Me and my pink elephant; by Wouter Geerse

IMTA BLOG by Wouter Geerse – Me and my pink elephant

A patient presents himself at the physiotherapy practice on a Friday morning. He is a 40 year old truckdriver. His main complaint is a intermittent, cramping backache that is bilateral between Th10 and S1. He experienced no symptoms in his legs or buttocks.
Provocation of this backpain is possible by walking. Sometimes he would be able to walk for one hour with no problem but sometimes he would have to stop after five minutes. When stopped the pain resolves in seconds. Besides walking, climbing stairs showed the same irregular appearance of symptoms. There was no pattern that he could find out during his day or week rhythm. The patient had no problems standing up from a chair, getting in and out of bed. Two days earlier he painted the ceiling and this was done without any backpain.
When taking up the history, the patient told that this cramping feeling was there for four weeks. He had never experienced this kind of back pain prior to this episode. The cause of this cramps was unclear to the patient. He was familiar with a feeling of stiffness locally in the lower lumbar area, but this was different to him.
And then he slipped a quick remark: “I did not worry about this backpain but my wife told me I should get it treated before Monday (so,in four days) because after my coronary catheterisation I will have to lay down a lot and not be able to be as active as I have to be for my back”. Further questioning on this topic revealed that he has had a heart infarction 7 years ago for which he was treated by catheterization. Now, the catheterization of next Monday takes place because of compaints of shortness of breath, chest pain and a feverish feeling which comes and goes.
I just read a chapter about vascular pain pattern in the head, neck and back region from Goodman and Snyder’s Differential Diagnosis for Physical Therapists (2007). And just followed an interesting course in Haemodynamics by Roger Kerry. Based on table 14-1 from Goodman and Snyder we should consider vascular diseases like an abdominal aortic aneurysm, endocarditis, myocarditis and peripheral vascular problems, when lumbar spine pain is apparent.
There are some risk factors for vascular suspicion (abdominal aortic aneurysm) present in this case (Ahmed et al, 2016; Goodman and Snyder, 2007):
• Smoking in the history
• Inactive daily lifestyle
• Overweight
• High levels of experienced stress (due to working circumstances)
• Earlier heart infarction at a young age
• Coronary disease in family
• Hypertension
De patient’s description of pain does not seem to be typical for a vascular source. Pain of vascular origin is mostly described as throbbing. He also did not experience abdominal pain. Vascular back pain does increase by activity (such as walking and climbing stairs) but the pattern was irregular.
I decided to continue to the physical examination with attention for the vascular signs which may be present. In standing there was no muscular atrophy in the legs (which may be so in the case of an arterial obstruction). Calf raises was done normally with no provocation of whatsoever. The active forward flexion was painless and range of motion was found normal. Extension was limited at L3-S1 and there he feels a local sensation of stiffness.
In supine, the inspection of the abdominal pulse is not remarkable but the value of this inspection is limited because of the size of the ‘abdominal wall’. Palpation of the width of the abdominal aorta was, based on my limited experience in this field, not clear.
After a short palpation of the PAIVMS in prone, the patient was asked to come from lying to sitting. In sitting, the patient feels a little increase in chest pain which disappeared in a few seconds.
The thoughts of the therapist were explained to the patient. We should wait and see until after the catheterization. The pattern of the low back cramping was not proven to be solely mechanical.
Two weeks later, the patient presents himself again in the physiotherapy practice and told me that the catheterization was inconclusive. His vascular system looked as good as it good be. The stent which was placed 7 years ago showed a minor calcification. The cardiologist told him that this could not be the source of the chest pain. He was sent home with new anticoagulants therapy.
Surprisingly, the patient already felt a lot better between Saturday and Monday. His back now felt stiff and tight in the left lumbar region every time after walking for one hour. Central and unilateral PA’s helped the patient combined with McKenzie’s active extension exercises to walk for one hour without the feeling of stiffness.
SO, concluding this patient: the prior suspicion of a vascular origin in this specific patient was declined by catheterization which is the gold standard for vascular obstructions. However, I think that is important to keep in mind also in low back pain patients which are relatively young we should also consider the vascular system. Of all the people with an Abdominal Aortic Aneurysm, 25% experiences low back pain.
First, it felt like “Don’t think of a pink elephant” for me because I just read about vascular diseases. But after all I am happy with being careful in managing this patient.

Literatura
Ahmed R, Ghoorah K and Kunadian V. Abdominal Aortic Aneurysms and risk factors for adverse events. Cardiol Rev. 2016;24(2):88-93.
Goodman CC and Snyder TEK. Differential Diagnosis for physical therapists – screening for referral. Saunders Elsevier: St. Louis. 4th edition. 2007: p629-657.

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