How would you treat this chronic low back pain case? Follow-up

I wrote a post several weeks ago giving readers history and objective findings of a difficult chronic low back pain case.  Revert back to it before reading on.

Patient was treated in physical therapy for 3 weeks with no expression of improvement per SANE scale, no change per GROC, only short term centralization phenomenon but no carry-over beyond 3 hours, and no changes in pain rating scale (still 6/10 currently, 6/10 at best and 6/10 at worse).  However, Oswestry score did decrease from 56% to 42%, a drop from 28 to 21 points, or 7 point difference.

Therefore, even though high construct of central sensitization, “ramped up CNS”…she was referred out as I wasn’t doing anything for her.

She returned to our office s/p 1 week ESI (epidural steroid injection) for further therapy with following results:

1. Her pain is significantly improved and highest pain has been in a week has been 2/10.

2. No leg symptoms (centralized)

3. Only has taken 1 pain pill in a week (initially took pain pills everyday).

Some insight/questions:

1. She did have a positive crossed SLR on initial evaluation (highly specific for IDH)…maybe she did need ESI based on this finding itself…or as my assumption…she was so ramped up that this gave a false positive finding.

2. Even though functionally improved, patient did not express changes at all with a multi-modal physical therapy treatment so don’t rely on functional scales.

3. It has been only a week s/p ESI, but was this the intervention needed for success?

What are your impressions for referring out for ESI? What signs/symptoms indicate success for this procedure, or is it just failure of PT intervention?

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What is the tissue source in low back pain? Part 2

I polled my readers several weeks ago asking them what they thought the tissue source was in low back pain?  Thanks to everyone who responded and provided feedback!  Results are:

tissue source in low back pain
tissue source in low back pain

An overwhelming winner at 41% “none: pain does not equal tissue damage”

So my next thought is: with this rationale, how would you treat an individual coming into your office?  I know this is a loaded question which varies from patient to patient, but everyone has their “go-to” treatment.  What is your typical “talk” that leads to an active recovery?

 

What is the tissue source in low back pain?

As I speak with more clinicians, I get wider and wider views of what the tissue (soft tissue or inert) source in low back pain.  For sake of this post, let’s say chronic low back pain…dubbed non-specific low back pain. The most common answers are the:

1. Intervertebral disc

2. Facet joints

3. Myofascial

4. Sacroiliac joint

5. None (unless symptoms are acute, pain does not equal tissue damage)

Training, type of patients, treatment approaches, research, media, and beliefs all play a combined role in creating a bias.  Two of my mentors are on exact opposite ends of the spectrum.

For instance, here is an example of the diversity in ratio:

Clinician 1: Sacroiliac Joint (80%), Facet Joint (10%), Myofascial (10%)

Clinician 2: Intervertebral Disc (30%), Facet Joint (60%), Sacroiliac Joint (10%)

DePalma et al in 2011 estimated the prevalence rates of discogenic, facet and sacroiliac joint in chronic low back pain patients whom have been in motor vehicle accidents.  After having diagnostic procedures that are “criterion standard” for diagnosing either of the 3 conditions above, here are the results:

Of the 27 patients, 15/27 (56%) were diagnosed with discogenic pain, 7/27 (26%) with sacroiliac joint pain, and 5/27 (19%) with facet joint pain.

The author’s conclusions:

Our study is the first to demonstrate that diagnostic spinal injections can identify particular spinal structures, namely the intervertebral disc, facet joint, and sacroiliac joint, as the specific source of chronic low back pain due to inciting motor vehicle collisions. The most common source of motor vehicle collision-induced chronic low back pain appears to be the disc followed by the sacroiliac and facet joints.

Granted this is a subgroup of chronic low back pain patients (small n too), but based on this data…

Clinician 3: Intervertebral Disc (55%), Sacroiliac Joint (25%), Facet Joint (20%)

Quite the variability right?

I want to know what YOU think.

I have had success in the past with polls (EBPpre-manipulation hold, and osteopractor word of the year), so I hope to get lots of engagement!

You know you see low back pain.

You know you have an opinion.

So let’s ALL engage to get a true sense of what clinicians think ALL over the world.

To participate, choose your TOP tissue choice of low back pain.  Then in comments, provide a ratio as I did above, your profession and explanation behind your rationale.

Differential Diagnosis – Low Back and Leg Extremity Case: Part 3

I recommend reading part 1 here and part 2 here prior to reading further on a challenging differential diagnosis case.

Below is a copy of this patient’s lumbar spine MRI.

Differential Diagnosis Low Back and Leg Case
Differential Diagnosis Low Back and Leg Case

Based on subjective and objective findings from part 1 and part 2, as well as a Normal MRI of lumbar spine as noted above, what is your impression of this patient?

How would you treat this chronic low back pain case?

Subjective History: 35 y/o female presents with hip and back pain.  She had no injury or accident but has been dealing with back pain for 5-6 years.  She sought care from surgeon who ordered MRI (5-6 yrs ago) that showed DDD but that she was too young for surgery and has to deal with the pain.  In Feb 2014, her right hip “gave out” on you on her way to work one morning.  The sensation was a pinching in the groin that hurt on every step.  It hurt so bad that she went to ER who then referred her to Dr. *&$^(.  She has had multiple x-rays, bone scan and then MRI of hip showing a torn labrum in April 2014.  She wound up losing her job after 14 yrs due to not being released to go to work.  She had another consult in Sept 2014 with a surgeon for hip, but was told to lose weight and she was not a candidate for surgery.  She started another job (that involved 8 hrs of standing) shortly thereafter but after one week, she could hardly stand due to right hip pain arising again and numbness in right leg.  She then sought care from her PCP, Dr. *^%*, who referred her for CT scan (for back) and then to Dr. *$&^.  She had a consultation and then referred to PT.  She was told she would have injections.

Onset

Date of Onset: Back pain and numbness in right leg for past 5-6 years. Right hip pain started Feb 2014. In 2010, she had to have ambulance get her from her house due to her back giving out and right leg “stuck” resulting in her having to be put asleep to get the right leg extended again. Onset Due To: Unknown. Recent Symptom Trend: Condition worsening.
Symptoms
Primary Symptoms: She c/o numbness down right leg from hip posteriorly to 5th digit. Provokes symptoms: Any movements. Hurts with standing/walking/sitting and doesn’t matter what type of chair. Relieves symptoms: trying to stretch (nothing specifically) and sometimes medication.

Pain Rating:

Currently: 6.5/10, Best: 3.5/10 (between stretching and medication), Worse: 10/10 (see above but also occurs weekly).

Sleep Disturbance: She barely sleeps. She tosses and turns all night only getting 4-5 hours. This has been going on for years.

Vocational
Current Status: Not working. Has lost 2 jobs in last few years due to functional limitations.

Objective
FABQ (work): 19, FABQ (physical activity): 22.

Oswestry: 56%

Observation: Unable to stand without dysfunctional pattern and using B UE for support.

Observation: Single leg stance 5″ on left limb, 1″ on right limb.

Palpation

Hypersensitivity along entire lumbar spine from L1-S4 mostly centrally > laterally ~3 fingerbreadths from SP

Lumbar Spine Flexion: 
Very restricted to patella bil and pain low back (all AROM equally painful in same location in LB)
Lumbar Extension:
Very restricted
Only ~5 degrees. (all AROM equally painful in same location in LB)
Lumbar L Side Bending: 
Very restricted
Only ~10 degrees. (all AROM equally painful in same location in LB)
Lumbar R Side Bending:
Very restricted
Only ~10 degrees ((all AROM equally painful in same location in LB))

Reflex Tests
Achilles Tendon Reflex (S1)
Absent (0) on right, 1+ on Left
Patellar Tendon Reflex (L4)
Diminished (1+) bilaterally

Neurodynamic Tests
SLR
Positive
~40 deg SLR for LB but not leg symptoms on LEFT, and ~20 deg SLR for LB but not leg symptoms on RIGHT (+ crossover)

Lower Extremity Dermatomes (to sharp prick):
L1: Inguinal Region: Intact

L2: Upper Thigh: Intact

L3: Mid Thigh: Intact

L4: Patella, medial leg, medial malleolus: Intact

L5: Dorsum of foot, 3rd metatarsophalangeal joint: Intact

S1: Lateral aspect of calcaneus, lateral aspect of posterior leg: Diminished
Absent to lateral aspect of foot from calcaneus to MCP of 5th digit.

S2:Medial aspect of posterior leg: Intact

Lower Extremity Myotome Strength

L2: hip flexion: 4/5
Generally weaker on right side
L3:Knee extension: 4/5
Generally weaker on right side
L4: Ankle Dorsiflexion: 4/5
Generally weaker on right side
L5: Great Toe Extension: 4/5
Generally weaker on right side
S1: Ankle Plantarflexion: 3-/5
Unable to perform single calf raise on RIGHT, 18 reps on LEFT
S2: Knee Flexion: 4/5
Generally weaker on right side

With the information provided, how would you proceed? What other objective/subjective information do you need?  Is this individual appropriate for PT services?

DIFFERENTIAL DIAGNOSIS — LOW BACK & LOWER EXTREMITY CASE: PART 2

Before reading the objective findings below, make sure you read the subjective history taking in Part 1 here of this differential diagnosis case.

Observation: Slouched posture. Decreased lumbar lordosis.

Gait: Stiff leg, wide-based gait pattern with very little knee flexion and hip extension.

Tenderness: Generalized tenderness in lower lumbar spine and SIJ with no particular one location.  This is the same in weight-bearing (standing/sitting) and non weight-bearing (prone).

Palpation: No warmth to and around the lumbar spine and pelvis.

Lumbar ROM: Painful in all directions but only limited by 25%. No particular DP. Symptoms are generalized in lumbar spine.  No peripherlization or centralization of symptoms with repeated movement exam in standing or prone.

Hip and knee ROM: Normal and unremarkable in all planes.

MMT: 4/5 hip flexion that causes low back pain.  Both knee flexion and knee extension is 4+/5 that also causes low back pain.  No myotomal weakness or remarkable findings distally.

Neurological: 

– Negative SLR and prone femoral neural tensioning test.

3+ B L4, 3+ B S1.

+ Babinski

– Hoffman sign

– Supinator sign

– 2+ B C5-C7

Based on the above information,

What are your top 3 differential diagnoses?

What type of information did you gain from the video above?

What other objective findings would you look for / test?

Would you treat, refer or treat and refer; and why?

Differential Diagnosis — Low back & lower extremity case: Part 1

Looking for feedback on this case.  Questions will be provided at end of blog post below case.

Script: Lumbar Disc Herniation.

Medical History: (I am listing the “Yes” remarks from intake form):

-Positive for arthritis

-Positive for sleeping difficulties

– She smokes 1/2 pack a day and 4 packs a week

– She doesn’t work out but does enjoy walking sometimes

Subjective History: 32 yo female presents with main complaint of back pain and BIL LE. It all started with Bil LE pain but she has had a history of low back pain which was just uncomfortable, but now it is unbearable.  This arose during the month of August following a surgical procedure following a miscarriage (patient was unsure of procedure but I am assuming D&C).  She consulted with her surgeon but he is unsure why she is having symptoms following this procedure.  She was then referred to a spine surgeon who referred to PT for 4 visits until he can order an MRI.

Prior history: She has had one other miscarriage in the past.  She says she is not sure why she miscarriaged then and even now.  Her MD doesn’t know either.  She is not sure if her mother had miscarriages either.  She has one son who is 6 years old.

Date of Onset: Mid-August 2014 (4 months ago). Onset Due To: Arose after D&C.

Recent symptom trend: Since August, the pain has spread from the thighs to the low back. Pain is mostly in the thighs, but will work to the calves at times, but cannot provide any further information of why.

Pain Rating
Verbal Pain Rating at Present: 8 /10
Verbal Pain Rating at Best: 6/10 (Over the past week)
Verbal Pain Rating at Worst: 10 /10 (Over the past week)

Quality of symptoms:  She describes the back pain as unbearable at times.  But for the most part, everything is just “sore”.  She has trouble moving around.  She feels like everything needs to pop. Her symptoms are mostly in the thighs, equally bilaterally, and circumferentially.  She says this is numbness/tingling and burning.  She also describes muscle spasms in the same location that is painful.

Provokes symptoms: Any movements could do it, but also she can have muscle spasms that arise just sitting.  She denies any postures, movements or positions that make symptoms better or worse.   Relieves symptoms: Lying down with heating pad (legs elevated).  Medication as prescribed.

Medication: Prescribed muscle relaxer (Skelaxin) that she takes 1-2x/day as needed.  Was prescribed a 10 day prednisone series

Sleep: She only gets half the amount of sleep than she did prior to procedure.  She says she wakes up several times a night and it can keep her awake for several hours at at time.  She just lies there and watches TV.

Further questioning:  PT in italics, patient in normal font.

Are you having any changes in your bowel or bladder? No.

Are you having any painful urination or bowel movements? No.

Are you having any pain with intercourse? No.

Any discoloration in your urine or bowels? No.

Are you having any abdominal pain? Yes but only came on after taking Diclofenac as prescribed by MD.  However, I am not taking this medication anymore due to the effects.

Where was it hurting in your abdomen? Generally in lower abdomen pointing diffusely in this region.

Do you notice the lower limb symptoms at different times of the day? Yes, it gets worse as day progresses but blames it on just being active to do daily tasks.

 

What are your top 3 diagnoses so far?

What other questions would you ask prior to proceeding to objective exam?

Left flank pain. Differential Diagnosis.

Quick case here.

I have a current 31 year old female patient who is seeking my care for shoulder pain following a work injury.  She arrived to our clinic the other day with excruciating left flank pain.

Subjective: She says she started having left low back pain that morning but very mild.  However, when she got to our clinic and used the restroom, her back pain became excruciating (10/10…to the point of tears).  She said it hurt more while using the restroom.

What is your diagnosis so far? 

Upon further questioning, she said she had some painful urination (dysuria) for the last few days but wasn’t as bad as currently in the clinic.

Does this change your diagnosis?

Upon further questioning, I ask the patient what she thinks is her problem.  She says a kidney stone.

Does this change your diagnosis?

She had reproduction of symptoms with percussion sign over involved costovertebral junction of 12th rib.

Should you perform further mechanical testing (i.e. active range, passive physiologicals?) or do you have enough info?

…………

I referred out immediately….

Okay, so this case was quite straight forward to refer out but good to share.

One thing I wanted to highlight is my question of “what do you think is your problem?”.  This is a simple question and we forget it sometimes.  Patients often times know is something is “mechanical or non-mechanical”.

Follow-up: She came back to me a few days later and said CT scan showed kidney stone in ureter (actually on both sides) and she thinks the stone has passed on one side but not the other.  She was put on morphine in the ER and now on Norco at home.  Occassional sharp back pain and is scheduled to see urologist.

This is scientifically accurate, but should it have more jazz?

Photo Courtesy: htt://uthmag.com

Max Zusman has a great Editorial Opinion in the Journal of Multidisciplinary Healthcare in 2013 entitled, “Belief reinforcement. one reason why costs for low back pain have not decreased”.  It is available via open source here.

There are definitely many points out of this piece that could be written about, but I like how he ends the article with a simple narrative of how a clinician could approach a patient prior to performing a manual technique.  It can be rewarding to read opinion pieces in journals as it is the only way to really write how you feel!  Otherwise the writing is more scientific.  Hence a great reason to start a blog.

Here is his exact quote,

Yes, my examination confirms that this particular area of your spine is not moving as it should.  The reason it is prevented from doing so is the presence of pain — that is a part of pain’s job, and we have already discussed the likely chemical basis for you pain.

Because you are unable to move about normally, to get you started I am going to use my hands to help your back move properly.  We are greatly assisted in this regard by the fact that when skillfully applied the treatment I use directly inhibits pain.

Pain inhibition is also useful when your own muscles begin to take over the work.  As things improve you will no longer need it. Nevertheless, I will continue to serve as your active movement guide, and general adviser, for as long as is necessary.

I really can’t disagree with this statement.  It is stated quite neutral, without any obligations to “put bones back in place” or “release muscles”.  It is scientifically accurate.

Although, I wonder if it could be jazzed up a bit more to maximize results?

Recently at the first week of AAMT Fellowship in Orthopedic Manual Therapy, Dr. Justin Dunaway gave an enlightening lecture on the biopsychosocial aspects of pain.  In particular, he spoke about the positive effect of expectation in leverage outcomes.

He quoted the 2008 Bialosky study examining the effect of subject expectation on hypoalgesia associated with SMT.  Even though the all groups demonstrated significant results in pain reduction, the negative expectation group (who would told that SMT is a form of manipulation used to treat low back pain that has unknown effects on perception of heat pain) actually had an increase in pain perception following the procedure.

In addition, he mentioned the Schenk 2013 study.  It concluded that “the deliberate employment of expectancy strengthening strategies in clinical practice offers an important opportunity to increase the therapeutic benefit for the patient”.  For all the brain therapists out there, this was the fMRI study looking at changes at the higher cortical areas.

We can’t leave out the recent Benz/Flynn 2013 study, entitled “Placebo, Nocebo, and Expectations: Leveraging Patient Outcomes”.  This is a must read.

All of us in clinical practice know that some individuals need to have more positive expectations that a treatment would work than others.  These are the ones that you may have to sway for the better, as their mindset is typically ‘glass half-empty’.  They may have already been told by a surgeon that PT is only short-term and will have to go to rehab for 4 weeks prior to receiving an MRI—in order to have surgery to fix the problem.  Whatever the story you may have heard—we all have these patients who need every bit of leveraging to maximize results.

What I am getting to is…maximize the expectation from your procedure.   You don’t have to sell it per say, but express to the patient what you normally see following the intervention.  We know we want a within-visit improvement to get between-visit results for backs and necks. An example:

I am going to perform a manual therapy technique to the area of interest.  I have had very good results with these procedures and based on everything that we have examined and spoke about with your condition so far, you should have excellent results.  Pain relief should be immediate and you should notice an improvement in how you move in the clinic today.

I am not a salesman by trade but my craft is to get people better. Maximizing expectation can be an important ingredient in that craft.

What do you add prior to your interventions?  I think Zusman’s explanation is well done, I just added a bit more expectation language to it. Do you think we should maximize expectations, or minimize the placebo that can go along with it? 

What are your thoughts on core endurance norms with LBP?

20140310-084617.jpg

My current intern and I recently had a young, 16 y/o female patient with a 3 year case of low back pain (yes, 3 yrs and just came to see us).  To make a long story short, after getting her symptoms calmed down (she had allodynia setting in to her low back), we started to perform more higher level activities as she is an all-state sprinter.  To find out, she could not hold herself up in a plank position to save her life!

We both were at awe of how “weak” her core was…especially considering she is an avid sprinter and recently competed in indoor track state finals.  So, I brought up this picture for my intern on McGill’s work on endurance norms for low back.

I am not a big advocate personally of simply looking at these norms to determine her level of performance, but I would like to see what others out there think.