Last week I was treating a young gentlemen for his second physical therapy visit (the initial evaluation was performed by a different physical therapist.) The young man presented with low back pain with right lower extremity numbness and tingling and occasional left lower extremity symptoms down to his knee as well. Prior to starting treatment, the gentleman heard that I perform manipulation often & felt like his low back needed to be popped. In my head, I was thinking this would likely be an option, but I wanted to recheck his status from the initial evaluation first.
Per the initial evaluation note, the only unusual finding was hyperreflexia (3+) on the R. Due to this neurological finding, I chose to perform my complete neurological screening. My second visit findings were:
Reflexes: Patellar: Right: 4+ (elicited while tapping quadriceps), Left: 3+
Achilles: Right: 2+, Left: 2+
Myotomes: Weakness on Right S1 (I also checked heel walking and toe walking which looked abnormal, but the patient had a unique compensation pattern.)
Clonus: Right: 20 beats; Left: 4 beats
Babinski: Inconclusive (no toe movement)
Delving further into a subjective, he denied changes in bowel and bladder, denied recent constitutional signs and symptoms, or unusual weakness or fatigue. He reported no significant PMH, except his mother has multiple sclerosis.
At the point, I knew I had enough findings NOT to treat this gentleman. Fortunately, I work at Concentra and our medical providers are within the same building. I had this patient seen that same day by the medical providers who have ordered an MRI.
The purpose of this post is to always reassess your patient's status to ensure they are appropriate for your care. If I would have chose to manipulate this patient, I could have caused further injury. Always reassess!
2/6/2015 11:22:59 am
Hi Jim, I'm a 1st year PT student. Just wondering, what were the main red flags that caused you to refer the patient? Was it the familial history of MS coupled with the clonus and abnormal babinski? Thanks for the post!
2/8/2015 11:34:32 am
10/18/2022 01:45:48 am
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1/13/2023 03:34:47 am
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