Sep 3, 2012

Case of the Week 9/3/12: Acute Lumbar Pain Part 3


Here is the final update for this case that I have been blogging about. It was a good write-up with use of MDT, FR, IASTM and now the SFMA to round out the return to function.

Parts 1 and 2 are here. Terminology review here.

Visit 8 was 2 weeks after visit 7. She ran 4 miles the week before and her only complaint at the time was severe "stiffness." The stiffness was most likely due to 2 things. 1) Still avoiding forward bending from apprehension and 2) sitting actively against her lumbar roll.

I find the second part is something very compliant patients do and it makes them excessively sore. It is important to note, especially when the patient states they are very "sore" after use of a lumbar roll that they sit against it to conform, but not push actively with their erectors into the chair and the roll. The erectors need to be relaxed once the lumbar spine is in a lordosis.

The patient's SFMA revealed
MSR: DN bilaterally
  • breakouts revealed: loss trunk rotation bilaterally and left hip IR, both DN
MSE: DN
  • breakout showed loss of hip extension and IR on the left
DS: DN
  • breakout revealed full ability to deep squat once her UEs were supported, indicating a motor control problem
  • rolling assessment went as follows - the usual
    • I demonstrate the upper and lower body rolling patterns
    • as a natural athlete, she says, "Erson, there is NO way I will not be able to do that."
    • She is able to easily do all directions except DN with lower body prone to supine right to left and upper body prone to supine left to right (the same diagonal)
    • she literally could not roll off of her stomach to save her life
  • I regressed each rolling pattern to half lying on pillows/foam roll until she was able to initiate the pattern and complete the roll with no issues (making it less gravity dependent to initiate the pattern)
Treatment: psoas release and IASTM to the left ITB. IASTM was also performed to the thoracic paraspinals followed by 3 supine thoracic thrust manipulations to various levels. Afterward, MSE and MSR were both FN.

Visit 9: She was back to running her normal 6 miles/day at her normal pace. The thoracic "stiffness" was mostly gone, but she still had some apprehension. This visit we concentrated on proper rolling again and then checked if it was time for flexion. A repeated motion exam for recovery of function phase is as follows:
  1. make sure the patient is Sx free
  2. test repeated extension (if that was the blocked/painful motion)
    1. if yes to pain free and full motion then
  3. test repeated flexion (or the motion that would provoke or worsen Sx)
  4. retest repeated extension
    1. if it is still pain free and remains full, it is ok to add flexion back into the program
Her repeated flexion, despite being nerve wracking, was pain free and full. It did not block or make extension painful. Blocking means a rapid loss of the opposite direction, which would mean the derangement may be reduced, but not stable. In her case, it was both reduced and stable so we added flexion in lying (knees to chest). She was to perform this 3-5 times/day then always follow with repeated extension in standing to check for loss. 

Rolling was still DN, but rapidly improving, she didn't require as much help or cuing. I have not seen her again, but she is back to full function and may return for some performance training and maintenance manual therapy prn, as many athletic patients do.


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