There are a couple of cases I'm gonna post up here to see what y'all think.
One right now involves a 19 y/o female who has complaints of LBP that worsens with prolonged standing/sitting. The pain is at the level of her kidneys and she reports that the pain is more intense after drinking caffeinated beverages. Pain has been constant since august and is never better than a 3/10. Flexibility is great in all planes of L-spine and B LE's. Stength is great in all movements. Palpable tenderness at L2 spinous process. hyperlordotic, no step-off. X-rays negative. Repeated motion made no change in pain level. Ab and erector strength 4/5.
My treatment began with lumbar stabilization ex's and postural muscle stengthening. Also going to work on abdominal/erector endurance.
When I asked fellow clinicians, they said just to treat it like an SI situation, another rattled off a ton of things (they escape me right now) on what it could be.
BTW, all low back special tests were negative.
Cases like this get my juices flowing in a good way (challenge) and a bad way (lost?).
My first inclination was decreased spinal stabilization, then when it was revealed about the pain with caffeinated drinks, I thought kidney involvement, but the patient stated the urologist performed light force blows to the kidney area and "ruled them out". Clinicians said there was no way it could be kidney because the urologist would be in a heap of trouble if he missed it. Oh yeah, she also has had multiple (12 or so) bladder infections over the course of 2 years and drinks only 32-40 oz of fluids a day (mostly lemonade and caffeinated beverages).
Things just don't jive in a way that I can relate to my previous experiences.
Joined: October 27, 2002
From: New York, NY
Wow, interesting case!! I am not sure of what's going on just from your description but a couple of things jump out at me.
1. Were you able to mechanically reproduce her pain at all? Any special tests, any repeated motions, any positioning reproduce it. If not.....you should be concerned. If she says sitting brings it on, have her sit in you office until it shows up so that you can verify that it's mechanical.
2. Caffeine can irritate the bladder and stomach. Not sure about the effect on the effect on the kidneys. But...if there is a clear case of the pain coming on most clearly, after caffeine, then it's probably not a PT issue and should be referred.
3. Don't ever assume a physician won't miss something, even a specialist. It happens all the time. I am not sure what light force blows to the Kidney would tell you but that doesn't sound like proper screeing to me. What about her urine and blood work?
4. Does she have a primary care you can talk to. How about calling the urologist to discuss the case? Right off the bat, I think you should be drinking a lot of fluid with a history of infections and it should not caffeinated or sugary beverages.
Joined: July 7, 1999
From: Montgomery, AL, USA
I want to second what Marc said. #3 first came to my mind. Wouldn't it be great if nobody ever missed anything, just because they would get in trouble if they did?
Also, the fluid intake is very suspect. Ony 1 quart of fluids and most of that is caffeinated and full of sugar? Averaging a bladder infection every other month for 2 years? Has she been on anti-biotics each time? Wouldn't her physician have discussed fluid intake with her? Maybe ask her what the doctor recommended she be drinking. Something just doesn't seem right. After so many bladder problems, it would seem very unlikely that she does not know her fluid intake is more than likely hurting her. Definantly need to discuss with her physician.
Joined: December 1, 2004
Sounds fishy. The constant pain that doesn't change with movements or positions, has been present for 4 months, and the report of caffienated drinks making it worse, all sounds systemic versus mechanical. Sounds like you need to dig a little deeper into this one. I would call the referring physician if no improvement was seen in 5 or so vists. In the meantime, how is her sitting and standing posture? Did you try PA mobs of the lumbar (especially L2) to see if it provokes pain? Are all SI joint provocation tests negative? (It doesn't sound like SI joint at all). How is her thoracic spine mobility? Does she hinge at L2 with extension? Does compression or traction change the symptoms? Any muscle tension in paraspinals? I think the lumbar stabilization approach is applicable in this case, but like I said, if no change, refer back to physician. Sarah
Joined: February 14, 2003
From: Madison WI USA
Yep, I agree with all of the above. Your best bet is to go through the primary MD, whether it be famlily practice or internal medicine. She is entitled to a second opinion, and Buddy's advice is spot on.
Joined: December 14, 2006
From: ny, ny
A few blows to the kidney is not enough to rule out pathology. This does not sound mechanical! I agree whole-heartedly with Buddy. Of course, since this has been around for 4 months, 2 weeks of a trial therapy would be ok. What gave you the idea that she was unstable? Sounds to me like her abdominals and lumbar erectors have symmetry in strength. Symmetry and coactivation provides stability, not gross muscle strength. If stability is her problem you may not get a favorable response in four visits. Stability training typically take s 6 weeks for positive results.