Differential diagnosis of endometriosis in patient with nonspecific low back pain: A case report

BackgroundEndometriosis is one of the most widespread gynecological disorders and a very common condition amongst fertile women, thus it has to be considered one of the possible sources of lumbopelvic pain. Endometriosis is commonly related to low back pain (LBP) and therefore often mistaken for a musculoskeletal disorder.The purpose of this case report is to underline the primary role of clinical reasoning and assessment process, which led the physiotherapist to the differential diagnosis, considering endometriosis among the possible causes of low back pain.Case presentationS.C, 45 years old, complained to physiotherapist of lumbar spine and left buttock pain, spreading to the hypogastric, inguinal and left pubic areas. The patient's past medical history included gynecological visceral disorders, regularly monitored. Functional evaluation and clinical tests revealed a disorder referred to the lumbar spine and sacroiliac region. Initial physical therapy management included education, manual therapy and therapeutic exercise. Nevertheless, after five treatment sessions, the symptoms remained unchanged, and therefore the patient was referred to a gynecologist for a consultation. The patient underwent a laparoscopy for endometriosis eradication and the intervention resulted in complete abolition of symptoms, enabling the patient to return to work and to do physical activities.Conclusionsthis case report highlights the importance of a thorough clinical assessment and the identification of relevant findings from patient's medical history to be carried out by the physiotherapist. Those are of crucial importance to make an appropriate differential diagnosis and to screen amongst the possible causes of lumbopelvic pain also visceral ones as endometriosis, which often manifests with associated symptoms such as nonspecific LBP.     

Ankylosing spondylitis in a patient referred to physical therapy with low back pain

Low back pain (LBP) is one of the most common and costly medical conditions in the United States; various studies have reported up to 80% of the adult population will experience a significant episode of LBP sometime within their lifetime. Although many cases of LBP are related to the musculoskeletal system and appropriate for the care of the physical therapist (PT), some episodes of LBP have a systemic cause. Thus, it is the role of the PT to ensure each patient is appropriate for physical therapy intervention throughout the episode of care. When the patient's condition is not appropriate for physical therapy intervention, it is the PT's responsibility to refer the patient to other medical professions to ensure optimal patient care. The purpose of this case report is to describe a patient referred to PT who was diagnosed with ankylosing spondylitis. The patient presented initially to physical therapy with a diagnosis of LBP. However, after several visits her symptoms were inconsistent with mechanical LBP and thus required further medical consultation.     

Ankylosing spondylitis in a patient referred to physical therapy with low back pain

Low back pain (LBP) is one of the most common and costly medical conditions in the United States; various studies have reported up to 80% of the adult population will experience a significant episode of LBP sometime within their lifetime. Although many cases of LBP are related to the musculoskeletal system and appropriate for the care of the physical therapist (PT), some episodes of LBP have a systemic cause. Thus, it is the role of the PT to ensure each patient is appropriate for physical therapy intervention throughout the episode of care. When the patient's condition is not appropriate for physical therapy intervention, it is the PT's responsibility to refer the patient to other medical professions to ensure optimal patient care. The purpose of this case report is to describe a patient referred to PT who was diagnosed with ankylosing spondylitis. The patient presented initially to physical therapy with a diagnosis of LBP. However, after several visits her symptoms were inconsistent with mechanical LBP and thus required further medical consultation.     

A calcific pelvic mass in a woman with chronic spinal pain: a case of mature cystic teratoma

OBJECTIVE: The purpose of this case is to describe findings of a mature cystic teratoma and to further provide differential diagnoses for ovarian pelvic masses and calcifications. CLINICAL FEATURES: A 27-year-old woman presented to a chiropractic teaching clinic with a chief complaint of chronic multilevel spinal pain. During a full spine radiographic examination, radiopaque densities were incidentally identified in the pelvic bowl visualized through a gonad shield. Follow-up pelvic radiography revealed several radiopacities of uniform density localized in the pelvic bowl. INTERVENTION/OUTCOMES: Medical (gynecological) consultation led to ultrasonography of the pelvis that revealed a mature cystic teratoma. The patient underwent complete excision of the mass through a laparotomy procedure. The patient continued to receive chiropractic treatment of her original cervical and lumbar spine complaints, further suggesting that the pelvic mass was not a source of her musculoskeletal complaints. CONCLUSION: This case demonstrates the detection and proper referral of a patient with a calcific mass. The presence of a pelvic mass, suspected of arising from the ovary, requires additional diagnostic imaging and careful clinical correlation.     

Physical therapist management of a patient with acute low back pain and elevated fear-avoidance beliefs

BACKGROUND AND PURPOSE: Elevated fear-avoidance beliefs are believed to be a precursor of chronic disability, yet effective intervention options have not been described in the literature. The purpose of this case report is to describe physical therapist management of a patient with acute low back pain and elevated fear-avoidance beliefs. CASE DESCRIPTION: The patient was a 42-year-old sales manager with acute low back pain. The patient had no previous history of activity-limiting low back pain and initially had limitations in straight leg raising, limitations in lumbar movement, and elevated fear-avoidance beliefs. INTERVENTION: Treatment-based classification and graded exercise were used. OUTCOME: Disability, fear-avoidance beliefs, and pain decreased 4 weeks after starting physical therapy. Six months later, disability and fear-avoidance beliefs had increased, but were still improved when compared with the initial measurements. DISCUSSION: Disability and fear-avoidance beliefs improved following a fear-avoidance-based physical therapy intervention. Research is warranted to investigate the effectiveness of this approach.     

Differential diagnosis of shoulder and cervical pain: a case report

Patients are frequently referred to physical therapy with the diagnosis of shoulder and arm pain. During examination and evaluation of the patient, the physical therapist must consider all potential causes of the patient’s symptoms. Three questions are used as the conceptual basis for a diagnosis-based clinical decision rule in the management of mechanical and non-mechanical musculoskeletal pain when addressing the differential diagnosis of a patient’s condition. This single patient case report describes the use of these three questions in the differential diagnosis of shoulder and arm pain. A 44-year-old male was referred with a diagnosis of shoulder impingement syndrome. Each of the three questions for differential diagnosis was addressed, and clinical tests and examination findings were used to differentiate the origin of the patient’s symptoms. The intervention provided is outlined along with the patient’s response to the different treatment strategies provided. This case identifies the need for a systematic method of differential diagnosis so that patients are appropriately managed.     

Mechanically induced pelvic pain and organic dysfunction in a patient without low back pain

Previous reports have identified mechanical disorders of the lumbar spine as a cause of pelvic pain and organic dysfunction (PPOD) in patients with low back pain. Less common however, are reports of mechanically induced pelvic pain and organic dysfunction in patients without accompanying low back pain. This report details the examination findings and treatment response of a patient with pelvic pain, organic dysfunction and clinical evidence of lower sacral nerve root compression (LSNRC) in whom low back pain was not an accompanying finding. Despite the absence of low back pain however, clinical evaluation revealed the characteristic findings of mechanically induced pelvic pain and organic dysfunction secondary to lower sacral nerve root irritation or compression as a result of a mechanical disorder of the low back. As in long standing cases of mechanically induced pelvic pain and organic dysfunction in which low back pain is present, this case also exhibited severe and widespread involvement of the pelvic organs. In spite of numerous failed attempts at treatment directed at the symptomatic component of the patients disorder, complete resolution of symptoms was achieved by manipulative treatment directed at the mechanical disorder of the lumbar spine.     

Chronischer Unterbauchschmerz der Frau

Background

Chronic pelvic pain in women represents a difficult diagnostic and therapeutic problem in the gynecological practice which is always a challenge when dealing with affected women.

Gynecological causes

Possible gynecological causes are endometriosis, adhesions and/or pelvic inflammatory disease (PID), pelvic varicosis and ovarian retention syndrome/ovarian remnant syndrome. Other somatic causes are irritable bowel syndrome, bladder pain syndrome, interstitial cystitis and fibromyalgia.

Psychosocial factors

Psychosocial causes contributing to chronic pelvic pain are a high comorbidity with psychological factors, such as anxiety disorders and substance abuse or depression but the influence of social factors is less certain. The association with physical and sexual abuse also remains unclear.

Diagnostics and therapy

Important diagnostic steps are recording the patient history, a gynecological examination and laparoscopy. Multidisciplinary therapeutic approaches are considered to be very promising. Basic psychosomatic care and psychotherapy should be integrated into the therapeutic concept at an early stage.     

Anterior sacral meningocele: management in gynecological practice.

We describe the case of a young woman with anterior sacral meningocele (ASM), initially identified during a routine ultrasound examination and subsequently diagnosed using magnetic resonance imaging (MRI). ASM is a rare disorder characterized by uni- or multilocular extensions of the meninges from the sacral spinal canal to the retroperitoneal presacral space. Common symptoms include lower back and pelvic pain, constipation, difficulties in defecation, dysmenorrhea and dyspareunia, and urinary incontinence, retention or urgency. Perineal and lower-extremity paresthesias may present when nerve roots are affected. Despite its more posterior location, ASM can mimic an ovarian cyst or other adnexal cystic mass, and in the obstetric patient can present a mechanical obstacle to delivery with a risk of rupture and infection during labor and delivery. Although it is a rare condition, we feel that awareness of the etiology, presentation and imaging characteristics of ASM is of importance and have therefore carried out a review of the literature, taking into account case findings and the obstetric and gynecological management of this disorder.     

Ovarian hormones and chronic pain: A comprehensive review

Most chronic noncancer pain (CNCP) conditions are more common in women and have been reported to worsen, particularly during the peak reproductive years. This phenomenon suggests that ovarian hormones might play a role in modulating CNCP pain. To this end, we reviewed human literature aiming to assess the potential role of ovarian hormones in modulating the following CNCP conditions: musculoskeletal pain, migraine headache, temporal mandibular disorder, and pelvic pain. We found 50 relevant clinical studies, the majority of which demonstrated a correlation between hormone changes or treatments and pain intensity, threshold, or symptoms. Taken together, the findings suggest that changes in hormonal levels may well play a role in modulating the severity of CNCP conditions. However, the lack of consistency in study design, methodology, and interpretation of menstrual cycle phases impedes comparison between the studies. Thus, while the literature is highly suggestive of the role of ovarian hormones in modulating CNCP conditions, serious confounds impede a definitive understanding for most conditions except menstrual migraine and endometriosis. It may be that these inconsistencies and the resulting lack of clarity have contributed to the failure of hormonal effects being translated into medical practice for treatment of CNCP conditions.     

Physical therapist management of tuberculous arthritis of the elbow

BACKGROUND AND PURPOSE: Tuberculous arthritis is not commonly seen by physical therapists in the United States. The purpose of this case report is to describe a case of tuberculous arthritis of the elbow. CASE DESCRIPTION: The patient was a 36-year-old man referred for physical therapy evaluation and intervention for chronic elbow pain. After an evaluation and a trial of physical therapy, the patient was referred back to a primary care provider for additional tests to rule out systemic pathology. An open debridement of synovium and biopsy of the capitellum and radial head was positive for acid-fast bacilli, which was later identified as Mycobacterium tuberculosis. OUTCOMES: The patient was placed on a 4-drug antituberculosis regimen that resolved all patient complaints and restored full elbow function. DISCUSSION: Tuberculous arthritis has characteristic findings during examination and in diagnostic tests. Although tuberculous arthritis is uncommon, it should be considered when patients have chronic or vague musculoskeletal complaints.     

Imaging of acute pelvic pain

Determining the cause of acute pelvic pain in the female patient is often a clinical challenge. Diagnostic imaging can be invaluable in this situation. Ectopic pregnancy, pelvic inflammatory disease, and hemorrhagic ovarian cysts are the most commonly diagnosed gynecologic conditions presenting with acute pelvic pain. Ovarian torsion and degenerating fibroids occur less frequently. Other causes to consider include endometriosis, and postpartum causes such as endometritis, or ovarian vein thrombosis. Finally, nongynecologic conditions may overlap in their presentation of acute pelvic pain and should also be considered. The most important of these is acute appendicitis.     

Expanded role for the physical therapist. Screening musculoskeletal disorders.

The primary purpose of this study conducted at two army hospitals was to evaluate the feasibility of using the physical therapist as the primary 'screener' for patients presenting with a complaint of low back pain. The study was organized into two phases. A base line phase consisted of a data collection period under standard operating conditions. Patient waiting times, treatment times, and total care times were measured for patients presenting to various clinics with a complaint of low back pain. The same data were collected during a screeing phase in which all patients presenting with a complaint of low back pain were referred directly to the physical therapist for primary evaluation. An assessment of physical therapist and patient satisfaction and acceptance was made. The quality of care rendered in the screeing clinic was assessed through patient interviews, physician interviews, and record reviews. This concept and the quality of care rendered were found to be acceptable to the patient, the physician, and the physical therapist.     

Application of a classification system and description of a combined manual therapy intervention: a case with low back related leg pain

Low back pain and leg pain commonly occur together. Multiple factors can cause low back related leg pain; therefore, identification of the source of symptoms is required in order to develop an appropriate intervention program. The patient in this case presented with low back and leg pain. A patho-mechanism based classification is described in combination with the patient’s subjective and objective examination findings to guide treatment. The patient’s symptoms improved marginally with intervention addressing primarily the musculoskeletal impairments and with intervention addressing primarily the neurodynamic impairments. Full functional improvements were attained with a manual therapy intervention directed at both mechanisms simultaneously. The approach described in this case address a mixed pathology utilizing passive accessory and passive physiological lumbar mobilizations in combination with lower extremity neurodynamic mobilization. The patient reported complete resolution of symptoms after a total of seven visits over a period of 6 weeks. While specific guidelines do not yet exist for treatment based on the classification approach utilized, this case report provides an example of manual therapy to address low back related leg pain of mixed pathology.     

Evaluation of back pain in children and adolescents

Back pain is fairly prevalent in healthy children and adolescents. When children or adolescents seek medical care for back pain, it is highly likely that underlying pathology will be identified. Common causes of back pain include nonspecific pain or muscle strain, herniated disk, spondylolysis, scoliosis, and Scheuermann's kyphosis. Less common causes include tumor, infection, and sickle cell crisis. If nonspecific back pain is suspected, treatment may include home-based exercise, physical therapy, or nonsteroidal anti-inflammatory drugs. If the history and physical examination suggest underlying pathology, radiography, complete blood count, erythrocyte sedimentation rate, and a C-reactive protein measurement should be performed. Follow-up magnetic resonance imaging, computed tomography, or bone scanning may be needed depending on the suspected cause. It is generally accepted that the following factors warrant immediate evaluation: patient age younger than four years, persistent symptoms, self-imposed activity limitations, systemic symptoms, increasing discomfort, persistent night-time pain, and neurologic symptoms.     

The Use of Spinal Cord Stimulation in Refractory Abdominal Visceral Pain: Case Reports and Literature Review

Abstract:   Patients will commonly seek medical attention for refractory abdominal pain. The many causes of abdominal pain include pathologies of the gastrointestinal, genitourinary, musculoskeletal, and nervous systems. Unfortunately, a large number of patients will develop chronic abdominal pain that is recalcitrant to definitive therapies and nonspecific treatments such as cognitive-behavioral, physical, and pharmacologic therapies. Although spinal cord stimulation is classically used for neuropathic and ischemic conditions, a growing number of reports describe its efficacy in visceral disease. We describe our experience with spinal cord stimulation in two patients with refractory abdominal pain. Although the exact etiology in these complex patients is not defined, it is theorized that visceral hypersensitivity is at least one component. Finally, we will summarize the applicable literature in order to explain a possible mechanism of analgesia in visceral disease.     

腹腔镜诊治妇科急腹症的临床探讨

目的:探讨腹腔镜在妇科急腹症诊治中的应用价值。方法:回顾分析应用腹腔镜诊断和治疗666例妇科急腹症的临床资料。结果:362例输卵管妊娠、111例黄体破裂、56例急性盆腔炎、76例卵巢囊肿蒂扭转、53例巧克力囊肿破裂、5例子宫穿孔、3例出血性输卵管炎,662例成功进行腹腔镜手术治疗,中转开腹4例。结论:应用腹腔镜诊断、治疗妇科急腹症是一种安全、有效、实用、微创的方法。