Created by: Melissa Buehler, SPT
24-year-old male reports to physical therapy with c/o right sided low back pain (LBP) radiating right leg pain. He reports right sided LBP (p1) with tingling and possible numbness into his right posterolateral aspect of his thigh, along the lateral lower leg and inferior aspect of his right foot (p2) (See Figure 1).
Current symptom behavior is described as:
- P1 is described as an intermittent, sharp, cramp-like pain in his lower buttocks which is aggravated with walking or standing for more than ten minutes. Symptoms go away after sitting for a minute.
- He experiences the n/t (p2) when he lies down to go to sleep at the end of a long day on his feet. Pt is unable to find a comfortable position for sleep and takes over an hour to fall asleep each night. Once the patient is asleep, he stays asleep.
He has a body mass index of 38, but he reports no other co-morbidities that may interfere with treatment. Pt is currently trying to lose weight through diet, but is unable to exercise due to his symptoms.
Pt states that he think the initially injury may have been two years ago when “training” for the military. Although, his original symptoms completely subsided after 6 months following initial injury. Pt reports that his symptoms re-appeared 9 months ago after he started a new job as EMT. He previously received physical therapy three months ago with no significant improvements, except his sitting tolerance had improved (previously, he was unable to sit for more than 15 minutes at time). After this round of therapy, he had an MRI which revealed a disc herniation at L5. Three weeks before starting the current round of PT, he had a epidural cortisone shot and started taking Gabapentin for his radicular symptoms. He was then referred back to physical therapy with a diagnosis of lumbosacral radiculopathy.
Since the shot, pt reports an improvement in symptoms in intensity but still experiences them after a short distance of walking, during a long day at work and at the end of each day.
He currently works as an EMT and fire fighter. His job requires heavy lifting, being fast on his feet, and riding in vehicles on dirt roads. He works long hours, sometimes having 90 hour work weeks. He is also a student, which requires being able to sit for at least 1-2 hours at a time. He enjoys hiking, hunting, and being outside. He’d like to perform work duties and hobbies with little pain and be able to lie on his back to get a good night’s rest.
Lumbar range of motion was found to be limited. Range of motion was measured using two inclinometers as described by Saur et al (1996). The numeric pain rating scale was used to assess the amount of pain each movement caused at p1 location. See Table 1 for Patient’s initial range of motion and pain measurements.
Table 1: Initial ROM and Pain measurements
|Range of Motion||NPRS Pain Scale (p1)|
A neurological exam consisting of myotome, dermatome and reflexive testing was performed in order to screen for advance neurological degeneration. When compared to his left, a decrease in strength on his right lower extremity (4/5 hip flexion, knee flexion & extension, DF and 1st MT extension) was found to be limited due to pain, not myotomal weakness. His reflexes and dermatomes (light touch only) were found to be normal when compared to his unaffected side.
Repeated flexion and extension was utilized in order to screen for signs of centralization or peripheralization with movement. No change in symptoms were reported.
Joint mobility of his lumbar spine was assessed using unilateral segmental mobility testing as described by Maitland (1986). Hypomobility with p2 reproductions was found at L4-5 on the right side.
Straight leg raise test (SLRT) was performed in order to determine whether or not his symptoms had a neuropathic origin. This assessment was performed with the patient in supine with a pillow under his head. His leg was passively lifted by the therapist, ensuring that his knee was full extension, ankle was at end-range ankle dorsiflexion and first metatarsal was in full extension (See figure 2). He had a positive straight leg test at 10˚.
Modified Oswestry Disability Index score was found to be 28% impaired.
Pt demonstrates LBP with radiating symptoms secondary to hypomobility of lumbar facets and decreased neurodynamics. Strength deficits of the LLE and posture deviations may be contributing to his impairments. Pt has an increase in pain with lumbar extension-based activities, such as lying supine or walking. Pt will benefit from skilled PT therapy in order to address the mobility, postural and strength deficits listed above.
Although lateral shift correction is the most appropriate answer for this case study, lumbar PA’s in a SLR position was used as treatment instead. This is a novel technique that deserves more attention in the literature. See NAOIMPT’s Chris Hoekstra demonstrating a similar technique.
With this case specifically, the patient experienced significant improvement and return to function after just 6 visits over a three week period. There is a limited quantity of high quality research articles on this topic, but it was been used for cervical radiculopathy pain. See the following article by Cleland et al. (2005), “Manual Physical Therapy Cervical Traction, and strengtheningExercises in patients with cervical radiculopathy, A Case Series.”