Test your knowledge of Aneurysms

Dissecting Thoracic Aneurysm:

  • Severe chest pain without change with change of position or lying down and can refer to upper back

Dissecting Abdominal Aneurysm:

  • sudden severe constant low back pain, boring, tearing
  • flank pain, abdominal pain and or groin pain
  • pulsating mass in the abdomen
  • fainting and hypotension
  • cyanosis
  • confused mental state, distressed

An abdominal aneurysm can be a deep seated boring lumbar pain, unrelated to activity or a severe tearing pain associated with dizziness and sweating.  Atherosclerotic changes in the posterior wall of the abdominal aorta have been linked to back pain in older adults. 1

Aortic Aneurysm 2, 3, 4

 

An aortic aneurysm can be asymptomatic or very symptomatic.  It can be found on a routine examination or x-ray.  On examination of the abdomen, it may be detected by noting a pulsating mass in the abdomen.  Once an aneurysm becomes symptomatic there may be abdominal, back, flank and groin pain.  An acute dissecting aortic aneurysm is where an aneurysm forms a hematoma in the media of the artery will cause intense, tearing, boring, sharp pain in the into the chest, abdomen, groin and back.  There may be a sudden drop in blood pressure.  No change of position will alter this pain and this is an emergency situation.

A patient’s age over 50 more so over the age of 65 is a risk factor but an aortic aneurysm can be congenital.  Starting a weightlifting program in the presence of atherosclerosis, hypertension or an asymptomatic aortic aneurysm may precipitate a rupture.  It is important that patients have a medical evaluation prior to starting a weight lifting program in this age group. Therapists can feel for a pulse on the surface of the abdomen at the umbilicus with the patient in hook/crook lie.  Slowly move the palpating hand laterally until the pulse disappears.  If this distance is greater than 2.5 centimeters, the patient should be referred out to an MD.

1) Maffey, Lorrie, Canadian Physiotherapy Association Curriculum Manual Therapy Courses (E-V Series),1999.

2) Dutton M.   Orthopaedic Examination, Evaluation, & Intervention.  New York: McGraw-Hill; 2004.

3) Goodman, C, Kelly Snyder, T. Differential Diagnosis for Physical Therapists.St. Louis: Elsevier, 2013.

4) http://emedicine.medscape.com/article/761627-overview

Differential Diagnosis of the Spine

Neurological Screening Tests

Test your knowledge on two  neurological screening tests

FEMORAL SLUMP TEST

The femoral slump test is used to test the upper and mid lumbar nerve roots for compression. It can be used as well as a prone femoral knee bend test and is thought to be superior to the prone test by differentiating between neural and non-neural structures. The patient is side lie with the cervical and thoracic spines flexed. The underside hip and knee are flexed. The upper knee is flexed and the hip is extended to the point of symptoms. If no symptoms are reproduced, the hip extension and knee flexion should stop once firm tension is noted. If symptoms are reproduced the patient is asked to extend their cervical spine while the tension is monitored in the uppermost leg.

The test has a high inter-therapist reliability for testing and for differential diagnosis of mid to upper lumbar root compression were a sensitivity of 100%, specificity of 83%, a positive predictive value of 67%, Negative predictive value of 100%, positive likelihood ratio of 6.0 and negative likelihood ratio of 0. This reliability of this test was studied over more than one day and was found to be reliable across days.

Trainor, K and Pinnington, MA.  Reliability and diagnostic validity of the slump knee bend neurodynamic test for upper/mid lumbar nerve root compression: a pilot study. Physiotherapy. 2011 Mar;97(1):59-64.

Clinical Prediction Rules for Spinal Fractures

Test your knowledge on the clinical prediction rules for spinal fractures.

To identify patients with a likelihood of vertebral compression fracture:

CPR Roman
1. Age > 52 years
2. no presence of referred leg signs
3. BMI of 22 or less
4. No regular exercise
5. female

.

Another CPR rule.

CPR Henschke

1. Female
2. age > 70
3. Significant trauma in young patients, minor in elderly
4. Prolonged use of corticosteroids.

Differential Diagnosis of the Spine

Clinical Screening Tools

Test your knowledge of Clinical Screening Tools.

KEHR’S SIGN

Kehr’s sign is pain that occurs in the tip of the shoulder when there is blood or other irritants in the peritoneal cavity associated with the spleen. It is irritation of the diaphragm and is felt via the phrenic nerve to above the clavicle. It is considered a classic symptom of a ruptured or abscessed spleen. Ruptured spleens can occur with mononucleosis. The sign is a pain in the upper left quadrant with palpable tenderness at the site and under the left rib cage. Signs of shock due to internal bleeding may occur. Important for Therapists who deal with sports injuries as it is the most common cause of death due to abdominal trauma in sports injuries.
Splenic abscess presents with fever and left upper abdominal pain. This test in conjunction with CT imaging has a diagnostic rate of 86.7%

MURPHY’S PERCUSSION

Murphy’s percussion is a test for kidney involvement with infection or inflammation. The test is performed by placing the hand over the costovertebral angle of the rib cage and thumping this hand with the other fist. If it reproduces the signs of flank or back pain it is a positive for kidney involvement although there are no specific studies to determine its reliability. This symptom may coincide with fevers and chills.


Kidney Location: By OpenStax College [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons
1. Soyuncu, S et al. Traditional Kehr’s sign: Left shoulder pain related to splenic abscess. Ulus Travma Acil Cerrahi Derg. 2012 Jan 18(1): 87-8.
2. Hansen, N. Peterson, R. Ruptured Spleen. Physio-pedia.com. n.d. web. Jan 12 2016.
3. Lake, C, Templin, K.  Thoracic Examination. Physio-pedia.com n.d. web. Jan 12 2016.
4. Goodman, C, Kelly Snyder, T. Differential Diagnosis for Physical Therapists.St. Louis: Elsevier

Pain

Pain and the need to be dynamic

This is a safe link to the Department of Health, Western Australia

painHEALTH has been developed through the Department of Health, Western Australia in collaboration with Curtin University, University of Western Australia and the Musculoskeletal Health Network.

The aim of the website is to help health consumers with musculoskeletal pain access reliable and usable evidence-informed information and skills to assist in the co-management of their musculoskeletal pain.

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