Periphere arterielle Verschlusskrankheit als Ursache für unilaterale Schmerzzustände im Gesäß- und Oberschenkelbereich

Zusammenfassung

Das gezielte und systematische Screening auf pathologische Prozesse oder schwere Verletzungen (Red-Flag-Screening), die sich nicht für physiotherapeutische Maßnahmen eignen, ist ein fester Bestandteil offizieller Leitlinien der World Confederation for Physical Therapy (WCPT). Mangelnde diagnostische Validität individueller Red Flags und die geringe Prävalenz einzelner schwerwiegender Pathologien (vorwiegend der LWS) stellen die Sinnhaftigkeit des Red-Flag-Screenings als Teil der klinischen Untersuchung infrage. Demgegenüber steht eine Vielzahl publizierter Fallbeispiele, die demonstrieren, dass ein umfassendes Screening-Verfahren einen wichtigen Beitrag zur Identifizierung verschiedenster Krankheitsprozesse leisten kann.

Der vorliegende Fallbericht beschreibt eine Patientin, die mit der Diagnose Lumboischialgie zur Physiotherapie überwiesen wurde. Durch eine Kombination aus gründlicher Anamnese, Erhebung verschiedener Risikofaktoren und nachfolgender physischer Untersuchung kamen beim behandelnden Physiotherapeuten Zweifel an einer neuromuskuloskeletalen Ursache der Beschwerden auf. Die von ihm angeratene fachärztliche Untersuchung führte zur korrekten Diagnose periphere arterielle Verschlusskrankheit.

Abstract

Systematic screening for pathological processes or serious injuries (red flag screening), which are not suitable for physiotherapy, is a core element of official guidelines of the World Confederation of Physical Therapy (WCPT). The lack of diagnostic validity of individual red flags and the low prevalence of single severe pathologies (predominantly of the lumbar spine) puts the purpose of red flag screening as integral part of the clinical examination into question. On the other hand, numerous published case reports which highlight the fact that a comprehensive screening process can play an important role in the identification of a wide variety of pathological processes.

This case report describes a female patient who was referred to physiotherapy with the diagnosis of sciatica. Using a combination of in-depth case history, questioning concerning risk factors and subsequent physical examination the treating physiotherapist doubted a neuromusculoskeletal origin of the patient’s pain complaints. His recommendation to consult a specialist doctor led to the correct diagnosis of peripheral arterial occlusive disease.

Schlüsselwörter

Red-Flag-Screening - Differenzialdiagnose - klinischer Entscheidungsprozess - Physiotherapie

Key words

red flag screening - differential diagnosis - clinical decision making process - physiotherapy

• Literatur

• 1 World Confederation for Physical Therapy. Policy statement: Standards of physical therapy practice. London: WCPT; 2011
• 2 World Confederation for Physical Therapy. Declaration of Principle: Ethical Principles. London: WCPT; 2007
• 3 World Confederation for Physical Therapy. WCPT guideline for physical therapist professional entry level education. London: WCPT; 2011
• 4 Wardle F, Maskell A, Selfe J. Granulocytic sarcoma – an unusual case of shoulder pain. J Orthopaed Med 2007; 29: 18-22
• 5 Boissonnault WG, Bass C. Physical therapists referring patients to physicians: a review of case reports and series. J Orthop Sports Phys Ther 2012; 42: 446-454
• 6 Coulon CL, Landin D. Lyme Disease as an Underlying Cause of Supraspinatus Tendinopathy in an Overhead Athlete. Phys Ther 2012; 92: 740-747
• 7 Heick JD, Boissonnault WG, King PM. Physical therapist recognition of signs and symptoms of infection after shoulder surgery: a patient case report. Physiother Theory Pract 2013; 29: 166-173
• 8 Mabry LM, Ross MD, Tonarelli JM. Metastatic cancer mimicking mechanical low back pain: a case report. J Man Manip Ther 2014; 22: 162-169
• 9 Smith BE, Diver CJ, Taylor AJ. Cervical Spondylotic Myelopathy presenting as mechanical neck pain: a case report. Man Ther 2014; 19: 360-364
• 10 Wahl CE, Smith D, Sesto M. et al. Differential Diagnosis of a patient with low back and toe pain. J Man Manip Ther 2013; 21: 81-89
• 11 Pottkotter K, Briggs MS, Di Stasi S. Brain meningioma in a patient with complaints of low back pain and leg weakness. Physiother Theory Pract 2013; 29: 413-418 doi: 10.3109/09593985.2012.734010
• 12 Rodeghero JR, Denninger TR, Ross MD. Abdominal Pain in Physical Therapy Practice: 3 Patient Cases. J Orthop Sports Phys Ther 2013; 43: 44-53
• 13 Lackenbauer W, Janssen J. Gallensteine als Ursache für muskulären Thorax-Schmerz. manuelletherapie 2016; 20: 233-236
• 14 Lackenbauer W, Janssen J. Lyme-Borreliose als Ursache für chronische HWS- Beschwerden mit Ausstrahlungen in die oberen Extremitäten. manuelletherapie 2017; 21: 43-46
• 15 Bell DA, Collie D, Statham PF. Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning?. Br J Neurosurg 2007; 21: 201-203
• 16 Henschke N, Maher CG, Refshauge KM. et al. Prevalance of and Screening for Serious Spinal Pathology in Patients Presenting to Primary Spine Settings with Acute Low Back Pain. Arthritis Rheum 2009; 60: 3072-3080
• 17 Cook C, Ross MD, Isaacs R. et al. Investigation of Nonmechanical Findings during Spinal Movement Screening for Identifying and/or Ruling Out Metastatic Cancer. Pain Pract 2012; 12: 426-433
• 18 Ahad A, Elsayed M, Tohid H. The accuracy of clinical symptoms in detecting cauda equina syndrome in patients undergoing acute MRI of the spine. Neuroradiol J 2015; 28: 438-442
• 19 Enthoven WTM, Geuze J, Scheele J. et al. Prevalence and ”Red Flags” regarding Specific Causes of Back Pain in Older Adults Presenting in General Practice. Phys Ther 2016; 96: 305-312
• 20 Henschke N, Maher CG, Refshauge KM. Screening for malignancy in low back pain patients: a systematic review. Eur Spine J 2007; 16: 1673-1679
• 21 Downie A, Williams CM, Henschke N. et al. Red Flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ 2013; 347: f7095 doi: 10.1136/bmj.f7095
• 22 Henschke N, Maher CG, Ostelo RW. et al. Red flags to screen for malignancy in patients with low-back pain. Cochrane Database Syst Rev 2013; (02) CD008686 doi: 10.1002/14651858.CD008686.pub2
• 23 Williams CM, Henschke N, Maher CG. et al. Red flags to screen for vertebral fracture in patients presenting with low back pain (Review). Cochrane Database Syst Rev 2013; 31: CD008643 doi: 10.1002/14651858.CD008643.pub2
• 24 Verhagen AP, Downie A, Popal N. et al. Red flags presented in current low back pain guidelines: a review. Eur Spine J 2016; 25: 2788-2802
• 25 Cook CE, George SZ, Reiman MP. Red flag screening for low back pain: nothing to see here, move along: a narrative review. Br J Sports Med 2017; pii bjsports-2017–098352. doi: 10.1136/bjsports-2017–098352
• 26 De Schepper EIT, Koes BW, Veldhuizen EFH. et al. Prevalence of spinal pathology in patients presenting for lumbar MRI as referred from general practice. Family Pract 2016; 33: 5156
• 27 Shroyer SR, Mehta S. A More Sensitive Risk Stratification Tool for Identifying Spine Infection than “Red Flags” or Fever. Ann Emerg Med 2013; 62: S6-S7
• 28 Hiett J, Chan D, Hourigan P. Back pain in the under 20 s would appear to be a “red flag” of dubious significance: Results of a retrospective case note analysis. Int Musculoskel Med 2014; 36: 19-22
• 29 Combs JA, Caskey PM. Back pain in children and adolescents: a retrospective review of 648 patients. South Med J 1997; 90: 789-792
• 30 Underwood M. Diagnosing acute nonspecific low back pain: time to lower the red flags?. Arthr Rheum 2009; 60: 2855-2857 doi: 10.1002/art.24858
• 31 Verhagen AP, Downie A, Maher CG. et al. Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review. Pain 2017; 158: 1860-1868 doi:10.1097/j.pain.0000000000000998
• 32 Ross MD, Boissonnault WG. Red Flags: To Screen or not to Screen?. J Orthop Sports Phys Ther 2010; 40: 682-684 doi: 10.2519/jospt.2010.0109
• 33 Deyo RA, Jarvik JG, Chou R. Low back pain in primary care. BMJ 2014; 349: g4266 doi: 10.1136/bmj.g4266
• 34 Boissonnault WG. Examination in Physical Therapy Practice: Screening for Medical Disease. Edinburgh: Churchill Livingstone; 1995
• 35 Wilkins E, Wilson L, Wickramasinghe K. et al. European Cardiovascular Disease Statistics 2017. Brussels: European Heart Network; 2017
• 36 Goodman CC, Snyder TEK. Differential Diagnosis for Physical Therapists. Screening for Referral. Philadelphia: Saunders Elsevier; 2013
• 37 Magee DJ. Orthopaedic Physical Assessment. Philadelphia: Saunders Elsevier; 2008
• 38 Gagnier JJ, Riley D, Altman DG. et al. The CARE guidelines: Consensus-based clinical case reporting guideline development. Dtsch Arztebl Int 2013; 110: 603-608 doi: 10.3238/arztebl.2013.0603
• 39 Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist. Philadelphia: Saunders Elsevier; 2009
• 40 Laslett M, Young SB, Aprill CN. et al. Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Austr J Physiother 2003; 49: 89-97
• 41 Jarvik JG, Deyo RA. Diagnostic Evaluation of Low Back Pain with Emphasis on Imaging. Ann Inter Med 2002; 137: 586-597
• 42 Dhaliwal D, Mukherjee D. Peripheral arterial disease: Epidemiology, natural history, diagnosis and treatment. Int J Angiol 2007; 16: 36-44
• 43 McDermott MM, Greenland P, Liu K. et al. Leg symtpoms in peripheral arterial disease: associated clinical characteristics and functional impairment. JAMA 2001; 286: 1599-1606