Monday, September 21, 2009

Abdominal Aortic Aneurysm (AAA)

Back pain that makes me sick to my stomach


           Back pain is probably the most prevalent complaint plaguing our health care system today.  However, the downfall of being in such a profession is when you’re a hammer all you see is a nail. It’s quick for manual therapist to forget that 7-8% of low back pain is non mechanical in nature. Furthermore, when you consider the number of visceral causes of low back pain you start to question every diagnosis. Visceral causes of back pain can include forms of cancer, endometriosis, kidney and prostate infections. Besides this redundant list there is one diagnosis which is life threading and that is Abdominal Aortic Aneurysm.
            An abdominal aortic aneurysm is when an infrarenal aortic artery diameter exceeds 3cm. Knowledge of this diagnosis is crucial for any health professional to make a timely referral and save a life. Although there is lacking research on AAA’s in the RCT form, there are numerous case studies allowing us to gather information. Normally case studies may be deemed to be low in value on the research totem pole but with such small prevalent conditions it can be an important source of information.  I particularly like case reports for this condition because I want to know every arbitrary symptom and findings these patients could possible present with. However, a fairly new case report publishes in Journal of Orthopaedic and Sports Physical Therapy (JOSPT) grabbed my interest even further. This case (referenced below) was shocking based on the age of the patient and size of the Aneurysm found. Again JOSPT does a great job as always providing video’s and power points on their online website to help readers get a better understanding of what’s being discussed.

What are the signs and symptoms?

            AAA’s are more prevalent in the geriatric population over 65. The pain or discomfort from AAA’s is caused by either the aneurysm itself pressing on structures or vertebral bodies being eroded due to such pressure.  Despite this some studies still report as high as 75% of AAA’s being  asymptomatic when discovered. Usually they are found accidentally on radiographs. SO LOOK FOR THIS IN YOUR PATIENTS WHO ARE ELDERLY, HAVE RADIOGRAPHS AND PRESENT WITH RISK FACTORS.
            When it is symptomatic it usually presents as pain or discomfort in the abdominal region, the low back, hip, groin and buttock area.  Other symptoms can include satiety, nausea, and unexplained weight loss as well. Radiculopathies and mylopathies are not usually reported.
            Due to the fact most patients with such a diagnosis will be asymptomatic it’s important to perform a thorough exam. Abdominal palpation skills are key because AAA’s measured 5cm or greater have a sensitivity of 82% being detected. This value changes depending on the size of the AAA. The good part about this is you have an increased chance of catching an AAA before it’s too late but the bad side is the greatest predictor of an aneurysm rupturing is its size.

Interesting factors regarding the published case

-Patient was only 38 years old
-Patient diagnosis was missed by his physician 
-Blood pressure was 120/80mmHg and regular heart beat of 66 beats per minute 
-While therapist was palpating the left trunk they felt a strong pulsate sensation (Normal in very thin people) 
-Mass was felt BOTH prone and supine position
-Patient was found with a 10 CM AAA and was sent for surgery two days later.

         Warning factors with patient in case report

-Smoked 10 cigarettes a day for a “number of years”
-Deep boring lumbar pain which never changed due to position, movement or time of day
-Increasing night pain waking the patient up 
-Hard to find a position of comfort or relieving
-NSAIDS did not relieve pain
-No other examination findings were positive for other sources of pain.

            The case report really hits home the importance of a thorough history and examination. It’s important to never rule out rare sources of pain because after all rare walks into your office all the time. If you don’t think so it’s just because your not looking for it and thus why it’s called rare. So remember just because your a hammer everything doesn’t have to be a nail.

Mechelli F, Preboski Z, & Boissonnault WG (2008). Differential diagnosis of a patient referred to physical therapy with low back pain: abdominal aortic aneurysm. The Journal of orthopaedic and sports physical therapy, 38 (9), 551-7 PMID: 18758044

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