chronic LBP (Full Version)

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rwillcott -> chronic LBP (April 15, 2008 9:38:04 PM)

I have a 50 year old male patient with a 4 year history of LBP.  He initially injured his back picking up a 30 lb pump.  Since then he has been having right sided LBP.  He has never had any radiating pain into his lower extremity.  He has had PT in the past which he stated would provide him with short-term relief.  He has also had chiro and massage with no improvements.  He reported being very apprehensive about lifting and manual labour.  He owns a construction company and must rely on his employees to do most of the work.  He finds this frustrating since he feels that he can't do a great job relying on his employees all the time.

Objectively, he reported improvements with sitting and lying on his back with his knees up.  He reported being worse in standing.  Objectively, there was no list noted.  Dermatomes, myotomes an reflexes WNL.  Acitve flexion was 75% with right LBP.  Extension was 50% with the same response.  No abberant movement patterns noted.  Repeated flexion in lying reduced his LBP.  Slump and was positive while SLR was negative. There were hypomobilities of L4/L5 and L5/S1. 

My impression is that he meets the flexion sub-group.  However, with the hypomobility I felt a manipultation may also help.  I sent him home with repeated flexion in lying.  I thought I would see how this helps first.  He also has a lot of fear of re-injury.  He seems discouraged as well.  He seems like his treatment plan should be a mix of graded exercise, flexion and manip.  However, I want to be very direct in my treatment plan.

How would others treat this patient?  I can provide further info if needed.



TexasOrtho -> RE: chronic LBP (April 15, 2008 9:53:55 PM)

RW I have a few questions:  Are his symptoms constant and how do they fluctuate throughout the day?  What's his daily activity like and how do they affect his symptoms?  What does he do when his symptoms are at their worst?  I've found that some patients will subconsciously move into positions of ease by flexing when extension hurts and vice versa.  This can sometimes clue me in as to whether I treat them with flexion or extension.

Sounds very posterior element-like upon initial glance.  (pain referral, comfort with flexion, etc...)  Initial onset is very disky but as you mentioned it was over four years ago and likely doesn't play into his current presentation.  If slump was positive I typically also perform neural mobilization via flossing technique of your choice.

If he's fearful, I'd spend a lot of time retraining his lifting mechanics in a variety of context to teach his LE's and LB to work well together.  Your typical battery of exercises will likely do the trick.

I'm not sure about the manip...I might wait until you see how your first-line treatments go.  Sounds like you are on the right track.  I'd like to hear how it pans out.



annpsu25 -> RE: chronic LBP (April 15, 2008 10:27:06 PM)

Did he have any diagnostic tests done?  If so, what were the results?  Any history of arthritis?  Any reports of weakness in the LE?  My first thought was spinal stenosis, as patients pain eases with sitting and flexion, and worsens with standing and extension.  Also, the hypomobilities could be caused by osteophytes.  What else can you tell us about this patient?  Has the pain worsened as time has gone on, or has it generally stayed the same?



bonez -> RE: chronic LBP (April 16, 2008 1:51:33 AM)

Just a question were any manual resrtictions found unilaterally in the thoracolumbar region? Is the painful sided hip flexor tight? I would concur re flossing but would also address the above questions if they were present as well.
If your neural screen was clean and no contraindications present to manipulation I would consider manipulation too



rwillcott -> RE: chronic LBP (April 16, 2008 6:52:26 AM)

His pain is intermittent and worsened with prolonged standing.  He finds relief with sitting.  I don't feel that he presents with spinal stenosis.  He had x-rays a couple of years ago which were negative.  Luckily his doctor advised him that more x-rays were not necessary.  There may be osteophytes present but I abandoned a pathoanatomical approach a few years ago.

I guess I posted this case since he fits into more than one sub-group of the TBC system.  I agree that some flossing may help.  Again, this is not a sub-group.  I'm curious how others deal with patients that are not simple extension sub-group etc.



SJBird55 -> RE: chronic LBP (April 16, 2008 7:18:22 AM)

Allisha - no clinical indicators were mentioned in the original post that would support any diagnostic tests for the low back complaint.  (I completely agree with the physician.) Just because a patient has low back pain, even for years, does not necessarily mean he should have any diagnostic testing.  Now, if he had a history of cancer (in particular cancer that has a greater likelihood of metastasizing), yes, diagnostic test away.

I'd definitely educate him on pain.  If he's fearful, that is probably your biggest obstacle.  His body is protecting him.  I'd continue with the flexion activities; I'd probably do PA mobilization; I'd do some neurodynamic stuff and have him doing that as a home program; I'd then get him into doing goofy activities to see how his body responds (again, he's afraid - I always communicate that I need to see what activities the body is protecting him from, so this WILL be scary for him, but not for me, but if we don't figure out when the problem happens, we can't help the body learn that things are really okay) - lifting 10# from waist height in front of him and placing it at a little lower level to his left and also to his right;  standing on something that is somewhat unstable (like 2 core stablizers or a BOSU or foam) and hanging onto a 5# resistance close to his waist - then as standing and keeping balance - hold the weight out on a 45 diagonal or so from his center at shoulder height, bring weight back to center to chest and then hold it in front of him at shoulder height, bring weight back to center and then out on a 45 diagonal to his left.  Generally, for attempting to do graded exposure, I get creative and dink around with different positions to see how his body responds.  He'll start getting a "clenching" feeling or a "tight" feeling.  If sharp pain occurs, you know you've found the culprit motion.  I generally have the person push through and do maybe 3-5 repetitions of what causes sharp pain.  (I always want to know if the pain changes.)  Then, we sit down and discuss pain and why the body might be responding with sharp pain.  These folks take time (multiple visits) and to really do a graded exposure, you probably should find what it is the body doesn't like and go from there.  I always end the session with assisting to find a way to have the "clenching" go away.  Believe it or not, with these types of patients, I have them in the clinic 20 minutes and out the door.  I break the "scary" activity into something that can be done at home - just 5 movement patterns or so 3-4 times a day.  Generally, they are scheduled 2x/week.  That's just me though.



Shill -> RE: chronic LBP (April 16, 2008 9:15:17 AM)

Rwillcott
You commented "His pain is intermittent and worsened with prolonged standing.  He finds relief with sitting. "  Does this mean that when he sits, his pain goes away, and stays away?  Is there pain with arising from sitting?  Does he ever have difficulty standing fully straight after sitting?  The apparent relief from sitting may not actually be relief, if after 20 minutes, sitting hurts again, OR if there is indeed pain with rising to stand.  I often find myself trying to convince the patients that sitting is not as helpful as it seems, if there is the pain associated with rising from sitting.  I tell them that it is likely what they are doing during the sitting (flexing under load) that results in the pain upon rising.  It may be that the unloading portion of the supine knees to chest is what helps.  I struggle with the supine flexion being helpful in the cases when loaded flexion is an aggravant.  However, if he remains improved for a while after the supine flexion, then he should stick with it, even if it may not make perfect sense.  I also have patients doing the pain relieving exercises every 2-3 hours, which admittedly is challenging for compliance, but if it relieves pain consistently, it makes sense to keep things relieved consistently.   Anyhoo, my 2 centavos.



steve -> RE: chronic LBP (April 16, 2008 11:59:06 AM)

Rwillcot,

I think you have some great suggestions above but would also suggest using the FABQ, ODQ and some inclinometer measurements of ROM so that I could determine of this fellow is really appropriate for manipulation (FABQ score) and give you some tangable outcomes to base his response to treatment. I find patients who have been in pain for four years very difficult to determine if they are getting better based only on their subjective comments.

Steve



kiwi PT -> RE: chronic LBP (April 16, 2008 9:00:07 PM)

Do you know what his prior chiropractic treatment consisted of (manipulation vs Activator Bull S@#$, vs voo doo) , and any more about his resonse to it? Was it short term improvement that didn't last, no change, aggravation? I would think it reasonable to attempt manipulation as a small peice of a multimodal treatment approach, especially if he had some short term improvements before, but I would also quickly transition to things he do more independently. I also agree that FABQ score may be important with this pt.

Kyle PT



annpsu25 -> RE: chronic LBP (April 16, 2008 9:08:58 PM)

quote:

ORIGINAL: SJBird55

Allisha - no clinical indicators were mentioned in the original post that would support any diagnostic tests for the low back complaint.  (I completely agree with the physician.) Just because a patient has low back pain, even for years, does not necessarily mean he should have any diagnostic testing.  Now, if he had a history of cancer (in particular cancer that has a greater likelihood of metastasizing), yes, diagnostic test away.


You are very correct!  I can't seem to get diagnostic testing out of my head when it comes to LBP.  I believe we discussed this in a previous post.  Thanks for reminding me, as I will be sure to remember this in the future!



rwillcott -> RE: chronic LBP (April 16, 2008 9:34:16 PM)

shill,

Prolonged sitting will increase his LBP.  I was uncertain about giving him repeated flexion exercises because of this.  However, he responded well to repeated flexion in lying during the assessment.  My feeling was that there was no disc protrusion and since it helped him in the clinic he would be safe with this exercise.

steve,

I will have him score the FABQ and RMQ next session.  Good advice to get some solid outcome measures with people who are chronic and displaying fear avoidance behaviors.  I have an inclinometer and tend to use it mainly for the cervical spine.  In Cleland's text his research for the use of the inclinometer for lumbar spine ROM is based on placement at T12/L1.  Do you have a preference for placement?

kiwi pt,

His chiro treatment did consist of manipulation.  He had short-term relief initally.  However, on one occasion he had pain during and after a manipulation was performed.  He stated this scared him and he never went back.  He has also had massage that consisted of CST techniques.  I had to refrain from bashing the masseur when he described the utterly useless techniques she performed with him.

I'll try to get some more outcomes and info and keep you posted.  Thanks for all the great advice!



kiwi PT -> RE: chronic LBP (April 16, 2008 10:40:43 PM)

Since he has a fear of it (manipulation), whether his fear is rational or not I wouldn't try to talk him into it unless the indicators for manip were overwhelming, which they don't seem to be.

Kyle PT



TexasOrtho -> RE: chronic LBP (April 16, 2008 10:54:04 PM)

If he has had manip with poor or no success, I would put it as a weapon of last resort.  I think you are on the right track with FABQ and/or other salient outcome measure to track this patient.  I would definitely be thinking a multimodal approach for this patient.  At his age, I'd be a little concerned about repeated flexion.  But hey, some backs to not read the McKenzie or structural paradigm textbooks.  Keep hacking away and sometimes the answer eventually runs up and kicks you in the face.

...man I must have some violence issues.



steve -> RE: chronic LBP (April 17, 2008 10:42:38 AM)

Rwillcot

I use the TL junction for measurement - I use the inclinometer with all my patients and find it very helpful in determining response to manual therapy. I measure them pre and post manual treatment. A significant improvement is predictive of improvement bnetween sessions.

I agree that manipulation would be a tool of last resort if he was scared by the chiro manip.

Good luck and keep us posted, great to hear all the different clinicians and their wisdom with these patient problems.

Steve



Shill -> RE: chronic LBP (April 17, 2008 5:13:05 PM)

Rwillcott,
Ive been there too, where they do best with the unloaded flexion despite not doing well at all with loaded.  Its sometimes tough for me to stay flexing when the loaded symptom behavior is so obviously bothered by it.  This is where I sure need to stick with what centralizes until something gives me an objective reason not to, despite my gut feel. 



Kaden -> RE: chronic LBP (April 18, 2008 2:53:07 PM)

Rwillcott,

I actually presented similar to your patient without as long of a chronic history.  Had an incident a few weeks back that left me with similar symptoms though and thought I would share.

I find it hard at times to classify someone into a flexion or extension preference when they do not have pain into the lower extremity.

Myself I got relief initially sitting but had pain with loaded flexion (especially prolonged sitting) but I get relief in supine flexion.  Foward flexion was okay.  I however, like your patient, had pain with slumping and my injury was lifting as well.

So...I theorized my pain was more discogenic and tried some extension as well (after supine flexion did not give any long term relief).  Interestingly, extension did not feel as good as supine flexion but when I eliminated the supine flexion work and focused on extension it was this position that gave me long lasting relief from my symptoms. 

When we don't have peripheral symptoms I think the position of comfort may not always be the position for longer term relief of symptoms.  We know with larger protrusion patients often will have more pain in extension but get relief in flexion but it is actually extension that centralizes the pain and we go here, not simply looking for relief.

As far as his pain in standing prolonged I too had this, intially, probably loading sesitive but as I worked prone this improved and got much better with some mobes to the lower lumbar spine. 

Bottom line, I think I was seeking the position of relief and this is not always the position that will get at the "root of the problem"




maddenpt -> RE: chronic LBP (April 21, 2008 10:42:00 PM)

Why the resistance to manipulation?

Something we have successfully used in our clinic for patients who have failed with manipulation (esp those who have failed with chiro...which is usually the lumbar roll...rotational movement for apophyseal pain) is to take them to end-range in the manip described by Flynn et al.  From the history there seems to be no reason not to do it...especially considering there is no radic.  If they have no pain at end-range, many times just having the patient take a deep breath in and relax will cause cavitation and instant relief...as long as you are confident.

The patient owns his own business...so what do you think is going to show up on the FABQ score that would change your treatment?

Also, where is the SI assessment?

With full knowledge and previous experience with the McKenzie MDT system, this is one of those mystery patients who used to frustrate me.  The first concept covered in the McKenzie course is "There is no magic bullet."

That's true...but there are magic guns.  Learn as many as you can.

We have found the Richard Jackson SI mobilizations work well...especially b/c they have gradients for patients with previous bad manip experiences.

Good luck!

Chad Madden, MSPT




rwillcott -> RE: chronic LBP (April 22, 2008 9:27:39 AM)

I've been meaning to provide an update on this patient.  He was seen last week and continued to report right sided LBP.  I had decided before his appointment that if repeated flexion did not reduce his symptoms I would try a manipulation.  As we dicsussed his back pain it became clear to me the amount of frustration and fear this man has regarding his LBP.  Since I was considering performing a manipulation with him I thought I would have him clarify if the chiropractic sessions helped him.  He said no and that the chiropractor had told him that this was something that he would have to live with forever.  He told me that the chiropractor advised him that the disc had 'blown' and was out of place and would never be the same again.  Ever since then he has avoided most activities that he felt could aggravate his back pain.  I spent a half an hour reviewing anatomy and the disc.  I assured him he had no signs that the disc was 'blown' and that it is safe for him to perform exercises.  I could see the sense of relief on his face.  He asked if it was okay to lift light weights at home and go for long walks.  I advised him that he should be doing this along with the exercises I prescribe.  Without scoring the FABQ it is clear that this paitent required education regarding his LBP and a graded exercise program should be beneficial. 



Shill -> RE: chronic LBP (April 22, 2008 1:03:45 PM)

I have used sidelying ABDuction of the hip for a repeated movement in unloaded position for folks with very one sided symptoms that dont continue to respond to flexion and extension.  Whether repeated or passive prolonged ABDuction of the affected side leg. 

Sounds like with some fear avoidance reassurance he will be doing well in no time.



rwillcott -> RE: chronic LBP (April 30, 2008 12:29:12 PM)

This guy was doing well with a graded exercise program.  However, yesterday he reported that he had an increase in his pain over the weekend.  He spent 3 hours in a flexed position on his hands and knees working on a floor!  He said he had been feeling great up until then and thought he should try doing more!  Needless to say I explained to him that this is not a good thing even for a healthy back.  I also decided to perform a supine rotational manipulation and also a manipulation in side lying.  This provided immediate pain relief.  Hopefully he can stay out of those aggravating positions.



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