Case of the Week 4-16-12: Mismanaged LBP | Modern Manual Therapy Blog

Case of the Week 4-16-12: Mismanaged LBP

A patient was recently referred to me by a neurologist who sends me a lot of cases. I was all ready to do the SFMA and look for some stability and mobility issues! However....

Typically, these cases have been to bigger groups and around the block along the sea of generic practitioners.

History: Pt used to work for a soft drink company and regularly delivered 100 77# boxes to a business on Mondays. He used to make a game of how fast he could do it. Seven years ago, he injured his lower lumbar spine. He ended up at a local POPTs and first had a few years of PT ("which did not work"), the physiatrists there also tried several different types of spinal injections including blocks and botox. This also did not relieve his complaints. For the last 2 years, he was receiving daily chiropractic adjustments, also with no change. I told him that horse is dead.

He currently c/o constant severe central lower lumbar pain that radiates to his right buttock every time he bears weight on his right LE. The Sx are rated 6-10/10 and worsen with bending, strain, lifting > 20#. The only position that relieves his complaints is self decompression, such as lifting his upper body on a chair, which completely but temporarily relieves his pain, or going on his inversion table.

Objective:

Observations:

  • sits laterally shifted to the left to unload right lumbar spine
  • severe tenderness (allodynia) to light touch lower lumbar spine 
  • no standing lateral shift
  • antalgic gait, decreased stance time on R, unable to walk correctly when prompted due to pain
Lumbar ROM
Sidegliding in standing - my bias to check first with unilateral lumbar sidegliding in standing repeated motions, and not sagittal plane: a few DIPs I trained taught me this along with an excellent CertMDT who became a fellow
  • Left mod loss, reproduces lumbar pain on right
  • Right, severely blocked, produced right buttock pain, no worse as a result
This was a rare opportunity for my students who were observing to see me not do any manual or any other tests, as the goal here is to essentially "correct the shift" which is more of a relevant lateral component or far lateral lumbar derangement. 

I explained to the patient, he's had plenty of opening/unloading, he does it several times a day, was manipulated daily for years and that has not increased his tolerance for loading of that side or closing. Most derangements respond better to closing the ipsilateral side.

I started with lateral shift corrections which were so blocked I started sweating doing them. After about 5 minutes, I got him almost 40% to end range. I next had him walk, with no more pain in the buttock and no antalgic gait. I did about 10 more minutes of lateral shift corrections - an awesome workout! We finally got him to end range, he now walked faster, with slight trunk rotation, and said he felt taller!

I got him to do some extension in standing against a table, after 2 sets of 10, he was going to end range. He was instructed pressups with his right LE upright in hip flexion, abduction and knee flexion, or the "road-kill" position of derangement reduction. He was unable to press-up in this position until I did sidegliding overpressure. 

After this he tried a press-up with both LEs in neutral but had end range sharp pain (at the cervical extension component) that did not improve after 10 reps. I did the traction MWM and he was able to complete 2 sets of 10 pain free to end range. He left feeling much better, reduced to 3-4/10 and was instructed on proper posture, but still had allodynia at the lower lumbar spine. 

He remains guarded that we will get him exercising regularly again, saying he dreams of running and working out. I told him to have faith and that we will get him there! It is always a good prognosis in MDT when you can centralize complaints on day 1. Unfortunately, he works 12 hour shifts for the next 3 days and I will not follow up with him until the last day of this week (saw him yesterday). At least he is not an acute shift, but MDT Dips have told me seeing a patient daily for the first 2-3 days really improves outcomes until they are very compliant and following their HEP.

Discussion: Loading made able to tolerate loading; opening did not relieve his complaints. Also, POPTs, especially one's with pain management, PT, and DC, SUCK. Seven years of this guy going to the same place? At least he's a WC patient who is still working... also better for prognosis.

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