Part 1 is here.
I had some great suggestions on the blog and on the facebook page.
Was the patient compliant? - Yes
Did I try rotational forces after progressing from the sagittal and transverse planes - Yes
Additional things I tried
- STM along the neural container with neurodynamic tensioners
- Neurodynamic sliders/slump sliders
- these seems to help temporarily for 1 visit
- pain science education - granted there really was not enough time for this, and it did not seem like central sensitization
- lumbar gapping with neurodynamic tensioners (Mulligan SMWM)
- stabilization - as he could not tolerate rolling patterns
After 5 visits, he was either no change on some visits, or so bad he could barely stand upright. He was often shifted away from that side and hunched forward. I decided he should schedule an MRI as he has always responded in the past. I diagnosed him as an irreducible derangement.
A MDT Diplomat was doing hours at our clinic, she evaluated and treated him from scratch. She gave him slouch overcorrect and repeated flexion on two different sessions. He was first slightly better, then the next visit came back worse again. She also diagnosed him as an irreducible derangement (without knowing my mechanical diagnosis).
This was after 5 sessions with me and 2 with the DIP. He got his MRI and it showed a minor cyst in his L5-S1 foramen on the involved side. Compared with his old MRI from a few years back (when he had complete resolution of his lumbar/hip complaints) it was a few mm larger. The specialist said it was not significant and ordered more PT. I told him to go get a second opinion. It turns out he saw a surgeon who removed the cyst and the patient called me very pleased the day after his surgery - he was completely pain free.
I am now treating him for some strengthening and conditioning as it was about 5 months that he was unable to work out or even WB on many days. So was he a derangement/rapid responder? Yes, remember that you can make someone worse rapidly just as you can make someone better.
We saved visits for his rehab which worked out really well. If you cannot make ANY changes in 6 visits, and half of the or more the patient is often worse, it may be time for a referral or further testing just to rule things out.