MANUAL THERAPY TREATMENT FOR LUMBAR STENOSIS …...The patient completed the Revised Oswestry...

MANUAL THERAPY LUMBAR STENOSIS

MANUAL THERAPY TREATMENT FOR LUMBAR STENOSIS AND

ACCOMPANYING RADIATING PAIN

A Case Report

Presented to

The Faculty of the Marieb College of Health and Human Services

Florida Gulf Coast University

In Partial Fulfillment

of the Requirement for the Degree of

Doctor of Physical Therapy

By

Ryan D Emery

2017


APPROVAL SHEET

This case report is submitted in partial fulfillment of the requirements for the

degree of

Doctor of Physical Therapy

_________________________

Ryan Emery

Approved: April 2017

Dr. Arie J. van Duijn, EdD, PT, OCS

Committee Chair

Dr. Eric Shamus, DPT, PhD, CSCS

Committee Member

The final copy of this case report has been examined by the signatories, and we

find that both the content and the form meet acceptable presentation standards

of scholarly work in the above mentioned discipline.


Acknowledgments

Firstly, I would like to that my independent study committee members, Dr.

Arie van Duijn and Dr. Eric Shamus for all of their assistance, feedback, and

guidance during the independent study and case report process.

I would also like to extend my gratitude to Dr. Tom Zeller for the

opportunity, as well as, his assistance and advice during the selection process

and treatment of my case report patient.

I am very thankful to the entire Florida Gulf Coast University Doctor of

Physical Therapy faculty and staff for their patience, guidance, and mentoring

during this doctoral program.

I would like to thank the members of my cohort for their continued support

and work that we completed together over the last three years.

Finally, I would like to thank my family for supporting me through this

graduate process and my life in general. Without you I would not be where I am

today.


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Table of Contents

Abstract 5

Background and Purpose 6

Case Description 7

Patient History and Systems Review 7

Clinical Impression #1 9

Examination 9

Clinical Impression #2 11

Intervention 14

Outcome 17

Discussion 19

References 25

Appendix A: Numerical Pain Rating Scale 29

Appendix B: Revised Oswestry Disability Index 30


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Abstract

Background and Purpose: Patients with lumbar stenosis and radiating pain are

frequently treated using various forms of manual therapy. This case report study

describes a single patient case and the treatment of lumbar stenosis and

radiating pain using manual therapy techniques. Case Description: A 53-year-

old female presented to outpatient care with 10/10 left lumbar pain and radiating

pain present to posterior lateral mid-calf. The patient was in a motor vehicle

accident three weeks ago. Symptoms were provoked during right rotation and

left lateral flexion of the lumbar spine as well as during prolonged sitting or

walking. A multi-modal manual therapy based treatment approach was utilized

which included: lumbar spine rotation (Grade II, III) mobilizations, soft tissue

mobilization, and therapeutic exercise for lumbar pelvic stabilizer muscle

strengthening and neuromuscular control. Outcome: After 12 visits over 5

weeks of treatment, the patient displayed significantly improved strength, range

of motion, level of disability, centralization of pain, and reduction of pain.

Discussion: While the results described in this case report cannot be

generalized, it does depict a successful outcome of a patient with lumbar

stenosis and radiating pain using manual therapy techniques and therapeutic

exercise.


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Background and Purpose

Radiating pain or radicular pain from the spine involves inflammation and

chemical changes that will cause increased sensitization of the nerve root or

spinal ganglion that results from compression, irritation, or pinching of the spinal

nerve root. The radiating pain may be due to disc protrusion, osteophyte

formation into the intervertebral foramen, or any local degenerative disorder that

compromise the intervertebral foramen including spinal stenosis (Hengeveld &

Banks, 2014). Radiculopathy may cause neurological signs or symptoms

including: myotomal weakness, changes in sensation in dermatomal patterns,

and pain that is described as lancinating, shocking, burning, or of electric

qualities (Hengeveld & Banks). Referred pain is perceived at a site other than

the painful stimulus. Pain perceived along the distribution of the sciatic nerve in

the posterior aspect of the lower extremity is a common referred pain pattern

resulting from nerve compression in the lumbosacral spine (Longo, Ropper, &

Zafonte, 2015). Conservative treatment including various forms of manual

physical therapy management have been demonstrated to be effective in the

management of lumbar pain by improving pressure pain thresholds (Willet,

Hebron, & Krouwel, 2010). A comprehensive clinical practice guideline was

constructed utilizing evidence based research. It was determined that manual

therapy interventions are indicated in patients with acute low back and back

related lower extremity radiating pain to improve spine and hip mobility as well as

reduce pain and level of disability (Delitto et al., 2012). Manual therapy

techniques including spinal mobilization have demonstrated positive effects on


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the presentation of lumbar radiating pain through pain modulating effects through

neural analgesic mechanisms (Dorron et al., 2016). Spinal manipulation has also

been demonstrated to address local hypomobility with reduction of compression

in the intervertebral foramen (Vieira-Pellenz et al., 2014). It is suggested that

conservative management of lumbar radiating pain should be attempted prior to

surgical management in the absence of worsening neurological signs or cauda

equina syndrome (Valat, Genevay, Marty, Rozenberg, & Koes, 2010). Research

has demonstrated that there are positive effects on both range of motion of the

lumbar spine as well as pain reduction with various grades of Maitland lumbar

manipulation techniques (Bhushan et al., 2016; Shum, Tsung, & Lee, 2013).

Likewise, there has also been research concerning the use of soft tissue

mobilization on decreasing pain and increasing tissue extensibility (Furlan,

Imamura, Dryden, & Irvin, 2009). A recent systematic review of literature also

demonstrated that there is evidence for the use of mobilization and soft-tissue

manual therapy techniques combined with exercise for both short and long term

pain and disability management (Hidalgo et al., 2013). This case report

demonstrates the positive effects of conservative physical therapy management

with use of manual therapy techniques and interventions in the treatment of

lumbar stenosis and accompanying radiating pain.

Case Description

Participant History and Systems Review

A 53-year-old female presented for physical therapy treatment with severe

(10/10) left lumbar spine pain and radiating pain in the left lower extremity that


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began after being in a motor vehicle accident. The patient first began having

pain after a motor vehicle accident approximately 3 weeks prior to physical

therapy evaluation. Diagnostic imaging including a MRI and radiographs were

completed after the motor vehicle accident which displayed left L4-L5 spinal

stenosis, L4-L5 facet arthropathy, disc bulges on L3-L5, and L4-L5 degenerative

disc disease. The patient described her pain as sharp and shooting pain and

rated it at 10/10 on the 11-point Numerical Pain Rating Scale (NPRS). She also

reported pain into the left lower extremity in the posterior thigh that extended to

the posterior lateral mid-calf. No associated numbness, paresthesia, weakness,

or cauda equina syndrome symptoms were reported. As a result of this lumbar

pain and radiating pain the patient was unable to sleep uninterrupted as well as

unable to complete many functional activities without severe increase of pain.

Activities that were limited included: prolonged standing, ambulation of

community distances, transfers, lifting or carrying objects required for household

activities, and recreational activities. The patient was only able to sleep on her

right side and her sleep was frequently disturbed by low back pain resulting from

turning, rolling, or moving while in bed. The current episode of pain also

prevented her from sitting upright at work as an office worker or moving about as

needed while at work. The patient felt that she was unable to perform her job

adequately due to pain and difficulty with moving secondary to pain. She was

anxious concerning her condition and how it may negatively impact her

professional, social, and personal life as well as the potential of long-term

disability. The patient’s goals for physical therapy were to return to prior level of


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function, to resolve her low back pain, and to allow for return to work at the level

of previous capacity.

Clinical Impression #1

The patient reports severe (10/10) low back pain with radiating left lower

extremity pain of spinal origin. There are significant functional limitations

secondary to this pain. Due to mechanism of injury as well as the radiating pain

pattern there is several potential differential diagnoses including: facet

dysfunction, intervertebral disc herniation, spinal stenosis, piriformis syndrome,

and sacroiliac joint dysfunction.

The examination plan included: neurological testing, postural assessment,

lumbar range of motion, passive intervertebral motion, strength of the lumbar

pelvic stabilizers, determination of a flexion or extension directional preference of

movement, and neurodynamic testing. Due to the patient presentation of low

back pain with mobility deficits it was determined that, based on evidence based

research, there was likely to be functional improvements through the use of

manual therapy techniques including spinal and soft tissue mobilization as part of

a multi-modal conservative approach.

Examination

The patient completed the Revised Oswestry Disability Index (ODI). She

scored 70%, which indicates complete disability. Physical examination of the

patient was limited due to the severity of the patient’s pain and irritability of

affected structures. She was observed to have forward flexed posture, increased

lumbar lordosis, rigid posturing, and antalgic motions secondary to severe low


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back pain. There was an increase of localized left lumbar pain at end range

motion in all directions of the lumbar spine. Right rotation and left lateral flexion

also increased left lower extremity radiating pain. Range of motion was

significantly limited in all directions secondary to pain at end range with greatest

limitations in right rotation and left lateral flexion. Pain was most severe with right

rotation and left lateral flexion with recreation of radiating lower extremity pain to

posterior lateral mid-calf. The patient reported a decrease in pain with slight

flexion, right lateral flexion, and left rotation. Palpation of the left lumbar erector

spinae, upper gluteal region, and quadratus lumborum also recreated localized

pain with significant tenderness to palpation. Palpation testing also revealed

that the patient had significant muscle guarding and tightness of left erector

spinae, paraspinals, and quadratus lumborum. Passive bilateral and left

unilateral posterior-anterior accessory range of motion also recreated pain in

lumbar spine and buttocks region. Passive intervertebral motion was determined

to be 2/6 in left L3-S1 segments with slight joint limitations of movement. There

was significant weakness of the lower abdominals and lumbar pelvic stabilizers,

2/5, with rapid fatigue and inability to maintain neutral spine position during

supine manual muscle testing. Neurodynamic testing using a straight leg raise

test caused local lumbar pain at 15 degrees of flexion of her left hip and at 30

degrees of flexion of her right hip. There was no increase or change in left lower

extremity pain or symptoms. The localized lumbar pain was reported to be sharp

and pulling. The pain descriptors reported during straight leg raise testing

differed from previous pain reported and fit the descriptors of pain of a muscular


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origin. However, neither increased peripheral pain symptoms in the left lower

extremity and no change was noted with increasing dorsiflexion. Straight leg

raise was determined to be negative due to no recreation of lower extremity pain

and symptoms. This test has a sensitivity of 0.91 and specificity of 0.26 for

lumbar disc herniation with a positive likelihood ratio of 1.2 and negative

likelihood ratio of 3.5 (Deville et al., 2000). Neurological testing revealed no

determinable myotomal weakness, sensory abnormalities, or abnormalities in

deep tendon reflexes.

Clinical Impression #2

The patient described was likely to have intermittent nerve root

compression with neurogenic claudication as a result of spinal stenosis. Left

lumbar referred pain to the lower extremity due to irritation of the nerve root due

to stenosis was suspected due to limitations in lumbar range of motion, preferred

posture, and joint restrictions. Significant muscle guarding and tightness due to

the motor vehicle accident is likely to further decrease inter-vertebral spacing and

increase localized inflammation causing additional lumbar and referred pain

symptoms. MRI impressions included: left L4-L5 spinal stenosis, L4-L5 facet

arthropathy, disc bulges on L3-L5, and L4-L5 degenerative disc disease. These

findings would further indicate potential irritation of the lower lumbar nerve roots

with narrowing of the intervertebral disc space, bulging of the disc, and

degeneration of the facet joint causing stenosis of the lateral intervertebral

foramen. Due to the presence of lateral stenosis as well as movement limitations

it was decided to initiate a plan of care including manual therapy spinal and soft


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tissue mobilizations and therapeutic exercise to improve strength and

neuromuscular control within the lumbar spine to reduce pain, inflammation,

functional limitations, and level of disability. This is based on the clinical practice

guidelines for low back pain (Delitto). The patient’s response to intervention and

her associated outcomes were evaluated and recorded every 3 visits to

determine appropriateness of interventions and progress toward short and long

term goals (Table 1).


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Table 1 Short and long term goals

Goal type and number Goal description

Short term goal (STG) #1 Improve lateral flexion to 20 degrees, flexion to 50 degrees, and rotation to 25 degrees bilaterally to allow for improved ability to complete ADLs including household chores, self-care tasks, and work related activities within 3 weeks.

STG #2 Improve strength of transverse abdominis and lower abdominals to 4-/5 to improve lumbar stabilization to allow for improved ability to transfer, bend, lift, carry, ambulate, stand, and sit for prolonged periods of time within 3 weeks.

STG #3 Patient will be able to sit for 15 minutes without increase of lumbar or radiating pain to improve ability to complete work tasks within 3 weeks.

Long term goal (LTG) #1 Improve lateral flexion to 30 degrees, flexion to 70 degrees, and rotation to 40 degrees bilaterally to allow for improved ability to complete ADLs including household chores, self-care tasks, and work related activities within 6 weeks.

LTG #2 Improve strength of transverse abdominis and lower abdominals to 5/5 to improve lumbar stabilization to allow for improved ability to transfer, bend, lift, carry, ambulate, stand, and sit for prolonged periods of time within 6 weeks.

LTG #3 Patient will be able to sit for 1 hour sessions without increase of lumbar or radiating pain to improve ability to complete work tasks within 6 weeks.


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Intervention

At the initial treatment session, manual therapy techniques were utilized to

address generalized lumbar hypomobility with emphasis on L4-L5 joint as

passive intervertebral motion testing, palpation, and diagnostic imaging

determined this segment displayed increased reactivity and left lateral stenosis.

Various manual therapy techniques and lumbar pelvic stabilization exercises

were completed (Table 2). After mobilization was completed, pain free lumbar

rotation range of motion was retested during the same treatment session. Range

of motion had improved and the patient reported decreased focal pain,

tenderness to palpation, and centralization of radiating pain to left buttocks.

Further education was given to the patient to reduce patient anxiety and to

reduce strain through the lumbar spine causing exacerbation of symptoms.


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Table 2 List of interventions

Intervention Parameters Position Target structure

Maitland Grade II and Grade III left rotational mobilization

60 seconds, 30 movements/minute 10 sets

Right side lying L4-L5 spinal segment

Maitland Grade II and Grade III flexion mobilization

60 seconds, 30 movements/minute 10 sets

Right side lying L4-L5 spinal segment

Soft tissue mobilization

15 minutes Seated in manual massage chair

Erector spinae, thoracolumbar fascia, gluteus medius, gluteus minimus, and quadratus lumborum

Lumbar pelvic stabilization exercises

See Table 3 Hook lying Transverse abdominis and neutral spine posture

Patient education regarding ergonomics and spine safety to avoid further exacerbation


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Table 3 Progression of lumbar pelvic stabilization exercises

Intervention Parameters Position

Transverse abdominis (TA) activation with posterior pelvic tilt

10 second isometric hold 10 repetitions 2 sets

Hook-lying

Alternating marching with TA activation

30 seconds 2 sets

Hook-lying

Straight leg raise with TA activation

30 seconds 2 sets per leg

Supine with non-moving leg in hook-lying

Side lying clam shell with TA activation


Side lying with hips at 60 degrees and knees at 90 degrees

Side lying straight leg raise with TA activation


Side lying with legs extended

Standing hip abduction with TA activation

20 repetitions 2 sets

Standing

Standing marching with TA activation

20 repetitions 2 sets

Standing

Patient response to initial plan of care was assessed and at the second

physical therapy session, the patient reported reduced pain to 9/10 and improved

motion and tolerance to activity. Patient reported that her radicular pain in left

posterior lower extremity extended only to the popliteal fossa. The interventions

(Table 2) were applied at this and each subsequent physical therapy visit with

progression of conservative lumbar pelvic stabilization exercises (Table 3). With

a reduction of muscle guarding the presence of directional preference was noted

with a flexion directional preference with further reduction of pain. The patient

had twelve total physical therapy visits following the aforementioned protocol.


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Reassessment of pain and associated neurological signs were made at each visit

to determine progress and appropriateness of selected interventions. Due to

improvements of neurological signs and symptoms using conservative physical

therapy management and manual therapy techniques, the referral of the patient

to a neurosurgeon for surgical management was not considered necessary.

Outcome

After twelve visits after their initial physical therapy evaluation the patient

reports their pain reduced to 5/10 levels and their lower extremity pain symptoms

have resolved at rest and with all activities except prolonged upright sitting.

There was also a significant centralization of pain with the most distal radiating

pain being present to the buttock region. The patient’s tolerance for sitting

improved with being able to sit upright for 30-minutes prior to increase of pain,

and ability to sit in a reclined or forward flexed position for greater than 1-hour

without increase of pain. The Revised Oswestry Disability Index (ODI) was

completed again and the patient reported a score of 46% indicating reduced level

and severity of disability resulting from current low back pain and dysfunction

(Table 4). The patient also was able to return to previous work and household

duties including those that required bending, carrying, lifting, and repetitive

motions. The patient reported that she could once again sleep through the night

and sleep on her left side without disruption due to low back or lower extremity

referred pain. The patient displayed significantly improved ROM throughout the

lumbar spine (Figure 1). The only remaining site of muscle guarding and

tenderness to palpation was present at the left lower lumbar paraspinals.


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Table 4 Progression of objective measures

Initial Evaluation (left/right)

Visit #3 (left/right)



Final (left/right)

Revised Oswestry Disability Index (ODI) 70%

46%

Pain level (NPS) 10/10

8/10

7/10

6/10 5/10

Most distal radiating pain Mid-calf

Popliteal fossa

Popliteal fossa

Buttock Buttock

Lumbar flexion 30°

40°

45°

52° 62°

Lumbar extension 10°

10°

10°

12° 15°

Lumbar lateral flexion 5°/10°

8°/15°

10°/20°

16°/22°

20°/25°

Trunk rotation 15°/5°

20°/5°

25°/10°

32°/20° 35°/30°

Figure 1 Lumbar Range of Motion (ROM) throughout physical therapy

0

10

20

30

40

50

60

70

Initial Evaluation 3 6 9 Final

Deg

rees

Visit #

Lumbar Range of Motion (ROM)

Lumbar flexion Lumbar extension

Lumbar lateral flexion (right) Lumbar lateral flexion (left)

Trunk rotation (right) Trunk rotation (left)


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Discussion

Spinal stenosis, degenerative disc disease, and disc related pathologies

can cause diminished space within the intervertebral foramen causing

compression on the spinal nerve root or spinal ganglion. Localized pain as well

as radiating pain into the lower extremity may present from compression,

irritation, or pinching of the neural tissue as well as accompanied inflammation

and chemical factors. This combination of factors can cause increased neural

sensitization (Latremoliere & Wolf, 2009).

MRI and routine advanced imaging are not associated with improved

patient outcomes and may demonstrate abnormalities that have a limited

relationship to the patient’s symptoms. The patient’s MRI displayed disc bulging,

however studies have shown that up to 81% of asymptomatic individuals will

demonstrate bulging of intervertebral discs (Jarvik & Deyo, 2002). Within the

case report patient’s age group, 80% of asymptomatic individuals will show signs

of disc degeneration and 60% will show signs of disc bulging on MRI imaging

(Brinjikji et al., 2014). Because of false positives as well as the costs of

diagnostic imaging it is suggested to treat conservatively for 4 to 6 weeks prior to

advanced diagnostic imaging should the symptoms be unable to be relieved

(Lateef & Patel, 2009).

There are various prognostic factors that predict the outcome of lumbar

spine disorders. The presence of radiating lower extremity pain is a poor

prognostic factor, as is high intensity of pain (Schistad, 2013). Anxiety related to

condition and pathology is also another poor prognostic factor that further


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complicates the conservative treatment of lumbar spine disorders (Campbell,

Foster, Thomas, & Dunn, 2013). This case study patient had radiating lower

extremity pain that was severe in intensity combined with anxiety. A positive

outcome with significant reduction of symptoms, functional limitations, and level

of disability was demonstrated even with this combination of poor prognostic

factors.

Placebo effect as well as natural spontaneous resolution of low back pain

can influence reported pain intensity level (Puhl, Reinhart, Rok, & Injeyan, 2011).

Further testing throughout the plan of care including manual muscle testing of

lumbar pelvic stabilizers and lumbar range of motion was conducted in addition

to pain reporting to demonstrate affects, beyond any placebo effect, on pain

intensity level and outcomes. This additional testing was utilized to determine

the effects of manual therapy and conservative treatment as well as the value of

the specific techniques being utilized for this patient. Lumbar range of motion,

reported pain level, and strength of the lumbar pelvic stabilizers all improved

significantly with this case report patient throughout the plan of care.

The use of spinal mobilization has been shown through evidence-based

research to decrease pain and disability associated with lumbar pain (Shum,

Tsung, & Lee, 2013). There is a hypoalgesic effect of spinal mobilization due to

stimulation of the dorsal root horn, descending pain pathway, or systemic release

of neurotransmitters (Bialoskey et al., 2009; Potter, McCarthy, & Oldham, 2005).

Manual therapy and spinal mobilization can be used to address hypomobility of a

spinal segment and has been shown to improve the accessory mobility and


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increase the mobility of the surrounding tissue to reduce compression on the

sensitive neural tissue (Olson, 2015). The use of manual therapy techniques

including flexion-distraction mobilization has shown to significantly increase disc

height (Choi et al., 2014). Also, research concerning mechanotherapy indicates

that movement of pathological structures cause increases of healing factors and

allow for proper alignment and reorganization of tissue (Khan & Scott, 2009). It

is possible that mobilizations of the L4-L5 segment served to move the

mechanical interface around the affected nerves that would serve to reduce

inflammation and compression surrounding these neural structures (Shacklock et

al., 2005). This case patient displayed an improvement in lumbar range of

motion as well as disability level and pain levels. Restriction of pain free range of

motion in the direction of foraminal closing within the lumbar spine remained,

however, the amount of range of motion restriction was greatly reduced.

Soft tissue mobilization has been shown to reduce focal points of pain due

to increased muscle compliance, decreased stiffness, improved circulation,

decreased neural excitability, changed parasympathetic activity, and promotion

of systemic release of endorphins. It has also been shown to decrease anxiety

that can also have a positive predictive effect on the patient’s pain level

(Weerapong, Hume, Kolt, 2005).

Initially, due to the mechanism of injury and associated muscle guarding

and strain, all motions of the lumbar spine were painful at end range of motion.

However, after the acute period ended the patient then fit into the directional

preference category with reduction of pain with flexion and opening of the left L4-


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L5 spinal segment. There is strong evidence for the use of mobilization

procedures in order to reduce pain and disability in patients who are experiencing

subacute or chronic low back and back related lower extremity pain (Delitto et al.,

2012). In addition to this there is evidence of centralization and reduction of

symptoms with the use of repetitive directional preference movements to

“improve mobility and reduce symptoms in patients with acute, subacute, or

chronic low back pain with mobility deficits”. This patient largely fit into the

“subacute low back pain with mobility deficits” ICF-based category. Because of

the classification of the patient into this ICF-based category, the emphasis of

treatment was to utilize manual therapy and therapeutic exercise to improve and

maintain spinal, hip, and lumbopelvic mobility and preventing further episodes of

pain therapeutic exercise for active stabilization and patient education (Delitto et

al.).

The 11-point Numeric Pain Rating Scale (NPRS)(Appendix A-1) was

utilized to track current pain levels of the patient. This survey has been studied

and utilized in patients with low back pain. There is an associated Standard

Error of Measurement (SEM) of 1.02. The Minimum Detectable Change (MDC)

in cases of lower back pain is 2 points based on a 95% confidence interval. The

Minimally Clinically Important Difference (MCID) at 4 weeks of physical therapy

treatment of lower back pain is 2.2 points (Childs et al, 2005). The patient

displayed a reduction of 5 points on the NPRS which is beyond the MDC and

MCID indicating a significant positive change throughout the course of

conservative physical therapy treatment in the severity of pain.


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The Revised Oswestry Disability Index (ODI)(Appendix A-2) is a survey

based on questions regarding the severity of low back pain and the functional

limitations and disability associated with that pain. Studies have shown that the

MDC of this survey is 15.35 in populations with sub-acute low back pain and a

MCID is 9.5. The sensitivity of this survey is 76% and the specificity is 63%

(Monticone et al, 2012). This test also has excellent test retest reliability and

excellent correlation between improved vs nonimproved patients (Frost et al,

2008; Grotle et al, 2012). The patient displayed 24% reduction of the Revised

Oswestry Disability Index score which is greater than the MDC and MCID

indicating a significant positive change in level of disability related to low back

pain and dysfunction.

It is suggested that lumbar stenosis and accompanying radiating pain be

treated conservatively (Valat, Genevay, Marty, Rozenberg, & Koes, 2010).

Additional research regarding the use of alternative manual therapy techniques in

the treatment of lumbar stenosis and lumbar spine disorders as part of physical

therapy treatment is indicated as these techniques utilized are only a small

portion of the techniques available. Other techniques may demonstrate differing

results in the outcomes of each individual patient. Although the results of this

case report cannot be generalized, it does depict the successful outcomes of one

patient using manual therapy techniques and therapeutic exercises as part of a

conservative physical therapy treatment. The treatment plan implemented

addressed severe lumbar spine pain and radiating lower extremity pain and

related functional limitations with positive outcomes including: centralized


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radiating pain, reduction of low back pain, reduction of physical disability,

improved pain free range of motion, resolution of various physical limitations, and

return to prior level of function.


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Appendix A: Numeric Pain Rating Scale


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Appendix B: Revised Oswestry Disability Index

Revised Oswestry Disability Index

This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability

to manage everyday life. Please answer every section and mark in each section only the ONE box that applies to you.

We realize that you may consider that two of the statements in any one section relate to you, but please just mark the

box that most closely describes your problem.

Section 1: Pain Intensity o The pain comes and goes and is very mild.

o The pain is mild and does not vary much.

o The pain comes and goes and is moderate.

o The pain is moderate and does not vary much.

o The pain comes and goes and is very severe.

o The pain is severe and does not vary much.

Section 2: Personal Care o I would not have to change my way of washing or dressing in order to avoid pain.

o I do not normally change my way of washing or dressing even though it causes some pain.

o Washing and dressing increases the pain, but I manage not to change my way of doing it.

o Washing and dressing increases the pain and I find it necessary to change my way of doing it.

o Because of the pain, I am unable to do some washing and dressing without help.

o Because of the pain, I am unable to do any washing and dressing without help.

Section 3: Lifting o I can lift heavy weights without extra pain.

o I can lift heavy weights, but it causes extra pain.

o Pain prevents me from lifting heavy weights off the floor, but I manage if they are conveniently positioned (e.g., on a

table).

o Pain prevents me from lifting heavy weights off the floor.

o Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently

positioned.

o I can only lift very light weights at the most.

Section 4: Walking* o I have no pain on walking.

o I have some pain on walking, but it does not increase with distance.

o I cannot walk more than one mile without increasing pain.

o I cannot walk more than 1/2 mile without increasing pain.

o I cannot walk more than 1/4 mile without increasing pain.

o I cannot walk at all without increasing pain.

Section 5: Sitting o I can sit in any chair as long as I like.

o I can only sit in my favorite chair as long as I like.

o Pain prevents me from sitting more than one hour.

o Pain prevents me from sitting more than 1/2 hour.

o Pain prevents me from sitting more 10 minutes.

o I avoid sitting because it increases pain right away.


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Appendix B: Revised Oswestry Disability Index (continued)

Section 6: Standing o I can stand as long as I want without pain.

o I have some pain on standing, but it does not increase with time.

o I cannot stand for longer than one hour without increasing pain.

o I cannot stand for longer than 1/2 hour without increasing pain.

o I cannot stand for longer than 10 minutes without increasing pain.

o I avoid standing because it increases the pain right away.

Section 7: Sleeping o I get no pain in bed.

o I get pain in bed, but it does not prevent me from sleeping well.

o Because of pain, my normal night’s sleep is reduced by less than 1/4.



o Pain prevents me from sleeping at all.

Section 8: Social Life

o My social life is normal and gives me no pain.

o My social life is normal, but increases the degree of pain.

o Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc.

o Pain has restricted my social life and I do not go out very often.

o Pain has restricted my social life to my home.

o I have hardly any social life because of the pain.

Section 9: Traveling o I get no pain while travelling.

o I get some pain while travelling, but none of my usual forms of travel makes it any worse.

o I get extra pain while travelling, but it does not compel me to seek alternative forms of travel.

o I get extra pain while travelling, which compels me to seek alternative forms of travel.

o Pain restricts all forms of travel.

o Pain prevents all forms of travel except that done lying down.

Section 10: Changing Degree of Pain o My pain is rapidly getting better.

o My pain fluctuates, but is definitively getting better.

o My pain seems to be getting better, but improvement is slow at present.

o My pain is neither getting better nor worse.

o My pain is gradually worsening.

o My pain is rapidly worsening.

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