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PHYS THER
Vol. 89, No. 3, March 2009, pp. 248-256
DOI: 10.2522/ptj.20070366
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Case Reports

Patient Screening by a Physical Therapist for Nonmusculoskeletal Hip Pain

William R VanWye

WR VanWye, PT, DPT, ACSM-RCEP, CSCS, is Staff Physical Therapist, Physical Medicine and Rehabilitation Services, Richard L Roudebush Veterans Affairs Medical Center, 1481 W 10th St, PMRS-117, Indianapolis, IN 46202 (USA).

Address all correspondence to Dr VanWye at: william.vanwye{at}va.gov


Submitted December 14, 2007; Accepted November 24, 2008


   Abstract
 
Background and Purpose: Mechanical hip pain and disease-based hip pain can have similar signs and symptoms, thereby presenting a differential diagnostic challenge for clinicians. Hip pain is a common complaint addressed by physical therapists; therefore, it would be advantageous for them to be knowledgeable about differential diagnosis for hip pain, so that they can screen for possible serious conditions outside the realm of physical therapist practice and make the appropriate referral.

Case Description: A 77-year-old man was referred for physical therapy by his primary care physician (PCP) with diagnoses of lumbar spine and left hip osteoarthritis and possible trochanteric bursitis. After the examination, the physical therapist determined that the patient should return to his PCP for further testing. Findings leading to this conclusion were pain severity out of proportion to the reported injury, the presence of night pain, a positive "sign of the buttock," and empty end feels of all hip joint motions, which represented a noncapsular pattern of joint restriction.

Outcomes: The patient was diagnosed later with primary lung adenocarcinoma with widespread metastases. A computerized tomography scan of the left hip revealed a metastatic lesion at the left proximal femur.

Discussion: Physical therapists’ ability to adequately screen for conditions requiring examination by a physician can lead to a more timely diagnosis of serious medical conditions. Investigators have found published descriptions of end feels, capsular versus noncapsular patterns of restriction, and the sign of the buttock to be beneficial screening tools for use in people with hip, pelvis, or lumbar spine pain.


   Introduction
Top
 Abstract
 Introduction
Case Description
 Outcomes
 Discussion
 Conclusion
 References
 
Hip pain is a common complaint, especially in older adults.1 More than 5 million people visited a physician in 2005 because of a musculoskeletal hip pain complaint.2 It is a familiar complaint addressed by physical therapists as well.3

Osteoarthritis (OA) is the most common form of arthritis in the United States. However, estimating the prevalence of any form of OA is made difficult by the variable diagnostic criteria used (ie, clinical signs and symptoms, radiographic evidence, or a combination of findings).4 Estimates of hip OA prevalence range from 9% to as high as 27% for people 45 years of age or older.4 Although there are numerous causes of hip pain, OA is recognized as the most common in people more than 50 years of age.5

Arthritis, including other rheumatic conditions, is the leading cause of disability in the United States.6 Furthermore, a 2003 analysis by the Centers for Disease Control and Prevention showed that the direct and indirect medical costs related to these conditions accounted for approximately $128 billion.7

There are several causes of hip pain, both neuromusculoskeletal and systemic.* Many of these conditions can have similar signs and symptoms; therefore, it would be prudent for physical therapists to be familiar with hip pain differential diagnosis, including screening for serious underlying pathology and making the appropriate referral. For example, some conditions in which the main complaint is "hip" or "buttock" pain are psoas muscle abscess, tumor or neoplasm (ie, metastases), septic arthritis, arterial insufficiency (eg, ruptured abdominal aneurysm), and occult hip fracture.8,14,15 Although rare, conditions such as psoas muscle abscess or septic arthritis of the hip joint have high mortality rates associated with delayed diagnosis and, therefore, are considered medical emergencies.8,15

The purpose of this case report is to describe a physical therapist's evaluation of a patient referred by his primary care physician (PCP) with diagnoses of lumbar spine and left hip OA and possible trochanteric bursitis. Examination and history findings of concern led the therapist to refer the patient back to the referring PCP.

At the time of the initial physical therapy visit, the physical therapist, who had a bachelor of science degree in physical therapy, had been practicing for 10 years and had worked in multiple outpatient settings.


   Case Description
Top
 Abstract
 Introduction
 Case Description
Outcomes
 Discussion
 Conclusion
 References
 
History

A 77-year-old man who was 1.56 m (5 ft 11 in) tall and weighed 88.45 kg (195 lb) was referred for outpatient physical therapy by his PCP. The physical therapy order read, "Complaints of lower back pain and left hip pain for approximately one month, having difficulty with bearing weight on the left leg. Please eval and make recommendations for treatment." The order included diagnoses of lumbar spine and left hip OA and possible trochanteric bursitis.

At the initial physical therapy visit, the patient's main complaint was left hip pain (Fig. 1). His symptoms began about 1 month before the physical therapy visit, when he and his wife were moving furniture. He described pain that was worse initially in the low back but extended to the left lateral and posterior aspects of the hip as well. After a few days, his back pain resolved, but the left lateral and posterior hip pain intensified. He noted pain with all movement of the left lower extremity, describing it as severe and rating it as 9/10 at worst, 3/10 at best, and 4/10 at the examination. He described the pain as sharp with standing and walking. Even though this sharp pain was typically relieved with rest, a constant dull ache remained. He could not lie on his left side, and the pain was severe enough to limit his ability to become comfortable and often woke him. He felt that his pain was more severe at night than at any other time, but he attributed this feature to lying on his left side, having difficulty becoming comfortable, and having nothing to divert his attention from the pain. The patient denied changes in sensation, bowel or bladder function, weight, or appetite as well as radiating pain. For pain management, the patient was taking 500 mg of hydrocodone every 6 hours and was using a heating pad as well; he reported that each of these helped minimally.


Figure 1
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  		Figure 1. Patient self-report pain diagram. L=left, R=right, solid black area=original presentation of pain, dots=initial examination complaint of deep ache at rest, x=initial examination complaint of sharp pain with weight bearing.

 
Before this incident, the patient was independent with ambulation, driving, and all activities of daily living (ADLs) and was an avid fisherman. However, since the injury, it had become increasingly difficult for the patient to accomplish ADLs without some form of assistance, and he began using a cane or standard walker (ie, a walker with no front wheels) to ambulate short distances. The patient's wife added that the preceding year had been very stressful for both of them because of ongoing problems with one of their children and that this recent injury had compounded their family issues.

Radiographs of the patient's lumbar spine, pelvis, and bilateral hips were obtained 2 weeks before the examination by the physical therapist. The radiology report read, "Osteopenia of the spine, lumbar vertebra are intact without fractures or dislocations, degenerative changes" and, regarding the hip and pelvis, "No acute fracture or dislocation is seen. There are moderate degenerative changes bilaterally (ie, hip joint) with osteophyte formation."

The patient's medical history included chronic low back pain, degenerative arthritis, episodes of dyspnea, benign paroxysmal positional vertigo, venous insufficiency, long-term use of anticoagulants, and a history of deep venous thrombosis. Although he had quit smoking cigarettes 7 years before this incident, the patient had smoked for nearly 50 years. Family history of cancer included his father, 2 brothers, and a child. There was no personal history of cancer.

Physical Examination

The patient was brought to the clinic in a wheelchair by his wife. He was able to rise to a standing position independently and ambulate 30 m (100 ft) using the clinic's front-wheel walker. His gait was antalgic, as he used a step-to pattern with toe-touch weight bearing and maintained left knee flexion throughout the gait cycle. The patient did not appear to exhibit Trendelenburg gait. The patient complained of left hip pain with all functional tasks and movement of the left lower extremity.

A formal assessment of trunk range of motion (ROM) was not performed. Instead, the physical therapist assessed the patient's trunk ROM using visual observation (eg, observation of the patient performing functional tasks such as donning and doffing his jacket, sitting transfers to and from standing and supine positions) and deemed it to be within functional limits. The therapist believed that such observation was sufficient because of the patient's overall presentation (ie, severity of pain with basic functional tasks). The patient experienced left hip pain during these tasks. The possibility that the patient's symptoms were referred from the back appeared unlikely because the back pain had resolved and the pain was isolated to the left hip.

The physical therapist used visual observation to obtain supine hip passive range of motion (PROM) measurements, as agreement between goniometric measurements and visual observations for hip PROM has been found to be good.16 The Table shows the patient's hip PROM details and normative data for comparison.17 The PROM for each left hip motion, including a straight leg raise, was limited and reproduced the patient's pain (ie, empty end feels). Because of pain before resistance and limited antigravity ROM, no manual resistance was used; therefore, all left hip motion manual muscle strength (force-generating capacity) grades were 3–/5.18 The right lower-extremity manual muscle strength grade was 4/5 to 5/5.18


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  		Table. Hip Passive Range of Motion (ROM) and Normative Data17

 
Finally, with the patient lying on his right side, palpation of the left greater trochanteric soft-tissue structures and palpation directly over the bone also reproduced the patient's pain. Further special or provocative orthopedic tests of the hip were not used, as these tests are typically used to aid in differential diagnosis and, because of the patient's pain with all active and passive ranges of motion, the physical therapist believed that any results would have added little clinical information.19 The results of bilateral lower-extremity dermatome testing were unremarkable. Myotome testing and reflex testing were not used because of the severity of pain and subsequent left lower-extremity guarding.

Evaluation and Prognosis

The patient was referred for physical therapy by his PCP with diagnoses of hip OA and possible trochanteric bursitis. Hip OA typically presents as morning stiffness relieved within an hour of waking.20,21 However, clinical features of severe hip OA include pain at rest, pain at night, restricted and painful ROM, difficulty with gait and ADLs, and variable pain locations and descriptions, ranging from dull ache to sharp or stabbing.21 Furthermore, the patient was extremely tender with palpation of the left greater trochanter, which has been associated with trochanteric bursitis or femoral stress fracture.22 Roberts and Williams5 reported that the most common cause of trochanteric pain, other than hip OA, is trochanteric bursitis.

Trochanteric bursitis also is commonly found in conjunction with hip OA.23 Characteristics of trochanteric bursitis include onset that may or may not be associated with trauma, initial pain in the low back area with progression of pain to the lateral aspect of the hip, pain that is worse at night, pain described as sharp or achy, and pain severity ranging from mild to disabling.23 On examination, people typically experience pain with hip abduction and lateral (external) rotation active ROM.22,23

Several factors may have led to the PCP's initial diagnoses. For example, the patient's signs and symptoms were moderately consistent with severe forms of hip OA and trochanteric bursitis. In addition, the patient had a history of low back pain and hip OA. The onset of symptoms also was associated with a specific incident of lifting furniture. Finally, the findings on radiographs of the lumbar spine, pelvis, and hips were deemed to be negative for fractures or dislocations.

Despite this reasoning, the treating physical therapist was concerned with many of the physical examination and history findings. For example, the patient's pain pattern (ie, severity) appeared to be incongruent with what would be expected with hip OA and trochanteric bursitis. In addition, the patient reported that the pain was worse at night and was unrelieved with a change in position. Furthermore, all left hip motions were limited and painful (ie, empty end feels) and, therefore, represented a noncapsular pattern of restriction. According to Cyriax, findings of limited and painful passive hip flexion with the knee flexed and extended, as well as a noncapsular pattern of restriction of the hip joint, constitute a positive "sign of the buttock," which he described as an indication of possible serious underlying pathology of the hip or pelvis.24(pp375–377) Finally, even though the patient did not have a history of cancer, several of his first-degree relatives did. Therefore, considering each of these findings, the therapist determined that the patient's presentation justified referral back to his PCP for further diagnostic testing.


   Outcomes
Top
 Abstract
 Introduction
 Case Description
 Outcomes
Discussion
 Conclusion
 References
 
Day 1 Events

After the initial physical therapy examination, the referring PCP was contacted to discuss the physical therapist's findings. The physical therapist described the concerns listed above and recommended further diagnostic imaging (such as magnetic resonance imaging [MRI] or computed tomography [CT]). The patient's PCP verbalized skepticism regarding the need for such imaging, citing the negative plain radiographs, and advised the physical therapist to continue with therapy until the next available PCP appointment.

The physical therapist instructed the patient in safe gait with a front-wheel walker and weight bearing as tolerated. The patient also was instructed to avoid pain-provoking activities. For home pain management, the patient and his spouse were instructed in the application of ice and analgesic gel to the painful region. The patient's treatment was placed on hold until his next PCP appointment, which was to be scheduled within the week.

Day 10 Events

Ten days after the initial physical therapy examination, the patient returned to physical therapy with his wife and other family members, who were concerned about his continued complaints of pain. The patient reported that he had seen his PCP 3 days before this visit. The patient's PCP ordered a second radiograph of the left hip. Again, it was concluded that the patient had no fracture or dislocation, with the impression of "unchanged bilateral hip and lumbar spine degenerative disease." No other testing was ordered. The patient's PCP concluded that the findings of the second examination were unremarkable and recommended that the patient continue physical therapy. The patient also was diagnosed by his PCP as having depression and was referred for counseling.

At the beginning of the physical therapy session, the patient was tearful, stating that his left hip pain was unbearable, rating it 10/10. The patient described pain at rest, pain worsening at night, and an inability to tolerate any movement of the left lower extremity. His family members noted that he also was exhibiting atypical behavior, such as irritability, confusion, and decreased appetite. His functional status had further declined.

Because of these current signs and symptoms, a pain rating of 10/10, and the initial suspicion that the patient's pain was not musculoskeletal in nature, the physical therapist referred the patient to the nearest emergency department (ED) to obtain immediate care. The patient's family members agreed with this recommendation.

Emergency Department (Day 10)

The patient was seen later the same day at an ED. The ED assessment noted a history similar to that given to the physical therapist by the patient. The patient reported to the ED staff a recent onset of nausea and vomiting. The ED physician assessment read, "His only complaint is left hip and thigh pain. X-rays done previously, reveal no fracture or dislocation, positive for arthritis. Discharge home, ED diagnosis of DJD [degenerative joint disease] of hip and spine."

Hospital Admission (Day 21)

The patient next was seen by his PCP for regular blood tests to assess the international normalized ratio because the patient was taking warfarin for a history of recurrent deep venous thrombosis. The international normalized ratio was found to be uncharacteristically high, even though there had been a reduction in the medication dose 1 month earlier. The patient's wife described him as being more irritable and confused and stated that she could no longer take care of him. Therefore, the PCP decided to admit the patient to a hospital to "expedite diagnostic testing."

Events on Days 22 Through 28

The patient was diagnosed with primary lung adenocarcinoma. A plain radiograph revealed "irregularity of the bony cortex along the lateral aspect of the proximal femur. Recommend bone scan for further evaluation" (Fig. 2). The bone scan revealed "increased perfusion, blood-pool phase, and delayed-phase uptake centered over the proximal left femur just distal to the lesser trochanter ... recommend whole-body bone scanning as well as CT scanning of chest, abdomen, and pelvis" (Fig. 3). A CT scan of the chest, abdomen, and pelvis confirmed widespread metastases (in the lungs, liver, brain, lumbar spine, and thoracic spine), including a metastatic lesion at the proximal left femur (Fig. 4).


Figure 2
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  		Figure 2. Anterior-posterior radiograph of the left hip revealing irregularity of the bony cortex along the lateral aspect of the proximal femur.

 

Figure 3
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  		Figure 3. Bone scan revealing increased perfusion, blood-pool phase, and delayed-phase uptake centered over the proximal left femur just distal to the lesser trochanter.

 

Figure 4
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  		Figure 4. Axial (transverse) computerized tomography scan revealing a metastatic lesion at the proximal left femur.

 

   Discussion
Top
 Abstract
 Introduction
 Case Description
 Outcomes
 Discussion
Conclusion
 References
 
Metastasis is the spread of cancer cells from the original site (ie, primary site) to a secondary site.12(pp336–338) The leading sites of metastasis for all cancers are bone, lymph nodes, lungs, liver, and brain.12(pp336–338) Bone metastasis is common in lung cancer.13,25 The thoracic spine has been reported to be the most common site of metastasis in patients with lung cancer,13(pp607–613),26 followed by the lumbar spine and cervical spine.26 Additionally, the femur has been reported to be the most common extravertebral site for metastasis in patients with lung cancer, with an incidence of 12%.26 Although more rare, there have been reports of lung cancer metastasis to more distal sites, such as the foot and ankle.27,28

Lung cancer is the leading cause of cancer-related death in the United States for both men and women.29 The leading risk factor for lung cancer is cigarette smoking; genetics plays a role as well.29 The most common form of lung cancer in the United States is a type of non–small cell lung cancer known as adenocarcinoma.13(pp607–613) Adenocarcinoma is a type of cancer that arises from glandular cells that line internal organs (such as the respiratory mucosa of the lungs).13(pp607–613) Although its growth rate is considered to be slow to moderate, adenocarcinoma metastasizes early throughout the lungs, brain, and other organs.13(pp607–613)

Hanagiri et al30 examined 177 patients diagnosed with stage I and II primary lung cancer and found postsurgical recurrence of metastases, both intrathoracic and extrathoracic, in 21% of these patients. Early metastasis can be attributed to the rich lymphatic and blood supplies of the lungs; these vast networks permit systemic spread.13(pp607–613) Metastasis also may occur through direct extension, which is the invasion of nearby structures by direct passage through the pleura.13(pp607–613)

Initial warning signs of lung cancer are commonly found in people who smoke cigarettes, as well as in people with many common pulmonary conditions (such as shortness of breath, coughing, and increased or bloody sputum production) and, therefore, can delay early diagnosis.12(pp161–163),13(pp607–613),29 Some advanced signs include weight loss, diminished appetite, nausea, vomiting, fatigue, weakness, wheezing, chest pain, hoarseness, productive cough with blood, headaches, and confusion.12(pp161–163),13(pp607–613),29 Because metastasis to the spine is quite common in people with lung cancer, it is important for physical therapists to be aware of the signs and symptoms of spinal metastasis and possible cord compression. These signs and symptoms include back pain, changes in deep tendon reflexes, diminished or absent lower-extremity sensation, muscle weakness, and loss of bowel or bladder control.12(pp161–163,336–338)

Routine chest radiographs typically yield early detection of lung cancer; however, because chest radiographs lack sensitivity, smaller, more resectable tumors typically are not detected.13(pp607–613) Because of this lack of sensitivity of radiographs and the advantage of assessing the entire thorax with CT, scanning by CT is recommended.31 Although MRI can be more accurate, CT may be preferential because of efficacy, improved patient tolerance, and safety (eg, claustrophobia and metal implants are issues encountered with MRI).31 Even with advancing technology, early detection has not led to improved mortality rates.29 The prognosis for all stages of lung cancer combined is poor, with a 5-year survival rate of 15%.29

In addition to risk factors such as the patient's history of smoking and family history of cancer, the physical therapist considered some of the clinical findings detailed below. For example, the therapist believed that the patient's pain severity was out of proportion with diagnoses of purely hip OA and trochanteric bursitis. Specifically, the patient's symptoms began 1 month before the initial examination, had not improved, and, according to the patient, had even worsened. Goodman and Snyder cautioned, "When the symptoms seem out of proportion to the injury, or when the symptoms persist beyond the expected time for that condition, a red flag should be raised in the therapist's mind."12(p57) In addition, the patient felt that his pain was worse at night, when he lay down to sleep. Although he attributed this feature to difficulty becoming comfortable, long-standing night pain that is unaltered with a change in position is associated with the possibility of a neoplasm or tumor.12(pp16,17,436)

Another alarming discovery was the presence of limited and painful left hip PROM (ie, empty end feels) in all directions. Cyriax defined empty end feels as motion restricted by the patient because of pain and associated this feature with the possibility of a more serious condition, such as an infection or a neoplasm or tumor.24(pp53–57) Cyriax also described the sign of the buttock as an indication of possible serious underlying pathology of the hip or pelvis.24(pp375–377) The 3 primary components include a limited and painful straight leg raise, limited and painful passive hip flexion with the knee flexed, and a noncapsular pattern of hip joint restriction.24(pp375–377) Cyriax included possible findings of limited trunk flexion, empty end feels of hip joint motions, pain with resisted hip movements, and a swollen buttock.24(pp375–377)

Cyriax claimed that a capsular pattern of hip joint restriction (eg, arthritic hip joint) would manifest as limitations in flexion, abduction, and medial (internal) rotation and minimal to no limitation in extension or lateral rotation.24(pp53–57) The patient in this case report exhibited limited and painful hip motions in all directions and, therefore, a noncapsular pattern of restriction. Consequently, the physical therapist deemed that the patient's presentation constituted a positive sign of the buttock. The validity of the capsular pattern for the hip described by Cyriax has been called into question and, unfortunately, no studies have examined the clinical accuracy of the sign of the buttock.32,33 However, earlier case reports found the sign of the buttock as well as the presence of empty end feels and the use of capsular versus noncapsular patterns of joint restriction to be beneficial screening tools that can be used to aid in proper intervention for people with pain in the hip, pelvis, or lumbar spine.34–39

Interestingly, the patient reported a traumatic event associated with the onset of pain. Traumatic onset is found more commonly in musculoskeletal complaints, whereas systemic pathology is associated more commonly with insidious and gradual onset.12(pp26,64) However, various authors10,11,36 have cautioned against assigning too much importance to such reports, especially when the trauma would be considered minor or trivial in nature, because it may act as a diversion from the true cause (eg, neoplasm) and delay proper treatment. It is not uncommon for patients with primary or secondary malignant processes of the musculoskeletal system to relate a traumatic event with the onset of symptoms.11,40,41

Finally, the patient was referred with negative findings (ie, no fractures or dislocations) on radiographs of the lumbar spine, pelvis, and hips. However, occult fractures of the proximal femur are not entirely uncommon on initial standard radiographs, especially in elderly patients.42–46 For this reason, advanced imaging (eg, CT, MRI) has been recommended for patients with negative findings on initial radiographs and continued hip pain, especially those over the age of 70 years.47,48

Other clinical tools may have aided in the differential diagnosis in this case. One relevant tool is the auscultatory patellar-pubic percussion test, which can be used when an occult hip fracture is suspected.49 The patient is positioned in the supine position with the lower extremities extended and symmetrical. The examiner then places the diaphragm of a stethoscope over the pubic symphysis and commences tapping each patella to compare the quality and intensity of the sound. In such a side-by-side comparison, the presence of diminished or muffled sound signifies a positive test and should prompt advanced imaging.49 This test was not used in this case because the physical therapist was unaware of its existence until a review of the literature regarding this case. Furthermore, many other common tests and measures were not used because it was determined that further tests, especially provocative or special tests, would have added little clinical information and would have resulted in unnecessary pain for the patient.

Although the physical therapist's examination findings were sufficient to determine that physical therapy intervention was not appropriate for the patient, there were areas for improvement in the therapist's actions. First, other examination tools and techniques, such as the auscultatory patellar-pubic percussion test mentioned above, might have assisted in this case. Second, during the initial call to the PCP, the therapist could have provided more-detailed findings, such as the sign of the buttock and the implications of this finding. Third, the therapist could have been more attentive when suggesting further testing. The therapist did not cite evidence to support such a request; this omission may have led the PCP to reject the suggestion and subsequently order a second radiograph. Finally, the therapist could have contacted the PCP when the patient was referred to an ED. This action might have led to cooperation among the therapist, the PCP, and the ED staff. By referring the patient to an ED and not informing the PCP, the therapist used what may be considered a passive-aggressive approach. Even with good intentions, such an approach may hinder the process of accurate diagnosis.


   Conclusion
Top
 Abstract
 Introduction
 Case Description
 Outcomes
 Discussion
 Conclusion
References
 
Physical therapists have been shown to be competent, effective, and cost-efficient in managing musculoskeletal conditions, which includes screening for conditions outside the scope of physical therapist practice.50–52 Physical therapists have been involved in screening for musculoskeletal disorders in the military for more 30 years; evidence shows that patients receiving care from physical therapists in a direct-access military setting are at minimal risk for grossly negligent care.53,54 Physical therapists working in outpatient settings are ideally suited to screen for conditions outside the scope of physical therapist practice and to make the appropriate referral. It would be of benefit to physical therapists to have regular contact with their referral sources with the goal of building relationships in which open dialogue is acceptable and expected. It also would be beneficial for physical therapists to use evidence to support claims or when sending requests to referring providers.

It is important for physical therapists to recognize warning signs, such as pain that appears to be out of proportion to the reported diagnosis or injury as well as pain that is worse at night. Cyriax's descriptions of end feels, capsular versus noncapsular patterns of joint restriction, and the sign of the buttock are useful screening tools, as in this case, for use in people with nonmusculoskeletal hip, pelvis, or lumbar spine pain.


   Footnotes
 
The author thanks Kevin Jones, PT, DPT, for review of the manuscript.

This work was solely researched and completed by the author and is not necessarily the opinion of the Richard L Roudebush Veterans Affairs Medical Center or any other federal agency.

* References 8–12(pp190, 205–212, 215, 239, 416–421, 434–469) and 13(pp947). Back


   References
Top
 Abstract
 Introduction
 Case Description
 Outcomes
 Discussion
 Conclusion
 References
 

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