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.

9 comments:

  1. Interesting case. The history is a terrible one huh? Daily chiropractic for 2 years!!?? I am not sure I would want to see someone daily for 2 years!!

    There was a lot of abbreviations and McKenzie jargon in there...I haven't trained in Mackenzie so my apologies for my ignorance.

    Can I ask:
    1. What is the diagnosis?
    2. What is the prognosis?
    3. What is the treatment plan?
    4. Did you really only do that much physical examination - no other baseline measures, questionnaires, etc?

    Thanks!

    Antony Lo

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  2. The diagnosis fits into the MDT classification of lumbar derangement, specifically posterolateral or far lateral (meaning responding to motions within frontal and/or sagittal plane)

    The prognosis is excellent because we centralized his complaints. Centralization has been demonstrated as an excellent prognosticator, especially if it occurs on day 1. Centralization is when Sx go from the periphery to more central, in this case from the buttocks on the right to the central lower lumbar spine.

    The treatment plan will be to further assess other adjacent joints on future visits, but for MDT, one of the first goals is to correct a lateral shift, despite him not having a lateral shift in standing, he often sits that way, so that's why I stopped right after history taking to start treatment after measuring his sidegliding in standing (which is not sidebending, it's more of a pelvic shear).

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  3. I am currently going through my Specialisation process here in Australia - I can't help but wonder if I would get "smashed" For such an approach...

    ...I am certainly not having a go - I have no doubt you are effective at what you do and Mackenzie does have some research backing to it...Also, I too don't go through the classic approach to problems.

    I am just wondering out aloud where the balance is...

    Thanks!

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  4. That's fine to wonder aloud, that's what makes you the Physio Detective! Most who do not have form MDT training are amazed at the seeming lack of comprehensive eval. Like I said, it was a rare opportunity for my students to see me do this without any of my normal assessments, like looking at functional movements, tissue and neurodynamic mobility.

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  5. My dad suffered lumbar problems some years ago and it also started from a lower back pain that he never minded. He waited until he can no longer walk properly before he decided to seek medial help. It turned out that he has lumbar radiculopathy and it took him months of physical therapy before he got back to normal.

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  6. Regular exercise can't only help achieve a healthy hurt and muscles. In fact, it can improve the muscoskeletal system as a whole. This includes the overall health of our bones as well.

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  7. Hi erson. what happened on follow up with this client? Were they compliant with HEP?

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    Replies
    1. He eventually stopped coming. I wasn't able to affect his area of hyper sensitivity after several visits trying many different approaches. Still be could work and walk so functionally much better.

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    2. Do you think the poor previous management added to the central sensitization that occurred? Do you have any clinic pearls for treating those with central sensitisation? Excellent blogs, they really have helped me take step back when treating my own clients

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