This post was written by H&W instructor Elizabeth Hampton. Elizabeth will be presenting her Finding the Driver course at Marquette University in 2015!
In the United States, estimated direct medical costs for outpatient visits for chronic pelvic pain (women aged 18-50 y) is approximately $881.5 million per year. (Singh et al). Most physical therapists start their pelvic health practice focusing on incontinence only to find their practice filling with pelvic pain clients who need our help. One of the most common questions we hear in Herman & Wallace’s Urogynecologic Pain course (PF2B) is, “What do we focus on first during a pelvic pain evaluation? A direct pelvic floor assessment or a musculoskeletal exam?” The answer depends upon many factors, including client presentation and goals, client history, functional assessment, clinical toolbox in addition to sound clinical reasoning. In addition to the direct pelvic floor assessment, there are additional key musculoskeletal screening tests that are an essential part of a pelvic pain assessment.
Peery et al (2012) noted that abdominal pain was one of the most common presenting reasons for an outpatient physician visit in the United States. Abdominal pain is one of the many complaints that our clients may report requiring differential diagnosis including urogynecologic, colorectal, musculoskeletal, visceral or neurogenic causes. Lower abdominal quadrant pain may denote serious emergent pathology. Clinical findings, physical exam and client symptoms in addition to smart differential diagnosis must be used to determine if the abdominal pain is musculoskeletal in nature. Direct access requires clinicians to be able to perform a skilled initial screening for abdominal pain in order to determine if it is abdominal wall versus a visceral origin. Assessment of bowel and bladder function and habits are essential to perform. This blog specifically addresses two physical exam tests that can be performed as part of the physical therapy screening of abdominal wall pain. According to Cartwright et al, the location of the abdominal pain should drive the evaluation. The screening of abdominal pain may include two common tests that are used to determine if pain is due to abdominal wall versus a visceral origin.
Carnett’s test is a simple clinical test that assesses abdominal pain response when a client tenses their abdominal muscles. A positive Carnett’s sign denotes the origin of symptoms within the abdominal wall with a negative tests suggesting intra-abdominal pathology. The test is performed in supine, the clinician palpating the area of abdominal pain and has the client lift their head and shoulders off the table. Conditions such as myofascial trigger points, scar and muscular pain would be flared with palpation of the contractile tissue with activation of the abdominal wall muscles. If the pain is due to visceral origin, appendicitis for example, the pain would remain unchanged with palpation with head lift. Although some perform Carnett’s test by lifting both legs off the table, this method may cause unnecessary pain in clients with poor lumbopelvic stability. (Figure 1) The head and shoulder lift option is felt to be comparable method of performing Carnett’s test.
Blumberg’s or Aaron’s sign is one physical exam test most commonly used to rule in appendicitis, peritonitis or a visceral driver of right lower quadrant pain. The test is performed by the clinician applying deep pressure over McBurney’s point (Figure 2) with an abrupt and rapid release of pressure. Although there are anatomical variations in appendix location, pain reproduction is consistent with a positive test and immediate referral to the ER is indicated.
In the Herman Wallace course “Finding the Driver in Pelvic Pain” participants learn a comprehensive musculoskeletal screen for functional mobility, abdomen, neural mobility and conductivity, pelvic ring, pelvic floor and biomechanical contributing factors to pelvic pain. Evidence based test item clusters are defined, along with their diagnostic accuracy, for all associated systems in order to outline a comprehensive screen for pelvic pain clients. To learn more about musculoskeletal screening for pelvic pain, check out faculty member Elizabeth Hampton PT, WCS, BCB-PMD’s course Finding the Driver of Pelvic Pain, which is next offered at Marquette University, April 23-25th, 2015.