The patient reports he has had a chronic history of low back pain that would increase and decrease over the last 10 years, but increased significantly 3 months ago with no mechanism of injury. Additionally, the patient reports he has had some numbness and tingling over his L distal leg & foot that he believed to be associated with the back pain. In 1986, the patient reports he fractured his lumbar spine playing football, which he associates with his current state. The patient reports he had an MRI that showed L3-5 HNP, L5-S1 spondylolisthesis, and "nerve root pinching." The back pain the patient currently has is a constant dull ache that sometimes has sharp increases. The back pain and LE N&T all increased with standing, walking, and prolonged sitting. Heat and stretching decrease the pain slightly. The aggravating factors in cases like can be confusing, because standing and walking pain are commonly associated with stenosis and sitting pain is often associated with discogenic pain. SIJ pain or the combination of stenosis and discogenic pain can manifest in all these situations. That leaves us with an interesting set of hypotheses. An additional one that should be considered, however, is that of lumbar hypermobility. A common report for this last one is that of pain in sitting, standing, and walking. These patients frequently have to change positions due to the development of pain. Why do they develop pain with prolonged positioning? Creep. With a joint positioned for an extended period of time one way, the tissue begins to stretch and eventually signals pain.
Multi-Segmental Flexion FN
Multi-Segmental Extension DN
Supine Lat Stretch Hips Flexed FN
Prone Press-Up DN (hinging at L3)
Thomas Test DN bilat
FABER DN on R and DP on L
Multi-Segmental Rotation DN bilat
Seated Trunk Rotation DN bilat
Prone Hip Rotation FN bilat throughout
Seated Hip ER Active/Passive FN bilat
Seated Hip IR Active/PAssive DN bilat
Single Limb Stance DN bilat
Hip ROM: flex 85 on L and 90 on R, ext 0 bilat, IR 30 on L and 35 on R, ER WNL bilat.
Hip Strength: WNL throughout bilat except ext 3+/5 bilat.
Knee Strength and ROM: WNL throughout bilat.
Ankle ROM: PF WNL bilat, DF 10 on L and 15 on R
Ankle Strength: DF WNL bilat, PF 23/25 on L and 25/25 on R.
Neuro Screen: dermatomes intact bilat throughout except L5-S1 on L diminished; (+) Slump Test on L; (-) SLR bilat.
Special Tests: (-) Ober Test bilat, (-) SIJ Compression/Distraction Test bilat, (-) Hip Scour bilat, (-) POSH Test bilat, (-) Sacral Thrust Test.
Palpation: L anterior inominate, R posterior inominate, L3 shifted anteriorly
I used many of the core stabilization exercises that you learned in school for the appropriate low back pain category, starting with education of anatomy/pathology/Transversus Abdominus activation. The transversus abdominus muscle wraps around the spine and acts like a corset to provide stability to the base activating before we see movement in the extremities. It has been shown that in those with low back pain, the transversus abdominus muscle has a delayed firing. Exercises training this muscle are progressed from positions like supine/sidelying/prone to seated to standing and then to more functional activities. Additionally, extensive time was spent educating patient on maintaining a neutral lumbar spinal position with upright activities (the patient responded well to postural corrections with a TA wall slide exercise that corrects posture). Throughout the treatment sessions, the patient would occasionally present with SIJ pain that was then immediately alleviated with manual therapy. The previously mentioned core stabilization exercises were essential for maintaining these gains. Manual therapy was also used to increase the hip mobility bilaterally. This is essential as decreased mobility in the hips with gait can transition to excessive mobility in the lumbar spine. In addition to normal exercise and manual therapy for lumbar stenosis, Whitman el al found that the inclusion of a body weight supported treadmill training program can prove beneficial. This patient in particular began with 75# unloaded at 1.3 mph and was progressed to 40# unloaded at 2.2 mph for 10 min. The patient expressed some relief with the harness placement alone (mimicking the corset-like feature of the transversus abdominus muscle) but reported no symptoms after the treadmill training each session. This intervention does exactly what the name implied: unloads the spine while allowing exercise without pain or decreased dysfunction. This type of intervention is more integral than traction for patients with lumbar hypermobility, because the unloader simply decreases the weight on the spine, while traction's goal is to lengthen tissue - not ideal for hypermobility. Additionally, I did trial IASTM over the patient's L foot once and the patient reported an immediate significant improvement in his foot N&T but they returned after treadmill training that day. The patient was discharged after approximately 10 treatment sessions as he reported feeling greater than 100% improved. For this patient, there was an expectation that back pain was a normal development with aging. With reports of feeling better than he has in over a year and being able to be pain-free with regular performance of his HEP, the patient was ready for discharge.
Upon looking back at this case, I think I should have included some thoracic manipulation as well as this can have a significant impact on the neural symptoms, as discussed previously in another post. Additionally, this case really opened my eyes to the applicability of BWSTT for patients with low back pain. My initial thoughts on it were that no significant changes would be made due to the return of normal body weight afterwards. After seeing the results of it with this patient, when combined with the appropriate exercise, manual therapy, and of course education. If anything, I think I learned just how underutilized BWSTT is used.
Whitman JM, Flynn TW, Childs JD, Wainner RS, Gill HE, Ryder MG, Garber MB, Bennett AC, Fritz JM. (2006). "A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial." Spine (Phila Pa 1976). 2006 Oct 15;31(22):2541-9. Web. 9 Feb 2014.
The Student Physical Therapist
On this page we're going to bring you some interesting cases that we come across. Not only do we hope to show you some of the clinical reasoning behind our decisions, but we'd like to hear from you!