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How to Screen if the Cervical Spine is Impacting Shoulder Pain. (Yes it’s in Your Scope!)

We’ve spent the last couple weeks at The Massage Development Center exploring a variety of shoulder diagnoses and treatments. But what happens when shoulder pain isn’t coming from a source in the glenohumeral joint or its structures? Are you able to screen for these conditions?

Now, I am a physical therapist and it was in my training to look at the cervical spine when evaluating a patient for a shoulder injury.

However, depending on your schooling and licensure, it may not have been part of your education. From my understanding, if you are a massage therapist, even what state or province you work in determines if you can do a full screen of the cervical spine.

However, I want to argue it is in everybody’s scope of practice to do due diligence to take a good history and make sure an outside referral isn’t warranted. My goal with this post is not to teach a bunch of cervical screening tests, but to familiarize everybody with risk factors in patient’s history and signs and symptom that would warrant further investigation either from you or outside referral.

Recognizing Referral Pain

The cervical nerve roots and cervical discs can refer to the shoulder area. Your patient may come in complaining of upper trapezius pain or rhomboid pain but it could be a C6-7 nerve root radiculopathy causing pain.

The referred pain may continue further down the upper extremity or may stop in the shoulder region. The following table outlines the common areas for referral:

Nerve Root Shoulder area referral pattern:

C2 – Pain primarily in the posterior aspect of skull, headaches, ears, eyes
C3 – Pain in necks and Upper Trapezius
C4 – Pain in Upper Trapezius, lower neck
C5 – Pain in upper lateral arm, neck, shoulder Weakness in Deltoid and           Elbow Flexion
C6 – Pain in the dorsolateral arm, Neck upper/middle trapezius                       Weakness in biceps
C7 – Pain Middle trapezius/rhomboid area and neck Weakness in triceps
C8 – Pain in neck and middle/lower trapezius Weakness largely in hand
T1 – Pain in lower trapezius and forearm Weakness largely in hand

If your practice acts allow differential assessment and shoulder tests are negative, it is worth considering cervical radiculopathy. Research shows that grouping the Spurlings Test (also known as the Foraminal Compression Test), Upper limb nerve tension testing, Cervical Distraction Test and the patient presenting with involved side cervical rotation of less than 60 degrees has a 90% positive likelihood ration that cervical radiculopathy is present.

What if your practice acts do not allow you to perform special tests for the neck?

Ask some questions and observe, to help determine if it might be cervical radiculopathy.

First does it look like your patient has less than 60 degrees of cervical rotation of their symptomatic side? Do they describe their pain as “pins-and-needles or tingling or stinging” or occasional numbness? Do they have muscle weakness? Does the pain increase when they rotate to that side and concurrently extend their neck (a sign of compressing the nerve root)?

In younger patients, the most common cause of nerve root irritation is disc herniation or a direct blow such as in football or hockey game (a “stinger”). In older patients, the leading cause is stenosis or bony spurs.

If the answer to these questions is yes, you may want to consider having your patient follow-up with another healthcare practitioner if they have not had the cervical spine evaluated (particularly if they have significant weakness present). However, largely these conditions will respond to massage therapy and strengthening along with other physical therapy treatments and potentially other medical management.

However, you may have patients whose history is not as straight forward or the presentation may be more serious and you need to do a more immediate referral. The cervical spine structures can also refer to the shoulder complex for much more serious reasons.

Knowing When To Refer Out

Upper cervical fractures can irritate nerve roots and refer to the shoulder as well. These typically won’t refer into the glenohumeral joint proper but may refer into the upper trap area. You may wonder how somebody could be walking around with an undiagnosed cervical vertebral fracture, but it is actually not that uncommon.

A Dens fracture of C2, for example, is often not seen unless an open mouth x-ray is performed (which is not always standard protocol or people think they are “fine” after an MVA). It is typically injured with a hyperextension type of injury (i.e. whiplash in a car accident or hyperextension of the neck in football with another player falling on the injured player). The fracture can compress the spinal cord and cause swelling which can also cause the nerve roots to refer pain. The injury does have a good outcome potential with proper treatment.

However, if your patient has the appropriate mechanism of injury and has neck pain, neck swelling, complaints of swallowing and has muscle weakness and has not been evaluated for a fracture you should refer out prior to treatment.

Cervical Central Cord Compression is probably the most severe diagnosis to should be making sure you screen. This occurs when the spinal cord becomes compressed from bone fragments from a fracture or disc, swelling due to an injury from a trauma or a tumor.

Because it may take time for swelling to develop and compress the cord, symptoms may develop over many hours or days so they may be walking in your office now experiencing a medical emergency. Your patient will have a history of major trauma (fall, motor vehicle accident, a blunt blow to the spine). Classic signs of central cord compression include: gait disturbances (they may be walking with a wide base of support or say they feel unsteady since the accident), arm and hand sensory complaints and muscle weakness including very quick atrophy of the muscles, and complaints of sudden onset incontinence (not just a few drops, full bladder uncontrollably leaking).

If these are new-onset symptoms with a trauma history, immediately send your patient to a physician or emergency room. You cannot be too careful with this sort of diagnosis.

It’s also important to remember that shoulder pain may not be referring from the cervical spine at all but from another area of the body such as abdominal gas, heart issues such as a heart attack or from an organ such as the gallbladder. We shared such a case of referred pain in a post you can find here. In summary, it is important to get a good patient history prior to treating their shoulder to assess whether the cervical spine may be involved. If it is out of the scope of your practice to assess the spine, then make sure you know the red flags and history that would warrant a referral to an outside practitioner. The human body is so interconnected and we should never work in isolation!

References:

Childress MA, Becker BA. Nonoperative Management of Cervical Radiculopathy. American Family Physician. 2016;93(9):746-754

Clark, Charles R. The Cervical Spine. Fourth ed. 2005. Web.

Hashmi SZ, Marra A, Jenis LG, Patel AA. Current Concepts: Central Cord Syndrome. Clinical Spine Surgery. 2018;31(10):407-412
Hutting N, Scholten-Peeters GGM, Vijverman V, Keesenberg MDM, Verhagen AP. Diagnostic accuracy of upper cervical spine instability tests: a systematic review. Physical Therapy. 2013;93(12):1686-1695

Schroeder GD, Vaccaro AR. Cervical Spine Injuries in the Athlete. Instructional Course Lectures. 2017;66:391-402.

How Recognition And Communication Can Help Cauda Equina Syndrome

Sometimes a patient walks into your clinic and it’s hard to decipher what’s going on with them.

It may be something we’ve never seen before, their signs and symptoms don’t add up, or their pain doesn’t seem to correlate to their description of the cause. When things don’t seem to add up, our clinical reasoning has to jump into full effect to figure out what’s going on.

Looking at the red flags of low back pain, one of the conditions that really stands out is Cauda Equina Syndrome.

While it is rarely seen in practice (I have yet to ever encounter a patient with it) it is something we should have a working knowledge of, so our clinical reasoning can jump into action.

Early recognition and referral to medical help can make a massive difference in its development and effect on a patient, so we have a responsibility to recognize and refer out when necessary, and in this case, it is!

Recognizing Cauda Equina

The Cauda Equina is a bundle of nerve roots that angle down in the vertebral canal from the end of the spinal cord, which looks like wisps of hair, giving it its name, meaning “horse’s tail”.

What causes Cauda Equina Syndrome is usually some sort of compression happening at the nerve roots around the lumbar to sacral area. The most common causes are:

  • Lumbar disc herniation, prolapse, or sequestration (one systematic review showed 45% were disc related)
  • Smaller prolapses due to spinal stenosis.

The less common causes are:

  • Epidural Haematoma.
  • Infection.
  • Primary and metastatic neoplasms.
  • Trauma.
  • Post-surgical.
  • Prolapse due to manipulation.
  • Chemonucleolysis.
  • After spinal anesthesia.
  • Patients with Ankylosing Spondylitis.
  • Gunshot wounds.
  • Constipation.

All of these things are important to ask during a patient history if you suspect a possibility of Cauda Equina, but more important is their clinical presentation. It may present as: 

  • Low back pain.
  • Saddle anesthesia.
  • Bilateral sciatica.
  • Weakness of their lower extremities.
  • Paraplegia.
  • Bowel, bladder, or sexual dysfunction.

The most commonly seen are low back pain and radicular leg pain because of tissue irritation around the lumbar spine.

When it comes to assessing patients who could possibly be dealing with this, one review showed they can be placed into three groups: 

  1. CESS (Cauda Equina Syndrome Suspicious or Suspected)
    • Bilateral radiculopathy.
    • Subjective sphincteric problems with no objective evidence of CES.
  2. CESI
    • Subjective symptoms and objective signs, but voluntary control of urination.
  3. CESR (Cauda Equina Syndrome Retention)
    • Neurogenic retention of urine with a paralyzed, insensate bladder along with urinary incontinence.

Now just as we see some “red flags” with low back pain, CES has also been divided into red flags and white flags and are divided into:

  • Definite Red Flags
    • Bilateral Radiculopathy.
    • Progressive neurological deficit in the legs.
  • Possible Red or White Flags
    • Impaired perineal sensation.
    • Impaired anal tone (not that I’m suggesting you should ever try to palpate this).
    • Urinary difficulties that are unspecified.
  • Definite White Flags
    • Urinary retention or incontinence.
    • Fecal incontinence.
    • Perineal anesthesia.

With this outline, we define the “true red flags” as someone who has bilateral radiculopathy, difficulties with urinating, or changes in bladder function, along with the loss of perineal sensation. However, there is nothing that gives a clear diagnosis because so many of the symptoms are objective. It is recommended that MRI is important, not because it can diagnose, but rather it shows which people with red flag symptoms have significant compression of the nerve roots, which may result in treatment before the development of the white flags which are more severe.

White flags are a way of saying “defeat or surrender” as the signs are often seen too late and are irreversible. Therefore the review outlining these red and white flags makes the argument that white flags should be removed because treatment at this stage might be too late to recover and avoid long term harm.

Another review even pointed out these different subclasses were too ambiguous as far as signs any symptoms go, so they should be avoided as well.

Then the argument is made that CES diagnosis should revolve around one or more of the following being present:  bladder or bowel dysfunction, reduced sensation in the saddle area, and sexual dysfunction with possible lower limb neurologic deficits.

Clear Communication And Reassurance

As we have talked about before, when it comes to low back pain, patient reassurance is a crucial aspect of helping them deal with these issues.

Much of the evidence shows good outcomes occur when patients have decompressive surgery early before there are incomplete lesions on the nerve. However, it is unclear as to which exact surgery (there are a few different types) works the best and is another factor that could affect patient outcomes.

So the important thing is for us to recognize these symptoms, realize there is an issue, and have our patients get the appropriate help, (which is most likely a trip to the hospital), as early recognition and treatment is key.

We want to ensure when talking to our patients that we are using clear and easily understandable terms, as well as proper descriptive terms when referring to doctors as this is a rare condition and is estimated a doctor may only see this once in their career.

It is crucial that our communication with patients is centered on them, not only in the way we talk, but also in the way we listen, as it has been shown they use very explicit language in their description of symptoms. It is then important for us to use terms they understand. Much of the research uses terms like “micturition” and “incontinence” which came across as very vague and hard to understand for patients. Rather, using terms like “urinating”, or “difficulties using the restroom” would be more appropriate. One patient was told their issue was serious if they were incontinent, yet the patient would be able to “force” themselves to use the toilet, so didn’t understand this was an issue.

So, clear communication is key to the emphasis and seriousness of their condition, as well as the importance of getting to the hospital quickly (better outcomes within 48 hours of recognition and treatment). While these can be difficult conversations to have, they are crucial ones because if this isn’t recognized and dealt with, there can be long term and VERY undesirable consequences, which are quite simply life altering. We can play a major role in this for our patients. While it may be difficult to have conversations (and some would argue we shouldn’t) centered around sexual dysfunction and using the toilet, we owe it to our patients as healthcare professionals to not only be open to,  but willing to talk about this for their better outcome.

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. 

Massage Therapy, Communication, And Helping Trauma Survivors

 

I’m one of those people that nod and smile to the person next to me on the bus and 15 minutes later I have heard most of their life story. You might be nodding and thinking “mmmhmm” right about now. In fact, I think if there was a group of massage therapists gathered and a similar question was asked, many would raise their hand at being “that person”.

Massage therapists have an intimate connection with their clients. Many of us work on clients who are only one sheet away from being naked in front of us. That means we need to be exemplary in our treatment of someone on the table. It’s not only a body, but a mind with varying experiences we are working with everytime we touch a client.

Let’s go back to questioning a group of MTs. If the question asked was “How many of you are survivors of trauma” there would no doubt be hands in the air.  A lot of MTs came to the profession because of their experience with massage during a traumatic recovery, or, seeing how it positively affected a loved one. 

But for the hands that remained down, does this mean they have not experienced trauma? 

Absolutely not. 

Many people prefer not to share their stories, which is understandable and acceptable. Do not expect that your client will share their personal past or trauma with you. Do treat everyone with the knowledge they may well be in the middle of a traumatic event, or have past event(s) that continue to have an impact on their lives.

When we speak of treating a client with a past trauma we usually think of a physical injury or PTSDPTSD often brings to mind those who served in the military, but in fact many situations may cause PTSD, as well as C-PTSD, Growing up in poverty, being adopted, survivor guilt, sexual abuse/rape, confinement of any sort (prison, residential treatment centersrepeated injury such as childhood physical and sexual abuse

The person currently in the middle of a divorce or custody situation. The one who just found out they cannot birth their own children. The client who spent part of their life living with abuse-whether verbal, physical or both. The one who has been body shamed by loved ones. A person who may have spent time in confinement. A former or current member of the military or someone who has seen the effects of war firsthand.

The stories are different, sometimes similar, but affect every human in a very personal manner, consistent with their other life experiences.

Nurturing, Ethical Standards, And Trauma

A few years ago, a client of mine I thought I knew well opened up after a year of sessions. 

The client told me they were glad that I worked through the sheets when doing gluteal work, as they had always felt uncomfortable having this type of work done, but enjoyed the benefits post massage. 

They told me about being aggressively assaulted by a group of people earlier in their life. This news was of course stunning. All I could do was stutter “I am so sorry” and continue with the session.  At the end of the session, the client thanked me for listening and not offering any advice, and again for providing the additional draping. This incident opened my eyes to the knowledge that as massage therapists we rarely know more than the basic details of a client’s history.

After working so closely with the public, I realized that most people have many hidden faces underneath. 

I changed my outlook to try and recognize that when someone comes in and says they are ‘not doing great’, there is no need for me to ask why. I am here to provide bodywork. If the client decides to share information with me, it stays in the room. I will not bring it up in another session (unless it is health related to their treatment) and will acknowledge that sometimes people need an ear, but that isn’t a request for feedback.

What we do is nurturing, but we are not “healers”. We must hold high ethical standards that go well beyond not dating clients. All clients must be treated equally, and strict adherence to scope of practice is mandatory. With this in mind and the knowledge that we cannot know if someone currently is experiencing, or has been affected in the past by trauma, all clients should be treated as though trauma has affected their life in some way.

When clients do indicate “PTSD” on their health history, do not inquire about specifics. 

Usually, boxes for anxiety, depression and insomnia are also checked as PTSD comes with a host of comorbidities.  Some, such as depression and anxiety, have been shown to be alleviated by massage therapy to some degree. Other symptoms like sleep disturbances may also benefit from the use of massage. 

A common side effect of PTSD are panic attacks. Some of us have already experienced a friend, family member or coworker have a panic attack. It is a scary and debilitating experience both for the person having the attack and the others present. I have personally witnessed several clients experience a panic attack during a session. I have found it is best to stop the bodywork, redrape the client and allow them the opportunity to end the session at that time. Every experience is different. Some clients need a few minutes, a sip of water, some need to have the therapist leave the room so they can regroup, or get dressed and end the session for that day.

Be sure to ask them if they are aware if this is a panic attack. If not, symptoms can be similar to cardiac events, so familiarize yourself with the symptoms of each, or call for emergency assistance if necessary. 

While studies suggest that massage therapy may be beneficial for symptom management of PTSD, it is a priority to ask all clients about their comfort of level of undress, areas of the body to be worked or not touched- and informed consent. Remind each client this is their session, and as a therapist, you are willing to work within their boundaries.

As discussed, we cannot identify trauma in a client and many clients may not feel comfortable enough to discuss trauma, especially during early sessions, so we must do our best to avoid triggers which may result in panic attacks or other symptoms of distress. As your therapeutic relationship develops, it may be more appropriate to discuss things as the patient opens up to you, but when starting out, try to avoid those triggers. 

Some suggestions are below.

Do’s And Dont’s 

Do: Create and maintain boundaries in your practice

Don’t: Deviate from boundaries

 

Do: Allow time for a thorough intake

Don’t: Rush your client

 

Do: Ask for emergency contact

Don’t: Ask marital status

 

Do: Have a box to check for pregnancy

Don’t: Ask about children

 

Do: Ask for preferred name & pronoun

Don’t: Assume nicknames or gender

 

Do: Request current health information

Don’t: Ask about heritage, accents

 

Do: Ask for surgical/accident history

Don’t: Set time limits (ie: 10 yrs)

 

Do: Add a box for PTSD

Don’t: Expect full disclosure

 

Do: Discuss levels of undress

Don’t: Ever adjust bras/underwear

 

Do: Ask clients about working gluteal areas

Don’t: Ask when client on table

 

Do: Discuss Informed Consent

Don’t: Make assumptions

 

Do: Avoid negative words & phrases

Don’t: Talk down to clients

 

Do: Greet every client with a smile & nod

Don’t: Force a handshake

 

Do: Respect personal space

Don’t: Initiate a hug

 

Do: Give advance warning of animals in practice

Don’t: Assume a client likes animals

 

Do: Ask client about music preference or none

Don’t: Play what you want to hear

 

Do: Appreciate client’s religious preference

Don’t: Display religious emblems

 

Do: Treat a body with respect

Don’t: Ask about scars or tattoos

 

Do: Provide appropriate draping

Don’t: Discuss client weight/height

 

Do: Acknowledge each client is an individual

Don’t: Council/compare clients

 

Do: Work in scope of practice

Don’t: Offer nutrition advice or sell other services you provide

Remember, we do not need to walk on eggshells, just work within our scope of practice, treat each client as an individual and understand there are many context layers in each person’s life experience.

 

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.