Red flags useful to screen for gastrointestinal and hepatic diseases in patients with shoulder pain: A scoping review

Acute pleurisy mimicking neck pain in a young volleyball player: a case report

INTRODUCTION

Patients presenting to direct access physiotherapists may present with a serious pathology that mimics a musculoskeletal condition. Recognition of atypical clinical patterns allows for referral to an appropriate provider when a serious pathology is present. This case report details a patient with a pulmonary pathology who presented to a physiotherapist with a complaint of neck and chest pain following medical consultations.

CASE PRESENTATION

A 29-year-old amateur volleyball player arrived at the physiotherapist's clinic five days after experiencing the onset of neck pain. She complained of pain on the right side, which extended to the trapezius, as well as occasional discomfort in the lower lateral and anterior chest. The patient noted that the pain worsened when lying supine or on her left side, and during coughing. After developing symptoms resembling a cold, she sought care at two different emergency clinics where physicians diagnosed seasonal flu and an unrelated muscle strain. Despite treatment, the pain persisted, accompanied by fever and general weakness, disrupting her sleep. Following a review of a medical history and a physical examination, musculoskeletal causes of pain appeared unlikely, prompting consideration of a pulmonary pathology. Referral to a specialist was deemed necessary.

CONCLUSION

This case report highlights the importance of screening for serious pathology in direct access physiotherapy, irrespective of a prior physician consultation.

Physiotherapists' awareness and use of red flags for the assessment of low back pain in Saudi Arabia

BACKGROUND

Physiotherapists must identify potential red flags that may impede recovery and function in individuals with low back pain (LBP) or put them at risk.

OBJECTIVES

This study aimed to (1) investigate physiotherapists' awareness and use of red flags for individuals with LBP in Saudi Arabia and (2) identify factors associated with their awareness and use of LBP red flags.

METHODS

This cross-sectional study collected data using an anonymous online questionnaire (February-July 2023). It included physiotherapists working in private/public hospitals in Saudi Arabia. The questionnaire asked about the participants' characteristics, their awareness of LBP red flags, and their use of red flags for LBP assessment.

RESULTS

A total of 643 participating physiotherapists (26.2 ± 3.8 years), 63.8% of whom were females, completed the survey. Most participants (94.4%) had adequate awareness of LBP red flags, and more than half (61%) had good utilization of red flags when assessing individuals with LBP. There was a positive correlation between the physiotherapists' awareness and use of LBP red flags.

CONCLUSION

The majority of the participating physiotherapists in Saudi Arabia were aware of LBP red flags, and many reported to have good use of red flags in clinical practice when assessing and managing individuals with LBP.

Impact of open bursectomy and biceps tendon release with closed manipulation in frozen shoulder

This retrospective observational study evaluated the efficacy of 2 different surgical approaches for the treatment of frozen shoulder (adhesive capsulitis). This study aimed to compare the efficacy, safety, and recovery times of the 2 treatment modalities. Fifty patients diagnosed with frozen shoulder and treated at Seyhan State Hospital were included in the study. The patients were retrospectively divided into 2 groups based on the treatment received. Group 1 consisted of 25 patients who underwent standard closed manipulation under anesthesia, a technique involving passive movements of the shoulder joint to tear the tight capsule and expand the range of motion (ROM). Group 2, which included 25 patients, underwent closed manipulation in addition to open bursectomy and biceps tendon capsule release. Open bursectomy involves surgical removal of the bursa to alleviate inflammation, while biceps tendon capsule release addresses chronic biceps tendonitis by partially removing the capsule of the tendon. Data on demographic information, operative details, preoperative and postoperative conditions, and patient-reported outcomes were collected and analyzed. Data analysis revealed that the combination of closed manipulation with open bursectomy and biceps tendon capsule release was more effective in reducing pain, increasing ROM, and improving quality of life than closed manipulation alone. The discussion would typically elaborate on how the results compare with existing literature, the clinical implications, and any potential limitations of the study. The results showed that the method that combined closed manipulation with open bursectomy and biceps tendon capsule release was better than closed manipulation alone in terms of reducing pain, increasing ROM, and improving quality of life.

Low back pain as main symptom in Low-grade Appendiceal Mucinous Neoplasm (LAMN): A case report

BACKGROUND

Low back pain is the leading cause of disability worldwide. It is also the main cause of the limitation of activities and absence from work in much of the world and a cause of great economic burden. The greatest percentage of low back pain is classified as nonspecific (i.e. not attributable to a defined pathology), while the others may concern specific pathologies of the lumbar region or suggest pathologies of non-musculoskeletal origin. Consequently, evaluating any signs and symptoms mimicking musculoskeletal conditions is crucial.

CASE DESCRIPTION

This case report describes a 64-year-old female patient who first presented to the physiotherapist with two weeks of low back pain, complaining of a different clinical presentation than the previous episodes. The patient's pain started spontaneously and was located in the lumbar region over a diffuse area. Symptoms were constant throughout the day and did not change with movement. Based on the examination findings, the physiotherapist decided to make an urgent referral to the patient's General Practitioner.

OUTCOMES

Following ultrasound examination and Computed Tomography scan, an 8.5 cm mass was confirmed in the abdominal region. It was surgically removed, and a histological diagnosis of Low-grade Appendiceal Mucinous Neoplasm (LAMN) was made.

CONCLUSION

The physiotherapist's evaluation and decision-making process was fundamental in the patient's referral due to suspected pathology not within the scope of practice. This revealed a rare condition, which, according to the existing literature, is usually diagnosed in the event of collateral imaging findings or upon presentation of complex and/or emergency clinical pictures.

Surgical Repair for Rhomboid Major Tear: A Case Report

Rhomboid tears are a rare type of tendon injury. Although rhomboid tears can present with periscapular pain and scapular dyskinesis, their clinical presentations and diagnostic procedures remain largely unknown. In addition, few reports are available on the surgical treatment of rhomboid tears. We report a rhomboid repair case for a complete rhomboid major tear diagnosed based on physical findings and magnetic resonance imaging (MRI). A 28-year-old man presented with right medial scapular pain that appeared after carrying a heavy box. He had right medial scapular tenderness, with worsening pain during shoulder joint elevation. The inferior pole of the right scapula was lateral compared with the left scapula, and a dent was observed on the medial scapula. Magnetic resonance imaging revealed a tear in the right rhomboid major at its insertion, with muscle retraction. Two months of conservative treatment failed to improve his symptoms; therefore, we performed a surgical repair. We created the bone holes on the medial border of the scapula and repaired the torn rhomboid major muscle to its insertion using the Krackow stitch technique. He had a satisfactory functional outcome without postoperative retearing. This case report provides new information on the clinical presentation and surgical procedure of rhomboid major tears and the first MRI finding that depicts a rhomboid tear clearly. In cases of rhomboid tears, persistent medial scapular pain and winging scapula can be clinically problematic, requiring surgery. In addition to physical findings, a periscapular MRI is useful in diagnosing rhomboid tears. The results of this case study suggest that surgical repair using locking sutures is an option for treating complete rhomboid tears with muscle retraction.

Acromioclavicular joint mobilizations for the management of grade I sternoclavicular joint sprain: a case report

OBJECTIVE

Injury to the sternoclavicular joint is a rare phenomenon that has implications for the shoulder complex. Limited literature exists on optimal physical therapy rehabilitation after a sternoclavicular ligament sprain. This case report details the physical therapy management and outcomes of a patient with a posterior sternoclavicular joint sprain.

CASE DESCRIPTION

The patient was a 34-year-old female who sustained a grade I posteriorly directed sternoclavicular sprain during a motor vehicle accident. She received a combination of acromioclavicular joint mobilizations and therapeutic exercise for her shoulder complex for five sessions over six weeks.

OUTCOMES

At discharge, the patient surpassed the minimally clinically important difference (MCID) and the minimal detectable change (MDC) in her Quick-DASH score. She surpassed the MDC and MCID in her Numerical Pain Rating Scale score. She was able to regain full functional use of her involved upper extremity and returned to her work and original exercise regimen with no further limitations.

CONCLUSION

The outcomes suggest that a combination of acromioclavicular joint mobilizations and therapeutic exercise for the shoulder complex was a suitable option for the conservative management of this patient's grade I sternoclavicular sprain.

Spontaneous Hepatic Rupture in a Pregnant Woman with Preeclampsia and HELLP Syndrome

Spontaneous hepatic rupture is a rare complication associated with preeclampsia and is characterized by hemolysis, elevated liver enzymes, and a low platelet count (HELLP syndrome), with a nonspecific clinical presentation and high mortality rate. We present the case of a 34-year-old primigravida woman in whom spontaneous hepatic rupture associated with HELLP syndrome was accidentally detected during cesarean delivery. The patient was successfully managed with liver packing and transcatheter arterial embolization, followed by plasmapheresis. Spontaneous hepatic rupture should be considered in any HELLP syndrome patient presenting with epigastric or right upper quadrant pain and early signs of hemodynamic instability. A multimodal approach can help achieve good clinical outcomes in patients with this rare presentation.

Effectiveness of Pain Neuroscience Education in Patients with Chronic Musculoskeletal Pain and Central Sensitization: A Systematic Review

OBJECTIVE

To collect the available evidence about the effectiveness of pain neuroscience education (PNE) on pain, disability, and psychosocial factors in patients with chronic musculoskeletal (MSK) pain and central sensitization (CS).

METHODS

A systematic review was conducted. Searches were performed on Pubmed, PEDro, and CINAHL, and only randomized controlled trials (RCTs) enrolling patients ≥18 years of age with chronic MSK pain due to CS were included. No meta-analysis was conducted, and qualitative analysis was realized.

RESULTS

15 RCTs were included. Findings were divided for diagnostic criteria (fibromyalgia-FM, chronic fatigue syndrome-CFS, low back pain-LBP, chronic spinal pain-CSP). PNE has been proposed as a single intervention or associated with other approaches, and different measures were used for the main outcomes considered. Conclusions, practice implication: PNE is effective in improving pain, disability, and psychosocial factors in patients with fibromyalgia, chronic low back pain (CLBP)-especially if associated with other therapeutic approaches-and also in patients with CFS and CSP. Overall, PNE seems to be more effective when proposed in one-to-one oral sessions and associated with reinforcement elements. However, specific eligibility criteria for chronic MSK pain due to CS are still lacking in most RCTs; therefore, for future research, it is mandatory to specify such criteria in primary studies.

Ultrasound Diagnostic and Physiotherapy Approach for a Patient with Parsonage-Turner Syndrome-A Case Report

Parsonage-Turner syndrome (PTS) is a rare neurological disorder that causes major diagnostic problems. This paper presents a case report of a patient with PTS and proposes a new physiotherapy program.

CASE DESCRIPTION

a 23-year-old man presents a sudden severe pain of his right arm. The man is consulted by several doctors and physiotherapists. Three magnetic resonance imagings (MRI), a nerve conduction study (NCS), and needle electromyography (EMG) are performed. After 6 months, based on medical history, physical examination and ultrasound imaging (UI), the physiotherapist suggests PTS, which is confirmed by a neurologist.

INTERVENTION

due to the lack of physiotherapy treatment standards in PTS, we apply neurodynamic techniques.

OUTCOMES

neurodynamic techniques are effective in reducing pain and paraesthesia, improving sensation, and reducing nerve swelling (assessed by UI), as well as improving manual dexterity and overall health status.

CONCLUSIONS

the patient with PTS is challenging for making an accurate diagnosis. This study shows an important role for UI, which shows changes in the musculocutaneous nerve, despite the lack of abnormalities in the MRI, NCS, and EMG, and helps in making an accurate diagnosis. This report also confirms that physiotherapy based on neurodynamic techniques may have beneficial effects in PTS.

Neoplastic malignant cord compression mimicking low back pain: A case report

BACKGROUND

The point prevalence of Cauda Equina Syndrome (CES) as a cause of Low Back Pain (LBP) is estimated at 0.04% in primary care, and it is reported as a complication in about 2% of patients with disc herniation. Compression of the cauda equina usually occurs as a result of disc prolapse. However, CES may be caused by any space-occupying lesion, including spinal stenosis, neoplasms, cysts, infection, and osteophytes. First contact physiotherapists may encounter patients with early CES, as the clinical presentation of CES can mimic non-specific LBP.

CASE PRESENTATION

This case report presents the medical history, diagnostic tests and relevant clinical data of a 52-year-old man complaining of LBP. The patient's medical history, his symptoms and the clinical findings led to the identification of a number of red flags (i.e. risk factors) suggestive of a non-musculoskeletal condition. The patient was referred to the emergency department for further investigation. Having undergone several diagnostic tests, the patient was diagnosed with CES due to malignancy.

CONCLUSIONS

This case report highlights the importance of differential screening throughout the treatment period, in order to identify red flags that warrant further investigation and a referral to an appropriate specialist. Physiotherapy screening should include clinical reasoning, careful analysis of clinical presentation and symptom progression, in addition to appropriate referral for medical assessment and diagnostic imaging, if necessary.

Aggressive Vertebral Hemangioma and Spinal Cord Compression: A Particular Direct Access Case of Low Back Pain to Be Managed-A Case Report

Hemangiomas are the most common benign tumours affecting the spine, with an incidence of 10-12% of the general population. Although most hemangiomas are asymptomatic, there are aggressive forms which can develop symptoms, leading patients to show signs of disability. This case report aims to highlight the importance of red flags screening, and to report the physiotherapist's clinical reasoning that led him to refer his patient to other healthcare professionals. This case also illustrated the pre- and post-surgical treatment of a specific low back pain case in a patient affected by aggressive vertebral hemangioma and spinal cord compression. The patient is a 52-year-old man, who reported intense pain in his sacral region about three months prior, which worsened while in sitting position. The physiotherapist proceeded with a complete medical history investigation and clinical examination. After an impaired neurological examination, the patient was referred to another health professional, who diagnosed multiple vertebral hemangiomas in the patient's lumbosacral tract. The therapeutic intervention included the patient's post-surgical rehabilitation following a vascular embolization. This case report shows the importance of proper patient screening. Indeed, during patients' assessment, it is paramount to recognize red flags and to investigate them appropriately. An early referral of patients with conditions that require the support and expertise of other professionals can lead to a timely diagnosis and avoid costly and unnecessary rehabilitation procedures. In this case, the interdisciplinary collaboration between physiotherapist and neurosurgeon was crucial in guiding the patient towards recovery.

Management of Low Back Pain in Primary Health-Care Settings: Physician's Awareness and Practices Based on Red Flags

Background

Low back pain (LBP) is one of the most common health problems. Red flags (RFs) of LBP are risk factors that are reported during clinical assessment to determine serious illness. This study aimed to assess primary health-care physicians’ knowledge of and practices for RFs of LBP and identify variables associated with a high level of knowledge and awareness about it.

Methods

An observational cross-sectional survey was conducted in 2021 among a random sample of 261 primary health care (PHC) physicians in the Jazan Region in southwest Saudi Arabia. A web-based questionnaire was used to collect data on LBP red flags awareness and practices. Descriptive (frequency and percentage) and inferential statistics were used for data analysis.

Results

The overall mean score of RFs knowledge among physicians was 82.33 ± 36.3, with 95% confidence interval (CI); (77.7–86.9). Regarding the Physician’s practices, more than 95% of the participants would refer patients to higher levels in the presence of symptoms or signs of RFs. General practitioners and residents were significantly more likely to ask for an Xray, even with symptoms that had persisted for less than 2 weeks without RF signs (p = 0.006). The overall percentage of patients with nonspecific LBP referrals was as high as 57.8%. The number of patients with LBP seen per month (fewer than 15) and female physician were associated with an increased level of knowledge (OR = 2.2, 95%, P < 0.05) and (OR = 2.2, 95%, P < 0.05) respectively.

Conclusion

Overall, awareness of RFs for LBP and referring critical patients who present with LBP is good among PHC physicians in the Jazan Region. Junior physicians have a low threshold to request images. The referral rate for nonspecific LBP is still high, which could overwhelm spinal clinics. Further educational programs for back pain management are recommended.

Treatment, Diagnostic Criteria and Variability of Terminology for Lateral Elbow Pain: Findings from an Overview of Systematic Reviews

Background: Lateral elbow pain (LEP) represents a musculoskeletal disorder affecting the epicondyloid region of the elbow. The terminological framework of this problem in literature, to date, is confusing. This systematic review (SR) aims to analyse the panorama of the scientific literature concerning the pathogenetic framework, treatment, and clinical diagnosis of LEP. Methods: We conducted an SR according to the guidelines of the PRISMA statement. We performed research using the electronic Medline, Epistemonikos, and Cochrane Library databases. The research started on 12 January 2022 and finished on 30 April 2022. We included all systematic reviews and meta-analyses published, in English, between 1989 and 2022. The articles’ selection was based on critical appraisal using Amstar 2. In the selected reviews we obtained the etiopathogenic terminology used to describe the symptoms, treatment, and diagnostic criteria of LEP. Results: Twenty-five SRs met the eligibility criteria and were included in the study. From these SRs, 227 RCT articles were analysed and different treatments proposals were extracted, such as exercise, manipulation corticosteroid injection, and surgery. In the selected articles, 10 different terms emerged to describe LEP and 12 different clinical tests. The most common treatments detected in this SR were a conservative multimodal approach (e.g., eccentric exercises, manual therapy, acupuncture, ultrasound), then surgery or other invasive treatments (e.g., corticosteroid injection, tenotomy). The most common term detected in this SR was “lateral epicondylitis” (n = 95, 51.6%), followed by “tennis elbow” (n = 51, 28.1%) and “lateral epicondylalgia” (n = 18, 9.4%). Among the diagnostic tests were painful palpation (n = 101, 46.8%), the Cozen test (n = 91, 42.1%), the pain-free grip-strength test (n = 41, 19.0%), and the Maudsley test (n = 48, 22.2%). A total of 43.1% of RCTs (n = 96) included subjects with LEP > 3 months, 40.2% (n = 85) included patients with LEP < 3 months, and 16.7% of the items (n = 35) were not specified by the inclusion criteria on the onset of symptoms. Conclusions: In this SR, a considerable terminological heterogeneity emerged in the description of LEP, associated with the lack of clear and recognised diagnostic criteria in evaluating and treating patients with lateral elbow pain.