Virtual Rounds Lumbar Case

1. Virtual RoundsLumbar Case NAME: Matt Anderson, DPT, OCS, CSCSDATE:2/15/2013 BODY REGION: Lumbar spine

2. Case Rationale • I chose this case because I expected a certain classification in the TBC (mobilization) due to the patient’s demographics and my experience. The classification that he fit, and that he responded to (stabilization), was not what I expected.

3. PATIENT PROFILE Patient Profile:Patient is a 36 y/o black male referred to PT for low back pain. The LBP started 8 months ago, and was insidious in onset. Former Army Infantryman x 10 years. Currently works a desk job, but enjoys running and lifting weights. Chief complaint: L>R low back pain at the mid-lumbar area, L paraspinal tightness, occasional L hip soreness. The patient took his hands on mid-low lumbar area and then moved them medial/lateral to the flank and back Self Reported Scores / Outcome Tools: (ODI, NDI, LEFS, DASH, etc) Pt FOTO score = 26/45 Fear = low

4. BODY DIAGRAM • Primary complaint (s) in depth: • P1: Intermittent achy low back pain, Pain now 4/10, at best 1/10, worst 8/10; Prolonged positions cause increase in pain in minutes, ease over several minutes OOP; pt reports that he constantly changes positions through the day, pt also regularly self-manipulates his spine; seems to be worse in AM, best in PM • P2: intermittent left posterior hip pain, soreness present after sitting at work for ¾ of the day; eases after standing for 15 minutes to 0/10; good at night Numbness and or Tingling: denies • Relationship between symptom areas: P1 always present, but can be only 1/10; Pt reports P1 and P2 are separate- not related P1 P2

5. PE Planning I. What areas/structures must be considered a source of symptoms?

6. Symptom Behavior • Aggravating and Easing Factors: • P1 Aggravating Factors: • 1: Bending forward for 1-2 minutes sustained (up to 8/10) • 2: Sitting x 3-5 minutes • Standing x 5-10 minuters • P1 Easing Factors: • 1: Changing positions • 2. Supine with feet resting on his bed • 3. Regular self-manipulation of the lumbar spine • P2 Aggravating Factors: • 1: Sitting at work for >3/4 of the work day • P2 Easing Factors: • 1: Standing for ~15 minutes

7. History • Sleep and 24 hour pattern: • Sleep: no trouble falling asleep/staying asleep. Normal side sleeper • Morning: Pt reports AM worse than PM • Evening/night: Pt reports that he feels better at night • Duration of current symptoms: ~8 months • Mechanism of injury / current history: Insidious onset, no know injury

8. PATIENT INTAKE • Medical History / Co-Morbidities / Review of Symptoms (ROS): • Allergic Urticaria, Hypertension, LVH, lactose intolerance • Red Flag Screen: no numbness/tingling, no falls, no gait dysfunction, no bowel/bladder changes, no saddle anesthesia • Yellow Flag Screen: (-) depression screen • Special Questions: • Diagnostic tests / Imaging : x-ray report: lumbar spine within normal limits • Medications : NSAIDS PRN

9. Clinical Reasoning • (S) What is the severity of the condition (min, mod, severe)? • Mild- able to perform all work duties and home duties •  (I) What is the irritability of the condition (min, mod, severe)? • Moderate: due to report of constantly having to change position and self-manipulate; Pain begins to increase over 1-5 minutes, but also returns to baseline quickly • (N) What is your primary nature statement of the problem - poor motor control; stabilization dysfunction • (S) What is the stage of the disorder: Chronic (8 months) • (S) What is the current stability of the disorder • Stable: has been acting the same for 8 months

10. Planning the PE • What will you include to rule in/out your hypotheses? • 1: Stabilization TIC • 2: Repeated movements (flexion, extension, Side glide) • 3: ROM testing • 4: Palpation of musculature surrounding area • 5: Muscle testing • 6: Clear joints above and below (t-spine and hip)

11. Physical Exam • Precautions and or Contraindications: None • Postural Observation: Flat thoracic spine, excessive lumbar lordosis • Neurological Examination: normal dermatome exam, equal/responsive DTR • Lumbar ROM: • Flexion: fingers to superior shin: aberrant movement during return* • Extension: Full motion- feels good- no change with REIS • Sidebending: L WNL; R full motion w/ pain produced on L side • Rotation: L 80%, R 80% w/ tightness felt on L • Thoracic spine: Low to mid-lumbar spine hypomobile; no comparable pain observed • Muscle length testing: • -Iliopsoas on R: moderate restriction, Piriformis on R: moderate restriction; bilateral hamstrings: mild restriction

12. Physical Exam • Palpation: L lumbar and low to mid thoracic paraspinals- moderate tenderness; L side: deep palpation of the Quadratuslumborum; L3-L5 palpation showed increased lordosis with paraspinal tenderness • Spinal Segmental and or Joint Restrictions: TL junction hypomobile; T6-T12 hypomobile with Grade IV CPA; L3-5 hypermobile with familiar pain in the low back region reproduced- grade III CPA • Manual Muscle testing:  WNL except: Glute max: R 4+/5, L 4-/5; Quad L 4/5 with shaking during MMT • Motor control: Difficulty with contraction of TA and multifidus • Special tests: + Prone instability Test • Other: Prone hip P/A hypomobility with limited passive and active hip extension

13. Assessment & Plan • What is your primary hypothesis following the PE: • Patient presents with signs consistent with reduced motor control / instability. He met 4 out of 4 criteria for the clinical prediction rule for spinal stabilization exercises in the TBC: aberrant motion, + prone instability test, age <40, and hypermobility present in the lumbar spine. He also reports having to constantly change positions, and self-manipulate himself, which, in PT’s experience, also gives evidence to the need for stabilization. • **The patient is a generally active individual, and is eager to return to working out. He would also like to feel more comfortable playing with his children (crawling, lifting, running, etc) He is motivated to exercise, and reports that he has tried to perform “core exercises”, but they have not been successful.

14. Day 1 Treatment Treatment provided today and the patient’s response to each intervention.   TREATMENTS Rx 1: Supine abdominal drawing in maneuver; 10 second hold, 10 repetitions Rx 2: Side plank on knees 5 x 10 second holds progress to 10x 10 over 7 days progress to full side plank 14 days RESPONSES TO… Rx 1: Pt sat for 2 minutes following treatment with reported 40% reduction in symptoms Rx 2: pt felt “tighter” in the mid-section in standing, with 50% reduction in pain (after standing for ~5 minutes while I printed handouts for his HEP)

15. Response & Assessment at Day 1 • Other treatment provided today and the patient’s response: • Manual Therapy: Hip distraction maipulation (Improvement in hip strength to 4+/5 with 5 degrees extension improvement); Mid-thoracic flexion HVLA thrust manipulation (performed prior to ADIM to facilitate contraction- pt reported reduction in stiffness in t-spine) • Exercise: Quadruped alternating arm lift with ADIM (10 x 2); Thomas position hip flexor stretch 15 seconds, 4 times • Education: Description of “inner core”: TA, multifidus, pelvic floor, and diaphragm • What changes did you note in your asterisks (test/retest)? • 40-50% reduction in reported pain with sitting and standing; improvement in hip motion and hip extension strength • Prognosis (note timeframe of expected level of recovery): • Good response to initial treatment. Almost 50% reduction in pain, with very motivated individual; Good overall prognosis for recovery • Plan of care (including plan for assessment on day 2): • Better: Advance trunk motor control exercises, continue MT • Worse: More specific multifidus exercises • Same: continue day 1 treatment, with increased verbal and tactile cues