Monday, October 1, 2012
Case of the Week 10-1-12: I Love Being Proven Wrong!
I had what seemed like a difficult case ahead of me. Chronic lumbar pain, antalgic gait, OOW for 10 months, had multiple sessions of PT, etc...
The MDT Diplomat who was mentoring at our clinic and I discussed outcomes. He stated studies had been done a while back by I believe Rath who found that if you there were not significant changes in the case within 6 visits, it is a difficult case. If you add the fact that the patient was now OOW for 10 months, getting to that 1 year anniversary made it less and less likely that she was going to return to work.
Worker's Comp studies show that at each measured time frame, 6 months, 1 year and up to 2 years, the patient becomes less and less likely to return to work. One study showed 0% returning to work after 2 years. The irony is that I also discussed this with a volunteer who watched me do this eval back to back with another one who has been OOW for 3 years. I explained the stats as outlined above.
Here is what I found on her eval.
Subjective: Pt reports lifting a patient at work 11/27/11 who fell. This resulted in injury to her hip and lumbar spine. Currently co constant L lumbar and L hip pain radiating to L shin. She also reports intermittent thoracic pain. Sx have worsened in the last week. She had two other bouts of PT which did not help, but they were not doing manual treatments according to patient. In addition to pain, she also reports severe weakness in LE, with inability to lift it. Sx worse with sitting/standing > 30 minutes, lying supine, in the morning, at night. Sx better as the day progresses.
Observations: fair sitting posture, antalgic gait, decreased stance time on the left, fear avoidance to all movements and upright postures
key: F = functional (WNL), D = dysfunctional, N = non-painful, P = painful, PDM = pain during movement, ERP = end range pain, LRF = lat rotation and flexion, MRE = med rotation and extension
flexion sev loss
extension sev loss
sidegliding Left mod PDM Right WNL
Flexion Left DP, sev Right FN
Extension Left DP, mod Right DN, min
Int Rot Left DN mod Right DN, mild
Ext Rot Left FN Right FN
Special tests: lower limb neurodynamic test positive on L with sciatic nerve bias
prone lying with hips offset to right centralizes L hip pain, better as a result, after several sets of sidegliding OP, pt's lumbar spine pain improved, able to sit upright with lumbar roll
Assessment: Signs and Sx consistent with chronic lumbar posterolateral derangement syndrome
This is how we left the first visit. She seemed slightly encouraged, but very doubtful that she would improve. She was instructed to perform modified hips offset with pressure on/off (walking with her forearms over to the left to further close the involved side), and use the lumbar roll at home.
Visit 2: Cancelled
Visit 3: This was about 1.5 weeks after the initial evaluation due to the cancellation. When I went to get her from the waiting room, there she was, sitting there with a smile on her face. She was also wearing shorts and a t-shirt (it was a colder day on the eval - so her arms and legs were covered). She had tats on her arms and legs. When you combine the smile with the tattoos, I absolutely 100% did not recognize her, especially when she smiled, said hello, and walked with no pain beside me to a plinth. I thought to myself "I must have confused her name with someone else."
She had been using the lumbar roll, and performing her exercises regularly. Her only complaints at this point was pain when getting into her SUV. LE pain was abolished and she had minor lumbar "aching." She was very pleasant, a totally different presentation than the always in pain, nothing works, everything hurts day 1.
Lumbar sidegliding was now WNL bilaterally, not reproductive of her complaints. There was mild end range discomfort with REIS. LLNT was also WNL on the left and her hip ROM was also FN in all planes. I performed some light IASTM to her paraspinals, did some P/A to lower lumbar spine. REIS was now full and pain free. She was instructed to perform this hourly and continue using her lumbar roll.
I also observed her getting into her SUV, and she quickly flexed her right hip to almost maximal flexion, ER, and abduction, as if she was trying to do a split with that side. I instructed her to contract her TA, hip hinge into the seat and then rotate into the seat. This was pain free. She could still do it quickly.
Visit 4: Minor "aching" in the lumbar spine that she did not care about in the least. She asked her occ health doc to return to work. He said he wanted her to feel better for a little while longer and scheduled another visit in 6 weeks. We reviewed the HEP and I performed IASTM to her lumbar paraspinals and P/A as above. REIS was pain free and full.
Visit 5: She was now 100% pain free in all ADLs. I confessed to her about not recognizing her the second visit. She said her occ health doc and her neurologist did not either. She told me her husband had been bathing her for months because she could not stand in the shower. Her neurologist agreed to let her return to work if I wrote a letter with limitations. She is currently scheduled to return to work full time, but 8 hour shifts instead of 12 sometime in the next few weeks. She is excited to return to work as a nurse.
I love being proven wrong! I told the volunteer on the first day, despite what I thought of what the outcomes may be, that "you should always try your best." So, always try, you never know what may happen. What the heck were they doing with her at the other 2 PT places for 8 weeks at a time?
I'll leave you with a quote that Frank Ward, PT, DipMDT told me (the surgeon's name who originally stated it has been lost with time,) "Always is never, never is sometimes, sometimes anything can be."
IFOMPT here I come!