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Pathological Cause of Low Back in a Patient Seen through Direct Margaret M. Gebhardt PT, DPT, OCS Access in a Physical Therapy Clinic: A Case Report

Staff Physical Therapist, Motion Stability, LLC, and Adjunct Clinical Faculty, Mercer University, Atlanta, GA

ABSTRACT cal therapists primarily treat patients that sporadic.9 Deyo and Diehl6 found that the Background and Purpose: A 66-year- fall into the mechanical LBP category, but 4 clinical findings with the highest positive old male presented directly to a physical need to be aware that although infrequent, likelihood ratios for detecting the presence therapy clinic with complaints of low back 7% to 8% of LBP complaints are due to of in LBP were: a previous history of pain (LBP). The purpose of this case report is nonmechanical spinal conditions or visceral cancer, failure to improve with conservative to describe the clinical reasoning that led to disease.5 Malignant neoplasms are the most medical treatment in the past month, an age a medical referral for a patient not respond- common of the nonmechanical spinal con- of at least 50 years or older, and unexplained ing to conservative treatment that ultimately ditions causing LBP, but comprise less than weight loss of more than 4.5 kg in 6 months led to the diagnosis of . 1% of all total LBP conditions.6 (Table 1).10 In Deyo and Diehl’s6 study, they Methods: Data was collected during the In this era of autonomous practice, analyzed 1975 patients that presented with course of the patient’s treatment in an out- increasing numbers of physical therapists are LBP and found 13 to have cancer. All 13 of patient orthopaedic setting. Findings: The treating patients through direct access. Cur- those patients had at least one of the above patient’s LBP was caused by a pathologi- rently, there are 47 states that allow some clinical findings. They also found that the cal vertebral fracture secondary to multiple form of direct access in which the patient absence of all 4 of these clinical findings myeloma. Clinical Relevance: This case does not require a physician’s referral to be will confidently rule out neoplasms.10 It is illustrates the need for physical therapists evaluated or treated by a licensed physical important for physical therapists to be aware to be aware of signs and symptoms that therapist.7 Having not been screened for of these findings as they relate to malignant appear to be of musculoskeletal origin, but underlying medical pathologies, it is impor- LBP, so that they are able to recognize the mask a more serious underlying pathology. tant for the physical therapist to be aware of need for referral and further diagnostic Conclusion: Autonomous practice provides signs and symptoms that would indicate fur- medical testing.8-10 The purpose of this case physical therapists with increased access to ther examination by a physician.8 Screening report is to describe the clinical reasoning patients prior to being seen by a physician. is defined by the Commission on Chronic that led to a medical referral for a patient Entry-level physical therapy and postprofes- Illness as “…the presumptive identification not responding to conservative treatment of sional education should continue to empha- of unrecognized disease or defect by the his LBP that ultimately led to the diagnosis size differential diagnosis and screening for application of tests, examinations, or other of multiple myeloma. medical conditions in which physical ther- procedures which can be applied rapidly to apy may not be appropriate. sort out apparently well persons who prob- DIAGNOSIS ably have the disease from those who prob- History Key Words: medical screening, differential ably do not. A screening test is not intended The patient was a 66-year-old male who diagnosis, clinical decision making to be diagnostic. Persons with positive or presented with LBP that started insidiously suspicious findings must be referred to their one week prior to his evaluation while play- INTRODUCTION physicians for diagnosis and necessary treat- ing golf. The patient was not assessed by In the United States, low (LBP) ment.”8 In regards to LBP, screening should another medical practitioner prior to his is the most common reason that patients are be used to identify the 7% to 8% of patients seeking physical therapy treatment. Upon being treated in outpatient physical therapy who are not from the mechani- interview, the patient reported that he was settings.1 In fact, more than a quarter of cal LBP as described by Jarvik and Deyo.5 relatively healthy with no report of previ- patients currently undergoing care in these Physical therapists are usually not privy to ous or current illnesses. He did remark that settings are being treated for LBP.1-3 Non- radiologic or laboratory testing and must he had a left rib fracture 3 years ago after specific back pain has been ranked as the base their screening on clinical presenta- reaching up to a shelf. The patient was not second leading cause of short-term disability tion.8 It is of utmost importance that physi- currently on any medications. The patient in persons aged 45 to 65 years.3,4 In classify- cal therapists know the signs and symptoms was a right-handed golfer who complained ing LBP, Jarvik and Deyo5 created 3 differ- and the combinations of signs and symp- of nonradiating, right-sided ential diagnostic categories: (1) mechanical toms that indicate a serious problem requir- that was activity dependent. The patient did LBP (eg, degenerative disk disease and frac- ing referral.3,8 not fill out a body diagram, but was able to ture), (2) nonmechanical spinal conditions Recognizing serious disease pathology is point to the area of his right flank extending (eg, neoplasia, , inflammatory sometimes difficult due to the fact that the distally to the superior border of his right arthritis), and (3) visceral disease (eg, prosta- symptoms initially present as musculoskel- iliac crest as his pain area. titis, endometriosis, pyelonephritis). Physi- etal dysfunction and are often vague and The patient is a successful businessman

Orthopaedic Practice Vol. 25;2:13 73 Table 1. Diagnostic Accuracy of Findings from the History in Patients with Cancer rotational mobilizations of the lumbar spine Causing Low Back Pain (data provided by Deyo and Diehl4). Likelihood ratios are effective in treating lumbar conditions were calculated from sensitivity and specificity values provided by Deyo and Diehl.4 with unilateral symptoms. This approach Reprinted with permission from the J Orthop Sports Phys Ther.18 was applied to the patient and 3 bouts of grade 2 and 3 lumbar rotational mobiliza- Sensitivity Specificity Positive LR Negative LR tions were applied to his right lumbar spine. Previous history of cancer 0.31 0.98 14.7 0.70 McKenzie theorists propose that repeated Failure to improve with a month of directional movements will help to central- 17 conservative therapy 0.31 0.90 3.0 0.77 ize symptoms that are discogenic in nature. Secondary to the patient’s “catch” when Age > 50 y 0.77 0.71 2.7 0.32 returning from flexion, repeated extension Unexplained weight loss 0.15 0.94 2.7 0.90 and prone push-ups were performed. The Duration of pain > 1 mo 0.50 0.81 2.6 0.62 patient reported decreased pain at the end No relief with bed rest >0.95 0.46 1.8 0.11 of the session and was prescribed prone push-ups for home. The patient was also Insidious onset of symptoms 0.61 0.58 1.1 0.67 referred to an orthopaedist for pain manage- DOI: 10.2519/jospt.2005.2105 ment. Between the patient’s third and fourth physical therapy visit, he was assessed by an orthopaedic physiatrist who specializes in spinal disorders. The patient was prescribed who owns and operates his own company. contributing to this mechanical dysfunc- a Medrol (Methylprednisolone) dose pack He admittedly takes pride in his overall tion at the lumbar spine. His dysfunction for inflammatory pain relief. The doctor health and fitness. was determined to be primarily mechanical reported that the patient’s pain was probably because his symptoms were activity-depen- diskal and to report back for an MRI if the Physical Examination dent and were precipitated by a specific symptoms persisted or did not resolve. After On initial evaluation, the patient ranked event that is known to cause similar LBP starting on the medications, the patient his pain as a 6/10. The pain at its best was a complaints with comparable deficits in hip came to his therapy session with reports of 4/10 and at its worst was an 8/10. Pain was internal rotation.9,12,13 His prognosis was decreased pain. The therapy session focused only aggravated when playing golf. Due to determined to be very good with a decrease on hip hinging with forward flexion to cor- the patient’s acute pain complaints, a limited in his pain complaints and return to func- rect his reverse lordosis, and the patient physical exam was performed. With lumbar tion within two to 3 visits. was able to accomplish this with minimal spine active range of motion, the patient pain by the end of the session. He did dis- was noted to have 25% lumbar flexion with Physical Therapy Intervention play a reverse Gower’s sign (using his hands a reverse lordosis. His flexion was limited Table 2 provides the relative dates and to assist) when going into flexion, but was secondary to pain. Passive range of motion course of physical therapy treatment. On the able to get into full flexion. In treatments (PROM) of his hips revealed full flexion, day of his initial evaluation, the patient con- 5 through 8, the patient’s pain continued extension, and external rotation. His right sented to dry needling (DN) for treatment to diminish, but complaints of pain when hip had 20° of internal rotation, while his of active myofascial trigger points in his right attaining supine and bending over to brush left had 15°. He presented with an antal- QL. The QL was selected secondary to its his teeth were still there. Pain was also pres- gic, and a pronated gait pattern associated pattern and the patient’s right ent at approximately 10° to 20° of lumbar with bilateral pes planus. His right quadra- QL tenderness to palpation.11 Dry needling flexion, but he was able to achieve full flex- tus lumborum (QL) and bilateral gluteus has been found to be an effective modality ion with corrected mechanics and the occa- medius, gluteus maximus, and multifidus for the treatment of active myofascial trig- sional reverse Gower’s sign. The treatment were found to be tender upon palpation. He ger points.14,15 At his second treatment ses- sessions focused on getting him out of his tested negative on his performance of the sion the patient reported decreased pain, but lordotic posture, strengthening his gluteal straight leg raise, crossed straight leg raise, then he sneezed and his symptoms flared up muscles, and improving walking and hip and slump tests. again. At that time, he presented with signif- flexion mechanics. He continued to report icant increased pain and reported pain with no change in pain with DN. Treatments Interpretation of the History and transitions such as supine to sit or supine to included DN, mobilization with move- Physical Exam sidelying. The patient was treated again with ment into flexion, gluteal re-education, Due to the patient’s relatively unre- DN in his right QL and bilateral multifidus Low-Dye taping, and lumbar mobilizations. markable medical history and mechanism secondary to the fact that he reported good The focus of treatment shifted from diskal of injury, he was diagnosed with QL spas- results after the first treatment. In his third in nature to facet joint impingement. The ming secondary to incorrect motor con- treatment session, the patient reported that patient stopped responding to DN (which trol patterns in the golf swing resulting in the DN only helped minimally and he was eliminated myofascial causes of pain) and over facilitation of this muscle. The referral now having difficulty donning his shoes and repeated movements (which eliminated pain pattern of the ipsilateral QL is almost socks. On exam, it was noted that he had a diskal origins). It was thought facet hypomo- identical to the patient’s reported pain com- significant catch on returning from lumbar bility was precipitating the patient’s pain as plaint.11 It was determined that his pronated flexion, which was still limited to approxi- it mimicked facet joint referral from L1-5.18 gait pattern and lack of gluteal strength were mately 25%. Maitland16 has reported that Treatment 9 occurred exactly one month

74 Orthopaedic Practice Vol. 25;2:13 Table 2. Dates of the Patient’s Visits and Interventions. Treatment Sessions Spanned vertebral fractures/collapse occur with possi- Over the Course of One Month. ble spinal cord compression.24 The pain associated with this cancer is aggravated with Date Medical and Physical Therapy Visits Physical Therapy Interventions movement and eases with rest.20,24 However, Day 1 Initial physical therapy visit. R QL IMT secondary to referred pain rest does not completely relieve the patient of pattern and R QL tenderness upon his symptoms as would be evident in a true palpation. musculoskeletal condition.20 Most patients Day 2 Second physical therapy visit R QL and B multifidus DN secondary will report that their pain is diminished in to positive response after the first treatment session. the morning, but increases throughout the day.24 There is significant renal involvement Day 5 Third physical therapy visit and referral Rotational lumbo-sacral mobilizations with this cancer and as a result, patients will to orthopedic physiatrist. and repeated extension and 23 prone-push-ups. suffer from weight loss and weakness. In fact, the triad of weakness, fatigue, and bone Day 6 Fourth physical therapy visit Neuromuscular re-education for hip hinging pain are the hallmarks of a patient present- ing with multiple myeloma.19 Even though Day 9 – Day 28 Fifth-ninth physical therapy visits Swayback postural corrections, gluteal this disease is incurable, early recognition is strengthening, gait mechanics, IMT, mobilizations with movement, important as severe skeletal deformities can Lowe-Dye taping, and lumbar spine result if the rapid destruction of bone is not mobilizations. halted.22 Unfortunately, the prognosis for Day 30 Tenth physical therapy visit and second Referral to physiatrist. this disease is poor with remission in those referral to orthopedic physiatrist. receiving treatment lasting approximately 3 21 Abbreviations: R, right; QL, quadratus lumborum; IMT, intramuscular manual therapy; DN, dry needling years and survival, 6 years from diagnosis. It is noted that 5,630 people die from this disease every year, accounting for 2% of all cancer deaths per year.22 from the patient’s initial evaluation and the with mechanical characteristics, but was in Low back pain is oftentimes consid- physical exam findings from the initial visit fact masking a more serious condition. This ered an advancement of cancer, yet it is still had remained unchanged. Despite the inter- case also displays the necessary communica- imperative to diagnose the person as early ventions, the patient’s condition gradually tion that needs to occur between the physi- as possible so that disease-specific interven- worsened. He was still having difficulty with cian and the therapist. Multiple myeloma’s tions can be started.6 The physical therapist transitions and reported he was having dif- first symptom is often musculoskeletal and needs to be aware of the patient’s signs and ficulty getting up off the floor. He was asked so at first glance, this patient was misdiag- symptoms as well as their response to treat- to attain quadruped and he had significant nosed by the physician as well.19-24 It was not ment over time as the patient progresses.10 difficulty getting into this position. In quad- until the second appointment with his phy- As the patient in this case progressed, he ruped, the patient was noted to be “shaking” sician, after speaking with the therapist, that became a nonresponder to treatments that in an effort to maintain this position. The the patient’s condition was then considered have proven to be effective for the muscu- patient demonstrated this shaking in previ- more pathological than mechanical LBP. loskeletal conditions in which they were ous visits, but never as pronounced as it was intended. He did not respond to (1) DN at that point. The patient commented on Pathology as a true myofascial pain patient would, (2) how the shaking had gotten so severe that In 2000, 13,600 new cases of multiple repeated movements as a diskal condition he was unable to walk down a flight of stairs myeloma were diagnosed and more than would, or (3) mobilizations as a facet limita- the previous day. He also made a comment 11,200 registered deaths in the United States tion would. that because of the pain he had been in over resulted from this disease.23 This cancer It is thought that the patient’s rib fracture the last month, he had lost approximately occurs most commonly in patients between 3 years prior to this most recent episode was 20 pounds. At this point the patient’s over- the ages of 50 to 70 with the median age actually the first pathologic fracture. The ribs all lack of progress within a normal expected being 65 years.20,21,23 Multiple myeloma is and thoracic spine are one of the first areas time frame for a musculoskeletal condition, a cancer of the bone marrow in which the in which pathologic fractures secondary to as well as his severe weakness and shaking plasma cells proliferate uncontrollably.22 multiple myeloma are seen.20 The patient and extreme weight loss led the treating cli- Osteoclast secreting factor is produced by initially sought treatment for what could nician to refer the patient back to the ortho- the plasma cells, which then stimulates have been muscle spasming. Those muscles paedist for further evaluation. Upon referral osteoclast activity.22-24 The increase in osteo- were released on the first visit, and with the to the orthopaedist, a pathologic fracture of clast activity contributes to the high rate vertebrae strength already being diminished, L4 was found. The patient was then referred of pathologic fractures seen with this dis- their stability was now taken away and to the hematology and oncology department ease.23,24 Bone pain, from pathologic frac- unable to withstand a forceful sneeze. The who later diagnosed him with multiple tures, is the most common (80%) and one patient in this case did have focal pain with myeloma. of the first symptoms in persons diagnosed specific movements (secondary to the patho- with this cancer.20,23,24 Due to the high con- logic fracture), with the most aggravating DISCUSSION tent of bone marrow, the spine, pelvis, and being attaining a supine position. Once the This patient case offers an opportunity to skull are the most commonly affected.21 patient was in supine, he did achieve some discuss a LBP scenario that initially presented Bone destruction can become so severe that pain relief, but not significant. Over time,

Orthopaedic Practice Vol. 25;2:13 75 the patient displayed the triad of weakness, sis on imaging. Ann Intern Med. 18. Fukui S, Ohseto K, Shiotani M, Ohno bone pain, and fatigue as noted by Batsis and 2002;137:586-597. K, Karasawa H, Nganuma Y. Distribu- McDonald.19 Using the 4 clinical guidelines 6. Deyo RA, Diehl AK. Cancer as a cause tion of referred pain from the lumbar established by Deyo and Diehl,6 the patient of back pain: frequency, clinical presen- zygapophyseal joints and dorsal rami. fulfilled 3 of the 4, except for a previous his- tation, and diagnostic strategies. J Gen Clin J Pain. 1997;13:303-307. tory of cancer. The combination of these Intern Med. 1988;3:230-238. 19. Batsis JA, McDonald FS. 76-year- clusters of symptoms is what prompted the 7. American Physical Therapy Association. old man with back pain and progres- referral back to the physician. Having a good Direct Access Map. http://www.apta. sive leg weakness. Mayo Clin Proc. relationship with the referring physician was org/uploadedFiles/APTAorg/Advocacy/ 2005;80:259-262. integral in having this patient diagnosed State/Issues/Direct_Access/DirectAc- 20. Boissonnault WG, Bass C. Patho- properly. The therapist was able to commu- cessMap.pdf#search=%22direct access logical origins if trunk and : nicate with the doctor immediately and have states%22. Accessed May 22, 010. Part III- Diseases of the musculoskel- the patient re-evaluated quickly. The patient 8. Roach KE, Brown M, Ricker E, Alten- etal system. J Orthop Sports Phys Ther. discussed in this case underwent a year of burger P, Tompkins J. The use of patient 1990;12:216-221. treatment and has been in remission for the symptoms to screen for various back 21. Goodman CC, Fuller KS, Boissonnault last two years. Other than adverse effects of problems. J Orthop Sports Phys Ther. WG. 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