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Patient Case #2: Acute on Chronic LBP and Neck pain
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Patient Case #2: Acute on Chronic LBP and Neck pain - October 6, 2005 8:34:00 AM
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JLS_PT_OCS
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From: USA
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HISTORY: 48 y.o male with long history of LBP for about 10 years, no hx of trauma. Recurrent symptoms, has been managed thus far with medications and rest only (thank you primary care people!). He was at a seminar event recently where he had to stand for long periods and has developed acute on chronic low back pain central mid Lx area and upper Tx pain that radiates to his R ear area with some headaches. Symptom duration of 2 days. Lx spine feels more comfortable when sitting. Denies any extremity referral or N&T. No systemic c/o or red flags. Pain 9/10 today, he was in mild distress. He was "walked over" from the primary care clinic because one of our very sharp Army Physician Assistants (who are awesome, by the way) knew that the guy could benefit from our manipulative skills in PT.
EXAM: Gait guarded, difficulty arising from sitting. No Oswestry or FABQ scores because I was too far behind in my schedule and he was a walkin patient. (like the excuse?)
Lx AROM limited all planes, especially into extension. Lx Hypomobility to PA spring testing. No change in symptoms with repeated motions in standing. Cluster of five SIJ tests (Gillet/Stork, thigh thrust/POSH, Pelvic Rock, Patrick/FABER, and Supine-sit) were negative.
Neg SLR, Neg Slump, Neuro screen NL.
Cx ROM limited all planes expecially flexion, points to R levator scap area along course of muscle as the worst part of the pain. Neg Spurling, neg quadrant, neg ULNT median1 (a la Shacklock). Strength B UE 5/5.
Global TTP to palpation at Cx area, R levator area worst.
TREATMENT: L/S "chicago" style manip (old reliable again) with immediate decrease in pain to 3/10 and improved ROM to almost NL of Lx spine. Prone Thoracic PA manipulation and sitting C/T junction manipulation (distraction/ traction style in near "full nelson" position).
Immediate improvement in Cx ROM to near full with decreased c/o tension in levator area. Cx spine not treated.
Left with pain 3/10 and a big smile on his face. "I can't believe I feel so much better."
PLAN: Discussed briefly active movement and deep breathing to help elicit ideomotor correction (thanks Barrett) instead of overly choreographed exercises. Followup in a few weeks to start progressive rehabilitation or PRN without appt as a walkin for more manipulative care if his pain gets over 4/10 (a standard instruction for people I do manipulation with).
DISCUSSION: I never did much palpation of landmarks or anything like that, and had great results with very general manipulative procedures not aimed at any specific "movement problem" like an ERS/FRS dysfunction, etc.
I basically noted limited movement, cleared red flags, cleared SIJ with the test cluster, basic neuro screen, and "got crackin'". This supports my point in general of how more specific manipulation may not be necessary or even a good idea in general practice.
Thoughts on this case?
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Patient Case #2: Acute on Chronic LBP and Neck pain - October 7, 2005 5:19:00 PM
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Ginaapt
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Joined: October 6, 2005
From: Boston
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Hey Jason.. whats a lumbar chicago style manip?havent heard of the term.
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Re: Patient Case #2: Acute on Chronic LBP and Neck pain - October 7, 2005 5:34:00 PM
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Jon Newman
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From: Amherst, WI
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Hi Ginaapt,
[URL=http://bmc.ub.uni-potsdam.de/1471-2296-6-29/]Here's a link.[/URL]
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Patient Case #2: Acute on Chronic LBP and Neck pain - October 7, 2005 7:17:00 PM
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nari
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From: Australia
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Jason
Good work..you neuromodulated him well. Why did you do ULNT1 on him? Just curious. (I would have tried that too plus ULNT3 and 4, but that is just me..)
Nari
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Re: Patient Case #2: Acute on Chronic LBP and Neck pain - October 7, 2005 9:13:00 PM
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Synergy
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From: Forney, TX
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Interesting case Jason! Can you describe in a little more detail the sitting C/T manipulation you mentioned? Also, in looking at your assessment, he only met one of the five criteria of Childs' CPR (at least that's my understanding) of potentially benefiting from manipluation. I know you didn't administer the FABQ, but how was his hip IR? He's had CLBP so he doesn't quite fit the 'less than 16 days' category. What made you decide to use the Chicago Roll if he only met one...maybe two of the criteria (if he had scores on the FABQ consistent with the literature)?
Thanks for these case studies..they're quite educational. :)
_____________________________
Chris Adams, PT, MPT
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Re: Patient Case #2: Acute on Chronic LBP and Neck pain - October 8, 2005 2:42:00 AM
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jma
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From: NY
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Nice case study!
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Re: Patient Case #2: Acute on Chronic LBP and Neck pain - October 8, 2005 5:31:00 AM
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eam
Posts: 289
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From: New York, NY 10028
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Jason,
Another nice case. Good ideas! What about soft tissue tone (i.e. SCM) which refers pain up into the head (ala HA)? Was he tender at all to palpation of the sp's in the thoracic spine? I have good success also with some of the prone techniques in the T spine but initially people cannot tolerate the direct PA pressure. And these are the people who will usually benefit from the manipulation. How do you get around that? I really enjoy these case studies. Thanks. :)
Erica
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Re: Patient Case #2: Acute on Chronic LBP and Neck pain - October 8, 2005 6:59:00 AM
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Synergy
Posts: 589
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From: Forney, TX
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Good points on the soft tissues Erica. I would also have a look at those suboccipital muscles to make sure they're not facilitated and restricting the suboccipital nerve.
Erica,
You could place this patient prone and manipulate the t-spine as well if they're not able to tolerate the prone technique. Quite often I come across people who tend to hold their breath despite verbal cues to exhale prior to manipulation. The supine technique works well for these folks and, in my opinion, seems to be a bit more specific.
_____________________________
Chris Adams, PT, MPT
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Re: Patient Case #2: Acute on Chronic LBP and Neck pain - October 11, 2005 3:09:00 AM
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JLS_PT_OCS
Posts: 1684
Joined: January 30, 2005
From: USA
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Thanks for the comments everybody. Let's do one at a time, first come first served.
Nari- I use the ULNT1 with neck patients because it is part of a test cluster I use to look for cervical radiculopathy. See these below:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12544957&query_hl=1
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11153552&query_hl=1
He didn't have any extremity symptoms, so I didn't do any further neurodynamic testing. I think of UNLT1 as the SLR for the UE, I do it sort of as a "checkthe box" regardless of where the complaint is.
Chris-
Even without the FABQ, he met 4 out of 5 at least: onset of symptoms was 2 days (remember, acute-on-chronic counts, too), his hip IR was greater than 35 (sorry I didn't include that above), his symptoms were above the knee, and he had Lumbar hypomobility. I didn't know his FABQ score, but with 4 out of 5 already, I had everything I needed.
The sitting C/T junction manip is a modification of the one on the manual therapy CDs by Flynn/ Whitman/ Wainner/ Magel. Still don't have those? :)
Erica-
I didn't really go into detail on the soft tissues, I didn't have much time. I do think lots of people with chronic neck/shoulder/head pain have that issue, I do try to address that with soft tissue work as well. But in this case, I didn't need to.
I didn't check him for Tx tenderness at the SPs. Neither the sitting C/T junction manip, nor the prone PA manip require contact on the spinous processes, so we're good there. I find, much like the Chicago technique, that the prone PA manips help the large majority of those with Tx complaints, and they're great for those with limited Cx motion, too.
Chris-
I agree on the supine Tx manip, but it has been my experience that this is less well tolerated for patients. And you know what I think about specificity of manipultion... :)
Thanks for the comments, everyone.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Patient Case #2: Acute on Chronic LBP and Neck pain - October 11, 2005 6:03:00 PM
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Randy Dixon
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Jason,
My thoughts on specific manipulation vs. general manipulation with absolutely no evidence to back it up. It's like getting a kink in a chain, usually you just have to rattle the thing and the part that needs fixing gets fixed, but sometimes it gets jammed and you have to go find it and fix it.
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Re: Patient Case #2: Acute on Chronic LBP and Neck pain - October 12, 2005 3:36:00 AM
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JLS_PT_OCS
Posts: 1684
Joined: January 30, 2005
From: USA
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I think that makes sense, Randy. I have had a few patients with problems that I thought seemed to be exactly like that.
The interesting question is how many of our patients truly have that type of problem?
I think this is yet another subgroup issue, and the few biomechanical cases we see tend to solidify this model in the minds of clinicians (all types). I think this leads to the idea that all spine problems are biomechanical, and hence the theoretical models of increasing complexity and decreasing clinical worth. Now if only there were a way to determine those few who have a "simple" biomechanical problem vs the oceans of people who just have pain and dysfunction without that magic "ERS" thing...
:)
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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