Case of the Week 11-19-12 Part 1: Lower Back Pain - Rapid Responder
There is another point that distinguishes a Rapid Responder from a Slow Responder. You can also make them worse very rapidly!
My deal with patients on evaluation is that we should both see improvements in their condition, function, pain, and/or motion, within 6 visits. If not a referral is in order. I had treated this particular patient for his right shoulder with good resolution (avoided R/C surgery), and lumbar/hip pain on two other occasions with good outcomes. This third episode in 4-5 years was his worst.
His eval was as follows:
Subjective: Pt reports onset of cramping in right calf 3-4 weeks ago. It has since worsened and progressed to R gluteal pain that radiates distally to below the knee. He also has intermittent central lumbar pain. His are Sx worse at night, but also felt during the day during WB ADLs. Sx rated 8-10/10. Functionally, he is limited in working out on the elliptical, supine lying, exercise.
Objective: fair sitting posture, moderate forward head
Key: F = functional (WNL), D=Dysfunctional, N = non-painful, P=Painful
flexion DN, mod loss
extension DN, sev loss
repeated extension in lying and standing, DN, sev loss, PDM, no worse as a result
repeated SGIS blocked and painful on the right, increased, no worse as a result
Flexion Left FN Right FN
Extension Left DN, mod Right DN, sev
Int Rot Left DN, mod Right DN, sev
Ext Rot Left FN Right DN, mod
Df Left DN, sev Right DN, sev
Pf Left FN Right FN
Myofascia: moderate restrictions in B lumbar paraspinal, B iliac crests medial to lateral, R gastroc/soleus posteriorly and superolaterally, R quadratus lumborum
lower limb neurodynamic test mod restricted painful on R with sciatic nerve bias.
We started with some of the things that made him better in the past, postural correction, functional release to the QL, psoas, right ITB and hamstings, hip MWM, and long axis distractions. He was instructed on SGIS for HEP to be performed hourly. On visits 2-3, he was no better, hip ROM was unchanged and now even measuring it caused pain in the lumbar spine, we tried repeated extension in standing and lying as HEP for the next few visits with adding neurodynamics to the sciatic nerve in tensioning and sliding. On visits 4-5 he was worse coming in (increased pain). After Tx, his complaints and function were made worse upon WB; his complaints had peripherlized with even less ability to WB on his right LE. He also now had a lateral shift away from the pain.
What would you do at this point?