Jul 8, 2013

Case of the Week 7-8-13: The Why's of Lumbar Derangement


Another lumbar eval.... thanks P90x! As you regular readers know, MDT works great to put out the fire. What about what caused it in the first place? That's where the SFMA comes in!

A reminder, here is the post you can always find in the top menu bar on abbreviations.

The Eval was as follows

Pt is a 43 yo CM who is employed as an IT Manager who reports to PT on with c/o L lower back and hip “sharp”  pain that is intermittent in nature. Sx onset was 4-6 weeks ago after starting P90x.  He rates his pain ranging from 2-8/10.  Sit-to-stand, stand-to-sit, and forward bending all increase pain.  Pt. reports pain as intermittent and not affected by time of day. He also reports a significant change in activity level in the past month as he has been exercising more.  PMH includes B frozen shoulder following an injury 10 years ago.

Objective

ROM

SGIS     Left DP, mod loss    Right FN
repeated SGIS to L PDM, improves L hip ROM and lumbar pain, remains better as a result

Hip (prior to SGIS)
Left Hip flex. = DN
Left Hip IR = DN

Knee
Left passive knee extension = DN

Lumbar
MSE = DP
MSF =FP with pain on return to extension

Shoulder
Left LRF = FN
Right LRF = FN
Left MRE = DN*
Right MRE = FN
Left IR = DN
Left ER =DN
*improved to FN with; cervical retraction L SB with over pressure

The shoulder we'll save for part 2 of this, needless to say, he did not come in for his bilateral "frozen" shoulders but was treated for them anyway, after having many months of previous PT years ago.

Day 1: Manual SGIS shift correction to the left (shoulders left, hips right) which was PDM, but rapidly improved hip motion, lumbar motion and pain. He was instructed on SGIS against the wall to self treat 10 times/hourly.

Day 2: Pt was at least 90% improved in all ADLs, added IASTM to lateral thigh patterns, released left QL and psoas which made SGIS FN. Reviewed ther ex for HEP. Hip was now FN in all AROM movements

Day 3: Pt was doing very well for at least 1 week, then exacerbated left lumbar and hip pain while moving furniture around. He was discouraged! Message #1: Rapid onset normally equals rapid resolution as you came in day 2 after injury!

After FR to Left QL, IASTM to lateral thigh patterns and left lumbar paraspinals, SGIS was still painful and he was not able to attain end range. Lumbar rotation in flexion (closing left side) was sustained for 10 minutes, which centralized and abolished lumbar and hip pain, he remained better as a result. The pt was instructed on lumbar rotation in flexion for HEP and to return to SGIS when it became more comfortable and he was able to attain end range.

Day 4: Back to pain free in all ADLs but felt apprehensive to work out. He stated squatting felt "off." Assessed Deep Squat which was DN with shift to the right, and had difficulty flexing left hip. ASLR breakout was still DN with mod loss, but PROM was FN indicating motor control/stability issue. Core activated ASLR was instructed for HEP, which was DN but improved over the first few measures. After light IASTM to the left anterior and lateral thigh patterns, plus light psoas release, core activated ASLR was FN. The pt was told to follow up 1 week later.

Day 5: Pt now pain free in all ADLs, Deep Squat as well as ASLR were now both FN. MSE and MSF were also FN. Why did working out hurt him in the first place? Every time he did some sort of squat or bending activity, he deviated slightly to the right due to the loss hip flexion/hinging on the left. This caused a loading loss on the left. Sure repeated SGIS to the left got rid of his complaints and improved his motion, but that alone did not have him owning his new motion. MDT certainly rapidly improved his pain and ROM, but it most likely would not have prevented him from injuring himself again. Giving him core activated ASLR gave him the ability to control the new motion and this was progressed to hip hinging  with a dowel in standing.

Now to address those shoulders.... stay tuned for part 2!

2 comments:

Ben Swinehart said...

Erson,

Why choose core activated ASLR as opposed to rolling patterns?

Could I request a future video of the ASLR breakout and your instruction of core activated ASLR correction, and some of your manual techniques to improve a dysfunctional ASLR?

Thanks,

Ben

Dr. Erson Religioso III, DPT said...

No specific reason why... just a hunch, also the HEP is the test and easier to use than having someone roll incorrectly at home. I filmed a lot of this stuff for Mike Reinold and I's new IASTM site.

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