Case of the Week 11-19-12 Part 1: Lower Back Pain - Rapid Responder | Modern Manual Therapy Blog

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?


  1. I think looking at repeated movements in the transverse plane may be worth exploring. As per MDT we've exhausted sagittal, followed by frontal plane movements. Since the P is asymmetric a technique such as sustained flexion/rotation in supine could be indicated. I'm thinking along the lines of a P/L or far lateral disc for my PT Dx Classification.

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  3. How was is neuro scan? Weakness? numbness/tingling? I would also like to know what his occupation is...sedentary? I would do acupuncture along the sciatic nerve pathway to help calm down a sensitized N.S. I would try some side lying flexion mobs at the lumbar spine to see how he responds. Maybe some crook lying lumbar traction (if in a lot of pain).

    Interesting case doc, always like hearing about the ones that don't miraculously respond in one session as is what many others on the internet report day after day. I find this stuff far more useful in my practice.

    Looking forward to the discussion!

  4. I did try frontal plane next, wait for part 2 to find out what happened!

  5. Yeah, no more accusations of always only posting miraculous cases! We can't do dry needling or acupuncture here in NY (actually no PT can do acupuncture in the US unless they're also an acupuncturist or MD/DO), but I did treat the neural container with IASTM and functional release. Good thinking Jesse!

  6. I would check the hep is being completed correctly and look to see if they are doing anything that may be irritating symptoms. would also look at the severe dorsiflexion restrictions. finally i would also look at some mulligan lumber NAGS and SNAGS. Failing that if Physio does continue to be unsuccessful referral for an injection should be considered as discussed during your ia appointment.

  7. The patient had been less than compliant with postural instructions in the past but always resolved. This time he was very compliant. I did try some Mulligan SMWMs - wait for part 2!