Low Back Pain

General Information
Case no.	10.A Low Back Pain
Author(s)	David Gillette, PT, DPT, Board Certified Clinical Specialist in Geriatrics Physical Therapy Bhavana Raja, PT, PhD Todd Davenport, PT, DPT, MPH, Board Certified Clinical Specialist in Orthopaedic Physical Therapy
Diagnosis	Low back pain without radiculopathy
Setting	Outpatient clinic
Learner expectations	☑ Initial evaluation ☐ Re-evaluation ☐ Treatment session
Learner objectives	Explain the processes of examination and evaluation for referral in an individual with low back pain related to medical pathology. Discuss the general referral pattern for retroperitoneal abdominal structures. Create a physical therapy plan of care for an individual with low back pain secondary to a medical condition across care settings.

Medical
Chief concern	Pain in lower back and abdomen, nausea
History of present illness	The patient is a 72-year-old man who self-referred to outpatient physical therapy with worsening low back pain. The patient reports first onset of low back pain in his 20 s while playing a game of baseball. Since that time, he has had intermittent episodes of pain that have “come and gone” on its own. He has self-managed his symptoms over the years with Tylenol, rest, and use of a heating pad. Episodes usually last 2 weeks. He noted current episode of pain beginning 3 days ago, beginning with an insidious onset. This is not unusual based on his prior pain presentations. Yet, this time, the pain has become very severe in a very short period of time. His symptoms are worsened with standing, walking, sitting, and laying supine. Tylenol, rest, and heating pad have not been helpful to alleviate symptoms.
Past medical history	Hypertension, chronic obstructive pulmonary disease (COPD), diabetes mellitus type 2, right hip osteoarthritis, hypercholesterolemia, obesity Tobacco: 1 pack per day for 40 years, expresses desire to quit Caffeine: 2 cups of coffee per day; recently quit soda Alcohol: occasionally
Past surgical history	Right total knee arthroplasty: 5 years ago; left rotator cuff repair: 2 years ago
Allergies	No known drug allergies.
Medications	Lisinopril, Atorvastatin, Metoprolol, Naproxen, Aspirin, Hyzaar Patient reports being noncompliant with medications
Precautions/orders	Activity as tolerated

Social history
Home setup	Resides in a multilevel home with wife. Two steps to enter, rail is on the left. Half bath + guest room are on the first floor. Bedroom and bathroom are located on the second floor. Flight of stair + right handrail to the second floor.
Occupation	Retired as research scientist 2 years ago; now drives Uber for extra income and volunteers at a local homeless shelter.
Prior level of function	Independent with functional mobility and activities of daily living (ADLs). No assistive device prior to recent hospitalization but has rolling walker and single point cane from prior surgery. Two noninjurious falls in the last year: one at night going to the bathroom quickly and one when walking on uneven sidewalk during the day. Spouse works full-time as a partner at a regional law firm; currently on a case that requires them to be gone during the week. Has estranged son and daughter from first marriage.
Recreational activities	Primarily watching TV and reading. Enjoys fishing from a boat, but now is limited due to back ache.

Pause points
Based on the above information, what are the priority: Diagnostic tests and measures? Outcome measures? Treatment interventions?

Pause points

Based on the above information, what are the priority:

Diagnostic tests and measures?
Outcome measures?
Treatment interventions?

Physical Therapy Examination
Subjective
“This is the worst back pain I’ve ever had. Nothing is helping and it’s not going away. In fact, it’s getting a lot worse, quickly. I wanted to see you before I go to my doc.”
Objective
Vital signs	Pre-treatment		Post-treatment
Blood pressure (mmHg)	131/88		128/84
Heart rate (beats/min)	112		115
Respiratory rate (breaths/min)	26		25
Pulse oximetry on room air (SpO₂)	98%		97%
Pain	“12/10” per patient report		“12/10” per patient report
Temperature (°F)	97.7		–
General	Presents seated in clinic waiting room, appears slightly pale. Reports mild nausea.
Cardiovascular and pulmonary	Tachycardia No adventitious cardiac and lung sounds. Pulsatile mass noted superior to the umbilicus, which is more noticeable. The lateral margins of the mass increase from superior to inferior from 3.5 to 9 cm apart at its widest point just superior to the umbilicus. The pulsatile mass is not painful with palpation. Auscultation positive for bruits over the abdominal aorta.
Gastrointestinal	Mild nausea Eating a normal diet. Bowel habit has not changed.
Musculoskeletal	Range of motion	Bilateral upper extremity (BUE): not apparently restrictive to functional mobility, though not formally tested. Bilateral lower extremity (BLE): not apparently restrictive to functional mobility, though not formally tested.
	Strength	BUE: grossly > 3 + /5 for the major antigravity muscle groups as demonstrated through functional mobility, not formally tested. BLE: grossly > 3 + /5 for the major antigravity muscle groups as demonstrated through functional mobility, not formally tested.
	Inspection	Patient stands in trunk and hip flexion. He has discomfort when asked to stand erect. A pulsatile mass is noted superior to the umbilicus.
Neurological	Balance	Sitting, static: independent Sitting, dynamic: independent Standing, static: independent Standing, dynamic: independent
	Cognition	Alert and oriented × 4
Functional status
Bed mobility	Rolling either direction: independent Supine to/from sit: independent, increased time to perform
Transfers	Sit to/from stand: independent
Ambulation	Ambulates from waiting room to/from treatment room (~150 feet) independently with no assistive device. Gait deviations notable for decreased cadence and stride length, with persistent trunk flexion throughout the gait cycle and limited hip extension and ankle dorsiflexion in terminal stance.
Stairs	Not assessed at this time

Pause points
Based on the above information: What is the best decision regarding the appropriateness of physical therapy (retain, refer, or comanage)? What are features of the case that are consistent with a decision to refer the emergency department?

Pause points

Based on the above information:

What is the best decision regarding the appropriateness of physical therapy (retain, refer, or comanage)?
What are features of the case that are consistent with a decision to refer the emergency department?

Assessment
☑ Physical therapist’s	Assessment left blank for learner to develop
Goals
Patient’s	“I want to understand what is happening with me and then go back to being able to fish without pain.”
Short term	1. Goals left blank for learner to develop 2.
Long term	1. Goals left blank for learner to develop 2.

Plan
☑ Physical therapist’s	The plan for this patient is to be referred to the emergency department for additional medical evaluation, including diagnostic imaging to either confirm or disconfirm a suspected abdominal aortic aneurysm (AAA).

Bloom’s Taxonomy Level	Case 10.A Questions
Create	1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient. 2. Develop two short-term physical therapy goals, including an appropriate timeframe. 3. Develop two long-term physical therapy goals, including an appropriate timeframe.
Evaluate	4. What is the best synthesis of this patient’s findings in order to establish a provisional diagnosis that guides additional patient care and case management?
Analyze	5. What palpation findings would suggest the presence of AAA?
Apply	6. What is the reliability of physical examination findings to determine the potential presence of AAA?
Understand	7. Is it safe to palpate the abdominal aorta in the presence of a possible dissection?
Remember	8. Where is the abdominal aorta located? 9. What is the frequency of AAA in the United States? 10. What is an aneurysm?

Bloom’s Taxonomy Level	Case 10.A Answers
Create	1. The patient is a 72-year-old man who presents with low back pain and pulsatile mass, which raises the index of clinical suspicion for AAA. This physical therapy assessment requires referral for additional testing and consultation to confirm, as may be considered medically appropriate. Recommend holding physical therapy at this time pending additional referral and consultation with the emergency department. 2. Short-term goals: Patient will follow up with emergency department immediately to evaluate for AAA. Patient will verbally demonstrate understanding of the plan for physical therapy to refer out to the emergency department at this time. 3. Long-term goals: Patient will follow up with outpatient physical therapist when medically appropriate to complete physical therapy evaluation.
Evaluate	4. According to the literature, the pretest probability of AAA is high in this patient secondary to the presence of two main risk factors. The odds ratios associated with male gender and age 70 years are 5.71 (95% confidence interval [CI]; 95% CI: 5.57–5.81) and 14.46 (95% CI: 13.45–15.55) for AAA. This means that (a) men are over 5 times more likely than women to present with AAA and (b) people aged ≥ 70 years are almost 15 times more likely than people aged 50 years to present with AAA. The patient’s previous history of smoking also places him at elevated risk of vascular pathology.
Analyze	5. AAA are defined as 3.0-cm enlargements of the abdominal aorta. The clinician uses their fingertips to assess the lateral margins of the abdominal aortic pulse, and then the distance is measured as an approximation of the diameter of the abdominal aorta. The advantages of using the fingertips instead of thumbs are (a) broader palpation surface for more patient comfort and (b) a decrease in likelihood of mistaking one’s own digital pulse for the patient’s pulse. Palpation distances may be greater as palpated from the abdomen, because pulsatile waves are transmitted through the abdominal tissues. (Fig. 10.1) Diagnostic ultrasound or computed tomography is required to confirm the diagnosis and characterize the size of an AAA.
Apply	6. Palpation to approximate the width of the abdominal aorta demonstrates moderate diagnostic accuracy overall to determine the presence of an AAA. According to Fink and colleagues, palpation yielded sensitivity of 68% (95% CI: 60–76%), specificity of 75% (95% CI: 68–82%), positive likelihood ratio of 2.7 (95% CI: 2.0–3.6), and negative likelihood ratio of 0.43 (95% CI: 0.33–0.56) with respect to diagnostic ultrasound. Sensitivity was increased for larger AAA (> 5.0 cm). In addition to size of the AAA, additional factors that affect diagnostic accuracy of palpation reduce as abdominal girth and abdominal wall stiffness increase.
Understand	7. It is safe to palpate a suspected case of AAA; there are no documented cases of dissection related to palpation.
Remember	8. The abdominal aorta begins at the diaphragm, generally at the T12 level, and is located to the left of the lumbar spine. The abdominal aorta bifurcates into the common iliac arteries at the level of the umbilicus. 9. AAA affects ~1.1 million older adults in the United States (1.4%). Rupture rates from natural history studies are ~5.3 to 6.3% per year but may be as high as 33%. Rupture rates increase positively with aneurysm size. 10. An aneurysm is a weakness of the arterial wall. There is no universally accepted mechanism for how aneurysms occur, but there are many well-characterized risk factors.

Fig. 10.1 Assessment of abdominal aorta. With the patient lying supine, the clinician stands at the side of the patient. Place fingertips over the epigastrium to determine the presence of a pulse, and with palms down and index fingers on either side of aorta slowly track laterally from the midline. Width of the aorta can be estimated by measurement of the finger distance from one another once the pulse disappears. An abdominal aortic aneurysm (AAA) is defined as 3.0-cm enlargements of the abdominal aorta. (Adapted from Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018;67(1):2–77 e72.)

Key points
1. Low back pain may arise from causes that are not amenable to physical therapy interventions.
2. AAA is more common in men than in women and in individuals older than 55 years, with increasing relative incidence over time.
3. Referral decisions should be made in a manner that considers a cautious interpretation of the patient’s subjective and objective findings. Thus, in the case of this symptomatic patient, emergent referral is necessary to exclude the possibility of AAA.

General Information
Case no.	10.B
Author(s)	David Gillette, PT, DPT, Board Certified Clinical Specialist in Geriatrics Physical Therapy Bhavana Raja, PT, PhD Todd Davenport, PT, DPT, MPH, Board Certified Clinical Specialist in Orthopaedic Physical Therapy
Diagnosis	Abdominal aortic aneurysm (AAA)
Setting	Emergency Department, with transfer to the Intensive Care Unit
Learner expectations	☑ Initial evaluation ☐ Re-evaluation ☐ Treatment session
Learner objectives	Explain the pathophysiology of the patient’s diagnosis. Relate the pathophysiology and progression of pathology from low back pain to the acute condition and its impact on activity/participation limitations seen in physical therapy practice. Select, implement, and interpret physical therapy interventions based on the medical examination findings. Develop an understanding of medical management and how it influences physical therapy plan of care.

Medical
Chief concern	Pain in lower back and abdomen, nausea.
History of present illness	The patient is a 72-year-old man who was referred to the emergency department today from outpatient physical therapy with a primary complaint of chronic low back pain and secondary complaints of nausea and abdominal pain that have been worsening over last few days. He denies any falls, or trauma. He was seen by his primary care physician 2 weeks ago and was referred to outpatient physical therapy for management of what was thought to be mechanical low back pain. However, during the physical therapy evaluation, the physical therapist noticed a pulsating mass in the patient’s abdomen and recommended the patient to go to the emergency department immediately. The patient drove from the physical therapist’s clinic to the emergency department of the hospital, where he was subsequently admitted for surgical intervention.
Past medical history	Hypertension, chronic obstructive pulmonary disease (COPD), diabetes mellitus type 2, right hip osteoarthritis, hypercholesterolemia, obesity Tobacco: 1 pack per day for 40 years, expresses desire to quit Caffeine: 2 cups of coffee per day; recently quit soda Alcohol: occasionally
Past surgical history	Right total knee arthroplasty: 5 years ago; left rotator cuff repair: 2 years ago.
Allergies	No known drug allergies.
Medications	Lisinopril, Atorvastatin, Metoprolol, Naproxen, Aspirin, Hyzaar. Patient reports being noncompliant with medications.
Precautions/orders	Bedrest

Social history
Home setup	Resides in a multilevel home with his wife. Two steps to enter, rail is on the left. Half bath + guest room are on the first floor. Bedroom and bathroom are located on the second floor. Flight of stairs + right handrail to the second floor. Spouse works full-time as a partner at a regional law firm; currently on a case that requires them to be gone during the week. Has estranged son and daughter from first marriage.
Occupation	Retired as research scientist 2 years ago; now drives Uber for extra income and volunteers at a local homeless shelter.
Prior level of function	Independent with functional mobility and activities of daily living (ADLs). No assistive device prior to recent hospitalization but has rolling walker and single point cane from prior surgery. Two noninjurious falls in the last year: one at night going to the bathroom quickly and one when walking on uneven sidewalk during the day.
Recreational activities	Primarily watching TV and reading. Fishing from a boat, but now is limited due to back ache.

Vital signs	Hospital day 0: emergency department	Hospital day 1: intensive care unit
Blood pressure (mmHg)	120/78	118/74
Heart rate (beats/min)	125	84
Respiratory rate (breaths/min)	20	16
Pulse oximetry (SpO₂)	91% on room air	95% on 4 L nasal cannula (NC)
Temperature (°F)	101.2	–

Fig. 10.2 Post-EVAR, a plain abdominal radiograph can help serve as a baseline for future stent graft follow-up.
(Adapted from Gover D, ed. Case 50. In: Top 3 Differentials in Vascular and Interventional Radiology: A Case Review. 1st ed. New York, NY: Thieme; 2018.)

Imaging/diagnostic test	Hospital day 0: emergency department	Hospital day 1: intensive care unit
Computed tomography (CT) scan with contrast	1. Widened aortic lumen measuring ~5.8 cm. 2. Mural thrombus surrounding the contrast material. 3. No contrast material in peritoneal cavity.	–
Abdominal X-ray	–	1. Fig. 10.2
Ultrasound	1. A 5.7-cm dilation of distal abdominal aorta.	–