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back pain case
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back pain case - August 21, 2006 12:39:00 PM
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ptjosh
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Joined: July 31, 2006
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16 year old male football player. Guard postion. Had a history of low back pain last football season that went away. During August practice and with bailing hay back pain flaired back up. MD had pt. off from practice times 1 week and referred him to PT. At initial exam pt. complained of upper lumbar pain (L2-L3) area that spread across low back to both sides but more on the left. Pt. had full lumbar spine ROM with mild pain at endrange flexion, signficantly painful extension, and mildy painful right sidebending and rotation. Pt. report laying prone significantly increased symptoms. Pain was 6-9/10 on average. Hip strength was 5/5 througout no significnat postural findings aside from the slouched position you would expect most 16 year old kids to present with. Pt. was seen for 4 visits for lumbar spine ROM with avoidance of extension, and spinal stability exercises including TA, multifudus, and general stability exercies on physioball. When seen last Friday pt. presented with full painfree lumbar spine ROM except for mild discomfort with extension and reported pain 1-2/10 at worst. Pt. was seen today and stated his back started hurting again during game on Friday and now felt worse then when he started. Pt. was very limited with all ROM and was very tender along L1-L3 and lumbar paraspinals. What are you thinking is going on?Any treatment suggestions or guidelines? The patient did not have any followups scheduled with physician so I suggested that they call to check in with the office and I plan to step in and talk to the MD tomorrow. I was thinking posibly a spondy? but pt. states he had x-rays which just showed DDD. Any input is appreciated.
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Re: back pain case - August 21, 2006 1:02:00 PM
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treybien
Posts: 85
Joined: August 5, 2002
From: Milwaukee, WI
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Bone scan?? Stress fracture or yeah a spondy??
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Re: back pain case - August 21, 2006 1:43:00 PM
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ginger
Posts: 658
Joined: February 26, 2005
From: Melbourne Victoria
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Why don't you just put your hands on and mobilise these painfull joints till they improve?
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: back pain case - August 21, 2006 4:32:00 PM
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drbuddy
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From: Pennsylvania
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Does he need to sit out a week or two?
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Re: back pain case - August 21, 2006 6:19:00 PM
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UTDC
Posts: 222
Joined: December 21, 2003
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Good call on the bone scan- more specifically a SPECT. He is the right demographic for a spondy
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Re: back pain case - August 22, 2006 1:29:00 AM
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Sebastian Asselbergs
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From: Barrie, Canada
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How nice would it feel for the patient to have a possible fracture/spondy go through this: "mobilise these painfull joints till they improve?" ?
Ginger, I realize you must do more than jump right in with spronging, but hey, you left yourself wide open with this one...
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Mundi vult decipi
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Re: back pain case - August 22, 2006 3:22:00 AM
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Shill
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From: Madison WI USA
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Yep, he needs to have bony bad things (as noted above)ruled out before anything continues. Let us know how these turn out when he comes back from the re-visit with the doc. Its always a great learning experience.
Steve
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Steve Hill PT
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Re: back pain case - August 22, 2006 3:41:00 AM
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ptjosh
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I suggested that he sit out until further consultation with the MD. I went over to talk to the doc this mourning but he wont be in till this afernoon. Thanks for the help, I wasn't sure if I should rule out spondy because he had already had x-rays or not.
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Re: back pain case - August 22, 2006 5:21:00 AM
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UTDC
Posts: 222
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Josh,
If he has no defect on plain film, now is the best time to get a SPECT. If you can catch the process in evolution, there is a chance that the pars defect can be prevented- 6 months in a TLO. If the plain films were already abnormal, essentially it would be "game over," as there is no going back.
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Re: back pain case - August 22, 2006 7:37:00 AM
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Sean Weatherston
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From: Idaho
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Spondy is certainly the first thing that comes to my mind.
Does DDD in a 16-year-old sound strange to anyone else?
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Sean Weatherston, PT, OCS, CSCS
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Re: back pain case - August 22, 2006 7:59:00 AM
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ptjosh
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It did sound strange indeed.
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Re: back pain case - August 22, 2006 11:27:00 AM
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Jeep
Posts: 353
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From: USA
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Radiographic DDD dx in a 16yo?????--- sounds VERY "suspicious"(IOW- a bad "read"- it happens). I'd like to see those films. My first thoughts would be the DDD is misused/misread/misdiagnosed most likely relative to a rudimentary disc- which is most likely in conjunction with other congenital and/or developmental defects.
Some thoughts:
-What films/views were done to determine this? recumbent?
-Who did the x-ray reading? I strongly recommend sending the films to a different rad or DC rad----to get a second reading.
-depending on the second "look-see", weight-bearing films may be prudent, as well as possibly advanced imaging.
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Re: back pain case - August 22, 2006 11:32:00 AM
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ptjosh
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Joined: July 31, 2006
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Spoke with MD this afternoon. Discussed possiblity of spondy. MD to see pt. on thursday and discuss further plan.
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Re: back pain case - August 22, 2006 12:41:00 PM
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Sean Weatherston
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From: Idaho
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Thanks Jeep, that was my suspicion.
Its also interesting to read a report and listen to what the patient was told...the two are often miles apart!
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Sean Weatherston, PT, OCS, CSCS
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Re: back pain case - August 22, 2006 12:48:00 PM
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PHSPT
Posts: 119
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From: Oklahoma
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I agree w Jeep,
AP views will not be able to show any pars defects.
Ensure an oblique view is obtained, and perhaps a lateral view in flexion/extension.
Even if this unfortunate young man has a spondy, question is how much listhesis is present?
Any yellow/red flags on this pnt pt josh? family hx, any lab work done?
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Re: back pain case - August 22, 2006 1:52:00 PM
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ginger
Posts: 658
Joined: February 26, 2005
From: Melbourne Victoria
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you folks scare the bejeesus out of me , to think I'd have just put my hands on this poor bugger and helped him recover from his back pain . Pheew!, god just as well you saved me from making an ass out of myself by actually using my hands to read and discover the intimate movement details of his spinal joints. More likely he would have died or something worse if I'd used my sensitive hands to gently effect real and immediate changes to ptrotective responses intimate to his joints. What would that have lead to , well maybe , he'd be a lot better by now. How would that look. Actually using clinical information wisely to assert control over what is almost certainly a case of a stiff back that had only been treated with the hit or miss effects of exercise based "treatments".
You folks really do need a kick in the collective .Honestly.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: back pain case - August 22, 2006 2:57:00 PM
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PainFree
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Joined: August 13, 2006
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Ginger,
Do you have a special & unique way of palpating these intimate spinal movements? Last I heard, manual procedures aren't that effective.
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Re: back pain case - August 22, 2006 3:42:00 PM
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ginger
Posts: 658
Joined: February 26, 2005
From: Melbourne Victoria
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Painfree, yes as a matter of fact I do, unique to me like all things skillfull are to everyone. The product of many years of hands on treatments where I have consistantly ignored the bleatings of those whose interests are served by offering yet more machines that go beep , in favour of the most useful of all instruments we have , hands.
I expect you are referring to yourself when referring to manual therapies as ineffective, mine certainly are not.
It is not difficult painfree, I've written page after page here on these forums extolling the virtues of a simple hands on approach. If you are unfamiliar with Continuous mobs, go to the manual therapies section of this forum and read the piece named "continuous mobilisation ", the method is not difficult to learn , is safe , effective and will produce results the exercise providers only dream about. Results that are long term , pain reducing , normalising in terms of spinal facet movements and their effects distally.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: back pain case - August 22, 2006 3:58:00 PM
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PainFree
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Ginger,
I should clarify....I think manual therapy is the way to go and I get fantastic results using an ecletic approach that I have refined in my fifteen years of practice. My comments were in reference to palpation skills which do not seem to have any consistency in their findings and meaning.
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Re: back pain case - August 22, 2006 4:34:00 PM
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ginger
Posts: 658
Joined: February 26, 2005
From: Melbourne Victoria
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Painfree it is very difficult territory for a trial attempting to rationaly assert precision over something so impossibly delicate and variable as the sensitivity of therapists hands. Perhaps those who have resolved to go no further towards manual therapies because of these studies would benefit from mentoring .
You have a series of skillfull talents gleaned from a vast sea of experience. It is this experience and sensitivity that is , most likely your best methoid of discerning change, monitoring feedback and producing good movement effects. Those that I refer to above seem immobilised by doubt, prefering to soothe their minds with yet more data, than to provide immediate and safe benefit . I contend those who are so unwilling , were poorly served with the kind of education that sought to" scienceify", their emeging skills, rather than ground them in simple talents we may share , and use well.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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