Dry needling in the management of chronic tension-type headache associated with levator scapulae syndrome: A case report.

Key Clinical Message: The use of DN to the muscular trigger points and distal periosteal enthesis of the levator scapulae may be a useful adjunct intervention within a multi-modal plan of care for the management of work-related chronic tension-type headaches associated with LSS. Abstract: Chronic tension-type headaches (CTTH) have a lifetime prevalence of 42% and account for more lost workdays than migraine headaches. Dry needling (DN) is being increasingly used by physical therapists in the management of CTTH; however, to date, the supporting evidence is limited. The purpose of this case report was to describe how three sessions of DN targeting myofascial trigger points in the levator scapulae (LS) muscle and its distal enthesis was used to treat a 63-year-old male patient who presented with work-related CTTH associated with levator scapulae syndrome (LSS). The patient was treated for five visits over the course of 2 months. At discharge and 6-month follow-up, the patient reported full resolution of symptoms. Self-report outcomes included the numeric pain rating scale and the Neck Disability Index. The use of DN to the LS muscle and its distal enthesis may be a valuable addition to a multi-modal plan of care in the treatment of work-related CTTH associated with LSS.

Recognition of a patient with neck autonomic dysfunction: findings from a rare case report of harlequin syndrome in direct access physiotherapy.

BACKGROUND: Harlequin syndrome is a rare autonomic condition consisting of unilateral facial flushing and sweating induced by heat, emotion or physical activity. The affected side presents anhidrosis and midline facial pallor due to denervation of the sympathetic fibers. CASE DESCRIPTION: This case describes a patient who reported right-side redness of the face associated with hyperhidrosis during physical activity. She had two previous major motor vehicle accidents. The patient demonstrated difficulties in the visual accommodation of the left eye, but cranial nerve assessment was unremarkable; the patient was then referred to an ophthalmologist, who excluded any autonomic dysfunction as the primary cause of convergence and visual acuity. OUTCOMES: A left-sided sympathetic dysfunction with Harlequin sign diagnosis was made followed by a progressive compensatory adaptation of the right face. The patient was educated and reassured about the benign nature of her problem. DISCUSSION: Knowledge of the autonomic nervous system is still limited in clinical practice. Although challenging, physiotherapists should develop the knowledge and ability needed to perform appropriate assessment of autonomic dysfunctions. CONCLUSION: A dispositional reasoning model should be considered in differential diagnosis.

A modern way to teach and practice manual therapy.

BACKGROUND: Musculoskeletal conditions are the leading contributor to global disability and health burden. Manual therapy (MT) interventions are commonly recommended in clinical guidelines and used in the management of musculoskeletal conditions. Traditional systems of manual therapy (TMT), including physiotherapy, osteopathy, chiropractic, and soft tissue therapy have been built on principles such as clinician-centred assessment, patho-anatomical reasoning, and technique specificity. These historical principles are not supported by current evidence. However, data from clinical trials support the clinical and cost effectiveness of manual therapy as an intervention for musculoskeletal conditions, when used as part of a package of care. PURPOSE: The purpose of this paper is to propose a modern evidence-guided framework for the teaching and practice of MT which avoids reference to and reliance on the outdated principles of TMT. This framework is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety, comfort, and efficiency. These practical elements are contextualised by positive communication, a collaborative context, and person-centred care. The framework facilitates best-practice, reasoning, and communication and is exemplified here with two case studies. METHODS: A literature review stimulated by a new method of teaching manual therapy, reflecting contemporary evidence, being trialled at a United Kingdom education institute. A group of experienced, internationally-based academics, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through reviews of contemporary literature and discussions in an iterative process. Public presentations were made to multidisciplinary groups and feedback was incorporated. Consensus was achieved through repeated discussion of relevant elements. CONCLUSIONS: Manual therapy interventions should include both passive and active, person-empowering interventions such as exercise, education, and lifestyle adaptations. These should be delivered in a contextualised healing environment with a well-developed person-practitioner therapeutic alliance. Teaching manual therapy should follow this model.

Percutaneous tendon dry needling and thrust manipulation as an adjunct to multimodal physical therapy in patients with lateral elbow tendinopathy: A multicenter randomized clinical trial.

OBJECTIVE: The purpose of this study was to assess the effects of adding electrical dry needling and thrust manipulation into a multimodal program of exercise, mobilization, and ultrasound in patients with lateral elbow tendinopathy. DESIGN: Randomized, single-blinded, multicenter, parallel-group trial. SETTING: Thirteen outpatient physical therapy clinics in nine different US states. PARTICIPANTS: One hundred and forty-three participants (n = 143) with lateral elbow tendinopathy were randomized. INTERVENTION: Cervical spine manipulation, extremity manipulation, and percutaneous tendon electrical dry needling plus multimodal physical therapy (n = 73) or multimodal physical therapy (n = 70) alone. MAIN MEASURES: The primary outcome was elbow pain intensity and disability as measured by the Patient-Rated Tennis Elbow Evaluation at baseline, 1 week, 4 weeks, and 3 months. Secondary outcomes included the Numeric Pain Rating Scale, Tennis Elbow Functional Scale, Global Rating of Change, and medication intake. RESULTS: The 2 × 4 analysis of covariance demonstrated that individuals with lateral elbow tendinopathy receiving electrical dry needling and thrust manipulation plus multimodal physical therapy experienced significantly greater improvements in disability (Patient-Rated Tennis Elbow Evaluation: F = 19.675; P < 0.001), elbow pain intensity (Numeric Pain Rating Scale: F = 22.769; P < 0.001), and function (Tennis Elbow Function Scale: F = 13.269; P < 0.001) than those receiving multimodal physical therapy alone at 3 months. The between-group effect size was large for pain and disability (Patient-Rated Tennis Elbow Evaluation: standardized mean difference = 1.13; 95% confidence interval: 0.78, 1.48) in favor of the electrical dry needling and thrust manipulation group. CONCLUSIONS: The inclusion of percutaneous tendon electrical dry needling and thrust manipulation into a multimodal program of exercise, mobilization and ultrasound was more effective than multimodal physical therapy alone in individuals with lateral elbow tendinopathy.Trial Registration: www.clinicaltrials.gov NCT03167710 May 30, 2017.

Spinal manipulation does not improve short-term pain and function in persons with painful shoulder: a systematic review with meta-analysis.

PURPOSE: To investigate the benefit of spinal high-velocity low-amplitude thrust (HVLAT) in improving pain and disability in persons with painful shoulder as primary outcomes. Function, quality of life, persons (and clinicians) satisfaction, adverse events rate, and time for recovery were secondary outcomes. METHODS: A systematic review with meta-analysis was conducted and MEDLINE, CENTRAL, Embase, and PEDro until 20 September 2023 were investigated. Two thousand eight hundred and ninety-nine records were retrieved and nine studies were included. Risk of bias of included studies was assessed through the Revised Cochrane risk-of-bias tool. The certainty of evidence of the pooled results was graded with GRADE approach. RESULTS: The analysis included nine studies (441 persons). The pooled results showed non-significant differences between HVLAT versus sham in pain at pre-post follow-up (MD -0.13, 95% confidence interval (CI) -0.60; 0.35; p = 0.61, I2 = 0%), and at <4 days follow-up (SMD 0.16, 95%CI -0.16; 0.48; p = 0.34, I2 = 23%); in function at <4 days follow-up (SMD -0.29, 95%CI -0.69; 0.11; p = 0.16, I2 = 50%). The certainty of evidence ranged from low to very low. CONCLUSIONS: HVLAT was not more effective than sham in improving pain and function at pre-post and at <4 days follow-up. When used as an "add-on technique", HVLAT did not improve pain nor disability.

High-velocity low-amplitude thrust (HVLAT) manipulation is no more effective than sham in improving shoulder pain at pre-post follow-up.Clinician should not be recommended to deliver HVLAT manipulation in subjects with painful shoulder with the purpose of reducing pain intensity.However, HVLAT manipulation should be considered within a multimodal approach to address function in painful shoulder subjects.

Ewing's sarcoma in a young man mimicking lateral elbow pain: A case report with 2 years follow-up.

BACKGROUND AND PURPOSE: Lateral elbow pain represents a common musculoskeletal disorder, mostly non-specific and benign. In rare cases, it can be the first symptom of a severe disease such as Ewing's sarcoma (ES). ES is the second most common primary malignant bone tumor in the young population, with a high probability of an unfavourable prognosis. CASE PRESENTATION: This case report presents the history of a young man presenting to the physical therapist with a diagnosis of "epicondylitis" in the right elbow, which was later revealed to be an aggressive ES of the ulna. Findings raising clinical doubts were (a) constant pain even at night and not dependent on load, (b) significant loss of function, (c) patient's young age, and (d) a palpable mass in the elbow. RESULTS: After diagnosis, the patient received medical (chemotherapy, radiotherapy and surgery) and a rehabilitation program. After treatment, the patient improved elbow function, decreased disability and returned to social participation, maintaining positive outcomes at the 2-year follow-up. DISCUSSION: In summary, this case report emphasizes the importance of differential diagnosis and screening for referral of red flags in physical therapy. Moreover, it describes the rehabilitation of a patient with ES, enriching the scientific literature in the field.

Spinal manipulation and electrical dry needling as an adjunct to conventional physical therapy in patients with lumbar spinal stenosis: a multi-center randomized clinical trial.

BACKGROUND CONTEXT: Nonoperative management of lumbar spinal stenosis (LSS) includes activity modification, medication, injections, and physical therapy. Conventional physical therapy includes a multimodal approach of exercise, manual therapy, and electro-thermal modalities. There is a paucity of evidence supporting the use of spinal manipulation and dry needling as an adjunct to conventional physical therapy in patients with LSS. PURPOSE: This study aimed to determine the effects of adding thrust spinal manipulation and electrical dry needling to conventional physical therapy in patients with LSS. STUDY DESIGN/SETTING: Randomized, single-blinded, multi-center, parallel-group clinical trial. PATIENT SAMPLE: One hundred twenty-eight (n=128) patients with LSS from 12 outpatient clinics in 8 states were recruited over a 34-month period. OUTCOME MEASURES: The primary outcomes included the Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI). Secondary outcomes included the Roland Morris Disability Index (RMDI), Global Rating of Change (GROC), and medication intake. Follow-up assessments were taken at 2 weeks, 6 weeks, and 3 months. METHODS: Patients were randomized to receive either spinal manipulation, electrical dry needling, and conventional physical therapy (MEDNCPT group, n=65) or conventional physical therapy alone (CPT group, n=63). RESULTS: At 3 months, the MEDNCPT group experienced greater reductions in overall low back, buttock, and leg pain (NPRS: F=5.658; p=.002) and related-disability (ODI: F=9.921; p<.001; RMDI: F=7.263; p<.001) compared to the CPT group. Effect sizes were small at 2 and 6 weeks, and medium at 3 months for the NPRS, ODI, and RMDI. At 3 months, significantly (p=.003) more patients in the MEDNCPT group reported a successful outcome (GROC≥+5) than the CPT group. CONCLUSION: Patients with LSS who received electrical dry needling and spinal manipulation in addition to impairment-based exercise, manual therapy and electro-thermal modalities experienced greater improvements in low back, buttock and leg pain and related-disability than those receiving exercise, manual therapy, and electro-thermal modalities alone at 3 months, but not at the 2 or 6 week follow-up.

Periosteal Dry Needling for Carpometacarpal Osteoarthritis: A Prospective Case Series.

BACKGROUND: Carpometacarpal (CMC) osteoarthritis (OA) of the thumb is a painful condition that affects over 15% of individuals above the age of 30 and up to 30% of post-menopausal women. Dry needling (DN) has been found to reduce pain and disability in a variety of neuromusculoskeletal conditions; however, DN in the management of CMC OA has not been well studied. METHODS: Consecutive patients with clinical and radiographic evidence of CMC OA were treated with DN. The primary outcome measure was pain using the Numerical Pain Rating Scale (NPRS) at 12 weeks. Secondary outcome measures were the Upper Extremity Functional Index (UEFI-20) and the Global Rating of Change (GROC) scale. Outcome measures were collected at baseline, 4 weeks, 8 weeks, and 12 weeks. RESULTS: Nine patients were treated for six sessions of periosteal DN over 3 weeks. Compared to baseline, statistically significant and clinically meaningful improvements were observed in thumb pain (NPRS mean difference: 2.6; p = 0.029) and function (UEFI-20 mean difference: 21.3; p = 0.012) at 12 weeks. CONCLUSION: Statistically significant and clinically meaningful within-group improvements in thumb pain and function were observed at 12 weeks following six sessions of periosteal DN treatment. DN may be a useful intervention in the management of patients with CMC OA of the thumb.

Effectiveness and Consequences of Direct Access in Physiotherapy: A Systematic Review.

Background. Direct access in physiotherapy (DAPT) occurs when a patient has the ability to self-refer to physical therapy without physician referral. This model of care in musculoskeletal diseases (MSDs) has shown better outcomes than the traditional-based medical model of care that requires physician referral to access physiotherapist services. This traditional physician referral often results in a delay in care. Unfortunately, DAPT is still not permitted in many countries. Objectives. The primary objective of this systematic review was to compare the effectiveness, safety, and the accuracy of DAPT compared to the physician-led model of care for the management of patients with musculoskeletal disorders. The secondary objective of the present study is to define the physiotherapists' characteristics or qualifications involved in DAPT. Materials and methods. Databases searched included: Medline, Scopus and Web of Science. Databases were searched from their inception to July 2022. Research strings were developed according to the PICO model of clinical questions (patient, intervention, comparison, and outcome). Free terms or synonyms (e.g., physical therapy; primary health care; direct access; musculoskeletal disease; cost-effectiveness) and when possible MeSH (Medical Subject Headings) terms were used and combined with Boolean operators (AND, OR, NOT). Risk of bias assessment was carried out through Version 2 of the Cochrane risk-of-bias tool (ROB-2) for randomized controlled trials (RCTs) and the Newcastle Ottawa Scale (NOS) for observational studies. Authors conducted a qualitative analysis of the results through narrative analysis and narrative synthesis. The narrative analysis was provided for an extraction of the key concepts and common meanings of the different studies, while the summary narrative provided a textual combination of data. In addition, a quantitative analysis was conducted comparing the analysis of the mean and differences between the means. Results. Twenty-eight articles met the inclusion criteria and were analyzed. Results show that DAPT had a high referral accuracy and a reduction in the rate of return visits. The medical model had a higher use of imaging, drugs, and referral to another specialist. DAPT was found to be more cost-effective than the medical model. DAPT resulted in better work-related outcomes and was superior when considering patient satisfaction. There were no adverse events noted in any of the studies. In regard to health outcomes, there was no difference between models. ROB-2 shows an intermediate risk of bias risk for the RCTs with an average of 6/9 points for the NOS scale for observational studies. Conclusion. DAPT is a safe, less expensive, reliable triage and management model of care that results in higher levels of satisfaction for patients compared to the traditional medical model. Prospero Registration Number: CRD42022349261.

Benefits and Harms of Spinal Manipulative Therapy for Treating Recent and Persistent Nonspecific Neck Pain: A Systematic Review With Meta-analysis.

OBJECTIVE: We aimed to estimate the benefits and harms of cervical spinal manipulative therapy (SMT) for treating neck pain. DESIGN: Intervention systematic review with meta-analysis of randomized controlled trials (RCTs). LITERATURE SEARCH: We searched the MEDLINE, Cochrane CENTRAL, Embase, CINAHL, PEDro, Chiropractic Literature Index bibliographic databases, and grey literature sources, up to June 6, 2022. STUDY SELECTION CRITERIA: RCTs evaluating SMT compared to guideline-recommended and nonrecommended interventions, sham SMT, and no intervention for adults with neck pain were eligible for our systematic review. Prespecified outcomes included pain, range of motion, disability, health-related quality of life. DATA SYNTHESIS: Random-effects meta-analysis for clinically homogenous RCTs at short-term and long-term outcomes. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 Tool. We used the Grading of Recommendations, Assessment, Development, and Evaluations approach to judge the certainty of evidence. RESULTS: We included 28 RCTs. There was very low to low certainty evidence that SMT was more effective than recommended interventions for improving pain at short term (standardized mean difference [SMD], 0.66; 95% confidence interval [CI]: 0.35, 0.97) and long term (SMD, 0.73; 95% CI: 0.31, 1.16), and for reducing disability at short-term (SMD, 0.95; 95% CI: 0.48, 1.42) and long term (SMD, 0.65; 95% CI: 0.23, 1.06). Transient side effects only were found (eg, muscle soreness). CONCLUSION: There was very low certainty evidence supporting cervical SMT as an intervention to reduce pain and improve disability in people with neck pain. J Orthop Sports Phys Ther 2023;53(9):510-528. Epub: 10 August 2023. doi:10.2519/jospt.2023.11708.

Physiotherapy Screening for Referral of a Patient with Peripheral Arterial Disease Masquerading as Sciatica: A Case Report.

Many causes potentially underline pain in the lower extremities, presenting a real challenge for primary care clinicians in the recognition of the source of the patient's complaints. Peripheral arterial disease (PAD) is defined as a total or partial blockage of the vessels that supply blood from the heart to the periphery. PAD of the lower extremities may masquerade as lumbosacral radiculopathy (LSR)-a common source of leg pain. Physiotherapists should be able to screen for PAD in people presenting with pain in the lower extremities. Failure to correctly screen for PAD could put the patient at risk of severe disability and possible permanent sequelae. This case report outlines the relevant concepts relating to the pathophysiology, screening, and differential diagnosis of PAD, and then further describes the relevant findings from the history and physical examination from the physiotherapist's perspective in a patient with an unusual symptom presentation. Although the patient was referred by a physician with a diagnosis of LSR, our case highlights the pivotal role of skilled physiotherapists in triaging a severe lower-limb PAD in need of referral. Therefore, this case report aims to increase clinicians' awareness of the clinical features of a complex case of PAD.

Recognition of Prodromal Hypoglossal Nerve Palsy Presenting with Neck Pain as Primary Complaint: Findings from a Rare Case Report in Direct Access Physiotherapy during the COVID-19 Pandemic.

Neck pain (NP) is the second most common musculoskeletal disorder. Spinal cysts (SCs) are cystic dilatations of the synovial sheaths in joints and tendons. SCs are extremely rare in the cervical spine. Typically, patients are unaware of having an SC due to its asymptomatic nature; however, when cervical SC extends, its volume could compress the surrounding structures, such as the hypoglossal nerve. Isolated hypoglossal nerve palsy (HNP) is very rare and typically presents with unilateral atrophy of the musculature of the tongue and contralateral tongue deviation. Often, patients with HNP also report occipital/neck pain. A 75-year-old man with occipital/neck pain as a primary complaint. Although difficult to observe because of the filtering facepiece two mask, difficulties in articulation and sialorrhea during the interview were noticed. These latter were cues to consider CN examination that revealed CN XII palsy. This prompted a referral for further examination that revealed an SC compressing the right hypoglossal canal. The patient was not considered a surgical candidate and was managed conservatively. This case report outlines the relevant findings relating to the triage of a rare isolated hypoglossal nerve palsy from the physiotherapist's perspective within a complex setting because of the COVID-19 pandemic. Although referred with a diagnosis of cervical radiculopathy, our case highlights that skilled physiotherapists may play a fundamental role in both the recognition and, when applicable, subsequent novel management of a non-musculoskeletal presentation.

Headache, Loss of Smell, and Visual Disturbances: Symptoms of SARS-CoV-2 Infection? A Case Report.

OBJECTIVE: The purpose of this case report is to describe the main components of the history and physical examination that led to idiopathic intracranial hypertension differential diagnosis, which initially was investigated as COVID-19. METHODS (CASE DESCRIPTION): A 28-year-old woman complaining of constant headache and loss of smell and taste was suspected as SARS-CoV-2 infection by her general practitioner. She underwent 3 molecular swab tests, all negative, then decided to seek her physical therapist for relieving headache. RESULTS: The full cranial nerve examination revealed impaired olfactory (CNI), abducens (CN VI), and facial (CN VII) nerves, leading the physical therapist to refer the patient to a neurosurgeon for a suspected central nervous system involvement. The neurosurgeon prescribed a detailed MRI and an ophthalmologic examination, which allowed for the final diagnosis of idiopathic intracranial hypertension. CONCLUSION: An urgent lumbo-peritoneal shunting surgery resolved the patient's symptoms and saved her sight. Despite the ongoing COVID-19 pandemic, health care professionals must pay attention to properly investigating patients' signs and symptoms using comprehensive clinical reasoning, considering the screening for referral to specialist medical attention. IMPACT: A thorough physical examination is required for every patient even if patients' signs and symptoms are in line with apparent common and widespread pathologies. Cranial nerve evaluation is an essential component of the physical therapist assessment and decision-making process. The ongoing pandemic highlighted the fundamental assistance of physical therapists toward physicians in the screening and management of musculoskeletal diseases.

Vascular flow limitations affecting the cervico-cranial region: Understanding ischaemia.

BACKGROUND: Blood flow and brain ischaemia have been of interest to physical therapists for decades. Despite much debate, and multiple publications around risk assessment of the cervical spine, more work is required to achieve consensus on this vital, complex topic. In 2020, the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) Cervical Framework adopted the dubious terminology 'vascular pathologies of the neck', which is misleading, on the premise that 1) not all flow limitations leading to ischaemia, are associated with observable blood vessel pathology and 2) not all blood flow limitations leading to ischaemia, are in the anatomical region of the 'neck'. OBJECTIVE: This paper draws upon the full body of haemodynamic knowledge and science, to describe the variety of arterial flow limitations affecting the cervico-cranial region. DISCUSSION: It is the authors' contention that to apply clinical reasoning and appropriate risk assessment of the cervical spine, there is a requirement for clinicians to have a clear understanding of anatomy/anatomical relations, the haemodynamic science of vascular flow limitation, and related pathologies. This paper describes the wide range of presentations and haemodynamic mechanisms that clinicians may encounter in practice. In cases with a high index suspicion of vascular involvement or an adverse response to assessment/intervention, appropriate referral should be made for further investigations, using consistent terminology. The term 'vascular flow limitation' is proposed when considering the range of mechanisms at play. This fits the terminology used (in vascular literature) at other anatomical sites and is understood by medical colleagues.

Physiotherapy Screening for Referral of a Patient with Patent Foramen Ovale Presenting with Neck Pain as Primary Complaint: A Case Report.

Neck pain is a common musculoskeletal disorder encountered by physiotherapists. However, it may be the early manifestation of more alarming conditions, such as cardiovascular diseases mimicking musculoskeletal pain. Patent foramen ovale (PFO) is a congenital heart defect consisting of a small opening between the right and the left atrium. A 56-year-old male presented with neck pain and head heaviness as primary complaints. The cardiovascular profile and the behavioral symptoms led the physiotherapist to find an exaggerated blood pressure response during exercise; in addition to subtle neurological signs, this prompted the physiotherapist to make an urgent referral. At the emergency department a PFO was diagnosed. To the best of the authors' knowledge, this is the first case to describe a rare clinical presentation of a PFO presenting neck pain as primary complaint. This case report emphasizes the importance for physiotherapists to be able to triage patients for conditions outside their scope suggestive of further medical investigation.

A guide to identify cervical autonomic dysfunctions (and associated conditions) in patients with musculoskeletal disorders in physical therapy practice.

BACKGROUND: Differential diagnosis is a hot topic in physical therapy, especially for those working in a direct access setting dealing with neck pain and its associated disorders. All international guidelines agree in recommending to first rule out non-musculoskeletal pathologies as the cause of signs and symptoms in the patient. Although the autonomic nervous system (ANS) has a crucial role and is also involved in pain conditions, coverage of it in neuroscience textbooks and educational programmes is limited and most healthcare professionals are unfamiliar with it. Although autonomic conditions are benign in nature, they are clinically of great importance as they may be a 'red flag' warning of an injury along the sympathetic pathway. Therefore, sound knowledge of the ANS system is essential for clinicians. OBJECTIVE: To develop physical therapists' knowledge of and confidence in understanding cervical ANS function and dysfunction, thus enhancing clinical reasoning skills and the pattern recognition process, and performing and interpreting objective examinations. METHODS: This master class provides an introductory guide and essential knowledge to facilitate clinicians to understand cervical autonomic dysfunctions and their clinical evaluation. The optimal referral method is also handled. CONCLUSIONS: Gaining knowledge and understanding of the ANS, its function, its dysfunction, and the related clinical manifestations is likely to lead to a decision-making process driven by 'science and conscience'. This will empower physical therapists to be aware of subtle clues that may be offered by patients during the interview and history intake leading to the appropriate physical examination and triage.

Spontaneous spleen rupture mimicking non-specific thoracic pain: A rare case in physiotherapy practice.

BACKGROUND: The prevalence of Thoracic Pain (TP) is estimated to be low compared to other common musculoskeletal disorders such as nonspecific low back pain (LBP). Notably, compared to LBP, TP or referral pain to the thoracic area potentially may involve serious pathologies. Visceral referral of pain may present to the thoracic spine or anteriorly in the abdomen or chest. Rupture of the spleen in the absence of trauma or previously diagnosed disease is rare and rarely documented in emergency medicine literature. The incidence of red flags are higher in the thoracic area in comparison to the lumbar or cervical regions, but TP can also be of musculoskeletal origin and for this reason it is important to assess the origin of pain. CASE DESCRIPTION: This case report describes the clinical history, evaluation and management of a 60-year-old complaining of upper thoracic, bilateral shoulder, and right upper quadrant abdominal pain. The patient's clinical findings from a physiotherapist's assessment led to a referral to a physician to explore a potential non-musculoskeletal origin. A splenectomy was required due to a non-traumatic rupture of the spleen. After 20 days of hospitalization from the surgery, the patient returned to all normal activities of daily living. DISCUSSION AND CONCLUSION: The purpose of this current case report is to describe the clinical reasoning of a physiotherapist screening a patient who presented with thoracic pain due to a spontaneous rupture of the spleen, that resulted in a referral to another health practitioner.

What to Look Out for, What to Do, and When: 3 Key Messages for Safely Treating Neck Pain, Headache, and/or Orofacial Symptoms in Musculoskeletal Rehabilitation Settings.

SYNOPSIS: Neck pain, headache, and/or orofacial symptoms are potentially the first (nonischemic) symptoms of an underlying vascular pathology or blood flow limitation. If an underlying vascular pathology or blood flow limitation is not recognized by the musculoskeletal rehabilitation clinician, it can subsequently be aggravated by treatment, raising the risk of serious adverse events. We argue that clinicians can make an important, and potentially lifesaving, difference by providing specific information and advice. This is especially the case in patients with an intermediate level of concern, for example, in patients who only show a few concerning features regarding a possible underlying serious condition and for whom an initial vasculogenic hypothesis was rejected during the clinical reasoning process. We present background information to help the reader understand the context of the problem and suggestions for how clinicians can provide appropriate information and advice to patients who present with neck pain, headache, and/or orofacial symptoms. J Orthop Sports Phys Ther 2023;53(2):59-63. Epub: 28 October 2022. doi:10.2519/jospt.2022.11568.

Intracranial Epidermoid Cyst Mimics Musculoskeletal Shoulder Disease: Findings from a Case Report in Physiotherapy Clinical Practice.

Shoulder pain is often attributable to a musculoskeletal disorder, but in some instances, it may be linked to pathologies outside the physiotherapist's area of expertise. Specifically, some intracranial problems can cause pain and disability to the shoulder complex. This case report aims to describe the clinical presentation, history taking, physical examination, and clinical decision-making procedures in a patient with an intracranial epidermoid cyst mimicking a musculoskeletal disorder of the shoulder girdle. A 42-year-old man complained of pain and disability in his left shoulder. Sudden, sharp pain was reported during overhead movements, associated with intermittent tingling of the left upper trapezius and left scapular area. Moreover, the patient reported reduced hearing in his left ear and left facial dysesthesia. The physical examination led the physiotherapist to hypothesize a pathology outside the physiotherapist's scope of practice and to refer the patient to another health professional to further investigate the patient through imaging. It is essential for the physiotherapist to recognize when the patient's clinical condition requires a referral to another healthcare professional. Therefore, the physiotherapist must be able to, in a timely manner, identify signs and symptoms suggesting the presence of medical pathology beyond his expertise, through appropriate medical history collection and physical evaluation.