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Symptoms - June 5, 2007 3:27:00 AM
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ALICIAPT13
Posts: 95
Joined: December 12, 2005
From: North Syracuse, NY
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I have seen a few patients who have all presented with symptoms that always seemed to be sciatic in nature: TTP at the piriformis, + SLR and slump, pain in the buttock/down the leg. The majority of the time these patients are overweight. I have yet to find an effective treatment for these patients and have only made small gains. I have a patient now who fits this description, yet has not gotten any better with 9 treatments. He carries his weight in front, and I am wondering if this is altering his posture, much like with a pregnant woman, and causing his pain. I have one last attempt with this man before I have another therapist look at him. Any suggestions???
Thank you!
Alicia
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Re: Symptoms - June 5, 2007 4:32:00 AM
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Dr.Wagner
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Without sounding crass...it sounds like you will chasing your tail until they begin to take ownership of their own health and begin to lose weight.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Symptoms - June 5, 2007 6:41:00 AM
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Shill
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From: Madison WI USA
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Find me a good study that correlates LBP with obesity. Knee pain, LE pain at any joint yes, but not LBP. Its reasonably assumed, but still assumed that the weight is a factor, but all one does by telling them to lose weight is frustrate them further. You should be able to get the pain down, THEN get the weight down.
Have you done a repeated movements evaluation as of yet? How do the symptoms behave?
Let us know what you have tried with your 9 treatments, so we can provide more specific advice.
Steve
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Steve Hill PT
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Re: Symptoms - June 5, 2007 8:13:00 AM
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Dr.Wagner
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From: Indianapolis
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You are serious?
You want a study specifically correlating LBP and obesity? So...obesity and knee pain wasn't enough? We need a STUDY to prove not only the kinetic chain,.
We need a study not only to prove the physics of weight distribution, strain on ligaments and tendons and the stretch of abdominal muscles, but to prove that this causes pain.
Do you work for a tobacco company?
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Symptoms - June 5, 2007 8:17:00 AM
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ALICIAPT13
Posts: 95
Joined: December 12, 2005
From: North Syracuse, NY
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Dr. Wagner - I guess I just have a hard time telling overweight people they are overweight (as if they don't already know!).
Findings:
- insidious onset
- (L) hip radiates to ankle
- denies numbness/tingling
- hip strength grossly 5/5 (B)
- + slump and SLR ~ 70 degrees (L)
- lumbar flexion limited and painful at beginning and end of range, not mid-range
- lumbar lateral flexion limited (B) and painful to (R)
- REIS and RFIS no change
- +1 TTP at (L) piriformis
- pain increases with getting OOB and when he first sits down
- pain decreases with sitting for 10 minutes and walking for a few minutes
Hope this sheds some light.
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Re: Symptoms - June 5, 2007 8:24:00 AM
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Chocco
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I have to agree with the Doc, Generally heavier set people tend to have an increased lordosis especially when in standing which would increase the effects of ddd, stenosis, spondylolesthesis etc.
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Re: Symptoms - June 5, 2007 8:26:00 AM
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Dr.Wagner
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From: Indianapolis
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Sorry, but we have an EPIDEMIC on our hands. We are ethically bound as providers of health care that it is ESSENTIAL for patients to lose weight in an effort to care for themselves physically.
Everyday I see obese children and adults. Ever seen a 90pound 6 year old? Or even more rare, a 300 pound 90 year old...80 year old?
Sometimes we DON'T need studies to justify treatments or advice.
While I cannot say that "it is clearly shown in our studies that drinking urine leads to bad breath"...I think the assumption is reasonable based upon my experience with urine.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Symptoms - June 5, 2007 9:28:00 AM
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Shill
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From: Madison WI USA
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Wags,
In my post, you wont read that I said obesity isnt a problem. Just that is has never been found to be anything other than a common sense relationship with LBP. You will also not read in my post that I dont suggest losing weight to contribute to a healthier lifestyle. Shouldnt all obese people have LBP, with your rationale? Hmmmmm. I respect your opinion, just not on this part of this issue!
I hear what you say Chocco, but can it be backed up? I dont disagree with any of the inferences, but they are just that until someone takes the time to study it/them. Sure it seems like there should be strain here and there due to body habitus, but we all know things are not always as they seem. Again, putting all of the eggs in this basket basically says the patient is screwed, with no chance of getting better until they get slim.
I guarantee better results from going at the pain as you would in someone who happens to be thinner, as opposed to employing the strategy of "Lose weight" as your back pain treatment strategy. Its a cop out.
And no, Dr Wagner, I dont work for a tobacco company, and the urine drinking reference is just plain weird. Funny, but weird.
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Steve Hill PT
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Re: Symptoms - June 5, 2007 9:34:00 AM
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Shill
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From: Madison WI USA
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Alicia,
Go with prone extension for a trial, whether it be POE or prone pressups. EIS didnt help, but that doesnt mean unloaded prone extension wont. There are a LOT of patients who benefit from this unloaded extension, and despite what I said above, there may be more load on the spine in this case, so unload it, extend it, and continue those until symptoms change, up to 5-7 sets of 10. Look for centralization, not just reduction with the extension. Walking relieves pain, so get him walking too. Walk during lunch, after work, in the AM. Two birds with one stone.
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Steve Hill PT
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Re: Symptoms - June 5, 2007 9:50:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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There are studies to show that physical inactivity are risk factors for chronic lower back pain. Most fat people don't exercise, therefore....
Steve, I think there are some more current studies that do link obesity to low back pain; however, there are still others that no not. It is equivocal.
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Alex Brenner, PT, MPT, OCS
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Re: Symptoms - June 5, 2007 10:54:00 AM
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OaksPT
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From: Va
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In Alicia's original description, she describes a male with a significant belly that may be causing a stenotic type of strain on the lumbar spine. So in this case, pain may have a contribution due to the nerves having a constant strain on them, if this patient is unable to change positions. But I have to agree with Shill, that loss of weight is helpful in reducing forces on the spine, and is imperative for remaining healthy, BUT, cannot be directly linked to pain as a causative factor. There may be tendencies in overweight people that contribute to their symptoms, but if all factors are the same, other than weight, how do we treat a thin person with the same findings as an obese patient.
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Scott Oaks PT,DPT
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Re: Symptoms - June 5, 2007 11:25:00 AM
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VagusX
Posts: 220
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From: Savannah, GA, USA
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Steve
weight needs to be addressed. We know about structural strains that occur on the spine by distended abdomens. Just ask your next 3rd trimester pregnant patient.
I would never go as far as to say the cause of your pain is because "you're fat." I tell them that there isn't a great correlation with weight and pain, but pain and weight will normally reduce if you get in the gym 30 mintues a day and eat right.
Alicia.
In one visit I wouldn't count on any miracles. If I only had one day I would focus my session on body mechanics. Jump on his back (not literally) every time he breaks a neutral spine position.
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Re: Symptoms - June 5, 2007 11:32:00 AM
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Sean Weatherston
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From: Idaho
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From my experience...getting them to take ownership/responsibility is critical...BUT!
They know they're fat, but honestly how easy is it to exercise to lose weight when your back is killing you? You know you need to exercise, so you try, and fail, and get hurt. Then you get depressed and gain weight, at get hurt more easily.
Do what you can to help them feel better in the short term, encourage, encourage, encourage them to be more active for the long term, and soon they have a bit of momentum.
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Sean Weatherston, PT, OCS, CSCS
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Re: Symptoms - June 5, 2007 12:47:00 PM
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Chocco
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I don't think that because your overweight you are not going to improve. In fact if you are able to counteract the effects of his excess weight be it by stretching or strengthening and stabelizing his core, they should improve regaurdless of their weight. It will however make it more difficult to improve with the weight as opposed to with out it. I hope that wording made sense
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Re: Symptoms - June 5, 2007 1:00:00 PM
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Chocco
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Alicia, What is his posture like ? Does he have an Increased or decreased lordosis. Is his R side bending pain related to joint compression or muscle tightness secondary to scoliosis or lat shift. Have you tried nerve glides or neural flossing exercises.
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Re: Symptoms - June 5, 2007 1:49:00 PM
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physioo
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From: Canada
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Tape her up...or him...
works magic
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Re: Symptoms - June 6, 2007 2:32:00 AM
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Shill
Posts: 1107
Joined: February 13, 2003
From: Madison WI USA
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vagus,
Again, I didnt say that weight didnt need to be addressed. It just isnt going to make or break that particular patient's ability to take care of this bout of back pain. It is going to help the overall quality of life and health.
The comparing pregnancy to obesity is like comparing apples to applesauce, with cinnamon. Its not exactly the same. The weight gain and tissue change with pregnancy is rapid, as opposed to slow, and hence the body doesnt have the time to adjust. Obviously there are hormonal influences on ALL soft tissues as well with pregnancy, and of course this is not present in the obese people, unless they happen to be expecting too.
I fully agree that the inactivity associated with largess can be one of the major factors in the pain.
This guy tolerates walking! Get him out there. It decreases his back pain. It will help him drop weight. It will help to make the changes necessary for overall health. Sure, the therapist may not seem like a genius to say "start walking", but it relieves his pain!. Isnt that a goal?
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Steve Hill PT
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Re: Symptoms - June 6, 2007 3:07:00 AM
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ALICIAPT13
Posts: 95
Joined: December 12, 2005
From: North Syracuse, NY
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I tried having the patient tilt the pelvis into a pain-free position and did some stabilization exercises while there. He was able to find a comfortable position with a slight posterior tilt. I guess I am going with the idea of being stenotic. Any thoughts?
Thank you
Alicia
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Re: Symptoms - June 6, 2007 3:33:00 AM
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Jon Newman
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From: Amherst, WI
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I'm with Steve on this fat and painful concept. I hear the same stories about back pain from all morphotypes/weight (it started when I tried to start the lawn mower for example) and all morphotypes/weight have similar rates of resolution (ceteris paribus) in my experience (despite morphotype remaining stable.) Why not simply advocate for weight loss based on what we do know about excess weight and health (HTN, diabetes, etc)? The "you're in pain because you're fat message" is mistaken at least.
I do agree with Alex that some of things that bring people to a pain state may also bring them to a state of being overweight.
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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: Symptoms - June 6, 2007 5:26:00 AM
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ptim
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Stenosis?
How old is he?
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