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Re: Bilateral leg pain
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Re: Bilateral leg pain - August 24, 2006 1:54:00 PM
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yarringtonpt
Posts: 112
Joined: July 4, 2006
From: Waynesville, NC
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Did treadmill test: walking 10 minutes - No pain
Recumbant bike: 10 minutes - no pain
Did some generic manual stretching to the hamstrings, hip rotators, glutes, hip flexors. 2 days ago.
Patient reports to PT today with no post exercise soreness. And, she has not had any leg pain at night since.
Exercise is medicine.
Maybe we are overthinking her pain complaints?
Thoughts?
Thanks everyone.
Eric
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: Bilateral leg pain - August 24, 2006 4:18:00 PM
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jboypt
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Eric,
My question is....are you certain there is no longer any pathology present? Is she better because of exercise, natural history, or she in a quiet phase of an active pathology. I don't think overthinking a pain c/o is ever bad. I would investigate end range extension in lying with overpressure 1 time. If she reports end range strain and not end range pain you know there is no joint displacement/pathology. However, if she reports end range pain with extension in lying with clinician overpressure, you have a unresolved problem.
John
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Re: Bilateral leg pain - August 25, 2006 2:49:00 AM
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yarringtonpt
Posts: 112
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From: Waynesville, NC
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John:
No, I definitely don't think I can say that she is better. It was just food for thought. Due to some probablw neural effect, which we may not fully understand, we have all seem patient's whose pain improves with simple movements. I'm certainly not done with this lady. Good suggestions.
Eric
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Eric Yarrington, PT, MPT, OCS
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Re: Bilateral leg pain - August 25, 2006 8:03:00 AM
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Jeffre
Posts: 130
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From: Lafayette, LA
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Funny how you can't provoke her pain and she dosen't hurt when she comes to therapy. These types always make me wonder. How is her affect? Perhaps a FABQ would be in order.
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"You are as well as your insurance company is willing to allow."
- Dr. Hibbert
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Re: Bilateral leg pain - August 25, 2006 8:30:00 AM
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yarringtonpt
Posts: 112
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From: Waynesville, NC
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Jeffre:
Affect is fine. Tired of hurting, but otherwise normal. Her most aggravating activities are stair climbing and prolonged gait >30 minutes; and pain at night. This may be why I have been unable to provoke. I'm also not sure how bad the pain is. Is it "normal" achiness/tiredness after prolonged activity in a sedentary person? I don't know. I'll keep the FABQ in mind.
Thanks,
Eric
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Eric Yarrington, PT, MPT, OCS
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Re: Bilateral leg pain - August 27, 2006 8:34:00 AM
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emad/emad
Posts: 42
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Hello Eric ;
Glad to know that your patient gets better .
Correct simple,fine ,attentive and gentle motion could be a very treatable method to address pain and neural sensitivity.
In fact,I do NOT know why treadmaill and prone on elbow tests ,for what ? and are those tests really reliable for the reason which i do not know ?
Cheers
Emad
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Re: Bilateral leg pain - August 27, 2006 10:39:00 AM
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srcase
Posts: 551
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From: Michigan
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Eric,
I am not normally a "stretching" type of therapist, but I think you hit the nail on the head with your last post. Deconditioned, sedentary people of this age tend to just get really tight, achey muscles. And I find that cardiovascular/muscular endurance exercise and gentle stretching help tremendously. Working on those tender points manually can be great too. Sometimes we forget that muscles can refer pain. The problem is getting them to continue to exercise at home. Some patients have cognitive deficits and can't remember simple stretches, even with pictures.
Maybe you were overthinking it. I wouldn't go crazy on the spinal stuff unless she really isn't making any progress. Even then, proceed with caution.
The only other thing that comes to mind is that some patients have leg pain from asthma medications, but I can't remember the specifics or which meds. Something to inquire about (along with the cholesterol drugs) if she is not progressing.
Sarah
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Re: Bilateral leg pain - August 27, 2006 3:02:00 PM
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rv36116
Posts: 216
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From: Texas
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I disagree with that Sarah. First off, if you can find muscles that bilaterally tighten magically and refer leg pain bilaterally, let me know. I'm no anatomy genius, but what muscles are going to:
1 - bilaterally refer pain into the legs
2 - cause intermittent pain at night when not being used
3 - be helped with pressing on them
Can you seriously take a look at the symptoms he described in the first post and point out 'muscle' as a possible cause and suggest pressing on points to relieve those symptoms?
When 'WOULD' you "go crazy on the spinal stuff" if you had a patient similar to this?
Thanks for your reply in advance.
[QUOTE]Sarah posted:
Working on those tender points manually can be great too. Sometimes we forget that muscles can refer pain.[/QUOTE]
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Re: Bilateral leg pain - August 27, 2006 3:23:00 PM
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nari
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From: Australia
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Sarah,
Did you really mean to say "muscles can refer pain" - or that muscles can appear to be a cause of pain? Somehow I do not think you meant what you wrote - hope that is so!
Eric, sounds like she is doing OK. Why not give her some time off and return in three weeks or if the symptoms redevelop? Chasing causes can be worrying for the patient.
Pain at night can indicate a few things, not the least pathology, but it is characteristic of chronic pain/sensitisarion, as emad wrote.
Nari
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Re: Bilateral leg pain - August 27, 2006 4:32:00 PM
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jboypt
Posts: 16
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Sarah,
If someone shows up with complaints of leg symptoms you absolutely have to rule out the lumbar spine as the source. Stretches are prescribed for tissue that has become tightened and not as random attempt to resolve complaints of leg pain. If tightness is the cause of symptoms (in the lumbar spine or peripheral joints) the pain pattern is consistent and never varies as it does with this patient. The point is that Eric still does not know what he is dealing with so why do random things that may or may not work?
Out of curiosity, what specific stretches would you prescribe and why?
John
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Re: Bilateral leg pain - August 27, 2006 4:38:00 PM
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jboypt
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Emad,
To my knowledge, prone on elbows by itself has not been studied as a specific test with or without reliability ascribed to it. However, prone on elbows can be used as a component of a mechancial examination which has high reliability and sensitivity. In fact, if performed by a skilled clinician it has been shown to be highly accurate and sensitive to rule in or out discogenic
pain with or without nerve root involvement.
If you are truly interested I will gladly send you the references regarding this post.
John
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Re: Bilateral leg pain - August 27, 2006 5:42:00 PM
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srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
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Rob, Nari:
Thanks for catching that. I didn't mean that the muscles themselves were causing the pain, but that as a 73 year-old, inactive person, she is most likely deconditioned and has adaptive shortening of her muscles which may be compromising the neurovascular structures peripherally.
Obviously, one has to clear the lumbar spine in order to proceed, but I was under the impression that Eric has already done that.
Most likely the patient does have some spinal contribution to her pain, and I'm not advocating ignoring the spine. The difficulty with this case is that the symptoms are not reproducible in the clinic. She may not be reporting accurately and/or is a poor historian....difficult to tell. However, the only change in symptoms has occurred with Eric's treatment of stretching and cardiovascular exercise. Soft-tissue mobilization (I never said trigger points) can also help decrease pain and improve circulation to the local tissues, in addition to the effects on the CNS and pain generators. I don't think this is way off base? I appreciate that you are keeping me honest, however! Keep it coming :)
jboy, specific stretching depends on the patient....I tend to do more active movements than passive streching...some call it functional stretching, dynamic stretching, or neuromobilization. If I do passive stretching, it is always with thought to positioning of the spine and followed up with active movement in the same direction for neuromuscular reeducation.
Ok, *closes eyes* fire away! Just remember I'm here to learn too.
Sarah
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Re: Bilateral leg pain - August 27, 2006 6:01:00 PM
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jboypt
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Joined: August 17, 2006
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Sarah,
I'm not sure I understood your post regarding the stretching. An example I was looking for would be something like this:
Diagnosis is frozen shoulder (or whatever) no tumor, no fracture.
With examination you find that patient's loss of motion is due to shoulder capsule tighntess (not
a tight muscle, nerve, or bony problem).
This patient's presciption is 10 reps of repeated
shoulder internal rotation 4 times per day with an
inflammatory contraindication (10 minute rule)
So back to your stretching recommendation for this patient's complaint of leg symptoms. What is the indication for "stretching" and in what direction?
John
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Re: Bilateral leg pain - August 27, 2006 7:14:00 PM
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nari
Posts: 1568
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From: Australia
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John,
How can one isolate one structure (capsule) and say it is tight and then stretch and strain it?
You're also stretching everything else in the vicinity - what has the capsule got to do with it?
I am sure you will back up with x studies done to show forced internal rotation produces some results - but give me Sarah's methods any day.
Coercive, forced PT was never in my books, though I got great results with much 'kinder' methods.
Nari
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Re: Bilateral leg pain - August 27, 2006 9:23:00 PM
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rv36116
Posts: 216
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From: Texas
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Coercive, forced PT isn't in my book either, nari, but I'd do the exact same thing for a frozen shoulder once a joint derangement is ruled out.
Otherwise, you're just going to see the patient for 3-6 months and have them creep along at a snails pace, which they could probably just go along with regular life and have the same effect 3-6 months down the road with out therapy.
Mechanically, if you have a "frozen shoulder" where every direction is limited, you will get the most bang for the buck with IR vs. multiple directions.
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Re: Bilateral leg pain - August 28, 2006 4:42:00 AM
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srcase
Posts: 551
Joined: November 30, 2004
From: Michigan
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Jboy,
I'm not sure if we're comparing apples and oranges here, but I'll give it a shot. For this particular patient with bilateral leg pain due to stenosis (if that's the diagnosis), I'd look at the length of the hip flexors (especially rectus femoris and iliopspoas) and hamstings, and possibly the external rotators of the hips. If the patient lacks full hip and knee extension in gait (which is likely), I'd work toward achieving more ROM in those directions, per the above methods.
My concern was taking a painfree patient through an aggressive spinal evaluation. I tend to be a little more conservative and work on movement impairments vs. trying to find a needle in a haystack.
Sarah
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Re: Bilateral leg pain - August 28, 2006 6:03:00 AM
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emad/emad
Posts: 42
Joined: July 4, 2006
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John;
Thanks ,let you post here that evidence supporting reliability of prone on elbow efficay in ruling discogenic pain .
Cheers
Emad
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Re: Bilateral leg pain - August 28, 2006 4:15:00 PM
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jboypt
Posts: 16
Joined: August 17, 2006
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Sarah,
Sounds good (regarding your stretches). However, I'm not sure what constitutes an aggressive or non-aggressive spinal exam. This patient has had symptoms for 2 months (chronic). As long as this patient does not have any red flags you're safe. In fact, Eric has not even been able to reproduce the symptoms. You have 2 choices with a spinal exam, provactive or reductive. Since this patiente has no symptoms you have to go provactive or you'll never learn anything. If a clinician is not comfortable treating spines and does not have training beyond PT school, then I agree with a "non-aggressive"exam. I'd hate to induce a lateral shift you could not reduce.
John
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Re: Bilateral leg pain - August 28, 2006 4:20:00 PM
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jboypt
Posts: 16
Joined: August 17, 2006
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Nari,
You're right. YOU can't isolate a capsule and I'm glad you're kind.
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Re: Bilateral leg pain - August 28, 2006 4:32:00 PM
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jboypt
Posts: 16
Joined: August 17, 2006
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Emad,
Please re-read my post regrading prone on elbows.
Here are some articles of note for you.
Donelson R, Aprill C, Medalf R, Grant W. A prospective study of cnetralisation of lumbar and referred pain. A predictor of symptomatic discs and anular competence. Spine, 22, 10, 1115-1122, 1997.
Fritz JM, Delitto A, Vignoovic M, Busse RG. Interrater reliability of judgements of the centralisation phenomenon and status change during movement testing in patients with low back pain. Arch Phys Med Rehabil 81, 57-61, 2000.
Let me know if you want more.
John
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