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A Case of Back Pain of Visceral Origin

By Sandy Rief, RMT

Introduction

This case study is based on a treatment to an 89 year old female client.  This client came to the clinic complaining of lower back pain that she felt was of such a severity that she could not wait for her regular therapist to treat her.  Her main complaint was pain on the right side of her lower back between her last rib and her iliac crest.  She described the pain as achy.  She also complained of pain in her upper right back near her right scapula.  The client had spent the previous few days making preserves and felt that this was the reason for her discomfort.

The client’s medical history stated that she seemed to always feel tired and that recently (within the last 3-4 years) she had a substantial weight loss.  This weight loss was contributed to issues with her right kidney.  The medical history also revealed that the client has an atrial fibrulation and hypertension.  Medications listed on the medical history were as follows: Warafin, Rampiril and Didrocal.

The client is a small framed person that at the time of treatment weighed approximately 80 pounds.  She uses a walker for stability and because of her height needed a stool to get on the table.  Usually, she would need assistance getting on and off the table but this day she assured me that she was able to accomplish this herself and would ask for help if needed.

Subjective and Objective Information

The client described the pain she was feeling as being around the ribs, in the lower back and up into her right shoulder and neck area on the right side of her body only.  She contributed this pain to the fact that she had been making preserves the past few days.  However, it should be noted that according to her file the last treatment she received 2 months prior with her regular therapist had been for pain in the same areas. 

ROM testing was not limited by pain or tissue stretch end feel that would usually be associated with muscle related ache.   There was pain with palpation over the area of the right kidney in the lower back. There was a feeling of bogginess or congestion as well as a slight temperature increase over the area as compared to surrounding tissue.  

Treatment

The treatment was 30 minutes in length including assessment.  I began with the client prone and then moved to supine with a pillow under the C/S for comfort.  The client is slightly hyperkyphotic.  She believes that her posture is in response to having to use a walker. Using general swedish massage to warm up the area I then concentrated on the areas that were causing the client pain.  I treated QL, erector spinae, levator scapula and the SITS muscles specifically.  A trigger point in her right levator scapula was treated with minimal effort returning the muscle to a texture that resembled that of the left levator scapula and of the surrounding muscles in the area.  It was noted in the file that in previous treatment the client had reported referral pain into the head. During this treatment there was no referral pain upon palpation of the trigger point in the right levator scapula.

My original clinical impression that the pain my client was feeling was delayed onset muscle soreness from all the extra work she had been doing did not make sense once the treatment began because there was a lack of trigger points or increased muscle tone. However, any suggestion to the client that her pain may be caused by her kidney resulted in her becoming quite upset.  She commented that her doctor had been monitoring her right kidney and that she was afraid that if anything happened she would have to be on dialysis.

During treatment the client mentioned that she had been lying on a heating pad trying to relieve the pain in her back.  I educated the client in the danger of doing such and suggested that if she wanted to apply heat that she need to lay the heating pad on her back and to only leave it there for 20 minutes at a time.  I also suggested that because of her high blood pressure that sitting for prolonged amounts of time in a hot bath was not advisable.

I suggested to the client at the end of the treatment that if her pain was not reduced by the massage treatment today or if the pain persisted or increased that she should contact her MD. She told me that she had an appointment in March to have the kidney checked.  A few weeks later a follow-up call was made.  The client had gone to see her MD.  Her medical doctor felt that further investigation into the matter was needed and ordered X-rays of the area to be done. 

Conclusion

This case emphasizes the importance of having a complete health history and file.  The information in this client’s file allowed me to know that the pain she was experiencing was a recurring issue and most likely not related to making preserves like the client suggested.  Knowing that the client had previous issues with her right kidney, inconclusive ROM testing, palpation and having some understanding of the common referral patterns associated with viscera led me to believe that the pain she was experiencing was related to her kidney.  The lack of increased muscle tone or trigger points also led me to believe that the pain she was experiencing was not related to muscle or other skeletal issues. 

Referring this client to her medical doctor was in my opinion reasonable and responsible client care considering the client’s age, health history, inconclusive test results and location of her pain. The client was hesitant to tell me whether or not she had seen her medical doctor during the follow up call and once again became quite upset at any suggestion that her kidney may be the source of her discomfort.  She has since returned to her regular therapist.

Biography

Sandy Rief is a massage therapist working at Westboro Physiotherapy Centre in Ottawa.