Here is a great case report recently of a patient in which I used Dr. Erson Religioso’s Edge tool to achieve what we all want for our patients, RESULTS!
A 45 year old female presents to the clinic with a 6 week history of left posterior thigh pain (to distal 1/3 of thigh). In general, it does not prevent her from performing ADLs or disturb her sleep, but only arises if she drives or rides in the vehicle. Symptoms will arise within 5 minutes and just get more intense until she gets out and walks or stands. This is affecting her day to day commute of 30 miles one way to work as a teacher.
Her past medical history is unremarkable and outside of work, she is very active working on her farm, coaching softball and occasionally playing pick up games of softball and flag football.
Her clinical exam is of the following:
A. She has pain free and full movements of the lumbar spine and hips except for peripherization (reproduction of concordant symptoms) with standing lumbar flexion.
B. DTRs and MMT unremarkable and symmetrical bilaterally.
I had a student at the time and we were previously talking about the benefits of centralization phenomenon in terms of prognosis and this would be another great example. Earlier that day, we worked on repeated movements on a different patient to show this effect with very positive results. I wanted to demonstrate similar effects with manual therapy so decided to perform manipulation of the lumbar spine.
Boom, centralization and even all symptoms abolished with testing of lumbar flexion in standing. We educated her to perform repeated extension in standing or even at the car (such as you would do on a wall in the clinic) for 10 reps every hour as able, but especially prior to getting into the vehicle.
The treatment seemed to be straight forward from here. Promote extension of the lumbar spine and symptoms would cease.
Follow up 2: She returned to the clinic and said she was doing better but still had symptoms that arose within 10 minutes of getting home (so would arise after 20 min instead of 5 min). She was adherent to the HEP. I found this to be very positive improvement and just needed more treatment. She again could still reproduce symptoms with standing lumbar flexion. On the 2nd visit, we decided to perform repeated extension in standing and prone (prone press ups) prior to manual therapy to see results. Boom, centralization and all symptoms abolished (great for an intern to see btw). I recommended same HEP and to add prone press ups in the morning and at night when she gets home (10 reps x 3 sets).
Follow up 3 and 4: Pretty much the same. The time frame until symptoms arose stayed the same while in the vehicle even though again able to centralize very quickly in the clinic. Treatment was same manual treatment and previous exercises, in addition to several bridging type movements in supine and hip and lumbar extension exercises prone. None of these caused pain and again patient departs without symptoms when asked to flex forward in standing.
On the 5th visit, it seemed as if we were plateauing with progression. As I typically tell my interns, ‘we need to go back to the drawing board’.
I decided to shine up the ‘ol Edge tool. Find out what I did on the next post so that patient could drive at least 3 hours without symptoms, or guess by commenting below 🙂
I’ll give you a hint…I only used it in one location