When You SHOULD NOT Treat Your Patients Thoracic Pain

When I was in physical therapy school, PTs in the States didn’t have direct access. 

I figured I needed to mainly focus on differential diagnosis of musculoskeletal issues and not worry about cancer or visceral referral pattern.  However, the States slowly has been adopting direct access for physical therapy and I also learned that regardless of having a referral, physicians don’t always spend enough time with patients to properly rule out other causes. 

The purpose of differential diagnosis is not to just identify a specific structure involved, but to also help determine prognosis, other psychosocial factors and to rule out serious pathology and identify conditions not appropriate for physical or massage therapy.

My patient was in her late 20’s and 6 weeks postpartum.  She had been having mid-thoracic pain and right scapular pain for almost 12 weeks.  Her physician sent her to therapy to receive manual therapy and strengthening. 

During the examination, I had difficulty reproducing her pain, but she stated her pain was worse at the end of the day after lifting, carrying and feeding her child all day.  She had weakness in her extensors and scapular retractors.  Even though I couldn’t reproduce her pain, I gave her some stretching and started some scapular stabilization exercises.  I figured her pain was from a sudden increase in lifting and carrying, sitting with her child and a change in her chest size.

Admittedly I treated her for 3 follow-up visits (with little change) before I realized what the problem was. 

On the third visit, her husband said: “I just don’t understand why the pain is always so bad late at night.”  He was more specific than she had been (end of the day).  The pain was late (10 pm) and often caused his wife violent vomiting.  That minute the lightbulb went on (and according to my patient I shouldn’t play poker because she knew!).  I asked her if she had ever had a White or light stool, she denied it, but her husband said: “don’t you remember the one when you were pregnant?”  She had a white bowel movement back when she was about 26 weeks pregnant!  She had denied pain anywhere else, but the minute I palpated her upper right abdominal quadrant she jumped off the table and reported radiation to her back/scapular area.

There it was….GALLBLADDER!  

She was admitted to the hospital an hour later and was in surgery 4 hours later.  The surgeon said she was days away from a rupture.

Quite honestly, I felt like an ass. 

I had seen her for 4 visits total before the husband had said the words that made gallbladder click in my head.  I realize she had seen both her Obstetrician and her Primary Care physicians prior to coming to see me, but that did little to make me feel much better at the time.  I had just started treating pregnancy and postpartum and couldn’t believe I almost missed something so important!  I went back and reviewed all my red flags and visceral referral patterns after this incident. 

I also share this story with every obstetrics in therapy class I teach.

Also, women and men often present differently with visceral referral patterns.  For gallbladder, women tend to have more vomiting than men.  Also, during pregnancy, the increase in estrogen leads to an increase in cholesterol in the bile and estrogen reduces gallbladder contractions.  The decrease in contractions leads to less bile leaving and an increased risk for gallbladder stones.  This can lead to severe pain and potential for infection.

Summary of Gallbladder symptoms:

  • Chills and/or low-grade fever
  • Dark colored urine
  • Jaundiced appearance
  • Light-colored stools
  • Nausea and vomiting (especially at night)
  • Stomach pain particularly after a high-fat meal
  • Right shoulder/scapular, mid back pain

We are never going to be perfect, but the goal is to learn from past patients and pick up on patterns faster the next time.  It also helps to share our experiences.  So keep these risk factors and symptoms in the back of your mind the next time your patient’s mid thoracic pain isn’t making sense! 

Critical Thinking For A Deep Vein Thrombosis

He came in complaining of extreme calf pain.

Everything seemed pretty straightforward, health history seemed fine, no real mechanism of injury, but it just seemed odd.

I tried doing the Homan’s sign orthopedic test but honestly couldn’t tell if I got a negative or a positive result because neither seemed very clear.

After three treatments it didn’t seem to be getting much better. We made an appointment for the following week but he didn’t show up, I kind of freaked out a little.

Did he have a DVT and I missed it?

I’ve only seen a case like this a couple of times and honestly to this day am not sure if I have ever done the orthopedic test properly because it never seemed really clear each time I tried it.

Deep Vein Thrombosis

If you’ve never heard of it, or are not sure what I’m talking about when referring to a DVT, it stands for “Deep Vein Thrombosis,” which is the formation of a blood clot in the lower limb. 

The big issue with this is if the clot dislodges it can become a pulmonary embolism blocking blood vessels in the lung, which, depending on the size of the clot could be life-threatening. If it is a smaller size clot, at a minimum it can cause damage to the lungs.

So, how do we know if this is what our patient has when they come in complaining of pain in the lower legs?

Well, first off we need to get a good thorough health history from the patient. When we look at the causes of a DVT, you could easily ask some questions that would throw up some red flags as an indicator without even observing the area of complaint. Some of the risk factors that cause a DVT include:

  • Family history of DVT.
  • Overweight or obese.
  • Damage to blood vessels:
    • broken bones
    • severe muscle damage
    • during surgery
    • varicose veins
    • vasculitis
  • Conditions that cause blood to clot more readily:
    • cancer
    • heart and lung disease
    • thrombophilia
    • Hughes syndrome (an immune disease that causes increased clotting)
  • Being inactive or immobile for extended periods:
    • Sitting for extended periods on a plane during travel (this is an important one)
    • long duration surgeries
  • Pregnancy.
  • Women on birth control or hormone replacement therapy.

Think about turning all of the above factors into questions during your intake. If your patient reports any of the above it’s a good sign to investigate a little deeper before progressing with your treatment. It is also worth noting, this typically happens unilaterally, so hopefully, only one side is of concern. 

If you get to the point of doing an assessment on the painful area some of the symptoms look like:

  • Heavy ache.
  • Pain, swelling, and tenderness in the area.
  • Red, warm skin, especially around the back of the leg close to the knee.

We were taught an orthopedic test in school called “Homans Sign”. From memory, you were supposed to squeeze the gastrocs while the knee on the affected side was bent and have the person dorsiflex their ankle. I have only known two people in my life who have been diagnosed with this, both told me that in their case the pain was so bad, there is no way they would have let someone do that to them (and yes I realize this is anecdotal evidence, but I thought it worth the share).

However, this test has come under some scrutiny lately. One study showed Homan’s sign was positive in 33% of patients with an actual DVT, but also in 21% of the patients who had no thrombosis. The estimated accuracy of the test ranges from 8% to 56% and also positive in more than 50% of patients who were symptomatic but did not have a DVT. So, it’s fair to say this orthopedic test is not a reliable test for us to use. 

In researching for this post I came to understand there is also occurrences of upper limb DVT’s, which can affect any veins of the upper extremity or thoracic inlet, including; jugular, brachiocephalic, subclavian, and axillary veins as well as the more distal brachial, ulnar, and radial veins.

Some of the risk factors in this case include: 

  • High body mass index.
  • Pregnancy.
  • Surgery.
  • Smoking.
  • Malignancy.
  • Foreign body in the vascular system (more than half the patients who had this, was because of pacemaker).

The more typical signs and symptoms are:

  • Swelling. 
  • Pain.
  • Edema. 
  • Cyanosis.

Some other symptoms like localized neck and shoulder pain, weakness, paresthesia, and elevated body temperature can occur but are less likely. 

Yet, another reason why our clinical reasoning has to be used when interviewing our patients. If we see any combination of the above signs and symptoms mentioned for lower or upper limb DVT, we MUST at a minimum refer out to a doctor, but more likely to the hospital to be sure of an accurate diagnosis, and of course to ensure patient safety. 

The Skilled Therapist

The whole reason behind this post was because of an article being shared around regarding DVT. 

It is the story of a 53-year-old woman who presented to a clinician with worsening shortness of breath, history of smoking and hypertension. Upon further investigation, they found increased calf muscle soreness over the previous two weeks after having an aggressive massage done while getting a pedicure. 

After more assessment, it showed defects in several pulmonary arteries and examination of the lower extremity suggested residual deep vein thrombosis. 

Fortunately, the article acknowledged that for this story and another one mentioned, the massage was being done by a layperson, not a skilled therapist, and massage was only partially responsible for the outcome. 

Now, I get it, we spend a lot of time on this site busting some massage therapy myths, however, this one is no myth. We actually want to reinforce the importance of this message. Note the article points out a skilled therapist was not involved. Well, I firmly believe that if you’ve been following this blog for any length of time YOU are a skilled therapist. Whether this is new information to you or just a review, it’s important to recognize those signs and symptoms and be able to communicate effectively with your patient in case you do need to refer them out because this is a medical emergency and should be treated as such. 

Understanding Depression, Ways To Recognize And Help

A couple of weeks ago, I was on my way to the gym when my mom called.

She started the conversation by saying she was thinking about me. My response was “why?”

I hadn’t heard the news yet, but she let me know that someone I’m a huge fan of had died. As the news about his death rolled in, it was confirmed that Anthony Bourdain had taken his own life. I’d read some of his books, cooked his food from one of my favourite cookbooks, watched his shows, and basically loved everything he did. I looked up to him.

Strange that someone who you’ve never met, can have an impact on you. Some may even think, strange for a mom to think about their son because of what a famous person did. But, perhaps she was thinking of me because of the way he did it.

I’ve written a little bit about it on this blog before, but have never gotten really personal with it. I debated hard whether I would write this post because it’s so personal. Depression is something I’ve dealt with a lot in my life, (I’m not sure if depression is actually a genetic thing, but it’s something that is certainly prevalent in our family) and was faced with suicide for the first time when I was around 12 years old. My uncle had taken his own life, years later my best friends dad, then one of my mentors at the firehall,  just a few years ago my brother, and a couple of months ago, a childhood friend.

So, any time something like this happens, maybe it hits a bit close to home.

Of course, when it’s a famous person, inevitably there is a lot of media attention. People take to social media to voice their opinions, mourn, share stories, and ask questions.

Most of the time people are left bewildered how someone who has “the ultimate life,” could possibly do something like this, they have it all!?

Then, of course, a barrage of the comments centre around how suicide is a selfish act because the person isn’t thinking about what they left behind, what they’ve done to family and friends, or that they took the easy way out.

Many friends who I’ve talked with since Bourdain’s death, haven’t really dealt with depression in their lives, so they have a difficult time understanding what could lead to this. I’m sure every person who deals with depression has varied experiences and different ranges of severity, so I can’t speak for others, or their experiences, but I will speak of mine.

Now for the personal part.

What Depression Feels Like

I can’t make a blanket statement on this as it’s going to be different for everyone.

Depression isn’t just simply a case of being “down” or feeling “blue” for a little while, it goes far beyond that. We are all meant to have a range of emotions and some days not feel as good as we do others. How could we ever experience how great happiness feels if we’ve never experienced grief or sadness?

Sadness can come and go depending on the experiences we have during the day. When you’re depressed, it’s like there’s a scratch on a record being played that is constantly skipping, playing the same line of a song over and over again. Only the line of the song is negative thoughts and no matter how hard you try, you can’t turn it off.

The longer it goes, the worse the negative thoughts get, and the harder it is to turn it off.

Possibly the worst part, is that you know those thoughts are wrong, you know they’re irrational, but there’s nothing you can do about it, they just keep pounding into your head. Then, you start to believe them.

When you start believing them is when things get really tough. You start to pull away from others because those negative thoughts aren’t just a matter of a feeling of sadness, it’s a feeling of worthlessness. You start to think that no one cares, that you’re not loveable, that maybe, just maybe, you’re as worthless as the thoughts in your head.

You could be laying in bed with someone you’re totally in love with, and when they tell you they love you, you don’t really believe it because, why would they!? When you already believe the negative thoughts in your head, why would anyone else think any differently? You assume everyone else thinks the same thing.

As it persists, things continue on that downward spiral. Sometimes laying in bed just thinking “maybe the world is a better place without me,” “maybe my friends and family would find it so much easier not having me around.” And the thoughts just won’t shut off, they won’t go away.

Then some of the isolation begins. You pull away from everything social because you’re not likeable anyway right?, so why subject your loved ones to HAVING to put up with you being around. It’s such an irrational thought, your loved ones having to PUT UP with you. It makes no sense, but you just can’t help it, it makes sense to you at the moment!

One of the strange things is that it doesn’t matter how good everything else in life is going, you could literally experience the greatest highs, and still have those negative thoughts constantly spinning in your head. One of the greatest experiences of my career was travelling to Russia this year with hockey, it was a major accomplishment, but there was still a night where I had to lock myself in the bathroom to have a good cry…damn those negative thoughts!

According to Mental Health First Aid Canadasome of the outward signs of depression can have both a physical appearance and a shift in attitude. 

Some signs of a change in physical appearance can be:

  • Looking sad, dejected, or anxious.
  • Speaking slowly in monotones.
  • Have a lack of attention to their physical appearance (look unkept).
  • Slowed thinking and body movements, agitation, pacing, or unable to sit still.
  • Decreased energy, tiredness, and fatigue.

With changes in attitude, a person may say things like:

  • I’m a failure.
  • I’ve let everyone down.
  • It’s all my fault.
  • I’m worthless.
  • I’m so alone.
  • Life is not worth living.
  • No one loves me.

Take a moment and just think about what it would be like having those thoughts repeatedly playing in your head. So, yeah I can see and understand why these famous people with the “ultimate lives” can get to a point where it seems like their only option is to end it all.

Treating Depression

There has been lots of discussion about what works for treating depression, that we need to raise awareness, and we certainly need to talk about it (the main reason for me writing this post).

What I haven’t seen much on, is how does the depressed person feel about all of these things?

This article was being shared around last week about the great effects of resistance exercise in reducing depressive symptoms. While this is great (and is hopefully used as a preventative measure), when you’re going through dark bouts of depression, the last thing you want to do is exercise. Just getting out of bed can be hard enough.

Raising awareness, yes we need to do this and fortunately, mental health, in general, is becoming more recognized and talked about. However, when you’re dealing with it, the last thing you want to do is raise awareness around your mental health. There’s a lot of fear associated with it.

Again, maybe irrational thoughts, but all you can think is:

  • No one would want to date someone who deals with this.
  • I could get turned down for that job I’m applying for if they find out.
  • People are going to look at me differently.
  • I’ll get less professional opportunities if people know.
  • No one would want to read a blog post I’m writing.

Talking about it, yes let’s get this going! However, it’s important to keep in mind that whether we like it or not, there is still a lot of stigma surrounding mental health (at this point). So, the depressed person may not want to talk to anyone about it, because remember, it’s also possible they think that NO ONE cares anyway.

While exercise and massage therapy are both recommended as lifestyle and alternative treatments for mild to moderate depression, anything more severe, the person should seek medical attention. This can be both medical and psychological treatment. Some of the best scientific evidence points to antidepressants, Electroconvulsive Therapy (ECT), and Cognitive Behaviour Therapy (CBT) as the best approaches for the treatment of depression.

The best thing we can do is start building relationships with medical professionals who provide the above therapies, so we can refer our patients when they need it. 

Assessing Risk Of Harm

This is one of the reasons it drives me bananas when some of our regulatory bodies say the biopsychosocial approach is out of our scope. Not only is massage therapy recommended as a treatment for depression, it’s also our responsibility to recognize and refer out should our patient need it.

How do we handle it if our patient is dealing with a mental health crisis and it gets to be too much for them?

Mental Health First Aid Canada gives four steps as crisis first aid in these situations:

  1. Engage the person in a serious conversation
    • Connect in a personal way.
    • Ask if they are feeling hopeless, or engaging in risky behaviour.
    • Show sensitivity and let them describe their feelings.
    • Listen for anything that could be an invitation to talk about suicide.
  2. Ask about suicide
    • Are you thinking about killing yourself, or having suicidal thoughts?
    • Asking this will not encourage suicidal thoughts, but rather it shows you care and are willing to talk with them, which can be a great relief for them.
    • Creating this conversation can identify you as a safe person to talk to.
  3. Explore and assess risk
    • Ask if they have a plan in place.
      • Have they made arrangements, or have things they could use to do it?
    • Ask about prior suicidal behaviour.
      • If they do, see if they need extra support, or if there are things that helped them in the past.
    • Ask about their supports.
      • See if they have people to turn to (at this point it might be you).
  4. Engage them in a plan for safety
    • Try and make sure they don’t have access to the means of killing themselves.
    • Develop a safety plan for a manageable period of time along with emergency or crisis line information.
    • Try to ensure no access to drugs/alcohol.
    • Listen to them.
    • Refer them to appropriate professional help.
    • Connect them with their support resources (and try not to leave them alone).
    • If necessary call 9-1-1.
    • Ensure your own safety.

While I hope this is something you never have to deal with, it’s an important conversation to have, as it could quite literally save one of your patients (or loved ones) lives.

While this is just a blog post, it should not be used as a substitute for more education about mental health, or suicide. I would encourage anyone reading this (healthcare professional or not) to take a mental health first aid course to better equip you to handle these situations should you ever need it. 

Whenever a famous person succumbs to mental health issues and takes their own life, it raises lots of awareness online. Along with that is discussions and opinions about the act of suicide itself. People make statements like: “it’s a selfish act,” and “why couldn’t they think about the ones they left behind?” While those things are all valid statements, as the ones left behind are left with nothing but hurt, and questions about how they didn’t see it coming, or just disbelief that it could ever happen. It may seem like a selfish act, but as we talked about earlier in the post, the person doesn’t believe that anyone cares, loves them, or that there is any other way out. From my own experiences, I’m not concerned about whether the person was selfish, it’s more sadness that whatever was going on in life was so bad, that the only thing they thought would fix it, was to end it all. So please, if you have any concern surrounding this with one of your patients, assist them to get the help they need. 

Red Flags For Low Back Pain, Or Clinical Decision Making?

It’s only happened a couple of times in my career.

You know that feeling you get when something just isn’t right? You’re not quite sure what it is, but something just seems off?

Twice I’ve had people come in where their pain and limited mobility had me questioning if they needed a trip to the emergency room. In one instance I called a family member who took the patient in, and everything checked out fine.

The other instance, the persons low back pain was so extreme, it just didn’t add up. There was no history of trauma or anything else that suggested the hospital was necessary, but I could barely touch the patient during the treatment because their low back was so sensitive. Afterward, I recommended seeing a doctor, or emergency room, but they refused. I never saw them again, so I’m not sure what the outcome was.

So how do we know when low back pain is an emergency, or just really painful?

Traumatic Injuries And The RTC

In old First Aid terms, there were criteria we would use at the scene of an accident to quickly decide if a patient had to have spinal immobilization used and if they needed to be immediately sent to the hospital. 

It was called the RTC (Rapid Transport Category), and it was a simple list which made it easier to decide how to provide the appropriate care to a patient. While this isn’t as useful in a clinical setting, it could be invaluable in a sport, or outreach setting if some type of emergency were to happen and you are required to provide care. In a clinical setting, it would be helpful during your patient interview in case you weren’t quite sure why a patient is having the issues they are presenting with.

The RTC criteria include quite an extensive list of things to watch for. Not all of them would be applicable to us, but here are some that would be:

  • Mechanism of injury
    • Fall from greater than 20ft
    • High-speed accident
    • Pedestrian struck at speeds higher than 30 km/hour
    • Broken windshield damaged steering wheel, or airbags deployed
    • A rollover accident
    • Severe crush injuries
    • Any other people involved in the accident that result in a fatality
    • Electrical injuries (we always assume spinal damage with electrocution)
  • Anatomy of injury
    • Severe brain injury
    • Penetrating injuries to anything but the limbs
    • Depressed skull fracture
    • Pregnant woman with fairly moderate trauma
  • Findings in the Primary Survey
    • Decreased level of consciousness
    • Cardiac arrest
    • Suspected heart attack
    • Poisoning
    • Status Epilepticus

Particularly for us in the clinical setting the mechanism of injury should be one category to take note of. Hopefully, if someone has been through an accident that traumatic, they have already been to the emergency room, or at least a doctor to be checked out, but this doesn’t always happen. Sometimes a patient may play it off and just think they need to see a chiro, physio, or massage therapist and book in with you before ever seeing a doctor, or even calling 9-1-1 after an accident.

I’m sure we all see patients on a regular basis who have been in a car accident. Knowing those above criteria and being able to ask some of those specific questions in your interview may give you a better idea as to how severe their injuries could be. Or, if they played it off and haven’t been checked out, you may want to refer them to a doctor just to be safe.

Whenever I teach a first aid course we talk about the signs and symptoms of a heart attack. This is where there could be a bit of a red flag, as it is quite common for women to experience back pain associated with a heart attack. However, it would be back pain combined with other symptoms like chest pain, nausea and vomiting, sweating, and shortness of breath.

This is certainly part of our role as healthcare professionals to recognize and help our patients if this is happening. 

Photo by: Lucina Medina

The Red Flags Of Low Back Pain

There seems to be a wide array of information on the red flags of acute low back pain.

Most of the concern is driven toward four issues:

One red flag that is unrelated to specific disease was the onset of pain in patients under 20 years old. However, one study actually calls this a “dubious distinction” and shows that age alone combined with pain is not enough to be considered a red flag, as most of the participants in the study were diagnosed with non-specific mechanical spinal pain.

When we look at the risk factors associated with spinal fractures, most information cites major or significant trauma, age, a history of osteoporosis, and the use of corticosteroids as the red flags to look out for. A systematic review showed that all of the above combined with the presence of a contusion brought the probability of a fracture up from 4% to a range between 9 and 62%. An Australian study showed that when three red flags (female, over 7o years of age, severe trauma, and use of corticosteroids) were all present, the chance of a fracture went from 4% to 90%. So, when looking at red flags for fractures, one red flag alone is not likely an issue, but a combination of the red flags is more likely to result in a fracture.

The commonly used red flags for infection were:

  • Fever/chills
  • Use of corticosteroids or immunosuppressant therapy
  • IV drug use
  • Pain worse at night
  • Night and rest pain
  • Tenderness over the spinous process

But the same systematic review showed that there is a lack of standardization with these red flags, and the risk of serious disease in patients with low back pain is less than 0.1%.

The same can be said for malignancy, as the one big red flag, in this case, is a history of cancer. Yet “history of cancer” isn’t clear enough as it doesn’t specify how long ago the person was diagnosed or the type of cancer they had. There are several cancer types that apparently put a person at greater risk for spreading to the spine, but if the person didn’t have one of those types, or had it 20 years ago, the likelihood of spinal malignancy is probably a lot less than someone diagnosed recently.

The two most common red flags with Cauda Equina were saddle anesthesia (perineal numbness)  and sudden onset of bladder dysfunction. Either way, I’d be referring out for that!

One thing that came out of most of the studies I could find was one resonating point. Clinical decision making and judgment of the therapist to determine if the patient needs to be referred out is more reliable than the list of red flags. So in other words, when in doubt, refer out! There are some other things to take into account with this whole red flag discussion and one review makes a great point as to why screening for red flags isn’t reliable. As practitioners, we don’t actually screen, we manage low back conditions. They actually encourage watchful waiting for changes in symptoms, as evidence is showing that early intervention with low back pain may actually be more harmful.

One thing I hadn’t ever heard of was “yellow flags,” however, I found it encouraging that it was mentioned in a paper from rheumatologists. They listed these yellow flags as:

  • A belief that back pain is harmful or disabling
  • Fear of pain and movement avoidance
  • Tendency to low mood and withdrawal from social interaction
  • Expectation of passive treatments rather than believing active participation helps

Biopsychosocial approach anyone? It’s great to see these “yellow flags” being mentioned with the same importance as the dreaded red flags.

Overall, it is probably good to be aware of those red flags to help guide your clinical decision making, but they aren’t the be all end all like we once thought they were. The valuable thing will be your judgment call and also making sure to monitor your patients progress. If your spidey senses start tingling, and something doesn’t seem right, don’t hesitate to refer out, it’s better safe than sorry.