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A Pain in the Leg…….

A Pain in the Leg……. Lynne Sturgill, PT, DPT, OCS Rounds March 12, 2010. History. 63 yo male UD theater professor referred to PT for evaluation of R leg pain Dx: Myofascial Pain Syndrome

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A Pain in the Leg…….

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  1. A Pain in the Leg……. Lynne Sturgill, PT, DPT, OCS Rounds March 12, 2010

  2. History • 63 yo male UD theater professor referred to PT for evaluation of R leg pain • Dx: Myofascial Pain Syndrome • Onset of symptoms after sitting on floor wrapping presents; exacerbated after loading and theater set for 4 ½ hours

  3. What is Myofascial Pain Syndrome?What information about the patient’s symptoms would you like to know?

  4. Initial Evaluation: Subjective • Constant R leg pain; > medial lower leg X 2 weeks • Worsening • best 4/10; worst 9/10 • Worse with standing, walking • Unable to tolerate > 5min • Better with sitting for short periods • Unable to sleep through the night • No bowel/bladder problems

  5. Initial Evaluation: Subjective • Not currently teaching • Off Winter Session • Married; 3 kids • Meds: Vicodin • Imaging: none • Previous hx R “sciatica” 1 year ago • No treatment but resolved completely • This leg pain “different” • Previous treatment • 3 Rx massage, stretching, MFR • No relief; worse? • Goals: get rid of leg pain, be able to teach 3 hr class in 4 weeks, play with kids/drive to activities, run 2 miles 3x/week

  6. Question # 1What type of drug is Vicodin? • Anti-inflammatory • Analgesic • Muscle relaxant • Suppressor of neural irritability

  7. Initial Evaluation: Modified Oswestry 58% = “Severe” disability • Pain Intensity • Pain meds provide moderate relief • Personal Care • Can take care of self if slow and careful • Lifting • Can manage light weights • Walking • Pain prevents walking > ½ mile • Sitting • Pain prevents sitting > 10 min • Standing • Pain prevents standing > 10 min • Sleeping • Sleeps < 4 hrs without meds • Social Life • Pain prevents going out • Travelling • Pain restricts travel > 1hr • Employment/ homemaking • Pain prevents physically stressful activities

  8. What is your initial hypothesis regarding this patient’s problem and why?What type of objective tests would you like to perform and why?

  9. Neurological Evaluation • Reflexes: • R KJ absent; L 2+ • R/L AJ 2+ • Dermatomes: • Decreased to light touch R medial lower leg • Ant thigh, lateral lower leg, toes, heel intact • Myotomes: • Hip flex, DF, toe ext, eversion 5/5 • PF NT secondary to pain with WB • R knee ext 4/5

  10. Question # 2What primary neurologic level appears to be involved? A. L2 B. L3 C. L4 D. L5

  11. Lower Quarter Screen: Neuro

  12. How can Anterior tib be testing normal if L4 nerve root involved?

  13. Initial Evaluation • Lumbopelvic Screen • FF, Seated PSIS (-) • Trunk AROM (baseline = 4/10) • Full flexion • Increased R LB, buttock and leg pain (5/10 leg) • 10% Ext * (8/10) • 10% R SB* (8/10) • 25% L SB* (5/10) *Increased leg pain; worse with ext/R SB • Repeated Motions • Flex, ext, pelvic translocations • All peripheralize; worst with ext

  14. Question # 3According to the Delitto classification algorithm, under which treatment classification does he fall? A. Flexion exercises B. Extension exercises C. Stabilization exercises D. Traction

  15. Initial Evaluation ( additional) • Inspection: antalgic gait, decreased stance R, step length L; no lateral shift • SLR (+) at 30 degrees R; (-) L • PA testing • Reproduction of leg pain with PA at L3, L4, L5, S1 • Hypomobile L2-L5 • Normal T12, L1, S1 • Palpation: no tenderness R piriformis; paravertebral muscle spasm L2-S1 R

  16. Has your hypothesis been confirmed?Anything else you want to do?

  17. Now what? • PT diagnosis • L4 radiculopathy • Absent KJ • Decreased sensation L4 dermatome • Quad weakness • MD diagnosis • Myofascial Pain Syndrome

  18. Collaboration with MD • MD prescribed Medrol dose pack • Sent pt for MRI • Radiologist impression: R focal neuroforaminal disc protrusion compressing R L4 nerve root

  19. L4 Radiculopathy • Frequency of L4 radiculopathy low compared to L5 or S1 • Highest incidence in patients in their 60’s • L3 or L4 radiculopathies = 5% of all cases requiring surgery • Rainville 2006

  20. L4 Radiculopathy • 48% of surgical candidates had decreased patellar reflex • 30% of surgical candidates had sensory deficits to pin prick • 56% of those with L3-L4 disc herniations had quadriceps weakness • 58% of those with quadriceps weakness had normal strength at time of discharge (3 months) • Rainville 2006

  21. Is this person a surgical candidate?Other procedures to consider?

  22. What are his impairments?What are you ideas for his Plan of Care?

  23. Impairments Plan of care TENS Joint mobilizations Soft tissue mobilization ROM exercises Education Traction Rainville et al notes 58% better in 3 months • Pain • Joint hypomobility • Muscle spasm • Limited and painful trunk ROM • Functional limitations • Peripheralizing of symptoms • Neurologic signs and symptoms • weakness

  24. Treatment (8 visits) Treatment Response KJ on traction 1+ during 2/8 treatments Decreased intensity of radiculopathy/increased pain in buttock Decreased intensity of radiculopathy Reported slept 30 minutes longer with TENS on • Static pelvic traction • 90/90 > 50 % BW X 15 min • Joint mobilization • Opening mobs in supine and sidelying • TENS • In clinic • Home unit

  25. Re-Evaluation After 8 visits: • Leg pain decreased from constant to intermittent • best = 0/10; worst = 4/10 • Able to stand/walk for 15-20 minutes • Oswestry = 36% Moderate Disability

  26. **New Complaint** • “Thigh muscle weakness” • Fasiculations Now what????

  27. Re-Evaluation • R KJ absent • Decreased sensation to light touch medial shin • Quad MMT 4/5 • Visible quad atrophy • Intermittent quad fasiculations at rest observed • Function = difficulty with stairs(step-to gait) and with sit-stand

  28. Question # 4MMT is the best way to quantify strength of the quadriceps in grades > 3+?A. TrueB. False

  29. Quad Strength Evaluation • Quad MVIC @ 60 degrees • L 670 N • R 225 N • R quad is 33% of L; 67% deficit! Now what???

  30. Consultation with MD • Discussed findings • Expressed concern about health of nerve and longevity of sx’s (i.e. 6 weeks) • MD ordered EMG

  31. EMG Findings • R Quad • Mild to moderate loss of motor units due to denervation • R Anterior Tib • Mild to moderate loss of motor units due to denervation • Signs of axonal sprouting • ? No clinical correlation

  32. Clinical Decision Making • Functional implications of severe Quad weakness? • Will Quad come back and how quickly? • 58% restoration in 3 months with L4 radiculopathy • Rainville et al • How can we strengthen the Quad without aggravation of back?

  33. Question #6What frequency would be best to start with for strengthening while maximizing tetany? A. 15 pps B. 25 pps C. 45 pps D. 75 pps

  34. NMES Application • Parameters • Pulse duration = 400 microsec • 75 pps/sec • 2 second ramp time • 10 second on / 50 second off time • 3 x 5” self-adherent electrodes • 60 degrees • 10 electrically elicited contractions each treatment • 50% or > than MVIC

  35. Additional Treatment • Quad strengthening • FAQ, SAQ with weight for HEP • Lumbar Joint Mobilizations • Traction • Improved reflex during and after traction 20% of treatments

  36. After 1 month NMES: OSW = 24% R quad reflex 1+ Radiculopathy abolished Occassional LBP Intermitent paresthesias localized to medial malleolus Quad index = 55% At Discharge-24 visits (3 months) OSW = 4% R quad reflex = 1+ Denied LE pain Occassional paresthesias Quad Index = 100% 1 year post data identical to discharge Results

  37. Questions?

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