Mobilization of the lumbar spine in a 76-year-old male with mechanical low back pain and an abdominal aortic aneurysm: A case report.

BACKGROUND: Abdominal aortic aneurysms (AAAs) are found in 1-12% of older males. Low back pain (LBP) is prevalent with incidence increasing with age and can respond to manual therapy (MT). To date, the safety of the application of MT for LBP in the presence of a known AAA has not been reported. This case reports on the short-term effects of MT in a patient with LBP and AAA and pre- and post-therapy imaging. CASE DESCRIPTION: A 76-year-old male presented with mechanical LBP, groin pain, and a known 4.2-cm AAA. A lumbar magnetic resonance imaging showed significant multilevel abnormalities. Abdominal screening did not elicit back or groin pain. Lumbar and hip range of motion and accessory motion testing reproduced his complaints. He was treated with lumbar and hip MT. OUTCOMES: After three visits, he reported that his groin pain resolved, and his back pain could be managed with home exercise. He reported a +6 on the global rating of change. Repeated follow-up imaging of his AAA demonstrated no significant change of his AAA. DISCUSSION: No immediate adverse events were recorded, and repeated follow-up imaging indicated no significant AAA expansion. Considering that mobilization causes similar displacement to active motion, research into the safety of MT in this population is warranted as are guidelines for appropriate initial and ongoing clinical screening during treatment in this population.

Frida Kahlo: Portrait of Chronic Pain.

The Mexican artist Frida Kahlo (1907-1954) is one of the most celebrated artists of the 20th century. Although famous for her colorful self-portraits and associations with celebrities Diego Rivera and Leon Trotsky, less known is the fact that she had lifelong chronic pain. Frida Kahlo developed poliomyelitis at age 6 years, was in a horrific trolley car accident in her teens, and would eventually endure numerous failed spinal surgeries and, ultimately, limb amputation. She endured several physical, emotional, and psychological traumas in her lifetime, yet through her art, she was able to transcend a life of pain and disability. Of her work, her self-portraits are conspicuous in their capacity to convey her life experience, much of which was imbued with chronic pain. Signs and symptoms of chronic neuropathic pain and central sensitization of nociceptive pathways are evident when analyzing her paintings and medical history. This article uses a narrative approach to describe how events in the life of this artist contributed to her chronic pain. The purpose of this article is to discuss Frida Kahlo's medical history and her art from a modern pain sciences perspective, and perhaps to increase our understanding of the pain experience from the patient's perspective.

Neuromuscular function in painful knee osteoarthritis.

Pain is a major cause of impaired mobility in elderly patients with chronic osteoarthritis (OA) of the knee. Central sensitization and impaired nociceptive inhibitory mechanisms have both been identified as contributing factors to heightened pain in this patient population. While central sensitization has been shown to produce enhanced pain responses and spread of pain to adjacent and remote body regions, conditioned pain modulation has also been shown to be adversely affected, and may be characteristic of those patients with chronic pain. Alterations of quantitative sensory testing measures have been demonstrated in patients with knee OA, and may serve as a clinical means of staging chronic musculoskeletal pain, including assessment of hyperalgesia and hypoesthesia. In addition, pain and altered somatosensation commonly associated with OA may be correlated with functional deficits.

Differential diagnosis and early management of rapidly progressing hip pain in a 59-year-old male.

OBJECTIVE AND IMPORTANCE: Rapidly progressing degeneration of the hip joint is an uncommon condition presenting to physical therapy. Differential diagnosis can often be difficult, as clinical and radiographic findings do not always coincide leaving clinicians with difficult decision making regarding course of treatment. The purpose of this case report was to describe the differential diagnosis and early management of a patient with rapidly progressing hip pain. CLINICAL PRESENTATION: A 59-year-old male with a complicated medical history was referred with a diagnosis of severe bilateral hip osteoarthritis. Clinical presentation of insidious onset, severe bilateral groin and anterior thigh pain with rapid progression of functional decline lead to the differential diagnosis of bilateral avascular necrosis. INTERVENTION: The patient received seven manual physical therapy sessions over the course of one month. CONCLUSION: During this time, the patient's Lower Extremity Functional Scale score worsened from 33 to 21. The persistence of the patient's painful symptoms and continued functional decline helped determine cessation of manual therapy and referral back to his GP for further diagnostic testing and eventual correct diagnosis. This case highlights the importance of monitoring patient prognosis using outcome measures leading to a change in patient management strategies.

Quantitative sensory testing changes in the successful management of chronic low back pain.

Individuals with chronic low back pain (LBP) represent a significant percentage of patients in physical therapy practice. The clinical pattern often includes diffuse pain and a variety of sensory complaints, making categorization difficult and leading to diagnoses such as non-specific LBP. Objective measures of sensory changes through quantitative sensory testing may help identify central sensitization of nociceptive pathways in this population. Identification of these somatosensory changes may contribute to clinical decision making and patient management. The purpose of this case report is to present objective evaluation findings, including altered somatosensation, in a patient with a 2-year history of LBP, and to describe changes in function and quantitative sensory testing with successful management.

Resolution of whiplash-associated allodynia following cervicothoracic thrust and non-thrust manipulation.

Whiplash injuries of the cervical spine comprise 30% of injuries reported following motor vehicle accident (MVA) and often progress to chronic painful conditions. The purpose of this case report is to describe the management of a 37-year-old female referred to physical therapy with neck and shoulder pain after whiplash injury. The patient demonstrated limited cervical and shoulder active range of motion as well as quantitative sensory testing (QST) results consistent with central nervous system sensitization. She was treated for 11 visits over a 6-week period with manual therapy and specific exercise directed to the cervicothoracic spine. Her pain decreased from 9/10 to 2/10 by the end of treatment and remained improved at 1/10 at the 6-month follow-up. Her Copenhagen Neck Functional Disability Scale decreased from 23/30 to 4/30 by the 11th visit. In addition, she demonstrated clinically significant increases in cervical active range of motion and normal somatosensation. Manual therapy of the cervicothoracic spine may be a beneficial adjunct to the standard care of patients with signs and symptoms of central sensitization after whiplash-associated disorder and primary report of neck and shoulder pain.

Clinical presentation and manual therapy for lower quadrant musculoskeletal conditions.

Chronic lower quadrant injuries constitute a significant percentage of the musculoskeletal cases seen by clinicians. While impairments may vary, pain is often the factor that compels the patient to seek medical attention. Traumatic injury from sport is one cause of progressive chronic joint pain, particularly in the lower quarter. Recent studies have demonstrated the presence of peripheral and central sensitization mechanisms in different lower quadrant pain syndromes, such as lumbar spine related leg pain, osteoarthritis of the knee, and following acute injuries such as lateral ankle sprain and anterior cruciate ligament rupture. Proper management of lower quarter conditions should include assessment of balance and gait as increasing pain and chronicity may lead to altered gait patterns and falls. In addition, quantitative sensory testing may provide insight into pain mechanisms which affect management and prognosis of musculoskeletal conditions. Studies have demonstrated analgesic effects and modulation of spinal excitability with use of manual therapy techniques, with clinical outcomes of improved gait and functional ability. This paper will discuss the evidence which supports the use of manual therapy for lower quarter musculoskeletal dysfunction.

Interpreting joint pain: quantitative sensory testing in musculoskeletal management.

SYNOPSIS: Pain is a common complaint among clients seeking physical therapy services, yet interpretation of associated sensory changes can be difficult for the clinician. Musculoskeletal injury typically results in nociceptive pain due to noxious stimuli of the damaged muscle or joint tissues. However, with progression from acute to chronic stages, altered nociceptive processing can give rise to an array of sensory findings. Specifically, patients with chronic joint injury may present with signs and symptoms typically associated with neuropathic injury, due to changes in nociceptive processing. Clinical presentation may include expansion of hyperalgesia into adjacent and remote areas, allodynia, dysesthesias, and perceptual deficits. Quantitative sensory testing (QST) may provide an objective method of examining sensation and, thereby, of recognizing potential changes in the nociceptive pathways. The purpose of this paper is to provide an overview of altered nociceptive processing and somatosensory changes that may occur following a musculoskeletal injury without associated neural injury. Recommendations are made on clinical uses of quantitative sensory testing in orthopaedic physical therapy practice, and supporting clinical and laboratory evidence are presented. Examples related to joint injury are discussed, specifically, osteoarthritis of the knee and low back pain. Quantitative sensory testing may be a useful clinical tool to aid clinical decision making and for determination of prognosis.