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JLS_PT_OCS -> Patient Case #2: Acute on Chronic LBP and Neck pain (October 6, 2005 8:34:00 AM)
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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
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