years postmastectomy) presents with pain in her midback. The pain is described as "sharp" and radiates around her chest to the sternum. She gets some relief from her pain by lying down. Her vital signs are normal, and there are no palpable or aberrant lymph nodes. She denies any changes in breast tissue on the right or the scar and soft tissue on the left. You do not have adequate training to perform a clinical breast examination, but the client agrees to visual inspection, which reveals nothing unusual. All other findings are within normal limits; you are unable to provoke or aggravate her symptoms. Neurologic screening examination is within normal limits. The client denies any history of trauma. What plan of action would you recommend? a. Refer her to a physician before initiating treatment b. Carry out a plan of care, and reassess after three sessions or 1 week, whichever comes first c. Document your findings, and contact the physician by phone or by fax while initiating treatment. d. Eliminate trigger points, and then reassess symptoms. 9. You are working with a client in his home who had a total hip replacement 2 weeks ago. He describes chest pain with increased activity. Knowing what could cause this symptom will help guide you in asking appropriate screening questions. Is this a symptom of: a. Asthma b. Angina c. Pleuritis or pleurisy d. All of the above 10. Cardiac pain in women does not always follow classic patterns. Watch for this group of symptoms in women at risk: a. Indigestion, food poisoning, jaw pain b. Nausea, tinnitus, night sweats c. Confusion, left biceps pain, dyspnea d. Unusual fatigue, shortness of breath, weakness, or sleep disturbance
CHAPTER 17
SCREENING THE CHEST, BREASTS, A N D RIBS
REFERENCES 1. Lovelace-Chandler V, Bassar M, Dow D, et al: The role of physical therapists assisting women in skill development in performing breast self-examination. Poster presentation. Combined Sections Meeting, New Orleans, February 2005. 2. Goodman CC, McGarvey CL: The role of the physical therapist in primary care and cancer screening: integrating clinical breast examination (CBE) in the upper quarter examination, Rehabilitation Oncology 21(2):4-11, 2003. 3. Swap C, Nagurney JT: Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary symptoms, JAMA 294(20):2623-2629, 2005. 4. Bruckner FE, Greco A, Leung AW: Benign thoracic pain syndrome: role of magnetic resonance imaging in the detection and localization of thoracic disc disease, J R Soc Med 82:81-83, 1989. 5. American Heart Association: Heart News. Available on-line at http://www.americanheart.org. Accessed January 31, 2006. 6. Harvard Women's Health Watch: Gender matters: heart disease risk in women, 11(9): 1-3, 2004. 7. National Heart, Lung, and Blood Institute: National Cholesterol Education Program (NCEP). Available on-line at http://hin.nhlbi.nih.gov/atpiii/calculator.asp?sertype=prof. Accessed January 31, 2006. 8. Marrugat J et al. Mortality differences between men and women following first myocardial infarction, JAMA 280: 1405-1409, 1998. 9. McSweeney JC: Women's early warning symptoms of acute myocardial infarction, Circulation 108(21):2619-2623, 2003. 10. Wolf JM, Green A: Influence of comorbidity on selfassessment instrument scores of patients with idiopathic adhesive capsulitis, J Bone Joint Surg Am 84-A(7): 1167-1173, 2002. 11. Smith R, Athanasou NA, Ostlere SJ, et al: Pregnancyassociated osteoporosis, QJM 88:865-878, 1995. 12. Baitner AC, Bernstein AD, Jazrawi AJ: Spontaneous rib fracture during pregnancy: a case report and review of the literature, Bull Hosp Jt Dis 59(3):163-165, 2000. 13. Boissonnault WG, Boissonnault JS: Transient osteoporosis of the hip associated with pregnancy, JOSPT 31(7):359-367, 2001. 14. Amagada JO, Joels L, Catling S: Stress fracture of rib in pregnancy: what analgesia? J Obstet Gynaecol 22(5):559, 2002. 15. Kovacs CS: Calcium and bone metabolism during pregnancy and lactation, J Mammary Gland Gland Biol Neoplasia 10(2):105-118, 2005. 16. Debnah UK, Kishore R, Black RJ: Isolated acetabular osteoporosis in TOH in pregnancy: a case report, South Med J98(ll):1146-1148, 2005. 17. Jemal A, Murray T, Ward E, Samuels A, et al: Cancer statistics 2005, CA Cancer J Clin 55(l):10-30, 2005. 18. American Cancer Society (ACS): What are the risk factors for breast cancer? Available at: http://www.cancer.org/ docroot/CRI/content/CRI_2_4_2X_What_are_the_risk_ factors_for_breast_cancer_5.asp. Accessed January 26, 2006. 19. Garfinkel L: Current trends in breast cancer, CA Cancer J Clin 43(l):5-6, 1993. 20. Coleman EA, Heard JK: Clinical breast examination: an illustrated educational review and update, Clin Excell Nurse Pract 5:197-204, 2001. 21. Barton MB, Harris R, Fletcher SW: Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA 282:1270, 1999.
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22. Goodman CC, McGarvey CL: An introductory course to breast cancer and clinical breast examination for the physical therapist is available. (Charlie McGarvey, PT, MS and Catherine Goodman, MBA, PT present the course in various sites around the U.S. and upon request.) 23. A certified training program is also available through MammaCare Specialist. The program isoffered to health care professionals at training centers in the United States. The course teaches proficient breast examination skills. For more information, contact: http://www.mammacare.com/ professional_training.htm. 24. Cady B, Steele GD, Morrow M, et al: Evaluation of common breast problems: guidance for primary care providers, CA Cancer J Clin 48(l):49-63, 1998. 25. Rubin RN: Woman with sharp back pain, Consultant 39(ll):3065-3066, 1999. 26. Gabriel SE, Woods JE, O'Fallon WM, et al: Complications leading to surgery after breast implantation, NEJM 336(10):718-719, 1997. 27. Benediktsson K, Perback L: Capsular contracture around saline-filled and textured subcutaneously-placed implants in irradiated and non-irradiated breast cancer patients: five years of monitoring of a prospective trial, J Plast Reconstr Aesthet Surg 59(l):27-34, 2006. 28. Henriksen TF, Fryzek JP, Holmich LR, et al: Reconstructive breast implantation after mastectomy for breast cancer: clinical outcomes in a nationwide prospective cohort study, Arch Surg 140(12):1152-1159, 2005. 29. Zuckerman D: Associated Press interview (December 20, 2005). National Research Center for Women and Families, Washington, D.C., 2005. 30. National Institute of Mental Health: Health Information— Anxiety Disorders. Available at: http://www.nimh.nih.gov/. Updated 1/27/06. Accessed January 27, 2006. 31. Velasquez EM, Anand RC, Newman WP, et al: Cardiovascular complications associated with cocaine use, J La State Med Soc 156(6):302-310, 2004. 32. Pletcher MJ, Kiefe CI, Sidney S, et al: Cocaine and coronary calcification in young adults: the Coronary Artery Risk Development in Young Adults (CARDIA) study, Am Heart J 150(5):921-926, 2005. 33. Pozner CN, Levine M, Zane R: The cardiovascular effects of cocaine, J Emerg Med 29(2):173-178, 2005. 34. Evans NA: Anabolic steroids: answers to the bigger questions, J Musculo Med 21(3):166-178, 2004. 35. Sullivan ML, Martinez CM, Gennis P, et al: The cardiac toxicity of anabolic steroids, Prog Cardiovasc Dis 41(1):1-15, 1998. 36. Jensen S: Musculoskeletal causes of chest pain, Aust Fam Phys 30(9):834-839, September 2001. 37. Peterson LL, Cavanaugh DG: Two years of debilitating pain in a football spearing victim: slipping rib syndrome, Med Sci Sports Exerc 35(10):1634-1637, 2003. 38. Thongngarm T, Lemos LB, Lawhon N, et al: Malignant tumor with chest pain mimicking Tietze's syndrome, Clin Rheumatol 20(4):276-278, 2001. 39. Fioravanti A, Tofi C, Volterrani L, et al: Malignant lymphoma presenting as Tietze's syndrome, Arthritis Rheum 49(5):737, 2003. 40. Simons DG, Travell JG, Simons LS: Travell & Simons' myofascial pain and dysfunction: the trigger point manual. Volume 1: Upper half of body, ed 2, Baltimore, 1999, Williams & Wilkins. 41. Hughes KH: Painful rib syndrome: a variant of myofascial pain syndrome, AAOfflV 46(3):115-120, 1998. 42. Saltzman DA, Schmitz ML, Smith SD, et al: The slipping rib syndrome in children, Paediatr Anaesth ll(6):740-743, 2001. 43. Meuwly JY, Wicky S, Schnyder P, et al: Slipping rib syndromes: a place for sonography in the diagnosis of a frequently overlooked cause of abdominal or low thoracic pain, J Ultrasound Med 21(3):339-343, 2002.
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44. Udermann BE, Cavanaugh DG, Gibson MH, et al: Slipping rib syndrome in a collegiate swimmer: a case report, J AM Train 40(2):120-122, 2005. 45. Dutton M: Orthopaedic examination, evaluation, and intervention, New York, 2004, McGraw-Hill.
46. Selke FW, Kelly TR: Thoracic outlet syndrome, Am J Surg 156:54-57, 1988. 47. Magee D: Orthopedic physical assessment, ed 4, Philadelphia, Saunders, 2002.
Screening the Shoulder and Upper Extremity
T
he therapist is well aware that many primary neuromuscular and musculoskeletal conditions in the neck, cervical spine, axilla, thorax, thoracic spine, and chest wall can refer pain to the shoulder and arm. For this reason, the physical therapist's examination usually includes assessment above and below the involved joint for referred musculoskeletal pain (Case Example 18-1). In this chapter we explore systemic and viscerogenic causes of shoulder and arm pain and take a look at each system that can refer pain or symptoms to the shoulder. This will include vascular, pulmonary, renal, gastrointestinal (GI), and gynecologic causes of shoulder and upper extremity pain and dysfunction. Primary or metastatic cancer as an underlying cause of shoulder pain also is included. The therapist must know how and what to look for to screen for cancer. Systemic diseases affecting the neck, breast, and any organs in the chest or abdomen can present clinically as shoulder pain (Table 18-1). Peptic ulcers, heart disease, ectopic pregnancy and myocardial ischemia are only a few examples of systemic diseases that can cause shoulder pain and movement dysfunction. Each disorder listed can present clinically as a shoulder problem before ever demonstrating systemic signs and symptoms.
USING THE SCREENING MODEL TO EVALUATE SHOULDER AND UPPER EXTREMITY Past Medical History As you look over the various potential systemic causes of shoulder pain listed in Table 18-1, think about the most common risk factors and red flag histories you might see with each of these conditions. For example, a history of any kind of cancer is always a red flag. Breast and lung cancer are the two most common types of cancer to metastasize to the shoulder. Heart disease can cause shoulder pain, but it usually occurs in an age specific population. Anyone over 50 years old, postmenopausal women, and anyone with a positive first generation family history is at increased risk for symptomatic heart disease. Alternately, although atherosclerosis has been demonstrated in the blood vessels of children, teens, and young adults, they are rarely symptomatic unless some other heart anomaly is present. Hypertension, diabetes, and hyperlipidemia are other red flag histories associated with cardiac related shoulder pain. Of course, a history of angina, heart attack, angiography, stent placement, and coronary artery bypass graft (CABG), or other cardiac procedure is also a yellow (caution) flag to alert the therapist of the potential need for further medical screening. 819
820
SECTION III
CASE EXAMPLE 1 8 - 1
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
E v a l u a t i o n of a P r o f e s s i o n a l Golfer
Referral: A 38-year-old male, professional golfer presented to physical therapy with a diagnosis of shoulder impingement syndrome, with partial thickness tears of the supraspinatus tendon. Prior to the physical therapy intervention, x-rays taken were reported as negative for fracture or tumor. An MRI was reported as positive for bursitis and supraspinatus tendinitis with some partial tears. The shoulder specialist also provided the client with one corticosteroid injection, which gave him some relief of his shoulder pain. Past Medical History: Past medical history and review of systems were negative for any systemic issues. He was on no medication at the time of evaluation. Clinical Presentation: Functional deficits were reported as pain with the take-away phase of the golf swing and with the adduction motion of the shoulder in follow through. He also reported a loss of distance associated with his drive by 20 to 30 yards. He had trouble sleeping and reported pain would wake him up if his head were turned into left rotation. He also had pain when turning his head to the left (e.g., when driving a car). UPPER QUARTER SCREEN Shoulder ROM Active ROM: Left 160° 165° T9 Tl
Right Flex Abd I.R. E.R.
170° 170° T7 T3
Passive ROM: Left 170° 170° 55° 60°
Right Flex Abd I.R. E.R.
175° 175° 60° 75°
Isometric Muscle Testing of Rotator Cuff: Abduction Abduction with internal rotation Internal Rotation External Rotation
Painful/strong Painful/strong Painless/strong Painless/strong
Special Tests: Hawkins/Kennedy + Neer + Speeds + External Rotation Lag Test Internal Rotation Lag Test Cervical ROM Flexion 40° Extension 20° [L] side bend 20° [R] side bend 25° [L] rotation 45° [R] rotation 70° Quadrant position
Report of left scapular pain Report of left scapular pain No report of pain Report of left scapular pain No report of pain Right and left: Reproduced left posterior scapular pain with radicular pain to the thumb and second finger area
Deep Tendon Reflexes Left
DTR
Right
2+ 0 2+
Biceps Triceps Brachioradialis
2+ 2+ 2+
Strength Left
Right Shoulder flexion Shoulder abduction Elbow flexion Elbow extension Wrist extension Wrist flexion Thumb extension Finger abduction
5/5 4/5 5/5 2/5 3/5 5/5 5/5 5/5
5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5
He did have intact sensation to light touch and proprioceptive sense. Strength testing on the Cybex weight lifting machines showed he was able to do 10 triceps extensions on the right with four plates while on the left, he was only able to do one repetition with one plate. Result: With the data obtained in the examination, the conclusion was made that he did have an impingement syndrome as described by Neer, with involvement of the bursa and rotator cuff tendons. Cyriax muscle testing revealed some musculotendon involvement with the strong/painful tests. The cervical findings required consultation with the referring physician. A provisional medical diagnosis was made of cervical radiculopathy with a C5-C6 herniated disc. The client 1
2
CHAPTER 18
CASE EXAMPLE 1 8 - 1
SCREENING THE SHOULDER AND UPPER EXTREMITY
821
Evaluation of a P r o f e s s i o n a l Golfer—cont'd
was referred to a neurosurgeon for evaluation. An MRI confirmed the diagnosis and the client underwent an anterior cervical fusion with disectomy. Summary: This case example helps highlight the importance of a complete examination process, even if a physician specialist refers a client for physical therapy services. The
therapist must "clear" or examine the joints above and below the region thought to be the cause of the dysfunction. The major reason for the symptoms or a secondary diagnosis may be missed if the screening step is left out because of a lack of time or assuming someone else checked out the entire client.
Voshell S: Case report presented in fulfillment of DPT 910, Institute for Physical Therapy Education, Widener University, Chester, Pennsylvania, 2005. Used with permission.
Knowledge of pathologic conditions, illnesses, and diseases helps the therapist navigate the screening process. For example, pulmonary tuberculosis (TB) is a possible cause of shoulder pain. Who is most likely to develop TB? Risk factors include • Health care workers • Homeless population • Prison inmates • Immunocompromised individuals (e.g., transplant recipients, long-term use of immunosuppressants, anyone treated for long-term rheumatoid arthritis, anyone treated with chemotherapy for cancer) • Older adult (over 65 years) • Immigrants from areas where TB is endemic • Injection drug users • Malnourished (e.g., eating disorders, alcoholism, drug users, cachexia) In a case like tuberculosis, there will usually be other associated signs and symptoms such as fever, sweats, and cough. When completing a screening examination for a client with shoulder pain of unknown origin or an unusual clinical presentation, the therapist might look at vital signs, auscultate the client, and see what effect increased respiratory movements have on shoulder symptoms (Case Example 18-2).
Clinical Presentation Differential diagnosis of shoulder pain is sometimes especially difficult because any pain that is felt in the shoulder often affects the joint as though the pain were originating in the joint. Shoulder pain with any of the components listed in this chapter should be approached as a manifestation of systemic visceral illness, even if shoulder 3
movements exacerbate the pain or if there are objective findings at the shoulder. Many visceral diseases present as unilateral shoulder pain (Table 18-2). Esophageal, pericardial (or other myocardial diseases), aortic dissection, and diaphragmatic irritation from thoracic or abdominal diseases (e.g., renal, hepatic/biliary) all can appear as unilateral pain. "Frozen shoulder," or adhesive capsulitis, a condition in which both active and passive glenohumeral motions are restricted, can be associated with diabetes mellitus, hyperthyroidism, ischemic heart disease, infection, and lung diseases (tuberculosis, emphysema, chronic bronchitis, Pancoast's tumors) (Case Example 18-3). Shoulder pain (unilateral or bilateral) progressing to adhesive capsulitis can occur 6 to 9 months after a coronary artery bypass graft (CABG). Similarly, anyone immobile in the intensive care unit (ICU) or coronary care unit (CCU) can experience loss of shoulder motion resulting in adhesive capsulitis (Case Example 18-4). Clients with pacemakers who have complications and revisions that result in prolonged shoulder immobilization can also develop adhesive capsulitis. 4
The Shoulder is Unique It has been stressed throughout this text that the basic clues and approach to screening are similar, if not the same, from system to system and anatomic part to anatomic part. So, for example, much of what was said about screening the neck and back (Chapter 14) applied to the sacrum, SI, pelvis (Chapter 15), buttock, hip, groin (Chapter 16), and chest, breast, and rib (Chapter 17). Presenting the shoulder last in this text is by design. These principles do apply to the shoulder, but beyond that: Text continued on p 825.
822
TABLE 18-1
SECTION III
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
Systemic Causes of Shoulder Pain
Neck
Chest
Abdomen
Cancer
Metastases (leukemia, Hodgkin's disease) Cervical cord tumors Bone tumors
Metastases to nodes in axilla or mediastinum Metastases to lungs from: Bone Breast Kidney Colorectal Pancreas Uterus Bone metastases to thoracic spine: Breast Lung Thyroid Breast cancer Lung cancer
Pancreatic cancer Spinal metastases Kidney Testicle Prostate
Cardiovascular/ Vascular
Thoracic Outlet syndrome
Angina/myocardial infarct Post-coronary artery bypass graft (ICU/CABG) Pacemaker (complications) Bacterial endocarditis Pericarditis Aortic aneurysm Empyema and lung abscess Collagen vascular disease
Dissecting aortic aneurysm
Pulmonary
Pulmonary tuberculosis
Pulmonary embolism Pulmonary tuberculosis Spontaneous pneumothorax Pancoast's tumor Pneumonia Kidney stones Obstruction, inflammation, or infection of upper urinary tract
Renal/Urologic
Gastrointestinal /Hepatic
Hiatal hernia
Gynecologic Other
Peptic/duodenal ulcer (perforated) Ruptured spleen Liver disease Gallbladder disease Pancreatic disease Ectopic pregnancy (rupture)
Mastodynia (breast) Infection: Mononucleosis Osteomyelitis Syphilis/gonorrhea Herpes zoster (shingles) Pneumonia Diabetes mellitus (adhesive capsulitis) Sickle cell anemia Hemophilia
Subphrenic abscess Diaphragmatic hernia Anterior spinal surgery (post-operative hemorrhage)
CASE EXAMPLE 1 8 - 2
Homeless Man w i t h Tuberculosis
Referral: A 36-year-old man was referred to physical therapy as an in-patient for a shortterm hospitalization. He was a homeless man brought to the hospital by the police and admitted with an extensive medical problem list including Malnutrition Alcoholism Depression Hepatitis A Broken wrist Shoulder pain Dehydration There was no past medical history of cancer. The client was a smoker when he could get cigarettes. He would like to support a one-pack-aday habit. Medical service requested an evaluation of the client's shoulder pain. X-rays were not taken because the man had full active range of motion, no history of trauma, and no insurance to cover additional testing. Clinical Presentation: The therapist was unable to reproduce the shoulder pain with palpation, position, or provocation testing. There was no sign of rotator cuff dysfunction, adhesive capsulitis, tendinitis, or trigger points in the upper quadrant. There was a noticeable stiffening of the neck with very limited cervical range of motion in all planes and directions. Vital signs were unremarkable, but the client was perspiring heavily despite being in threadbare
TABLE 18-2
clothing and at rest. He reported getting the "sweats" everyday around this same time. The therapist asked the client to take a deep breath and cough. He went into a paroxysm of coughing, which he said caused his shoulder to start aching. The cough was productive, but the client swallowed the sputum. Auscultation of lung sounds revealed rales (crackles) in the right upper lung lobe. Supraclavicular lymph nodes were palpable, tender, and moveable on both sides. The therapist contacted the charge nurse and reported the following concerns: • Constitutional symptoms of sweats and fatigue (although fatigue could be caused by his extreme malnutrition) • Pulmonary impairment with reproduction of symptoms with respiratory movements • Suspicious (aberrant) lymph nodes (bilateral) • Cervical spine involvement with no apparent cause or recognizable musculoskeletal pattern Result: Consult with the physician on call resulted in a medical evaluation and x-ray. Client was diagnosed with pulmonary tuberculosis, which was confirmed by a skin test. Shoulder and neck pain and dysfunction were attributed to a pulmonary source and not considered appropriate for physical therapy intervention. The client was sent to a halfway house where he could receive adequate nutrition and medical services to treat his tuberculosis.
Location of Shoulder Pain
Systemic origin Peptic ulcer Myocardial ischemia Hepatic/biliary: Acute cholecystitis Liver abscess Gallbladder Liver disease (hepatitis, cirrhosis, metastatic tumors) Pulmonary: Pleurisy Pneumothorax Pancoast's tumor Pneumonia Kidney
Right shoulder location
Systemic origin
Left shoulder location
Lateral border, R scapula R shoulder, down arm
Ruptured spleen Myocardial ischemia Pancreas Ectopic pregnancy (rupture)
L L L L
Infectious mononucleosis (hepatomegaly, splenomegaly)
L shoulder/L upper trapezius
Pulmonary: Pleurisy Pneumothorax Pancoast's tumor Pneumonia Kidney Postoperative laparoscopy
Ipsilateral shoulder; upper trapezius
R R R R R
shoulder; between scapulae; subscapular area shoulder upper trapezius, R shoulder shoulder, R subscapula
Ipsilateral shoulder; upper trapezius
Ipsilateral shoulder
shoulder (Kehr's sign) pectoral/L shoulder shoulder shoulder (Kehr's sign)
Ipsilateral shoulder L shoulder (Kehr's sign)
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SECTION III
CASE EXAMPLE 1 8 - 3
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
Cardiac Cause of Sh oulder Pain
A 65-year-old retired railroad engineer has come to you with a left "frozen shoulder." During the course of the subjective examination, he tells you he is taking two cardiac medications. What questions would you ask that might help you relate these two problems or rule out cardiac as a possible cause? (shoulder/cardiac) Try to organize your thoughts using these categories: • Onset/History of shoulder involvement • Medical Testing • Clinical Presentation • Past Medical History Physical Therapy Screening Interview Onset 1 History
• What do you think is the cause of your shoulder problem? • When did it occur, or how long have you had this problem (sudden or gradual onset)? • Can you recall any specific incident when you injured your shoulder, for example, by falling, being hit by someone or something, automobile accident? • Did you ever have a snapping or popping sensation just before your shoulder started to hurt? (ligamentous or cartilagenous lesion) • Did you injure your neck in any way before your shoulder developed these problems? • Have you had a recent heart attack? Have you had nausea, fatigue, sweating, chest pain, or pressure? Any pain in your neck, jaw, left shoulder, or down your left arm? • Has your left hand ever been stiff or swollen? (Complex Regional Pain Syndrome after myocardial infarction) • Do you think your shoulder pain is related to your heart problems? • Shortly before you first noticed difficulty with your shoulder were you involved in any kind of activities that would require repetitive movements, such as painting, gardening, playing tennis or golf? Medical Testing • Have you had any recent x-rays taken of the shoulder or your neck? • Have you received medical or physical therapy treatment for shoulder problems before?
If yes, where, when, why, who, and what (see Chapter 2 for specific questions)? • Have you had any (extensive) medical testing during the past year? Clinical Presentation Pain 1 Symptoms
Follow the usual line of questioning regarding the pattern, frequency, intensity, and duration outlined in Fig. 3-6 to establish necessary information regarding pain. • Is your shoulder painful? If yes, how long has the shoulder been painful? Aggravating 1 Relieving
Activities
• How does rest affect your shoulder symptoms? (True muscular lesions are relieved with prolonged rest [i.e., more than 1 hour], whereas angina is usually relieved more immediately by cessation of activity or rest [i.e., usually within 2 to 5 minutes, up to 15 minutes.]) • Does your shoulder pain occur during exercise (e.g., walking, climbing stairs, mowing the lawn or any other physical or sexual activity? (Evaluate the difference between total body exertion causing shoulder symptoms versus movements of the upper extremities only reproducing symptoms. Total body exertion causing shoulder pain may be secondary to angina or myocardial infarction, whereas movements of just the upper extremities causing shoulder pain are indicative of a primary musculoskeletal lesion.) Past Medical History • Have you had any surgery during the past year? • How has your general health been? (Shoulder pain is a frequent site of referred pain from other internal medical problems; see Fig. 18-2) • Did you ever have rheumatic fever when you were a child? What is your typical pattern of chest pain or • angina? • Has this pattern changed in any way since your shoulder started to hurt? For example, does the chest pain last longer, come on with less exertion, and feel more intense? • What medications are you taking? • Do your heart medications relieve your shoulder symptoms, even briefly?
CHAPTER 18
CASE EXAMPLE 1 8 - 3
SCREENING THE SHOULDER AND UPPER EXTREMITY
825
Cardiac Cause of S h o u l d e r Pain—cont'd
If yes, how long after you take the medications do you notice a difference? Does this occur every time that you take your medications? Evaluating subacute/acute/chronic musculoskeletal lesion versus systemic pain pattern (see Chapter 3, Night Pain, for specific meaning to the client's answers to these questions): • Can you lie on that side? • Does the shoulder pain awaken you at night? If yes, is this because you have rolled onto that side? • Do you notice any chest pain, night sweats, fever, or heart palpitations when you wake up at night? • Have you ever noticed these symptoms (e.g., chest pain, heart palpitations) with your shoulder pain during the day?
Shoulder pain is difficult to diagnose because any pain felt in the shoulder will affect the joint as though the pain was originating in the joint.
John Mennell
• Do these symptoms wake you up separately from your shoulder pain, or does your shoulder pain wake you up and you have these additional symptoms? (As always when asking questions about sleep patterns, the person may be unsure of the answers to the questions. In such cases the physical therapist is advised to ask the client to pay attention to what happens related to sleep during the next few days up to 1 week and report back with more information.) Other Clinical Tests: In addition to an orthopedic screening examination, the therapist should review potential side effects and interactions of cardiac medications, take vital signs, auscultate (including femoral bruits), and palpate for the aortic pulse (see Fig. 4-52).
The client may wrongly attribute onset of symptoms to an activity. The alert therapist may recognize a true causative factor.
6
... even when there is a known cause, especially in the older adult.
Catherine Goodman It is not uncommon for the older adult to attribute "overdoing" it to the appearance of physical pain or neuromusculoskeletal dysfunction. Any adult over age 65 presenting with shoulder pain and/or dysfunction must be screened for systemic or viscerogenic origin of symptoms, even when there is a known (or attributed) cause or injury. In Chapter 2 it was stressed that clients who present with no known cause or insidious onset must be screened along with anyone who has a known or assumed cause of symptoms. Whether the client presents with an unknown etiology of injury or impairment or with an assigned cause, always ask yourself these questions. Follow-Up Questions • Is it really insidious? • Is it really caused by such and such (whatever the client told you)?
Shoulder Pain Patterns In Chapter 3 (Pain Types and Viscerogenic Pain Patterns) we presented three possible mechanisms for referred pain patterns from the viscera to the soma (embryologic development, multisegmental innervations, and direct pressure on the diaphragm). Multisegmental innervations (see Fig. 3-3) and direct pressure on the diaphragm (see Figs. 3-4 and 3-5) are two key mechanisms for referred shoulder pain. MULTISEGMENTAL
INNERVATIONS
Because the shoulder is innervated by the same spinal nerves that innervate the diaphragm (C3C5), any messages to the spinal cord from the diaphragm can result in referred shoulder pain. The nervous system can only tell what nerves delivered the message. It does not have any way to tell if the message sent along via spinal nerves C3 to C5 came from the shoulder or the diaphragm. So it takes a guess and sends a message back to one or the other. This means that any organ in contact with the diaphragm that gets obstructed, inflamed, or infected can refer pain to the shoulder by putting
826
SECTION III
CASE EXAMPLE 1 8 - 4
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
P l e u r a l E f f u s i o n w i t h F i b r o s i s , Late Complication of CABG
Referral: A 53-year-old man was referred to physical therapy by his primary care physician for left shoulder pain. Past Medical History: The client had a recent (6 months ago) history of cardiac bypass surgery (also known as coronary artery bypass graft or CABG) and had completed Phase 1 and Phase 2 cardiac rehab programs. He was continuing to follow an exercise program (Phase 3 cardiac rehab) prescribed for him at the time of his PT referral. Clinical Presentation: The client looked in good health and demonstrated good posture and alignment. Shoulder range of motion was equal and symmetric bilaterally but the client reported pain when the left arm was raised over 90 degrees of flexion or abduction. His position of preference was left side lying. The pain could be reduced in this position from a rated level of 6 to a 2 on a scale from 0 (no pain) to 10 (worst pain). Scapulohumeral motion on the left was altered compared to the right. Medial and lateral rotations were WNL with the upper arm against the chest. Lateral rotation reproduced painful symptoms when performed with the shoulder in 90 degrees of abduction. Physiologic motions were fully present in all directions on the left but seemed "sluggish" compared to the right. Neuro screen-negative Vital signs: Blood pressure: 122/68 mm Hg Resting pulse: 60bpm Body temperature: 98.6° F Cardiopulmonary screening exam: Diminished basilar (lower lobes) breath sounds on the left compared to the right Decreased chest wall excursion on the left; increased shoulder pain with deep inspiration Dyspnea was not observed at rest When asked if there were any symptoms of any kind anywhere else in the body, the client reported ongoing but intermittent chest pain and shortness of breath for the last 3 months. The client had not reported these "new" symptoms to the physician.
What are the red flags (if any)? Is an immediate medical referral indicated? Red Flags • Age over 40 • Previous (recent) history of cardiac surgery • Unequal basilar breath sounds • Unreported symptoms of chest pain and dyspnea • Autosplinting (lying on the affected side diminishes lung movement, reducing shoulder pain) Medical Consultation: Shoulder problems are not uncommon following CABGs but the number and type of red flags present caught the therapist's attention. The client was not in any apparent physiologic distress and vital signs were within normal limits (although he was on antihypertensive medications). Since he was referred by his primary care physician, the therapist made telephone contact with the physician's office and faxed a summary of findings immediately. A program of physical therapy intervention was determined but the therapist insisted on speaking with the physician first before proceeding with the program. The physician approved the therapist's treatment plan but requested immediate follow up with the client who was seen the next day. Result: The client was diagnosed with pleural effusion causing pleural fibrosis, a rare long term complication of cardiac bypass surgery. The physician noted that the left lower lobe was adhered to the chest wall. There is a high risk of post-operative effusion early on after bilateral internal mammary artery harvests for bypass surgery. Early effusions (less than 30 days after CABG) occur in up to two-thirds of all patients; late effusions (30 days after CABG) develop in one-third of all patients. The client was treated medically but also continued in physical therapy to restore full and normal motion of the shoulder complex. The physician also asked the therapist to review the client's cardiac rehab program and modify it accordingly due to the pulmonary complications. 5
CHAPTER 18
SCREENING THE SHOULDER AND UPPER EXTREMITY
pressure on the diaphragm, stimulating afferent nerve signals, and telling the nervous system that there is a problem. DIAPHRAGMATIC IRRITATION
Irritation of the peritoneal (outside) or pleural (inside) surface of the central diaphragm refers sharp pain to the ipsilateral upper trapezius, neck and/or supraclavicular fossa (Fig. 18-1). Shoulder pain from diaphragmatic irritation usually does not cause anterior shoulder pain. Pain is confined to the suprascapular, upper trapezius, and posterior portions of the shoulder. If the irritation crosses the midline of the diaphragm, then it is possible to have bilateral shoulder pain. This does not happen very often and is most common with cardiac ischemia or pulmonary pathology affecting the lower lobes of the lungs on both sides. Irritation of the peripheral portion of the diaphragm is more likely to refer pain to the costal margins and lumbar region on the same side. As you review Fig. 3-4, note how the heart, spleen, kidneys, pancreas (both the body and the tail), and the lungs can put pressure on the diaphragm. This illustration is key to remembering which shoulder can be involved based on organ pathology. For example, the spleen is on the left side of the body so pain from spleen rupture or injury is referred to the left shoulder (called Kehr's sign) (Case Example 18-5).
827
Either shoulder can be involved with renal colic, but it is usually an ipsilateral referred pain pattern depending on which kidney is impaired (see Fig. 10-7). Bilateral shoulder pain from renal disease would only occur if and when both kidneys are compromised at the same time. The body of the pancreas lies along the midline of the diaphragm. When the body of the pancreas is enlarged, inflamed, obstructed or otherwise impinging on the diaphragm, back pain is a possible referred pain pattern. Pain felt in the left shoulder may result from activation of pain fibers in the left diaphragm by an adjacent inflammatory process in the tail of the pancreas. Keep in mind that shoulder pain also can occur from diaphragmatic dysfunction. For anyone with shoulder pain of an unknown origin or which does not improve with intervention, palpate the diaphragm and assess its excursion and timing during respiration. Reproduction of shoulder symptoms with direct palpation of the diaphragm and the presence of altered diaphragmatic movement with breathing offer clues to the possibility of diaphragmatic (muscular) involvement. Fig. 18-2 reminds us that shoulder pain can be referred from the neck, chest, abdomen, and elbow. During orthopedic assessment, the therapist always checks "above and below" the impaired level for a possible source of referred pain. With this guideline in mind, we know to look for potential musculoskeletal or neuromuscular causes from the cervical spine and elbow.
Associated Signs and Symptoms
Fig. 18-1 • Irritation of the peritoneal (outside) or pleural (inside) surface of the central area of the diaphragm refers sharp pain to the upper trapezius muscle, neck, and supraclavicular fossa. The pain pattern is ipsilateral to the area of irritation. Irritation to the peripheral portion of the diaphragm refers sharp pain to the costal margins and lumbar region (not shown).
One of the most basic clues in screening for a viscerogenic or systemic cause of shoulder pain is to look for shoulder pain accompanied by any of the following features: • Pleuritic component • Exacerbation by recumbency • Coincident diaphoresis (cardiac) • Associated gastrointestinal (GI) signs and symptoms • Exacerbation by exertion unrelated to shoulder movement (cardiac) • Associated urologic signs and symptoms Shoulder pain with any of these present should be approached as a manifestation of systemic visceral illness. This is true even if the pain is exacerbated by shoulder movement or if there are objective findings at the shoulder. Using the past medical history and assessing for the presence of associated signs and symptoms will alert the therapist to any red flags suggesting a systemic origin of shoulder symptoms. For 7
828
SECTION III
CASE EXAMPLE 1 8 - 5
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
Rugby i n j u r y : K e h r ' s S i g n
Referral: A 27-year-old male accountant who has an office in the same complex with a physical therapy practice stopped by early Monday morning complaining of left shoulder pain. When asked about repetitive motions or recent trauma or injuries, he reported playing in a rugby tournament over the weekend. "I got banged up quite a few times, but I had so much beer in me, I didn't feel a thing." Clinical Presentation: Pain was described as a deep, sharp aching over the upper trapezius and shoulder area on the left side. There were no visual bruises or signs of bleeding in the upper left quadrant. Vital signs were taken and recorded: Pulse: 89 bpm Respirations: 12 per minute Blood pressure: 90/48 mm Hg (recorded sitting, left arm) Temperature: 97° (reported as the client's "normal" morning temperature) Pain: Rated as a 5 on a scale from 0 to 10 Range of motion was full in all planes and movements. No particular movement increased or decreased the pain. Gross manual muscle test of the upper extremities was normal (5/5 for flexion, abduction, extension, rotations). Neurologic screen was negative. All special shoulder tests (e.g., impingement, anterior and posterior instability, quadrant position) were unremarkable. What are the red flags here? What are your next questions, steps, or screening tests? Red Flags: • Hypotension • Left shoulder pain within 24 hours of possible trauma or injury • Unable to alter, provoke, or palpate painful symptoms • Clinical presentation is not consistent with expected picture for a shoulder problem; lack of objective findings
What are your next questions, steps, or screening tests? Repeat blood pressure measurements, bilaterally. Perform percussive tests for the spleen (see Fig. 4-50). Depending on the results of these clinical tests, referral might be needed immediately. In this case, the percussive test for enlarged spleen was inconclusive, but there was an observable and palpable "fullness" in the left flank compared to the right. Result: This client was told: Mr. Smith, your exam does not look like what I would expect from a typical shoulder injury. Since I cannot find any way to make your pain better or worse and I cannot palpate or feel any areas of tenderness, there may be some other cause for your symptoms. Given your history of playing rugby over the weekend, it is possible you have some internal injuries. I am not comfortable treating you until a medical doctor examines you first. Bleeding from the spleen can cause left shoulder pain. When I tapped over the area of your spleen, it did not sound quite like I expected it to, and it seems like there is some fullness along your left side that I am not seeing or feeling on the right. I do not want to alarm you, but it may be best to go over to the emergency department of the hospital and see what they have to say. You can also call your regular doctor and see if you can get in right away. You can do that right from our clinic phone. Final Result: This accountant had clients already scheduled starting in 10 minutes. He did not feel he had the time to go check this out until his lunch hour. About 45 minutes later an ambulance was called to the building. Mr. Smith had collapsed and his co-workers called 9-1-1. He was rushed to the hospital and diagnosed with a torn and bleeding spleen, which the doctor called a "slow leak." It eventually ruptured, leaving him unconscious from blood loss.
CHAPTER 18
SCREENING THE SHOULDER AND UPPER EXTREMITY
Cervical spine
829
signs and symptoms is present. Based on the results of this review we formulate our final screening questions, tests, and measures. Always remember to end each client interview with the following (or similar) question: Follow-Up Questions • Do you have any symptoms of any kind anywhere else in your body that we haven't talked about yet?
SCREENING FOR PULMONARY CAUSES OF SHOULDER PAIN
Fig. 18-2 • Musculoskeletal and systemic structures referring pain to the shoulder. (Modified from Magee DJ: Orthopedic physical assessment, ed 2, Philadelphia, 1992, WB Saunders; p 1 25.)
example, a ruptured ectopic pregnancy with abdominal hemorrhage can produce left shoulder pain in a woman of childbearing age. The woman is sexually active and there is usually a history of missed menses or recent unexplained/unexpected bleeding. Another example is the left shoulder pain lasting several days that can occur after laparoscopy. During the procedure air is introduced into the peritoneum to expand the area and move the abdominal contents out of the way. Residual gas present postoperatively can put pressure on the diaphragm and refer pain to the shoulder. Likewise distention of the renal cap from kidney disorders can cause pain to the ipsilateral shoulder (again, via pressure on the diaphragm). In the first case a recent surgery would be part of the past medical history. In the case of a kidney disorder causing shoulder pain, accompanying urologic symptoms are usually present. The client may not recognize the connection between painful urination and shoulder pain or the link between gallbladder removal by laparoscopy and subsequent shoulder pain. It is the therapist's responsibility to assess musculoskeletal symptoms, making a diagnosis that includes ruling out the possibility of systemic disease.
Review of Systems Associated signs and symptoms feature heavily in the Review of Systems as we step back and look to see if a cluster of any particular organ-dependent
Extensive disease may occur in the periphery of the lung without pain until the process extends to the parietal pleura. Pleural irritation then results in sharp, localized pain that is aggravated by any respiratory movement. Clients usually note that the pain is alleviated by lying on the affected side, which diminishes the movement of that side of the chest (called "autosplinting") whereas shoulder pain of musculoskeletal origin is usually aggravated by lying on the symptomatic shoulder. Shoulder symptoms made worse by recumbence is a yellow flag for pulmonary involvement. Lying down increases the venous return from the lower extremities. A compromised cardiopulmonary system may not be able to accommodate the increase in fluid volume. Referred shoulder pain from the taxed and overworked pulmonary system may result. At the same time, recumbency or the supine position causes a slight shift of the abdominal contents in the cephalic direction. This shift may put pressure on the diaphragm, which in turn presses up against the lower lung lobes. The combination of increased venous return and diaphragmatic pressure may be enough to reproduce the musculoskeletal symptoms. Pneumonia in the older adult may appear as shoulder pain when the affected lung presses on the diaphragm; usually there are accompanying pulmonary symptoms, but in older adults, confusion (or increased confusion) may be the only other associated sign. The therapist should look for the presence of a pleuritic component such as a persistent or productive cough and/or chest pain. Look for tachypnea, dyspnea, wheezing, hyperventilation, or other noticeable changes. Chest auscultation is a valuable tool when screening for pulmonary involvement.
830
SECTION III
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
SCREENING FOR CARDIAC CAUSES OF SHOULDER PAIN Pain of cardiac and diaphragmatic origin is often experienced in the shoulder because the heart and diaphragm are supplied by the C5 to C6 spinal segment, and the visceral pain is referred to the corresponding somatic area (see Fig. 3-3). Exacerbation of the shoulder symptoms from a cardiac cause occurs when the client increases activity that does not necessarily involve the arm or shoulder. For example, walking up stairs or riding a stationary bicycle can bring on cardiac induced shoulder pain. In cases like this, the therapist should ask about the presence of nausea, unexplained sweating, jaw pain or toothache, back pain, or chest discomfort or pressure. For the client with known heart disease, ask about the effect of taking nitroglycerin (men) or antacids/acid-relieving drugs (women) on their shoulder symptoms. Vital sign and physical assessment including chest auscultation are important screening tools. See Chapter 4 for details.
Angina or Myocardial Infarction Angina and/or myocardial infarction can appear as arm and shoulder pain that can be misdiagnosed as arthritis or other musculoskeletal pathologic conditions (see complete discussion, Chapter 6; see Figs. 6-8 and 6-9). Look for shoulder pain that starts 3 to 5 minutes after the start of activity, including shoulder pain with isolated lower extremity motion (e.g., shoulder pain starts after the client climbs a flight of stairs or rides a stationary bicycle). If the client has known angina and takes nitroglycerin, ask about the influence of the nitroglycerin on shoulder pain. Shoulder pain associated with myocardial infarction is unaffected by position, breathing, or movement. Because of the well-known association between shoulder pain and angina, cardiac related shoulder pain may be medically diagnosed without ruling out other causes, such as adhesive capsulitis or supraspinatus tendinitis when, in fact, the client may have both a cardiac and a musculoskeletal problem (Case Example 18-6). Using a review of symptoms approach and a specific musculoskeletal shoulder examination, the physical therapist can screen to differentiate between a medical pathologic condition and mechanical dysfunction (Case Example 18-7). 8
Complex Regional Pain Syndrome (CRPS) Complex regional pain syndrome (CRPS, types I and II) characterized by chronic extremity pain following trauma is sometimes still referred to by the outdated term shoulder-hand syndrome (see Case Example, Chapter 1). Type I was formerly known as reflex sympathetic dystrophy or RSD. Type II was referred to as causalgia. CRPS was first recognized in the 1800s as causalgia or burning pain in wounded soldiers. Similar presentations after lesser injuries were labeled as RSD. Shoulder-hand syndrome was a condition that occurred after a myocardial infarct (heart attack), usually after prolonged bedrest. This condition (as it was known then) has been significantly reduced in incidence by more up-to-date and aggressive cardiac rehabilitation programs. Today CRPS-I, primarily affecting the limbs, develops after bone fracture or other injury (even slight or minor trauma, venipuncture, or an insect bite) or surgery to the upper extremity (including shoulder arthroplasty) or lower extremity. Type I is not associated with nerve lesion, whereas Type II develops after trauma with nerve lesion. CRPS-I is still associated with cerebrovascular accident (CVA), heart attack, or diseases of the thoracic or abdominal viscera that can refer pain to the shoulder and arm. This syndrome occurs with equal frequency in either or both shoulders and, except when caused by coronary occlusion, is most common in women. The shoulder is generally involved first, but the painful hand may precede the painful shoulder. When this condition occurs after a myocardial infarction, the shoulder initially may demonstrate pericapsulitis. Tenderness around the shoulder is diffuse and not localized to a specific tendon or bursal area. The duration of the initial shoulder stage before the hand component begins is extremely variable. The shoulder may be "stiff' for several months before the hand becomes involved, or both may become stiff simultaneously. Other accompanying signs and symptoms are usually present, such as edema, skin (trophic) changes, and vasomotor (temperature, hydrosis) changes. 9
10
Clinical Signs and Symptoms of
Complex Regional Pain Syndrome (Type 1) Stage I • • •
(acute, lasting several weeks)
Pain described as burning, aching, throbbing Sensitivity to touch Swelling Continued on p. 833
CHAPTER 18
CASE EXAMPLE 1 8 - 6
SCREENING THE SHOULDER AND UPPER EXTREMITY
S t r a n g e Case of the Flu
Referral: A 53-year-old butcher at the local grocery store stopped by the physical therapy clinic located in the same shopping complex with a complaint of unusual shoulder pain. He had been seen at this same clinic several years ago for shoulder bursitis and tendinitis from repetitive overuse (cutting and wrapping meat). Clinical Presentation: His clinical presentation for this new episode of care was exactly as it had been during the last episode of shoulder impairment. The therapist re-instituted a program of soft tissue mobilization and stretching, joint mobilization, and postural alignment. Modalities were used during the first two sessions to help gain pain control. At the third appointment, the client mentioned feeling "dizzy and sweaty" all day. His shoulder pain was described as a constant, deep ache that had increased in intensity from a 6 to a 10 on a scale from 0 to 10. He attributed these symptoms to having the flu. It was not until this point that the therapist conducted a screening exam and found the following red flags: • Age • Recent history (past 3 weeks) of middle ear infection on the same side as the involved shoulder
CASE EXAMPLE 1 8 - 7
831
• Constant, intense pain (escalating over time) • Constitutional symptoms (dizziness, perspiration) • Symptoms unrelieved by physical therapy treatment Result: The therapist suggested the client get a medical check-up before continuing with physical therapy. Even though the clinical presentation supported shoulder impairment, there were enough red flags and soft signs of systemic distress to warrant further evaluation. Taking vital signs would have been a good idea. It turns out the client was having myocardial ischemia masquerading as shoulder pain, the flu and an ear infection. He had an angioplasty with complete resolution of all his symptoms and even reported feeling energetic for the first time in years. This is a good example of how shoulder pain and dysfunction can exactly mimic a true musculoskeletal problem-even to the extent of reproducing symptoms from a previous condition. This case highlights the fact that we must be careful to fully assess our clients with each episode of care.
Angina v s . S h o u Ider P a t h o l o g y
Referral: A 54-year-old man was referred to physical therapy for pre-prosthetic training after a left transtibial (TT) amputation. Past Medical History: A right transtibial amputation was done four years ago Coronary artery disease (CAD) with coronary artery bypass graft (CABG), myocardial infarction (heart attack), and angina Peripheral vascular disease (PVD) Long-standing diabetes mellitus (insulin dependent x47 years) Gastroesophageal reflux disease (GERD) Clinical Presentation: At the time of the initial evaluation for the left TT amputation, the client reported substernal chest pain and left upper extremity pain with activity. Typical anginal pain pattern was described as subster-
nal chest pain. The pain occurs with exertion and is relieved by rest. Arm pain has never been a part of his usual anginal pain pattern. He reports his arm pain began 10 months ago with intermittent pain starting in the left shoulder and radiating down the anterior-medial aspect of the arm, halfway between the shoulder and the elbow. The pain is made worse by raising his left arm overhead, pushing his own wheelchair, and using a walker. He was not sure if the shoulder pain was caused by repetitive motions needed for mobility or by his angina. The shoulder pain is relieved by avoiding painful motions. He has not received any treatment for the shoulder problem.
832
SECTION III
CASE EXAMPLE 1 8 - 7 Vital Signs:
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
A n g i n a v s . S h o u Ider Pathology—cont'd
Heart rate Blood pressure
88bpm 120/66 mm Hg (position and extremity, not recorded) Respirations WNL Vital Signs after transfer and pregait activities: Heart rate 92 bpm Blood pressure 152/76 mm Hg Respirations "Minimal shortness of breath" recorded Neuro screen: WNL Special Tests: Yergason's sign: Positive Apprehension test: Positive Relocation test: Positive Speed's test: Positive
Palpation of the biceps and supraspinatus tendons increased the client's shoulder pain. Active Range of Motion (Left shoulder) Flexion 100° Abduction 70° I/E Rotation 60°
There is a capsular pattern in the left glenohumeral joint with limitations in rotation and adduction. Significant capsular tightness is demonstrated with passive or physiologic motions (joint play) of the humerus on the glenoid. Manual Muscle Test (gross) Bilateral UE
4/5 (throughout available active ROM)
Review of Systems: Dyspnea, fatigue, sweats with pain; when grouped together, these three symptoms fall under the Cardiovascular category; these do not occur at the same time as the shoulder pain. • How can you differentiate between medical pathology and mechanical dysfunction as the cause of this client's shoulder pain? • Is a medical referral advised? 1. Complete special tests for shoulder impingement, tendonitis, and capsulitis as demonstrated. 2. Assess for trigger points; eliminate trigger points and reassess symptoms. 3. Carry out a Review of Systems to identify clusters of systemic signs and symptoms. In
this case, a small cluster of cardiovascular symptoms were identified. 4. Correlate symptoms from Review of Systems with shoulder pain (i.e., Do the associated signs and symptoms reported occur along with the shoulder pain or do these two sets of symptoms occur separately from each other?). 5. Assess the effect of using just the lower extremities on shoulder pain; this was difficult to assess given this client's status as a bilateral amputee without a prosthetic device on the left side. Result: Test results point to an untreated biceps and supraspinatus tendinitis. This tendinitis combined with adhesive capsulitis most likely accounted for the left shoulder pain. This assessment was based on the decreased left glenohumeral active range of motion and decreased joint mobility. With objective clinical findings to support a musculoskeletal dysfunction, medical referral was not required. There were no indications that the shoulder pain was a signal of a change in the client's anginal pattern. Left shoulder impairments were limiting factors in his mobility and rehabilitation process. Shoulder intervention to alleviate pain and to improve upper extremity strength were included in the plan of care. The desired outcome was to improve transfer and gait activities. Left shoulder pain resolved within the first week of physical therapy intervention. This gain made it possible to improve ambulation from 3 feet to 50 feet with a walker while wearing a right lower extremity prosthesis. The client gained independence with bed mobility and supine-to-sit transfers. The client continued to make improvements in ambulation, range of motion, and functional mobility. Physical therapy intervention for the shoulder impairments had a significant impact on the outcomes of this client's rehab program. By differentiating and treating the shoulder movement dysfunction, the intervention enabled the client to progress faster in the transfer and gait training program than he would had his left shoulder pain been attributed to angina. 8
Data from Smith ML: Differentiating angina and shoulder pathology pain, Physical Therapy Case Reports 1(4):210-212, 1998.
CHAPTER 18
SCREENING THE SHOULDER AND UPPER EXTREMITY
• Muscle spasm • Stiffness, loss of motion and function • Skin changes (warm, red, dry skin changes to cold (cyanotic), sweaty skin) • Accelerated hair growth (usually dark hair in patches)
Stage II
(subacute, lasting 3 to
6 months) • •
Severity of pain increases Swelling may spread; tissue goes from soft to boggy to firm • Muscle atrophy • Skin becomes cool, pale, bluish, sweaty • Nail bed changes (cracked, grooved, ridges) •
Bone demineralization (early onset of osteoporosis)
Stage III
(chronic, lasting more than
6 months) •
Pain may stay same, improve, or get worse; variable • Irreversible tissue damage • Muscle atrophy and contractures • Skin becomes thin and shiny • •
Nails are brittle Osteoporosis
Thoracic Outlet Syndrome (see discussion,
Chapter 17) Compression of the neurovascular bundle consisting of the brachial plexus and subclavian artery and vein (see Fig. 17-10) can cause a variety of symptoms affecting the arm, hand, shoulder girdle, neck, and chest. Risk factors and clinical presentation are discussed more completely in Chapter 17 (Case Example 18-8).
Bacterial Endocarditis The most common musculoskeletal symptom in clients with bacterial endocarditis is arthralgia, generally in the proximal joints. The shoulder is affected most often, followed (in declining incidence) by the knee, hip, wrist, ankle, metatarsophalangeal and metacarpophalangeal joints, and by acromioclavicular involvement. Most clients with endocarditis related arthralgias have only one or two painful joints, although some may have pain in several joints. Painful symptoms begin suddenly in one or two joints, accompanied by warmth, tenderness, and redness. One helpful clue: as a rule, morning stiffness is not as prevalent in clients with endocarditis as in
833
those with rheumatoid arthritis or polymyalgia rheumatica.
Pericarditis The inflammatory process accompanying pericarditis may result in an accumulation of fluid in the pericardial sac, preventing the heart from expanding fully. The subsequent chest pain of pericarditis (see Fig. 3-9) closely mimics that of a myocardial infarction because it is substernal, is associated with cough, and may radiate to the shoulder. It can be differentiated from myocardial infarction by the pattern of relieving and aggravating factors. For example, the pain of a myocardial infarction is unaffected by position, breathing, or movement, whereas the chest and shoulder pain associated with pericarditis may be relieved by kneeling with hands on the floor, leaning forward, or sitting upright. Pericardial pain is often made worse by deep breathing, swallowing, or belching.
Aortic Aneurysm Aortic aneurysm appears as sudden, severe chest pain with a tearing sensation (see Fig. 3 - 1 0 ) , and the pain may extend to the neck, shoulders, lower back, or abdomen but rarely to the joints and arms, which distinguishes it from a myocardial infarction. Isolated shoulder pain is not associated with aortic aneurysm; shoulder pain occurs when the primary pain pattern radiates up and over the trapezius and upper arm(s) (see Fig. 6-11). The client may report a bounding or throbbing pulse (heart beat) in the abdomen. Risk factors and other associated signs and symptoms help distinguish this condition.
SCREENING FOR GASTROINTESTINAL CAUSES OF SHOULDER PAIN Upper abdominal or gastrointestinal problems with diaphragmatic irritation can refer pain to the ipsilateral shoulder. Peptic ulcer, gallbladder disease, and hiatal hernia are the most likely GI causes of shoulder pain seen in the physical therapy clinic. Usually there are associated signs and symptoms such as nausea, vomiting, anorexia, melena, or early satiety but the client may not connect the shoulder pain with GI upset. A few screening questions may be all that is needed to uncover any coincident GI symptoms. The therapist should look for a history of previous ulcer, especially in association with the use of
CASE EXAMPLE 1 8 - 8
House P a i n t e r
Referral: A 44-year-old female referred herself to physical therapy for a two-month long history of right upper trapezius and right shoulder pain. She works as a house painter and thinks the symptoms came on after a difficult job with high ceilings. She reports new symptoms of dizziness when getting up too fast from bed or from a chair. She is seeing a chiropractor and a naturopathic physician for a previous back injury 2 years ago when she fell off a ladder. She wants to try physical therapy since she has reached a "plateau" with her chiropractic care. Past Medical History: Other significant past medical history includes a total hysterectomy 4 years ago for unexplained heavy menstrual bleeding. She does not smoke or use tobacco products, but admits smoking marijuana occasionally and being a "social drinker" (wine coolers and beer on the weekends or at barbeques). She is nulliparous (never pregnant). She is not on any medications except ibuprofen as needed for headaches. She takes a variety of nutritional supplements given to her by the naturopath. No recent history of infections or illness. Clinical Presentation: There is no numbness or tingling anywhere in her body. No changes in vision, balance, or hearing. The client reports normal bowel and bladder function. Postural screen: Moderate forward head position, rounded shoulders, arms held in a position of shoulder internal rotation, minimal lumbar lordosis Neuro screen: WNL TMJ screen: Negative Vertebral artery tests: Negative Upper extremity ROM: Limited right shoulder internal rotation; all other motions in both UEs were full and pain free Spurling's test: Negative Cervical of the left C45; test: spine mobility Restriction no apparent cervical
instabilities; tenderness along the entire right cervical spine with mild hypertonus Trigger Points: Positive for right sternocleidomastoid, right upper trapezius, and right levator scapula TrPs Are there any red flags to suggest the need to screen for medical disease?
What other tests (if any) would you like to do before making this decision? • Age • Unexplained dizziness • Failure to progress with chiropractic care • Surgical menopause and nulliparity (both increase her risk for breast cancer; early menopause puts her at risk for osteoporosis and accelerated atherosclerosis/heart disease) Assessment: It is likely the client's symptoms are directly related to postural overuse. Long hours with her arms overhead may be contributing factors. A more complete exam for thoracic outlet syndrome is warranted. Physical therapy intervention can be initiated, but must be reevaluated on an on-going basis. Eliminating the trigger points, improving her posture, and restoring full shoulder and neck motion will aid in the differential diagnosis. The therapist should assess vital signs including blood pressure measurements in both arms (looking for a vascular component of thoracic outlet syndrome) and from supine to sit to stand to assess for postural orthostatic hypotension. True postural hypotension must be accompanied by both blood pressure and pulse rate changes. Depending on the results, medical evaluation may be warranted, especially if no underlying cause can be found for the dizziness. Although there is no reported visual changes or loss of balance with the dizziness, a vestibular screening examination is warranted. Given her age and risk factors, she should be asked when her last physical exam was done. If she has not been seen since her hysterectomy or within the last 12 months, she should be advised to see her personal physician for follow-up. She should be encouraged to exercise on a regular basis (more education can be provided depending on her level of knowledge and the therapist's level of expertise in this area). If baseline bone density studies have not been done, then she should pursue this now. Likewise, she should ask her doctor about baseline testing for thyroid, glucose, and lipid values if these are not already available. In a primary care practice, risk factor assessment is a key factor in knowing when to carry out a screening evaluation. Patient education about personal health choices is also essential. In any practice we must know what impact medical conditions can have on the neuromuscular and musculoskeletal systems and watch for any links between the visceral and the somatic systems.
CHAPTER 18
SCREENING THE SHOULDER AND UPPER EXTREMITY
nonsteroidal antiinflammatory drugs (NSAIDs). Shoulder pain that is worse 2 to 4 hours after taking the NSAID is a yellow flag. With a true musculoskeletal problem, peak NSAID dosage (usually 2 to 4 hours after ingestion; variable with each drug) should reduce or alleviate painful shoulder symptoms. Any pain increase instead of decrease may be a symptom of GI bleeding. The therapist must also ask about the effect of eating on shoulder pain. If eating makes shoulder pain better or worse (anywhere from 30 minutes to 2 hours after eating), there may be a gastrointestinal problem. The client may not be aware of the link between these two events until the therapist asks. If the client is not sure, follow up at a future appointment and ask again if the client has noticed any unusual symptoms or connection between eating and shoulder pain.
SCREENING FOR LIVER AND BILIARY CAUSES OF SHOULDER PAIN As with many of the organ systems in the human body, the hepatic and biliary organs (liver, gallbladder, and common bile duct) can develop diseases that mimic primary musculoskeletal lesions. The musculoskeletal symptoms associated with hepatic and biliary pathologic conditions are generally confined to the midback, scapular, and right shoulder regions. These musculoskeletal symptoms can occur alone (as the only presenting symptom) or in combination with other systemic signs and symptoms. Fortunately, in most cases of shoulder pain referred from visceral processes, shoulder motion is not compromised and local tenderness is not a prominent feature. Diagnostic interviewing is especially helpful when clients have avoided medical treatment for so long that shoulder pain caused by hepatic and biliary diseases may in turn create biomechanical changes in muscular contractions and shoulder movement. These changes eventually create pain of a biomechanical nature. Referred shoulder pain may be the only presenting symptom of hepatic or biliary disease. Sympathetic fibers from the biliary system are connected through the celiac and splanchnic plexuses to the hepatic fibers in the region of the dorsal spine. These connections account for the intercostal and radiating interscapular pain that accompanies gallbladder disease (see Fig. 9-10). Although the innervation is bilateral, most of the biliary fibers reach the cord through the right 11
835
splanchnic nerves, producing pain in the right shoulder.
SCREENING FOR RHEUMATIC CAUSES OF SHOULDER PAIN A number of systemic rheumatic diseases can appear as shoulder pain, even as unilateral shoulder pain. The HLA-B27-associated spondyloarthropathies (diseases of the joints of the spine), such as ankylosing spondylitis, most frequently involve the sacroiliac joints and spine. Involvement of large central joints, such as the hip and shoulder, is common, however. Rheumatoid arthritis and its variants likewise frequently involve the shoulder girdle. These systemic rheumatic diseases are suggested by the details of the shoulder examination, by coincident systemic complaints of malaise and easy fatigability, and by complaints of discomfort in other joints either coincidental with the presenting shoulder complaint or in the past. Other systemic rheumatic diseases with major shoulder involvement include polymyalgia rheumatica and polymyositis (inflammatory disease of the muscles). Both may be somewhat asymmetric but almost always appear with bilateral involvement and impressive systemic symptoms.
SCREENING FOR INFECTIOUS CAUSES OF SHOULDER PAIN The most likely infectious causes of shoulder pain in a physical therapy practice include infectious (septic) arthritis (see discussion, Chapter 3; see also Box 3-6), osteomyelitis, and infectious mononucleosis (mono). Immunosuppression for any reason puts people of all ages at risk for infection (Case Example 18-9). Osteomyelitis (bone infection) is caused most commonly by Staphylococcus aureus. Children under 6 months of age are most likely to be affected by
Haemophilus
influenzae
or
Streptococcus.
Hematogenous spread from a wound, abscess, or systemic infection (e.g., tuberculosis, urinary tract infection, upper respiratory infection) occurs most often. Osteomyelitis of the spine is associated with injection drug use. Onset of clinical signs and symptoms is usually gradual in adults but may be more sudden in children with high fever, chills, and inability to bear weight through the affected joint. In all ages there is marked tenderness over the site of the infection when the affected bone is superficial (e.g., spinous
836
SECTION III
CASE EXAMPLE 1 8 - 9
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
Osteomyelitis
Referral: SC, an active 62-year-old cardiac nurse, was referred by her orthopedic surgeon for "PT [for] possible rotator cuff tear (RCT), three times a week for four weeks." SC reported an "open" MRI was negative for RCT and plain films were also negative. She noted that laboratory testing was not done. Past Medical History Medications: Current medications included Motrin 800 mg tid for pain; Decadron 0.75 mg qid for atypical dermatitis and asthma (45-year use of corticosteroids); Avapro 75 mg qid to control hypertension; Hydrodiuril 25 mg qid to counteract fluid retention from corticosteroids; and Chlor-Trimeton 12 mg qid to suppress the high level of blood histamine resulting from the long-term comorbid condition of atypical dermatitis and asthma. Social History: The client consumes one glass of wine per day, quit smoking in 1961, and has never done illicit drugs. Clinical Presentation Pain Pattern: The client presented with primary complaints of severe and limiting pain of nearly four weeks duration with any active movement at her left (L) shoulder and at rest. Her pain was rated on the visual analog scale (VAS) as 7/10 at rest and 9/10 to 10/10 with motion at glenohumeral (GH) joint. Pain onset was gradual over a 3-day period; she was not aware of injury or trauma. She reported an inability to: (1) use her left upper extremity (UE); (2) lie on or bear weight on left side; (3) perform activities of daily living (ADLs); (4) sleep uninterrupted due to pain, awakening 4 or 5 times nightly; or (5) participate in regular weekly Yoga classes. Vital Signs: Temperature: 37 degrees C (98.6 degrees F.); Blood pressure: 120/98 mm Hg. SC reported that her medication combination of Decadron and Chlor-Trimeton had been implicated in the past by her physician as acting to suppress low-grade fevers. Observation: Slight puffiness, minimal swelling, observed in the left supraclavicular area. SC holds left upper extremity at her side with the elbow flexed to 90 degrees and the shoulder held in internal rotation. Standing posture: Forward head position with increased cervical spine lordosis and tho-
racic spine kyphosis, with an inability to attain neutral or reverse either spinal curve. Palpation revealed exquisite tenderness at distal clavicle and both anterior and posterior aspects of proximal humerus. Cervical spine screen: Spurling's compression,
distraction, and Quadrant testing were all negative; deep tendon reflexes at C5, C6, and C7 were symmetrically increased bilaterally; dermatomal testing was WNL; myotomes could not be reliably tested due to pain. Special
tests
at
the
shoulder
could
not
be performed or were unreliable due to pain limitation. Range of Motion: Left GH joint AROM and PROM were severely limited. AROM: Unable to actively perform flexion or abduction at left shoulder. PROM If left shoulder (measured in supine with arm at side and elbow flexed to 90 degrees): Flexion:
35 degrees
Abduction: 35 degrees Internal rotation: 50 degrees External rotation: -10 degrees All ranges were pain limited with an "empty" end feel. Evaluation/Assessment: SC's signs, symptoms, and examination findings were consistent with those of a severe, full-thickness RCT, including severity of pain and functional loss with empty end-feel at GH joint ROM. However, the inability to obtain results of special test results at the shoulder limited the certainty of the RCT diagnosis. Red flags included age over 50, severe loss of motion with empty end feel, constancy and severity of pain, inability to relieve pain or obtain a comfortable position, bony tenderness, and insidious onset of the condition. Additional risk factors included long-term use of corticosteroids to treat atypical dermatitis with asthma. Based on the objective examination findings, including swelling, bone tenderness, along with the severity and unrelenting nature of her pain, the presence of a more serious underlying systemic medical condition was considered (in addition to a possible unconfirmed RCT). Associated Signs and Symptoms: SC denied a fever, chills, night sweats, pain in other
CHAPTER 18
CASE EXAMPLE 1 8 - 9
SCREENING THE SHOULDER AND UPPER EXTREMITY
837
O s t e o m y e l i t i s -cont'd
joints or bones, weight loss, abdominal pain, nausea or vomiting. Outcomes: The client made very little progress after the prescribed physical therapy intervention. The severity of pain and functional loss remained unchanged. Numerous attempts were made by the client and the therapist to discuss this case with the referring physician. The client eventually referred herself to a second physician.
Result: The client was diagnosed with osteomyelitis as a result of a repeat MRI and a triple-phase bone scan, and laboratory test results of elevated levels of ESR and CRP values. A surgical biopsy confirmed the diagnosis. She underwent three different surgical procedures culminating in a total shoulder arthroplasty (TSA) along with repair of the fullthickness RCT
West PR: Case report presented in fulfillment of DPT 910, Institute for Physical Therapy Education, Widener University, Chester, Pennsylvania, 2005. Used with permission.
process, distal femur, proximal tibia). The most reliable way to recognize infection is the presence of both local and systemic symptoms. Mononucleosis is a viral infection that affects the respiratory tract, liver, and spleen. Splenomegaly with subsequent rupture is a rare but serious cause of left shoulder pain (Kehr's sign). There is usually left upper abdominal pain and, in many cases, trauma to the enlarged spleen (e.g., sports injury) is the precipitating cause in an athlete with an unknown or undiagnosed case of mono. Palpation of the upper left abdomen may reveal an enlarged and tender spleen (Fig. 4-50). The virus can be present 4 to 10 weeks before any symptoms develop so the person may not know mono is present. Acute symptoms can include sore throat, headache, fatigue, lymphadenopathy, fever, myalgias, and, sometimes, skin rash. Enlarged tonsils can cause noisy breathing or difficulty breathing. When asking about the presence of other associated signs and symptoms (current or recent past), the therapist may hear a report of some or all of these signs and symptoms.
SCREENING FOR ONCOLOGIC CAUSES OF SHOULDER PAIN A past medical history of cancer anywhere in the body with new onset of back or shoulder pain is a red flag finding. Brachial plexus radiculopathy can occur in either or both arms with cancer metastasized to the lymphatics (Case Example 18-10). Questions about visceral function are relevant when the pattern for malignant invasion at the
shoulder emerges. Invasion of the upper humerus and glenoid area by secondary malignant deposits affects the joint and the adjacent muscles (Case Example 18-11). Muscle wasting is greater than expected with arthritis and follows a bizarre pattern that does not conform to any one neurologic lesion or any one muscle. Localized warmth felt at any part of the scapular area may prove to be the first sign of a malignant deposit eroding bone. Within 1 or 2 weeks after this observation, a palpable tumor will have appeared, and erosion of bone will be visible on x-ray films. 2
Primary Bone Neoplasm Bone cancer occurs chiefly in young people, in whom a causeless limitation of movement of the shoulder leads the physician to order x-rays. If the tumor originates from the shaft of the humerus, the first symptoms may be a feeling of "pins and needles" in the hand, associated with fixation of the biceps and triceps muscles and leading to limitation of movement at the elbow (Case Example 18-12).
Pulmonary (Secondary) Neoplasm Occasionally the client requires medical referral because shoulder pain is referred from metastatic lung cancer. When the shoulder is examined, the client is unable to lift the arm beyond the horizontal position. Muscles respond with spasm that limits joint movement. If the neoplasm interferes with the diaphragm, diaphragmatic pain (C3, C4, C5) is often felt at the
838
SECTION III
CASE EXAMPLE 1 8 - 1 0
SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
Upper E x t r e m i t y Radiculopathy
Referral: A 72-year-old woman was referred to physical therapy by her neurologist with a diagnosis of "nerve entrapment" for a postural exercise program and home traction. She was experiencing symptoms of left shoulder pain with numbness and tingling in the ulnar nerve distribution. She had a moderate forward head posture with slumped shoulders and loss of height from known osteoporosis. Past Medical History: The woman's past medical history was significant for right breast cancer treated with a radical mastectomy and chemotherapy 20 years ago. She had a second cancer (uterine) 10 years ago that was considered separate from her previous breast cancer. Clinical Presentation: The physical therapy examination was consistent with the physician's diagnosis of nerve entrapment in a classic presentation. There were significant postural components to account for the development of symptoms. However, the therapist palpated several large masses in the axillary and supraclavicular fossa on both the right and left sides. There was no local warmth, redness, or tenderness associated with these lesions. The therapist requested permission to palpate the client's groin and popliteal spaces for any other suspicious lymph nodes. The rest of the examination findings were within normal limits. Associated Signs and Symptoms: Further questioning about the presence of associated signs and symptoms revealed a significant disturbance in sleep pattern over the last 6 months with unrelenting shoulder and neck pain. There
shoulder at each breath (at the fourth cervical dermatome [i.e., at the deltoid area]), in correspondence with the main embryologic derivation of the diaphragm. Pain arising from the part of the pleura that is not in contact with the diaphragm is also brought on by respiration but is felt in the chest. Although the lung is insensitive, large tumors invading the chest wall set up local pain and cause spasm of the pectoralis major muscle, with consequent limitation of elevation of the arm. If the neoplasm encroaches on the ribs, stretching the muscle attached to the ribs leads to sympathetic spasm of the pectoralis major. By contrast, the
were no other reported constitutional symptoms, skin changes, or noted lumps anywhere. Vital signs were unremarkable at the time of the physical therapy evaluation. Result: Returning this client to her referring physician was a difficult decision to make since the therapist did not have the benefit of the medical records or results of neurologic examination and testing. Given the significant past medical history for cancer, the woman's age, presence of progressive night pain, and palpable masses, no other reasonable choice remained. When asked if the physician had seen or felt the masses, the client responded with a definite "no." There are several ways to approach handling a situation like this one, depending on the physical therapist's relationship with the physician. In this case the therapist had never communicated with this physician before. A telephone call was made to ask the clerical staff to check the physician's office notes (the client had provided written permission for disclosure of medical records to the therapist). It is possible that the physician was aware of the masses, knew from medical testing that there was extensive cancer, and chose to treat the client palliatively. Since there was no indication of such, the therapist notified the physician's staff of the decision to return the client to the MD. A brief (one-page) written report summarizing the findings was given to the client to hand-carry to the physician's office. Further medical testing was performed, and a medical diagnosis of lymphoma was made.
scapula is mobile, and a full range of passive movement is present at the shoulder joint.
Pancoast's Tumor Pancoast's tumors of the lung apex usually do not cause symptoms while confined to the pulmonary parenchyma. Shoulder pain occurs if they extend into the surrounding structures, infiltrating the chest wall into the axilla. Occasionally, brachial plexus involvement (eighth cervical and first thoracic nerve) presents with radiculopathy. This nerve involvement produces sharp neuritic pain in the axilla, shoulder, and subscapular area on the affected side, with eventual atrophy of the
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CASE EXAMPLE 1 8 - 1 1
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S h o u l d e r and Leg Pain
Referral: A 33-year-old woman came to a physical therapy clinic located inside a large health club. She reported right shoulder and right lower leg pain that is keeping her from exercising. She could walk, but had an antalgic gait secondary to pain on weight bearing. She linked these symptoms with heavy household chores. She could think of no other trauma or injury. She was screened for the possibility of domestic violence with negative results. Past Medical History: There was no past history of disease, illness, trauma, or surgery. There were no other symptoms reported (e.g., no fever, nausea, fatigue, bowel or bladder changes, sleep disturbance). Clinical Presentation: The right shoulder and right leg were visibly and palpably swollen. Any and all (global) motions of either the arm or the leg were painful. The skin was tender to light touch in a wide band of distribution around the painful sites. No redness or skin changes of any kind were noted. Pain prevented strength testing or assessment of muscle weakness. There was no sign of scoliosis. Trendelenburg test was negative, bilaterally. Functionally, she was able to climb stairs and walk, but these and other activities (e.g., exercising, biking, household chores) were limited by pain. How do you screen this client for systemic or medical disease?
You may have done as much screening as is possible. Pain is limiting any further testing. Assessing vital signs may provide some helpful information. She has denied any past medical history to link with these symptoms. Her age may be a red flag in that she is young. Bone pain with these symptoms in a 33-year old is a red flag for bone pathology and needs to be investigated medically. Immediate medical referral is advised. Result: X-rays of the right shoulder showed complete destruction of the right humeral head consistent with a diagnosis of metastatic disease. X-rays of the right leg showed two lytic lesions. There was no sign of fracture or dislocation. CT scans showed destructive lytic lesions in the ribs and ilium. Additional testing was performed including lab values, bone biopsy, mammography, and pelvic ultrasonography. The client was diagnosed with bone tumors secondary to hyperparathyroidism. A large adenoma was found and removed from the left inferior parathyroid gland. Medical treatment resulted in decreased pain and increased motion and function over a period of 3 to 4 months. Physical therapy intervention was prescribed for residual muscle weakness.
Data from Insler H, et al: Shoulder and leg pain in a 33-year old woman, Journal of Musculoskeletal Medicine 14(6)36-37, 1997.
upper extremity muscles. Bone pain is aching, is exacerbated at night, and is a cause of restlessness and musculoskeletal movement. Usually general associated systemic signs and symptoms are present (e.g., sore throat, fever, hoarseness, unexplained weight loss, productive cough with blood in the sputum). These features are not found in any regional musculoskeletal disorder, including such disorders of the shoulder. For example, a similar pain pattern caused by trigger points of the serratus anterior can be differentiated from neoplasm by the lack of true neurologic findings (indicating trigger point) or by lack of improvement after treatment to eliminate the trigger point (indicating neoplasm). 12
Breast Cancer
Breast cancer or breast cancer recurrence is always a consideration with upper quadrant pain or shoulder dysfunction (Case Example 18-13). The therapist must know what to look for as red flags for cancer recurrence versus delayed effects of cancer treatment. See Chapter 13 for a complete discussion of cancer screening and prevention. Breast cancer is discussed in Chapter 17.
SCREENING FOR GYNECOLOGIC CAUSES OF SHOULDER PAIN Shoulder pain as a result of gynecologic conditions is uncommon, but still very possible. Occasionally a client may present with breast pain as the
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SYSTEMIC ORIGINS OF PAIN AND DYSFUNCTION
Osteosarcoma
Referral: A 14-year-old boy presented to a physical therapist at a sports-medicine clinic with a complaint of left shoulder pain that had been present off and on for the last four months. There was no reported history of injury or trauma despite active play on the regional soccer team. Past Medical History: He has seen his pediatrician for this on several occasions. It was diagnosed as "tendinitis" with the suggestion to see a physical therapist of the family's choice. No x-rays or other diagnostic imaging was performed to date. The client could not remember if any laboratory work (blood or urinalysis) had been done. The client reports that his arm feels "heavy." Movement has become more difficult just in the last week. The only other symptom present was intermittent tingling in the left hand. There is no other pertinent medical history. Clinical Presentation: Physical examination of the shoulder revealed moderate loss of active motion in shoulder flexion, abduction, and external rotation with an empty end feel and pain during passive range of motion. There was no pain with palpation or isometric resistance of the rotator cuff tendons. Gross strength of the upper extremity was 4/5 for all motions.
CASE EXAMPLE 1 8 - 1 3
There was a palpable firm, soft, but fixed mass along the lateral proximal humerus. The client reported it was "tender" when the therapist applied moderate palpatory pressure. The client was not previously aware of this lump. Upper extremity pulses, deep tendon reflexes, and sensation were all intact. There were no observed skin changes or palpable temperature changes. Since this was an active athlete with left shoulder pain, screening for Kehr's sign was carried out but was apparently negative. What are the red flags? • Age • Suspicious palpable lesion (likely not present at previous medical evaluation) • Lack of medical diagnostics • Unusual clinical presentation for tendinitis with loss of motion and empty end feel but intact rotator cuff Result: The therapist telephoned the physician's office to report possible changes since the physician's last examination. The family was advised by the doctor's office staff to bring him to the clinic as a walk-in the same day. X-rays showed an irregular bony mass of the humeral head and surrounding soft tissues. The biopsy confirmed a diagnosis of osteogenic sarcoma. The cancer had already metastasized to the lungs and liver.
B r e a s t Cancer
Referral: A 53-year-old woman with severe adhesive capsulitis was referred to a physical therapist by an orthopedic surgeon. A physical therapy program was initiated. When the client's shoulder flexion and abduction allowed for sufficient movement to place the client's hand under her head in the supine position, ultrasound to the area of capsular redundancy before joint mobilization was added to the treatment protocol. During the treatment procedure the client was dressed in a hospital gown wrapped under the axilla on the involved side. With the client in the supine position, the upper outer quadrant of breast tissue was visible and the physical therapist observed skin puckering (peau d'orange) accompanied by a reddened area. Result: It is always necessary to approach situations like this one carefully to avoid embarrassing or alarming the client. In this case the
therapist casually observed, "I noticed when we raised your arm up for the ultrasound that there is an area of your skin here that puckers a little. Have you noticed any changes in your armpit, chest, or breast areas?" Depending on the client's response, follow up questions should include asking about distended veins, discharge from the nipple, itching of the skin or nipple, and the approximate time of the client's last breast examination (selfexamination and physician examination). Although not all therapists are trained to perform a clinical breast exam (CBE), palpation of lymph nodes and muscles such as the pectoral muscle groups can be performed. There was no previous history of cancer, and further palpation did not elicit any other suspicious findings. The physical therapist recommended a physician evaluation, and a diagnosis of breast cancer was made.
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SCREENING THE SHOULDER AND UPPER EXTREMITY
primary complaint, but most often the description is of shoulder or arm, neck, or upper back pain. When asked if the client has any symptoms anywhere else in the body, breast pain may be mentioned. Pain patterns associated with breast disease along with a discussion of various breast pathologies are included in Chapter 17. Many of the breast conditions discussed (e.g., tumors, infections, myalgias, implants, lymph disease, trauma) can refer pain to the shoulder either alone or in conjunction with chest and/or breast pain. Shoulder pain or dysfunction in the presence of any of these conditions as part of the client's current or past medical history raises a red flag.
Ectopic Pregnancy The therapist must be aware of one other gynecologic condition commonly associated with shoulder pain: ectopic (tubal) pregnancy. This type of pregnancy occurs when the fertilized egg implants in some other part of the body besides inside the uterus. It may be inside the fallopian tube, inside the ovary, outside the uterus or even within the lining of the peritoneum (see Fig. 15-6). If the condition goes undetected, the embryo grows too large for the confined space. A tear or rupture of the tissue around the fertilized egg will occur. An ectopic pregnancy is not a viable pregnancy and cannot result in a live birth. This condition is life threatening and requires immediate medical referral. The most common symptom of ectopic pregnancy is a sudden, sharp or constant one-sided pain in the lower abdomen or pelvis lasting more than a few hours. The pain may be accompanied by irregular bleeding or spotting after a light or late menstrual period. Shoulder pain does not usually occur alone without preceding or accompanying abdominal pain, but shoulder pain can be the only presenting symptom with an ectopic pregnancy. When these two symptoms occur together (either alternating or simultaneously), the woman may not realize the abdominal and shoulder pain are connected. She may think there are two separate problems. She may not see the need to tell the therapist about the pelvic or abdominal pain, especially if she thinks it is menstrual cramps or gas. In addition, ask about the presence of lightheadedness, dizziness, or fainting. The most likely candidate for an ectopic pregnancy is a woman in the childbearing years who is sexually active. Pregnancy can occur when using
841
any form of birth control, so do not be swayed into thinking the woman cannot be pregnant because she is on the pill or some other form of contraception. Factors that put a woman at increased risk for an ectopic pregnancy include • History of endometriosis • Pelvic inflammatory disease (PID) • Previous ectopic pregnancy • Ruptured ovarian cysts or ruptured appendix • Tubal surgery Many of these conditions can also cause pelvic pain and are discussed in greater detail in Chapter 15. If the therapist suspects a gynecologic basis for the client's symptoms, some additional questions about past history, missed menses, shoulder pain, and spotting or bleeding may be helpful.
PHYSICIAN REFERRAL Here in the last chapter of the text there are no new guidelines for physician referral that have not been discussed in the previous chapters. The therapist must remain alert to yellow (caution) or red (warning) flags in the history, clinical presentation, and ask about associated signs and symptoms. When symptoms seem out of proportion to the injury, or they persist beyond the expected time of healing, medical referral may be needed. Likewise pain that is unrelieved by rest or change in position or pain/symptoms that do not fit the expected mechanical or neuromusculoskeletal pattern should serve as red flag warnings. A past medical history of cancer in the presence of any of these clinical presentation scenarios may warrant consultation with the client's physician.
Guidelines for Immediate Medical Attention • Presence of suspicious or aberrant lymph nodes, especially hard, fixed nodes in a client with a previous history of cancer • Clinical presentation and history suggestive of an ectopic pregnancy
Clues to Screening Shoulder/Upper Extremity Pain • See also Clues to Differentiating Chest Pain, Chapter 17 • Simultaneous or alternating pain in other joints, especially in the presence of associated signs and symptoms such as easy fatigue, malaise, fever • Urologic signs and symptoms
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• Presence of hepatic symptoms, especially when accompanied by risk factors for jaundice • Lack of improvement after treatment, including trigger point therapy • Shoulder pain in a woman of childbearing age of unknown cause associated with missed menses (rupture of ectopic pregnancy) • Left shoulder pain within 24 hours of abdominal surgery, injury, or trauma (Kehr's sign, ruptured spleen)
• Shoulder pain relieved by nitroglycerin (men) or antacids/acid-relieving drugs (women) (angina) • Difference of lOmmHg or more in blood pressure in the affected arm compared to the uninvolved or a symptomatic arm (dissecting aortic aneurysm, vascular component of thoracic outlet syndrome)
Pulmonary Past Medical History • History of rheumatic disease • History of diabetes mellitus (adhesive capsulitis) • "Frozen" shoulder of unknown cause in anyone with coronary artery disease, recent history of hospitalization in coronary care or intensive care unit, status post-coronary artery bypass graft (CABG) • Recent history (past 1-3 months) of myocardial infarction (chronic regional pain syndrome [CRPS]; formerly reflex sympathetic dystrophy [RSD]) • History of cancer, especially breast or lung cancer (metastasis) • Recent history of pneumonia, recurrent upper respiratory infection, or influenza (diaphragmatic pleurisy)
Cancer • Pectoralis major muscle spasm with no known cause; limited active shoulder flexion but with full passive shoulder motions and mobile scapula (neoplasm) • Presence of localized warmth felt over the scapular area (neoplasm) • Marked limitation of movement at the shoulder joint • Severe muscular weakness and pain with resisted movements
Cardiac • Exacerbation by exertion unrelated to shoulder movement (e.g., using only the lower extremities to climb stairs or ride a stationary bicycle) • Excessive, unexplained coincident diaphoresis • Shoulder pain relieved by leaning forward, kneeling with hands on the floor, sitting upright (pericarditis) • Shoulder pain accompanied by dyspnea, toothache, belching, nausea, or pressure behind the sternum (angina)
• Presence of a pleuritic component such as a persistent, dry, hacking, or productive cough; blood-tinged sputum; chest pain; musculoskeletal symptoms are aggravated by respiratory movements • Exacerbation by recumbency despite proper positioning of the arm in neutral alignment (diaphragmatic or pulmonary component) • Presence of associated signs and symptoms (e.g., tachypnea, dyspnea, wheezing, hyperventilation) • Shoulder pain of unknown cause in older adults with accompanying signs of confusion or increased confusion (pneumonia) • Shoulder pain aggravated by the supine position may be an indication of mediastinal or pleural involvement. Shoulder or back pain alleviated by lying on the painful side may indicate autosplinting (pleural).
Gastrointestinal • Coincident nausea, vomiting, dysphagia; presence of other gastrointestinal complaints such as anorexia, early satiety, epigastric pain or discomfort and fullness, melena • Shoulder pain relieved by belching or antacids and made worse by eating • History of previous ulcer, especially in association with the use of nonsteroidal antiinflammatory drugs
Gynecologic
• Shoulder pain preceded or accompanied by onesided lower abdominal or pelvic pain in a sexually active woman of reproductive age may be a symptom of ectopic pregnancy; there may be irregular bleeding or spotting after a light or late menstrual period. • Shoulder pain with reports of lightheadedness, dizziness, or fainting in a sexually active woman of reproductive age (ectopic pregnancy)
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SCREENING THE SHOULDER AND UPPER EXTREMITY
Right renal artery
Cardiac: Angina • Pancreas
Liver
Myocardial Infarction
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N
Aortic Aneurysm
Stomach Duodenum Liver Gallbladder Common bile duct Stomach Duodenum Gallbladder
Gastrointestinal
Kidnev Disorders
Pleuropulmonary
Breast
Fig. 18-3 • Composite picture of referred shoulder and upper extremity pain patterns. Not pictured: trigger point referred pain (see Fig. 17-7).
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KEY POINTS TO REMEMBER / Shoulder dysfunction can look like a true neuromuscular or musculoskeletal problem and still be viscerogenic or systemic in origin. / Any adult over age 65 presenting with shoulder pain and/or dysfunction must be screened for systemic or viscerogenic origin of symptoms, even when there is a known (or attributed) cause or injury. / Knowing the key red flags for cancer, vascular disease, pulmonary, Gl and gynecologic causes of shoulder pain and/or dysfunction will help the therapist screen quickly, efficiently, and accurately. / Painless weakness of insidious onset is most likely a neurologic problem; painful, insidious weakness may be caused by cervical radiculopathy, chronic rotator cuff problems, tumors, or arthritis. A medical differential diagnosis is required. / As mentioned throughout this text, the therapist can collaborate with colleagues in asking questions and 13
SUBJECTIVE
reviewing findings before making a medical referral. Perhaps someone else will see the answer or a solution to the client's unusual presentation. Or perhaps another opinion will confirm the findings and give you the confidence you need to guide your professional decision making. / Postoperative infection of any kind may not appear with any clinical signs/symptoms for weeks or months, especially in a client who is on corticosteroids or immunocompromised. / Consider unreported trauma or assault as a possible etiologic cause of shoulder pain. / Palpate the diaphragm and assess breathing patterns; shoulder pain reproduced by diaphragmatic palpation may point to a primary diaphragmatic (muscular) problem.
EXAMINATION
Special Questions to Ask: Shoulder and Upper Extremity General Systemic • Does your pain ever wake you at night from a sound sleep? (Cancer) Can you find any way to relieve the pain and get back to sleep? If yes, how? (Cancer: pain is usually intense and constant; nothing relieves it or if relief is obtained in any way, over time pain gets progressively worse) • Have you sustained any injuries in the last week during a sports activity, car accident, etc? (Ruptured spleen associated with pain in the left shoulder: positive Kehr's sign) • Since the beginning of your shoulder problem, have you had any unusual perspiration for no apparent reason, sweats, or fever? • Have you had any unusual fatigue (more than usual with no change in lifestyle), joint pain in other joints, or general malaise? (Rheumatic disease) • For the therapist: Has the client had a laparoscopy in the last 24 to 48 hours? (Left shoulder pain: positive Kehr's sign)
Cardiac • Have you recently (ever) had a heart attack? (Referred pain via viscerosomatic zones, see explanation Chapter 3) • Do you ever notice sweating, nausea, or chest pain when the pain in your shoulder occurs? • Have you noticed your shoulder pain increasing with exertion that does not necessarily cause you to use your shoulder (e.g., climbing stairs, stationary bicycle)? • Do(es) your mouth, jaw, or teeth ever hurt when your shoulder is bothering you? (Angina) • For the client with known angina: Does your shoulder pain go away when you take nitroglycerin? (Ask about the effect of taking antacids/acid-relieving drugs for women.) Pulmonary • Have you been treated recently for a lung problem (or think you have any lung or respiratory problems)? • Do you currently have a cough? If yes, is this a smoker's cough? If no, how long has this been present?
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SUBJECTIVE
• • • •
SCREENING THE SHOULDER AND UPPER EXTREMITY
845
EXAMINATION —cont'd
Is this a productive cough (can you bring up sputum), and is the sputum yellow, green, black, or tinged with blood? Does coughing bring on your shoulder pain (or make it worse)? Do you ever have shortness of breath, have trouble catching your breath, or feel breathless? Does your shoulder pain increase when you cough, laugh, or take a deep breath? Do you have any chest pain? What effect does lying down or resting have on your shoulder pain? (In the supine or recumbent position, a pulmonary problem may be made worse, whereas a musculoskeletal problem may be relieved; on the other hand, pulmonary pain may be relieved when the client lies on the affected side, which diminishes the movement of that side of the chest.)
Gastrointestinal • Have you ever had an ulcer? If yes, when? Do you still have any pain from your ulcer? Have you noticed any association between when you eat and when your symptoms increase or decrease? • Does eating relieve your pain? (Duodenal or pyloric ulcer) How soon is the pain relieved after eating? • Does eating aggravate your pain? (Gastric ulcer, gallbladder inflammation) • Does your pain occur 1 to 3 hours after eating or between meals? (Duodenal or pyloric ulcers, gallstones) • Fo the client taking NSAIDs: Does your shoulder pain increase 2 to 4 hours after taking your NSAIDs? If the client does not know, ask him or her to pay attention for the next few days to the response of shoulder symptoms after taking the medication. • Have you ever had gallstones? • Do you have a feeling of fullness after only one or two bites of food? (Early satiety: stomach and duodenum or gallbladder)
• Have you had any nausea, vomiting, difficulty in swallowing, loss of appetite, or heartburn since the shoulder started bothering you? Gynecologic • Have you ever had a breast implant, mastectomy, or other breast surgery? (Altered lymph drainage, scar tissue) • Have you ever had a tubal or ectopic pregnancy? • Have you ever been diagnosed with endometriosis? • Have you missed your last period? (Ectopic pregnancy, endometriosis; blood in the peritoneum irritates diaphragm causing referred pain) • Are you having any spotting or irregular bleeding? • Have you had any spontaneous or induced abortions recently? (Blood in peritoneum irritating diaphragm) • Have you recently had a baby? (Excessive muscle tension during birth) If yes: Are you breastfeeding with the infant supported on pillows? Do you have a breast discharge, or have you had mastitis? Urologic • Have you had any recent kidney infections, tumors, or kidney stones? (Pressure from kidney on diaphragm referred to shoulder) Trauma • Have you been in a fight or been assaulted? • Have you ever been pulled by the arm, pushed against the wall, or thrown by the arm? If the answer is "Yes" and the history relates to the current episode of symptoms, then the therapist may need to conduct a more complete screening interview related to domestic violence and assault. Specific questions for this section have been discussed in Chapter 2; see also Appendix B-3.
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STUDY
STEPS IN THE SCREENING PROCESS If a client comes to you with shoulder pain with any of the red flag histories and/or red flag clinical findings to suggest screening, start by asking yourself these questions: • Which shoulder is it? • Which organs could it be? (Use Fig. 3-4 showing the viscera in relation to the diaphragm and Tables 18-1 and 18-2 to help you.) • What are the associated signs and symptoms of that organ? Are any of these signs or symptoms present? • What is the history? Does anything in the history correlate with the particular shoulder involved and/or with the associated signs and symptoms? Conduct a Review of Systems as discussed in Chapter 4 (see Box 4-17). • Can you palpate it, make it better or worse, or reproduce it in any way? COULD IT BE CANCER?
Remember, the therapist does not make a determination as to whether or not a client has cancer. The therapist's assessment determines whether the client has a true neuromuscular or musculoskeletal problem that is within the scope of our practice. However, knowing red flags for the possibility of cancer helps the therapist know what questions to ask and what red flags to look for. Watch for • Previous history of cancer (any kind, but especially breast or lung cancer) • Pectoralis major muscle spasm with no known cause, but full passive ROM and a mobile scapula. Be sure to assess for trigger points (TrPs). Reassess after trigger point therapy. • Were the symptoms alleviated? Did the movement pattern change? • Conduct a neurologic screening exam. • Shoulder flexion and abduction limited to 90° with empty end feel. • Presence of localized warmth over scapular area. Look for other trophic changes. COULD IT BE VASCULAR?
Watch for • Exacerbation by exertion unrelated to shoulder movements Does the shoulder pain and/or symptoms get worse when the client is just using the lower
extremities? What is the effect of riding a stationary bike or climbing stairs without using the arms? • Excessive, unexplained coincident diaphoresis (i.e., the client breaks out in a cold sweat just before or during an episode of shoulder pain. This may occur at rest, but is more likely with mild physical activity). • Shoulder pain relieved by leaning forward, kneeling with hands on the floor, sitting upright (pericarditis). • Shoulder pain accompanied by dyspnea, temporomandibular joint (TMJ) pain, toothache, belching, nausea, or pressure behind the sternum. • Bilateral shoulder pain that comes on after using the arms overhead for 3 to 5 minutes. • Shoulder pain relieved by nitroglycerin (men) or antacids/acid-relieving drugs (women) [angina] • Difference of lOmmHg or more (at rest) in diastolic blood pressure in the affected arm (aortic aneurysm; vascular component of thoracic outlet syndrome) Remember to correlate any of these symptoms with • Client's past medical history (e.g., personal and/or family history of heart disease) • Age (over 50, especially postmenopausal women) • Characteristics of pain pattern (see Table 6-5; these characteristics of cardiac related chest pain can also apply to cardiac-related shoulder pain) COULD IT BE PULMONARY?
• Ask about the presence of pleuritic component • Persistent cough (dry or productive) • Blood-tinged sputum; rust, green or yellow exudate • Chest pain • Musculoskeletal symptoms are aggravated by respiratory movements; ask the client to take a deep breath. Does this reproduce or increase the pain/symptoms? • Watch for the exacerbation of symptoms by recumbence even with proper positioning of the arm. Lying down in the supine position can put the shoulder in a position of slight extension. This can put pressure on soft tissue structures in and around the shoulder, causing pain in the presence of a true neuromuscular or musculoskeletal problem.
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CASE
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STUDY — c o n t ' d
• For this reason, when assessing the affect of recumbence, make sure the shoulder is in a neutral position. You may have to support the upper arm with a towel roll under the elbow and/or put a pillow on the client's abdomen to give the forearms a place to rest. • Pain is relieved or made better by side lying on the involved side. This is called autosplinting. Pressure on the rib cage prevents respiratory movement on that side thereby reducing symptoms induced by respiratory movements. This is quite the opposite of a musculoskeletal or neuromuscular cause of shoulder pain; the client often cannot lie on the involved side without increased pain. • Ask about the presence of associated signs and symptoms. Remember to ask our final question: • Are there any symptoms of any kind anywhere else in your body? In the older adult, listen for a self-report or family report of unknown cause of shoulder pain/dysfunction and/or any signs of confusion (confusion or increased confusion is a common first symptom of pneumonia in the older adult). COULD IT BE GASTROINTESTINAL (GI) OR HEPATIC?
• Ask about a history of chronic (more than six months) NSAID use and history of previous ulcer, especially in association with NSAID use. This is the most common cause of medicationinduced shoulder pain in all ages, but especially adults over 65. • History of other GI disease that can refer pain to the shoulder such as: • Gallbladder • Acute pancreatitis • Reflex esophagitis • Watch for coincident (or alternating) nausea, vomiting, dysphagia, anorexia, early satiety, or other GI symptoms. Clients often think they have two separate problems. The client may not think the therapist treating the shoulder needs or wants to know about their GI problems. The therapist who is not trained to screen for medical disease may not think to ask. • Ask if shoulder pain is relieved by belching or antacids. This could signal an underlying GI problem or for women, cardiac ischemia.
• Look for shoulder pain that is changed by eating (better or worse within 30 minutes or worse 1-3 hours after eating). The therapist does not have to identify the specific area of the GI tract that is involved or the specific pathology present. It is important to know that true neuromusculoskeletal shoulder pain is not relieved or exacerbated by eating. If there is a peptic ulcer in the upper GI tract causing referred pain to the shoulder, there is often a history of NSAID use. This client will have that red flag history along with shoulder pain that gets better after eating. There may also be other GI symptoms present such as nausea, loss of appetite, or melena from oxidized blood in the upper GI tract. If there is liver impairment as well, there can be symptoms of carpal tunnel syndrome (CTS). For a list of possible neuromusculoskeletal and systemic causes of CTS, see Table 11-2. Again, CTS in the presence of any of these systemic conditions should be assessed carefully. Likewise, CTS may be the first symptom of some of these pathologies. The client with shoulder pain (GI bleed) and symptoms of CTS (liver impairment) may demonstrate other signs of liver impairment such as: • Liver flap (asterixis) • Liver palms (palmar erythema) • Nail bed changes (white nails of Terry) • Spider angiomas (over the abdomen) These tests along with photos and illustrations are discussed in detail in Chapter 9. COULD IT BE BREAST PATHOLOGY?
Remember that men can have breast diseases, too although not as often as women. Red flag clinical presentation and associated signs and symptoms of breast disease referred to the shoulder may include • Jarring or squeezing the breast refers pain to the shoulder • Resisted shoulder motions do not reproduce shoulder pain but do cause breast pain or discomfort • Obvious change in breast tissue (e.g., lump(s), dimpling or peau d'orange, distended veins, nipple discharge or ulceration, erythema, change in size or shape of the breast) • Suspicious or aberrant axillary or supraclavicular lymph nodes
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PRACTICE QUESTIONS 1. A 66-year-old woman has been referred to you by her physiatrist for preprosthetic training after an above-knee amputation. Her past medical history is significant for chronic diabetes mellitus (insulin dependent), coronary artery disease with recent angioplasty and stent placement, and peripheral vascular disease. During the physical therapy evaluation, the client experienced anterior neck pain radiating down the left arm. Name (and/or describe) three tests you can do to differentiate a musculoskeletal cause from a cardiac cause of shoulder pain. 2. Which of the following would be useful information when evaluating a 57-year-old woman with shoulder pain? a. Influence of antacids on symptoms b. History of chronic NSAID use c. Effect of food on symptoms d. All of the above 3. Referred pain patterns associated with impairment of the spleen can produce musculoskeletal symptoms in: a. The left shoulder b. The right shoulder c. The mid- or upper back, scapular, and right shoulder areas d. The thorax, scapulae, right or left shoulder 4. Referred pain patterns associated with hepatic and biliary pathology can produce musculoskeletal symptoms in: a. The left shoulder b. The right shoulder c. The mid or upper back, scapular, and right shoulder areas d. The thorax, scapulae, right or left shoulder 5. The most common sites of referred pain from systemic diseases are: a. Neck and hip b. Shoulder and back c. Chest and back d. None of the above 6. A 28-year-old mechanic reports bilateral shoulder pain (right more than left) whenever he has to work on a car on a lift overhead. It goes
7.
8.
9.
10.
away as soon as he puts his arms down. Sometimes he has numbness and tingling in his right elbow going down the inside of his forearm to his thumb. The most likely explanation for this pattern of symptoms is: a. Angina b. Myocardial ischemia c. Thoracic outlet syndrome d. Peptic ulcer A client reports shoulder and upper trapezius pain on the right that increases with deep breathing. How can you tell if this results from a pulmonary or a musculoskeletal cause? a. Symptoms get worse when lying supine, but better when right sidelying when it is pulmonary b. Symptoms get worse when lying supine, but better when right sidelying when it is musculoskeletal Organ systems that can cause simultaneous bilateral shoulder pain include: a. Spleen b. Heart c. Gallbladder d. None of the above A 23-year-old woman was a walk-in to your clinic with sudden onset of left shoulder pain. She denies any history of trauma and has only a past history of a ruptured appendix three years ago. She is not having any abdominal pain or pain anywhere else in her body. How do you know if she is at risk for ectopic pregnancy? a. She is sexually active and is late for her period b. She has a history of uterine cancer c. She has a history of peptic ulcer d. None of the above The most significant red flag for shoulder pain secondary to cancer is: a. Previous history of coronary artery disease b. Subscapularis trigger point alleviated with trigger point therapy c. Negative neurologic screening exam d. Previous history of breast or lung cancer
SCREENING THE SHOULDER AND UPPER EXTREMITY CHAPTER 18
REFERENCES 1. Neer CS: Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report, JBJS 54(l):41-50, 1972. 2. Cyriax J: Textbook of orthopaedic medicine, ed 8, Baltimore, 1982, Williams and Wilkins. 3. Mennell JM: Joint pain: diagnosis and treatment using manipulative techniques, Boston, 1964, Little, Brown. 4. Connolly JF: Unfreezing the frozen shoulder, J Musculoskel Med 15(ll):47-56, 1998. 5. Sadikot RT, Rogers JT, Cheng D-S, et al: Pleural fluid characteristics of patients with symptomatic pleural effusion after coronary artery bypass graft surgery, Arch Internal Med 160(17):2665-2668, 2000. 6. Mennell JM: The musculoskeletal system: differential diagnosis from symptoms and physical signs, Sudbury, MA, 1992, Jones and Bartlett.
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7. Hadler NM: The patient with low back pain, Hospital Practice, October 30, 1987, pp 17-22. 8. Smith ML: Differentiating angina and shoulder pathology pain, Phys Ther Case Rep 1(4):210-212, 1998. 9. Oaklander AL, Rissmiller JG, Gelman LB, et al: Evidence of focal small-fiber axonal degeneration in complex regional pain syndrome-I (reflex sympathetic dystrophy). Pain 120(3):235-243, 2006. 10. Janig W, Baron R: Is CRPS I a neuropathic pain syndrome? Pain 120(3):227-229, 2006. 11. Rose SJ, Rothstein JM: Muscle mutability: general concepts and adaptations to altered patterns of use, Phys Ther 62:1773, 1982. 12. Cailliet R: Shoulder pain, ed 3, Philadelphia, 1991, FA Davis. 13. McFarland EG, Sanguanjit P, Tasaki A, et al: Shoulder examination: established and evolving concepts. J Musculoskel Med 23(l):57-64, 2006.
Answers for Practice Test Questions Chapter 1 Introduction to Screening for Referral in Physical Therapy 1. (b) The function of a diagnosis and diagnostic classifications is to provide information (i.e., identify as closely as possible the underlying neuromusculoskeletal [NMS] pathology) that can guide efficient treatment and effective management of the client. 2. False—See Box 1-1. 3. (b) 4. (c) 5. (b) 6. (e) 7. (a) 8. A yellow flag is a cautionary or warning symptom that signals, "Slow down, and think about the need for screening." A red flag symptom requires immediate attention, either to pursue further screening questions or tests, or to make an appropriate referral. The presence of a single yellow or red flag is not usually cause for immediate medical attention. Each cautionary or warning flag must be viewed in the context of the whole person, given his or her age, gender, past medical history, and current clinical presentation. 9. Past medical history, risk factor assessment, clinical presentation (including pain types and pain patterns), associated signs and symptoms, review of systems. Each client can be framed by these five components. Any suspicious finding or response in any of these areas warrants a closer look. 10. Check your list against Box 1-2; see also Appendix A-2. Chapter 2 Introduction to the Interviewing Process 1. (b) Nonsteroidal antiinflammatory drugs (NSAIDs) can be potent renal vasoconstrictors that cause increased blood pressure and resultant lower extremity edema as sodium and water are conserved by the body.
• Are any other symptoms of any kind anywhere else in your body that we haven't discussed yet? • Is there anything else you think is important about your condition that we have not discussed yet? • Is there anything else you think I should know? 4. (b) Antidepressants Antidepressants are divided into three groups: tricyclics, monoamine oxidase inhibitors (MAOIs), and miscellaneous antidepressants. The tricyclics work by blocking reuptake of norepinephrine and serotonin into nerve endings and increasing the action of norepinephrine and serotonin in nerve cells. Any of the antidepressants can have gastrointestinal adverse effects, but especially, the selective serotonin uptake inhibitors (SSRIs) such as Paxil, Zoloft, Prozac, and Celexa. 5. (c) 6. (a) True 7. (d) 8. True. This includes any woman who has experienced a surgical menopause (e.g., oophorectomy for ovarian cancer) or any postmenopausal woman who is not taking hormone replacements. 9. (e) All of these are red flags, along with previous history of cancer, symptoms that last longer than expected (beyond physiologic time period for healing), age, gender, comorbidities, bilateral symptoms, other constitutional symptoms, unexplained falls, substance use/abuse, unusual vital signs, and constant and intense pain; see also Appendix A-2. 10. The first question should always be, "Did you actually see your physician?" Then ask questions directed at assessing for the presence of constitutional symptoms. For example, after paraphrasing what the client has told you, ask, "Are you having any other symptoms of any kind in your body that you haven't mentioned?" If no, ask more specifically about the presence of associated signs and symptoms, including naming constitutional symptoms one by one. Follow up with Special Questions for Men (see Appendix B-21).
2. (a) Although all details obtained from the Family/Personal History form, interview, and objective examinations provide important information, it is well documented that 80% (or more) of the information needed to determine the cause of symptoms is actually gathered during the Core Interview of the Subjective Examination.
11. (d) Water retention. Look for sacral and pedal edema.
3. Any of the following questions (or similar questions) is appropriate:
12. (c) Inform the primary care provider of both conditions; the therapist can also screen for
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potential adverse effects of NSAIDs and can monitor blood pressure. 13. (b) It may not be necessary to screen every client for alcohol use. You may not conduct a full screening assessment when someone appears to have been drinking, but it may still be appropriate to ask, "I smell alcohol on your breath. How many drinks have you had?" Screening questions should be asked privately and confidentially without other family and friends listening. Chapter 3 Pain Types and Viscerogenic Pain Patterns 1. (b) 2. (a) Pain that wakes a client up as soon as he or she rolls onto that side is indicative of an acute inflammatory process. Night pain associated with neoplasm is more likely to wake the client up after he or she falls asleep, when the tumor keeps normal tissue from obtaining essential blood and nutrients, thus creating tissue ischemia and subsequent pain. With chronic musculoskeletal conditions, the client can often get to sleep with just the right positioning and may even be able to sleep on that side for up to an hour or two before pressure and ischemia develop, causing pain. 3. (a) Left shoulder pain associated with damage or injury to the spleen is called Kehr's sign. 4. (a) True. See Table 3-2. 5. (b) Throbbing, pounding, and beating are more often associated with pain of a vascular nature. Aching, heavy, and sore are words used to describe musculoskeletal pain. According to the McGill Pain Questionnaire, words like agonizing, piercing, and unbearable convey more emotional content than is communicated by actual descriptors of organic disease. See Table 3-1; see also Fig. 3-11.
involved side and applying pressure to that area. Gallbladder pain is sometimes relieved by leaning forward. Cardiac pain brought on by use of the upper extremities overhead may be relieved by bringing the arms back down to the sides. 10. (a) True. Visceral involvement can occur without preceding or prodromal symptoms, but most often, associated signs and symptoms are present. Because visceral pain can be referred to the neck, back, or shoulder, the client who experiences gastrointestinal (GI) or genitourinary (GU) symptoms does not report these additional symptoms to the therapist when providing information about the musculoskeletal condition. 11. (d) Irritation of the retroperitoneal space begins when bleeding occurs behind the stomach, most often from a posterior duodenal ulcer. Rupture of the spleen causes Kehr's sign. The pancreas and low back structures are not formed from the same embryologic tissue. Disease of the pancreas, whether it involves the head, the body, or the tail, can put pressure on the corresponding portion of the respiratory diaphragm, resulting in shoulder or low back pain according to the location of the diaphragmatic irritation. Central diaphragmatic pressure results in referred pain to the ipsilateral shoulder; peripheral involvement of the diaphragm results in low back pain. This can occur in the right shoulder when the head of the pancreas is distended far enough, but it is more likely to affect the left shoulder via disease in the tail of the pancreas. Chapter 4 Physical Assessment as a Screening Tool 1. (c) Percussion and palpation can change bowel sounds. Look and listen before you palpate. 2. (a)
6. (a) Neoplasm, in particular, primary bone cancer.
3. (c)
7. (e) Artificial sweeteners have come under fire, primarily by manufacturers of artificial sweeteners. Evidence supplied by two prominent board certified neurosurgeons (see text) combined with the author's own clinical experience is sufficient to include this agent as a causative factor in joint pain.
4. (c)
8. (a) Bone pain would be accompanied by a positive heel strike test. Symptoms of angina are sometimes relieved by antacids in women. Even if bone pain were caused by metastases from the GI tract, eating would not alleviate the symptoms. 9. (b) False. Some types of viscerogenic pain can be relieved by a change in position early in the disease process. For example, pain from an inflammatory or infectious process that affects the kidney may be reduced by leaning toward the
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5. First of all, do you need to? How far out from the first medical diagnosis and final treatment is the client? Is the client still being treated? Without laboratory values, physical assessment becomes much more important. Check vital signs; observe the skin, eyes, and nailbeds, and ask about the presence of associated signs and symptoms. 6. We confess this is a bit of a "trick" question. Thoughts on this topic vary. Some therapists advocate taking each client's body temperature (answer "e") as one of the simplest and most inexpensive ways to screen for the presence of systemic problems. Others are more selective in the screening process and advise answer "d" (b and c) as the most appropriate response. The decision may depend, in part, on the type of practice or
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clinical setting in which you practice. For the new graduate, it is highly recommended that all vital signs be taken on all clients until the therapist is proficient in this skill area. With experience, each clinician will develop the decision-making skills needed to determine when additional screening, and which screening tests, should be carried out. 7. Bruits are abnormal blowing or swishing sounds heard on auscultation of narrowed or obstructed arteries. Bruits with both systolic and diastolic components suggest the turbulent blood flow of partial arterial occlusion that is possible with aneurysm or vessel constriction. The therapist is most likely to assess for bruits when the client or patient is older than 65 years of age and describes problems (i.e., neck, back, abdominal, or flank pain) in the presence of a history of syncopal episodes, a history of cardiovascular disease (CVD), serious risk factors for CVD, or a previous history of aortic aneurysm. Look for other signs of peripheral vascular disease that may account for the client's current symptoms. Symptoms may be described as "throbbing" and may increase with activity and decrease with rest. In the most likely candidate, neck or back pain is not affected by physical therapy intervention. The client is an older adult, a postmenopausal woman, and/or has significant risk factors for CVD or a history of CVD. 8. (d) You may decide to conduct additional tests and provide the information to the physician. This should include a review of past medical history, current medications, and any pharmaceuticals she may be taking, as well as any other symptoms present but unnoticed or unreported. Carry out a screening interview using Special Questions for Joint Pain (see Appendix B-16). 9. Yes. The therapist must be familiar with past medical history and any factors that could put the client at risk for a medical incident of any type. Health status can change for any client within a 2-week period, but especially, the aging adult. Surgery is a major event that is traumatic to the physiologic body, despite the client's previous excellent health. Surgery can trigger the onset of new health problems or may bring to fulmination something that was present only subclinically before the operation. Some postoperative complications do not develop until 10 to 14 days later. Exercise is an additional physiologic stressor. Symptoms may not be seen when the client is at rest or sedentary and may occur only after exercise has been initiated. Time pressure and the complexities of today's health care delivery system can also result in conditions remaining unnoticed by the examining
health care professional. Systemic diseases often develop slowly and gradually over time. It is not until the disease has progressed enough that the client shows any signs and symptoms of visceral or systemic involvement. What the physician, physician's assistant, nurse, or nurse practitioner observed preoperatively may not be the clinical presentation seen by the therapist postoperatively. 10. Bad breath (halitosis) can be a symptom of diabetic ketoacidosis, dental decay, lung abscess, throat or sinus infection, or gastrointestinal disturbance from food intolerance, Helicobacter pylori bacteria, or bowel obstruction. Keep in mind that ethnic foods and alcohol can affect breath and body odor. After past medical history has been assessed for any of these conditions, it may be necessary for the therapist to ask directly, "I notice an unusual smell on your breath. Do you know what might be causing this?" Ask appropriate follow-up questions depending on the type of smell that you perceive. You may wish to consider screening for alcohol use at a later time, after you have established a good rapport with the client. 11. The patient's blood pressure (vasomotor) system is "untuned"; peripheral blood vessels do not constrict properly, so venous pooling may occur. The patient also may be receiving medication(s) that have the potential to reduce blood pressure directly or as an adverse effect of the drug or drugs in combination. Other factors may include dehydration, if the patient has not been on intravenous fluids and has not maintained adequate fluid intake. Chapter 5 Screening for Hematologic Disease 1. (b) 2. (b) 3. When you live at an elevation of 3500 feet above sea level (or higher) and the client describes symptoms of unknown origin such as headache, dizziness, fatigue, and changes in sensation of the feet and hands (decreased feeling, burning, numbness, tingling, [polycythemia] or joint pain, swelling, and loss of motion [sickle cell disease]) 4. (c) Platelets are affected by anticoagulant drugs, including aspirin and heparin. Platelets are important in the coagulation of blood, a necessary process during and after surgery. 5. (b) 6. Local heat applied to the involved joint(s) 7. (b)
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8. (1) Trunk flexion over the hips produces severe pain in the presence of iliopsoas bleeding. Only mild pain occurs on trunk flexion over the hips for a hip hemorrhage. (2) Gently rotating the hip internally or externally causes severe pain in the presence of a hip hemorrhage but only minimal (or no) pain with iliopsoas bleeding. 9. Nadir, or the lowest point the white blood count reaches, usually occurs 7 to 14 days after chemotherapy or radiation therapy. At that time, the client is extremely susceptible to infection; the therapist must follow all universal precautions, especially those pertaining to good handwashing. 10. (1) Client tolerance; (2) Perceived exertion levels Chapter 6 Screening for Cardiovascular Disease 1. (b) 2. Myocardial ischemia is a deficiency of blood supply to the heart muscle that is usually caused by narrowing of the coronary arteries. Angina pectoris is the chest pain that occurs when the heart is not receiving an adequate supply of blood, and therefore, has insufficient quantities of oxygen for the workload. Myocardial infarction is death of the heart tissue when blood supply to that area is interrupted. 3. Monitor vital signs, and palpate pulses. Evaluate past and current medical history for the presence of coronary artery disease. Any suspicion of thoracic aneurysm must be reported to the physician immediately. It is beyond the scope of a physical therapist's practice to suggest the possibility of an aneurysm. Rather, clinical observations should be documented and submitted to the physician. A summary comment can be made such as, "This clinical presentation is not consistent with a musculoskeletal problem. Please evaluate." 4. The three Ps include: • Pleuritic pain (exacerbated by respiratory movement involving the diaphragm, such as sighing, deep breathing, coughing, sneezing, laughing, or the hiccups; this may be cardiac with pericarditis, or it may be pulmonary); have the client hold his or her breath, and reassess symptoms—any reduction or elimination of symptoms with breath holding or the Valsalva maneuver suggests a pulmonary or cardiac source of symptoms. • Pain on palpation (musculoskeletal origin) • Pain with changes in position (musculoskeletal or pulmonary origin; pain that is worse when lying down and that improves when sitting up or leaning forward is often pleuritic in origin).
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5. Palpitations may be considered physiologic (i.e., "within normal limits") when they occur at a rate of less than six per minute. Palpitations lasting for hours or occurring in association with pain, shortness of breath, fainting, or severe lightheadedness require medical evaluation. Palpitations in any person with a history of unexplained sudden death in the family require medical referral. Palpitations can also occur as an adverse effect of some medications, through the use of drugs such as cocaine, as the result of an overactive thyroid, or because of caffeine sensitivity. Palpitations as a recurring symptom (even if less than six/minute) should always be reported to the physician. 6. Past medical history/risk factors—Personal or family history of coronary artery disease, heart disease, angina, myocardial infarction, or risk factors associated with these (see Table 6-3). Assess menstrual history: A menopausal or postmenopausal woman with a high risk for heart disease may develop symptomatic coronary artery disease. Clinical presentation—Objective findings from the clinical evaluation do not seem consistent with temporomandibular dysfunction; assess the effect of using a stationary bicycle or treadmill (stairs or walking will also work) without upper extremity exertion on jaw pain. Increased pain or symptoms with increased lower body exertion may be a sign of cardiac involvement and should be reported to the referring dentist. Associated signs and symptoms—Assess for coincident nausea, diaphoresis, pallor, or dyspnea during painful or symptomatic periods. Look for recent history (last 6 weeks to 6 months in onset) of shortness of breath at night, extreme fatigue, lethargy, and weakness. Ask about the presence of other body aches and pains (be alert for "heartburn" unrelieved by antacids, isolated right biceps muscle aching, and breast or chest pain). Measure vital signs for any unusual findings, and assess changes in vital signs with changes in workload during exercise. 7. The onset of myocardial infarction can be precipitated by working with the arms extended over the head. Ischemia or infarction may be the cause of this client's symptoms. Assess for history of heart disease and the presence of known hypertension, angina, past episodes of heart attack, or congestive heart failure. Assess vital signs and changes in vital signs with increased workload and assess the effect of increasing the workload of the lower extremities only. Evaluate for thoracic outlet syndrome (TOS), especially with a cardiovascular component (see Table 17-5). Evaluate for and treat trigger
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points of the chest, upper abdomen, and upper extremity. This client should be evaluated by his physician; the therapist's information gathered from the assessment will be helpful in the medical differential diagnosis. 8. Examine this client for the presence of cyanosis, orthopnea, and tachycardia; for changes in renal function (decreased urination during the day but frequent urination at night); and for a spasmodic cough triggered by lying down or at night. These may be indicators of congestive heart failure and must be reported to the physician. Take note of whether this client is taking NSAIDs and digitalis together; this combination of medications can cause ankle swelling—a symptom that must also be reported to the physician. 9. (d) Arterial and occlusive diseases are synonymous for the same thing: Occlusion of the arteries produces arterial disease; occlusion of the veins produces venous disorders. Arteries and veins constitute the major peripheral blood vessels; therefore, any diseases or disorders of the arteries and/or veins are included in peripheral vascular disorders. 10. (c) Pain from arterial disease is relieved by dangling (not elevating) the extremity to help blood flow distally; the feet are cold and demonstrate pallor from loss of blood flow. 11. (a) 12. (c) Chapter 7 Screening for Pulmonary Disease 1. As always, look at past medical history, risk factors, clinical presentation, and associated signs and symptoms. Ask about a past medical history (within the last 6 to 8 weeks) of upper respiratory infection, pneumonia, pleurisy, or traumatic injury. Evaluate whether the symptoms can be reproduced with palpation or movement. Pulmonary symptoms may be exacerbated or increased by the supine position and alleviated or decreased when the patient is lying on the involved side (autosplinting). Look for associated signs and symptoms such as fever, chills, night sweats, digital clubbing, persistent cough, or dyspnea. Examine the client for trigger points; reexamine after any trigger points have been eliminated. 2. (c) 3. In accordance with our screening model, we always take a look at past medical history, risk factors, clinical presentation, and associated signs and symptoms. This patient's age, history
of tobacco use, and previous history of breast cancer are red flags and risk factors for cancer recurrence and other systemic disorders. The following tests and measures can help the therapist to differentiate musculoskeletal from systemic origin of symptoms in this case: • Vital signs and pulmonary auscultation • Palpation (Can symptoms be reproduced with palpation? [Bone mets are not usually painful to palpation, whereas trigger points or impaired soft tissue structures may be painful upon palpation.]). Are the intercostal spaces symmetric? Asymmetry may be noted with rib dysfunction. • Active and passive spinal motion (Can symptoms be reproduced, alleviated, or changed in any way with active spinal movement? Are the accessory motions within normal limits?) • Ask about the presence of other pulmonary signs and symptoms. • Is the pattern of symptoms consistent with a musculoskeletal disorder? Because breast cancer can metastasize to the bone, and especially, to the thoracic spine, a neurologic screening examination may be in order, depending on the client's response to previous questions and tests. 4. (f) Pain can also radiate to the costal margins or upper abdomen (see Figs. 7-9 and 7-10). 5. False. However, medical referral is usually not considered necessary when a client presents with a singular systemic sign or symptom, especially in the presence of a clear clinical presentation of a musculoskeletal pattern. 6. (e) 7. Autosplinting occurs when lying on the involved side quiets respiratory movement and reduces or eliminates symptoms. Most musculoskeletal problems are made worse by placing this kind of pressure on the symptomatic shoulder, neck, or thoracic spine. The therapist must also evaluate the presence of associated signs and symptoms, the effect of increased respiratory movements on symptoms, and the effect of the supine position (recumbency) on shoulder/upper trapezius pain. 8. These have equal significance when viewed as part of a continuum; dyspnea that has progressed from exertional to rest is a red flag symptom. The usual progression of dyspnea is for a client to first notice shortness of breath after a specific length of time or intensity while engaging in an activity such as walking or climbing stairs. Progression to dyspnea at rest usually occurs after the client notices shortness of breath sooner and with less intensity in the activity.
ANSWERS FOR PRACTICE TEST QUESTIONS
Exertional dyspnea may be the result of deconditioning alone without a specific pulmonary disease. In addition, early, mild congestive heart failure may be characterized by shortness of breath at rest that is not present with exertion. In such a case, increased stroke volume that results from increased activity may improve venous return enough to alleviate dyspnea with exertion. Over time, as the congestion progresses, dyspnea will increase with less provocation and will occur at rest as well as with exertion. Either exertional dyspnea or dyspnea at rest that is out of proportion to the situation should be considered a red flag. Progression to dyspnea at rest usually occurs after the client notices shortness of breath that occurs sooner and with less intensity in the activity. 9. (b) 10. (d) Chapter 8 Screening for Gastrointestinal Disease 1. (b) Melena 2. (a) Kehr's sign (left shoulder pain) can occur as the result of blood (e.g., following trauma to the spleen, ruptured ectopic pregnancy) or air (laparoscopy) in the abdomen. Kehr's sign following a laparoscopy will resolve within 24 to 48 hours as the gas bubble is absorbed or passed. The physician must be notified of shoulder pain associated with traumatic injury, nonsteroidal antiinflammatory drug (NSAID)-associated gastrointestinal bleeding, or possible ectopic pregnancy for possible medical evaluation (even if the clinical presentation is consistent with musculoskeletal dysfunction) (see Shoulder, Chapter 18). 3. (d) 4. (d) 5. (b) 6. Infection of the peritoneum (e.g., peritonitis, appendicitis) can cause abscess formation of the psoas (or obturator) muscle, resulting in right lower quadrant (abdominal or pelvic) pain in association with specific movements of the right leg (see Iliopsoas Muscle Test, Fig. 8-3, and Obturator Muscle Test, Fig. 8-6). 7. (b) 8. (d) Psoas abscess can affect the hip, buttock, groin, and parts distal but does not cause sacral pain; hemorrhoids and rectal fissures may cause rectal or anal pain, but not sacral pain; Crohn's disease can be accompanied by sacroiliitis, but this client does not have a reported history of Crohn's disease; narcotics are well known for con-
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stipation as a common adverse effect, especially in the older adult. 9. Using Special Questions to Ask for possible GI involvement, carefully screen for any other associated signs and symptoms. Have the client pay close attention to digestion and bowel habit patterns over the next 24 to 48 hours. Ask her to report any gastrointestinal symptoms and any changes in bowel odor, color, or consistency. Provide her with a home program to improve strength, balance, and coordination, and observe or test for functional improvement. If she reports any additional gastrointestinal signs and symptoms, especially if no improvement in her physical status is observed, immediate medical referral is required. Otherwise, send the physician a brief note outlining your findings, your program, and any progress (or lack of progress), and include a question such as: Dr. Smith, Mrs. Jones has had several episodes of lightheadedness. At the same time, she says her legs feel "rubbery and weak." This is not a typical musculoskeletal pattern. Is there any connection between her use of NSAIDs (she is taking a prescription NSAID and an over-the-counter NSAID daily) and this pattern of weakness? Always remember to relay information and ask questions that demonstrate that you are practicing within the scope of physical therapy practice. 10. (a) or (d) Some physicians and physical therapists advocate taking the body temperature as part of a vital sign assessment in all clients (answer [a]). Others suggest that this may not be necessary in cases in which a clear musculoskeletal cause is noted for the clinical presentation, as well as an absence of any systemically associated signs and symptoms. As a general guideline, vital sign assessment can provide valuable screening and overall health information. For the student and inexperienced clinician, we highly recommend this practice. For further discussion of this topic, see Chapter 4. Chapter 9 Screening for Hepatic and Biliary Disease 1. (c) Technically, answer (b) is also correct because referred shoulder pain may be the only presenting symptom of hepatic or biliary disease. However, when the overall referral pattern is viewed, answer (b) leaves out the upper back and scapulae; answer (d) refers to the part of the body between the neck and the abdomen and includes the primary pain pattern present in the right upper quadrant but not the mid or upper back associated with the referred pain pattern. Kehr's sign—left shoulder pain associated with blood or
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air in the abdominal cavity—is not part of the hepatic/biliary system. 2. Radiating pain to the mid back, scapula, and right shoulder occurs as the result of splanchnic fibers (a network of nerves innervating the viscera of the abdomen) that synapse with adjacent phrenic nerve fibers—the branch of the celiac plexus (also known as the solar plexus) that innervates the diaphragm. The liver is innervated by the hepatic plexus, also a part of the celiac plexus (see Fig. 3-3). Interconnecting nerve fibers between the phrenic nerves and the brachial plexus then refer pain to the right shoulder. These connections occur bilaterally, but most biliary fibers reach the dorsal spinal cord through the right splanchnic nerve to produce pain primarily in the right shoulder. 3. Normally, the breakdown of protein in the gut (whether derived from food or blood in the stomach) produces ammonia that is transformed by the liver to urea, glutamine, and asparagine. These substances are then excreted by the renal system. When the liver is diseased and unable to detoxify ammonia, ammonia is transported to the brain, where it reacts with glutamate, an excitatory neurotransmitter, thus producing glutamine. Reduction in brain glutamate impairs neurotransmission, leading to altered nervous system metabolism and function. Additionally, ammonia may cause the brain to produce false neurotransmitters. The result of this ammonia abnormality is peripheral nerve disease with numbness and tingling of the hands and/or feet that can be misinterpreted as carpal/tarsal tunnel syndrome. Check also for asterixis. 4. Ask about numbness and tingling in the feet. Tarsal tunnel symptoms do not always occur with upper extremity numbness and tingling, but when both are present, a medical evaluation is required. Ask the client about any associated signs and symptoms, especially constitutional symptoms (see Systemic Signs and Symptoms Requiring Physician Referral at the end of this chapter). Look for liver flap, liver palms, and other skin and nailbed changes. Look for risk factors associated with liver impairment (e.g., alcohol use, hepatotoxic medications, previous history of any type of cancer). If subjective and objective examinations do not reveal any red flags, treatment may be initiated. If treatment does not result in objective or subjective improvement, ask the client again about the development of any new symptoms, especially constitutional symptoms or other associated symptoms discussed here.
Failure to progress in treatment should result in physician evaluation or reevaluation. The development of any new systemic symptoms requires medical evaluation as well. 5. Jaundice is first noted as a yellowing of the sclerae of the eyes. The skin may take on a yellow hue as well, but this is not as easily observed as the change in the eye. This change in eye and skin color can also occur with pernicious anemia, a condition that may be accompanied by peripheral neuropathy as well. 6. Given most people's concern about their physical appearance, it is best not to point out the change in eye color directly, but rather, ask some questions that may provide you with the information needed. For example, • Mrs. Jackson, have you ever been given a diagnosis of jaundice, hepatitis, or anemia? • Are you experiencing any new symptoms or problems that we haven't discussed? • Have you noticed any smells or foods that you cannot tolerate? • Have you (or your husband) noticed any changes in your skin or eyes? • At this point, if nothing comes to light, you may broach your observation by saying, "I have noted some yellowing of the white part of your eye. Is this something you have noticed or discussed with your physician?" 7. (d) 8. (c) Answer (a) (decreased serum albumin) is not a good laboratory measure because serum albumin has to be severely decreased for tissue damage to occur; coagulation times is a much better indicator of potential tissue injury in a clinical setting. 9. (d) 10. (b) 11. (b) Albumin is a protein that is formed in the liver and that helps to maintain normal distribution of water in the body.
Chapter 10 Screening for Urogenital Disease 1. (d) 2. (e) 3. (d) 4. Anyone with back pain or shoulder pain of unknown origin, especially when accompanied by changes in urination, blood in the urine, or constitutional symptoms. 5. Dyspareunia—Difficult or painful sexual intercourse in women
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Dysuria—Painful or difficult urination Hematuria—Blood in the urine Urgency—A sudden, compelling desire to urinate 6. Urge incontinence—Inability to hold back urination when one is feeling the urge to void (putting the key in the door or passing by a bathroom may trigger urine to leak) Stress incontinence—Involuntary escape of urine due to strain on the bladder (e.g., cough, sneeze, standing up, lifting, exercising) 7. "Skin pain" may be a sign of referred pain from the upper urinary tract because visceral sensory fibers via the autonomic nervous system and cutaneous sensory fibers via the peripheral nervous system (dermatomes) enter the spinal cord in close proximity and even converge on some of the same neurons. When visceral pain fibers are stimulated, concurrent stimulation of cutaneous fibers also occurs that is then perceived as "skin pain." 8. A physical therapist who is screening for prostate involvement must ask direct questions. A medical evaluation is necessary to identify actual prostate disease. Questions may include the following (see also Appendix B-27): • Are you experiencing any other symptoms of any kind? (If no, you may have to prompt with specifics: Have you had any fever or chills? Muscle or joint aches?) • Have you ever had any problems with your prostate in the past? • When you urinate, do you have trouble starting or continuing the flow of urine? • (Alternate questions): Has your urine stream changed in size? Do you urinate in a steady stream, or does the flow of urine start and stop? • Are you getting up to urinate at night? (If the answer is "yes," make sure this is something new or unusual for the client.) • Have you noticed any blood in your urine (or change in the color of your urine)? 9. Visceral pain is not well differentiated because innervation of the viscera is multisegmental with few nerve endings (see Fig. 3-3). As was previously discussed in question (7), renal/ urologic pain enters the spinal cord at the same level and in close proximity to cutaneous nerves in these multiple segments (from T10 to LI). Stimulation of these renal/urologic fibers can lead to stimulation of cutaneous fibers. As a result, renal and urethral visceral pain may be felt as skin pain throughout the T10-L1 dermatomes. 10. If the diaphragm becomes irritated as the result of pressure from a distended kidney (caused by
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tumor, cyst, inflammation), pain can be referred via interconnections between the phrenic nerve (innervating the diaphragm) and the cervical plexus (innervating the shoulder). Chapter 11 Screening for Endocrine and Metabolic Disease 1. Proximal muscle weakness, myalgia, carpal tunnel syndrome, periarthritis, adhesive capsulitis (shoulder) (see Table 11-1) 2. Endocrine disorders, infectious diseases, collagen disorders, cancer, liver disease (see Table 11-2). 3. Depends on the underlying disease process. For example, thickening of the transverse carpal ligament is associated with acromegaly and myxedema. Increased volume of the contents of the carpal tunnel occurs with pregnancy, neoplasm, gouty tophi deposits, and lipids in diabetes mellitus. Hormonal changes (e.g., menopause, pregnancy) can also result in carpal tunnel syndrome (CTS). See also liver-related causes in Chapter 9). 4. (f) 5. Polydipsia, polyuria, polyphagia 6. The major differentiating factor between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) is the absence of ketosis in HHS. 7. Yes. If their glucose levels are high, you will not endanger them any further with a small amount of sugar, and you may help someone who is experiencing hypoglycemia associated with diabetes mellitus. 8. (a) 9. (d) 10. (d) 11. (b) 12. (a) The American Diabetes Association recommends that people with diabetes maintain a level of 7% or below on the A1C; this reflects average blood-sugar levels over a period of 2 to 3 months. 13. (d) Chapter 12 Screening for Immunologic Disease 1. (c) Although the muscles and connective tissues are involved, the underlying cause is thought to be dysregulation of the autonomic nervous system as it interfaces with the neurohormonal system. 2. (a) Answers (b) and (c) are more characteristic of osteoarthritis (OA); rheumatoid arthritis (RA) is rarely accompanied by night pain, and advanced
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structural damage is more typical of OA because PA. has a tendency to "burn itself out"; answer (d) describes pain of vascular insufficiency. 3. (a) Psoriatic arthritis (b) Systemic lupus erythematosus (subcutaneous nodules may also occur with SLE) (e) HIV infection (d) Scleroderma (h) Rheumatoid arthritis (g) Allergic reaction (see Table 12-1) (f) Lyme disease (c) Thrombocytopenia 4. Many red flag clues must be considered. The therapist may observe or hear reports of any one or combination of the following: • Previous history of allergies, especially if the client has received medications over the past 6 weeks (even if the client is no longer taking the medications) • Recent history or presence of burning or urinary frequency (urethritis) • Recent history or presence of conjunctivitis or eye crusting, redness, burning, or tearing that lasts only a few days • Recent report or presence of skin rash, especially combined with a report of exposure to ticks • Positive family history for arthritis, spondyloarthropathy, psoriasis • Recent report of dry mouth or sore throat • Recent history of operative procedure • Other extra-articular signs or symptoms, such as diarrhea, constitutional symptoms, or other symptoms already mentioned • Enlarged lymph nodes 5. (c) 6. An electric shock sensation down the spine and radiating to the extremities when the neck is flexed; this is a fairly common sign in multiple sclerosis but may also accompany disc protrusion against the spinal cord. 7. (f) 8. (b) 9. (d) 10. (b) Symptoms of hives, itching, periorbital edema, and gastrointestinal involvement may occur with allergic reactions, but these do not usually require immediate medical treatment. The possible exception may include facial hives accompanied by constriction of the throat or upper respiratory symptoms (listed in answer [b]), leading to an inability to breathe.
Chapter 13 Screening for Cancer 1. Previous personal history of cancer; age in correlation with a personal or family history of cancer; age and gender in correlation with incidence of certain cancers; exposure to environmental and occupational toxins; geographic location; lifestyle (e.g., consumption of alcohol, smoking cigarettes, poor diet) 2. In any patient or client who is undergoing cancer treatment (especially chemotherapy), laboratory values offer a guide for determining appropriate frequency, intensity, and duration of exercise. In an outpatient setting, laboratory values may be unavailable or outdated. Without the benefit of laboratory values (and even when laboratory values are available), the therapist can and should monitor vital signs and rate of perceived exertion (RPE), and should look for associated signs and symptoms (e.g., pallor, dyspnea, unexplained or excessive diaphoresis, heart palpitations, visual changes, dizziness). Anything out of the ordinary should be considered a yellow (cautionary) flag that requires careful observation, further evaluation, and possibly medical referral. 3. (a)