Msc manipulative physiotherapy CasMsc manipulative physiotherapy Case Presentation IIIe Presentation III

D Chan

Physiotherapist

Background Information

• Mr Chung M/36

• Occupation: Airport van driver and worker

• Job nature: needed to drive small van, transfer and lift baggage

• Reason of referral: LBP for physical rehabilitation

Subjective Examination

Main complaint:• Immediate Pain over back when lying on bed at

night• Left buttock pain when getting out of the airport

van

(P1 & P2 are not related subjectively)

Subjective Examination

Body Chart

P1: central low thoracic superficial dull ache, VAS 5/10 (he could pinpoint the pain site at spinuous process of T9)

P2: Left buttock to lateral thigh down to 5th toe

Buttock: deep, ‘locking’ ‘clicking’ discomfort, VAS 3/10. lower leg and toe: numbness

Subjective Examination

• 24-Hour Pattern:

– P1: No morning stiffness. Increase at work and changing diaper for his daughter at home. Lying on bed at night with immediate pain.

– P2: no morning /night pain. Just activity related (getting out of the van)

P1: (1) lying supine on bed immediately at night. VAS 5/10, needed to put pillow underneath back (Lumbar region), VAS ↓to 2/10, can sleep afterwards (2) changing diaper for his daughter (functional demonstration: flexed trunk in standing), VAS 6/10, needed to straighten his back immediately afterwards, VAS to 2-3/10

P2: after sitting in the airport van for 10-20 minutes, as he got out of the van and stepped on the ground, VAS 5/10. totally subsided after a few steps of walking

Easing Factors: as above strategies. No use of medication

Aggravating Factors:

Subjective Examination • Special Questions:

– Good general health. Medication o Severe night pain o Surgery o Weight Loss o

– No recent PT Rx – Bilateral hand/foot tinglingo Gait disturbanceo

– Bowel and bladder disturbanceo Saddle anaesthesiao

– X-ray (taken after IOD in 2002): no #. mild degree of convexity towards right side at T5-6. anterior osteophytes (lipping)

• Recent: sudden onset/recurrent of back pain one year ago after lifting baggage for 1/52, gradual increase in pain this year. Insidious onset of P2 2/12 ago, constant till now.

• Past: 8-9 years ago, worked in basement/ under the plane for baggage delivery. He stepped on a roller and fell backwards and hit on the luggage and hurt his back (IOD). PT Rx that time: EPTs, Taping (with effect), no MT due to much pain. Almost complete recovery

History

Sources of the symptoms (P1)Joints underlying the symptomatic

area:

Muscles & other structures

underlying the symptomatic area:

Structures referring to the symptomatic

area:

• IV joints (low Tx and upper Lx)• Facet joints

• paraspinal muscles• IV disc

•Mid Tx and Lx

Sources of the symptoms (P2)Joints underlying the symptomatic

area:

Muscles & other structures

underlying the symptomatic area:

Structures referring to the symptomatic

area:

(L) SI joint(L) Hip joint(L) Knee joint(L) Ankle joint

(L) Gluteal muscles(L) Quadriceps mm (L) ITB and TFL

Lx IV joints and (L) facet joints

S/E Hypothesis P11. Low thoracic IV joint pain

• Supporting Statement1. P1 increased on supine lyi

ng (direct force on the area)

2. P1 decreased by putting pillow on Lx (unloading the Low Tx)

3. Pain site is very localized and palpable

4. Same site as old injury

• Neglecting Statement

S/E Hypothesis P21. Piriformis syndrome

• Supporting Statement1. prolonged sitting (on har

d surface) then started WB increase pain

2. Compression of sciatic nerve can cause distal symptoms

3. Easy to subside due to decreased stretching in standing position

• Neglecting Statement

1. No history of trauma (e.g. twisting the hip)

2. no exercise habit leading to overuse

S/E Hypothesis P22. Hip joint pain with referred symptoms (OA)

• Supporting Statement1. prolonged sitting then sta

rted WB increase pain2. Relieved by several steps

of walking 3. Hip problem can be prese

nted as buttock pain4. Hip pain can refer downw

ards

• Neglecting Statement1. Rather young age2. No history of trauma 3. No c/o pain on walking stai

rs/SLS/ squatting (which are common in hip problem)

4. Distal numbness

Irritability• P1: moderate

– quite easy to provoke– Moderate intensity: VAS 5/10– quite easy to decrease

• P2: low to moderate– Needed 10-20 minutes to provoke– Moderate intensity: VAS: 5/10– Easy to subside: a few steps of walking

O/E Plan

• standard tests – P1: move to P1– P2: move to the limit of symptoms

• Palpation, PAIVMs

• Special tests: piriformis stretch test

Objective Examination• Posture: mild poking chin with rounded shou

lder, increased mid Tx kyphosis

• Low Tx:– F: to mid shin, VAS 2/10,usual P1, OP: same– E: – SF L: SF R: – Rot L: Rot R: – ＊ F/Rot L: VAS to 4/10 with OP (usual P1)

Objective Examination

• Palpation: – Spasm o Sweating o Temperature o mm pain o

– ＊ central PA to T8 and 9 with usual pain, VAS 4/10, stiffness++

– Other levels and unilateral PAs: no pain

Objective Examination

• L gluteal muscles: usual P2, VAS 5/10 (especially dig into the site of piriformis muscle). R: no pain

• L Hip: F/E, IR/ ER: Po

• L Hip Q: usual P2(stretching) as Hip add with Hip F 90

• Observation: L hip kept ER in supine lying • ＊ Piriformis stretch test: +ve on L (with toes num

bness if sustained), -ve R• SLR: Bil 40 degrees, no usual pain• Stairs : Po ,squatting : Po

O/E Hypothesis P1Low thoracic IV joint pain with stiffness

• Supporting Statement1. P1 increased on supine lyi

ng (direct force on the area)

2. P1 decreased by putting pillow on Lx (unloading the Low Tx)

3. Pain site is very localized and palpable

4. Same site as old injury5. Central PA caused usual p

ain6. Other possible structures s

creened

• Neglecting Statement

O/E Hypothesis P2Piriformis syndrome

• Supporting Statement1. prolonged sitting (on har

d surface) then started WB increase pain

2. Compression of sciatic nerve can cause distal symptoms

3. Easy to subside due to decreased stretching in standing position

4. Piriformis stretch test: +ve

• Neglecting Statement

1. No history of trauma (e.g. twisting the hip)

1st Rx session

(1) Central PA T9, Gd III x 2lots C/O: VAS 3-4/10 O/E: Lx F+Rot: VAS 2/10 (improved)(2) L piriformis passive stretching x 3 C/O: VAS 4/10 O/E: piriformis stretch test: less tightness, same pain (improved)

Piriformis Syndrome(J.W. Thomas Byrd, MD; Oper Tech Sports Med 13:71-79 © 2005)

• can result from overuse or repetitive trauma.

• Overtraining and repetitive trauma, whether from exercise or sitting on hard surfaces (“wallet neuritis”)

• Acute trauma• The sciatic nerve is suscepti

ble to entrapment anywhere along its course from the lumbar spine through the posterior thigh

• Sitting for prolonged periods of time is typically uncomfortable and becomes increasingly intolerable.

• The patient will characteristically describe posterior hip and buttock pain and a variable pattern of radicular symptoms.

• These distal symptoms may be spotty and ill defined but will follow the pattern of the sciatic distribution.

Piriformis syndrome:

• Palpation for the piriformis

• Straight-leg raise findings are variable

2nd Session• C/O:

– P1: same that night. Increased mildly on Friday, with resting pain to today. Still painful when changing diaper for her daughter, VAS 5/10, but P1 became diffused. Same pain when lying supine on bed

– P2: (Day off till today) no P2 emerged

– No unaccustomed activities or Rx

• O/E (asterisks reassessed): – Lx F: to shin, VAS 2/10, with OP: VAS 3/10; + L Rot: VA

S 4/10

– Usual P1 with central PA to T9, VAS 4/10 with Gd III

– Muscle soreness on palpation of R paraspinal muscles in mid Tx region

2nd Session• O/E:

– L piriformis stretch test: still tight and with usual P2, VAS 4/10

– Other screening tests done: Lx, SIJ, knee, ankle: -ve. Hip accessory movements: -ve

– Neurological Exam: NAD

Post Rx Soreness Condition worse

- P1 remained same range

- Severity of P1 higher

- O/E ＊ remains ISQ

- Disappear in 1-2 days

- P1 move far to left

- O/E ＊ worsened

- Unfavourable findings in O/E

- Worse > 1-2 days

S/E O/E

P1 same same

P2 better same

Differentiate between:Post Rx soreness and Condition worse

2nd Session (1) Central PA T9, Gd III x 2 lots C/O: VAS 4/10 O/E: Lx F+Rot: VAS 1-2/10

(2) L piriformis passive stretching x 3 C/O: VAS 4/10 O/E: piriformis stretch test:

same pain

(3) Self stretching ex to L piriformis mm

3rd Session• C/O:

– P1: still painful that night and next day. Decreased P1 on Wednesday, VAS 1-2/10 when lying on bed. Did not change diaper in aggravating position. Overall improvement: 40-50%. Pain not diffuse now

– P2: nil pain / numbness since last Rx during aggravating activities. Overall improvement: 80-90%

– No unaccustomed activities or Rx

3rd Session• O/E (asterisks reassessed):

– Lx F: to distal 2/3 shin, VAS 0/10, with OP: VAS 0/10; + L Rot: VAS 0/10, VAS 1/10 on return

– Usual P1 with central PA to T9, VAS 3-4/10 with Gd III+

– No back muscle soreness

– L piriformis stretch test: mild decreased tightness and with usual P2, VAS 4/10

3rd Session (1) Central PA T9, Gd III+ x 2 lots C/O: VAS 3-4/10 O/E: Lx F+Rot: post Rx

soreness throughout range,

VAS 3/10, no usual pain

(2) L piriformis passive stretching x 3 C/O: VAS 4-5/10 O/E: piriformis stretch test:

same pain, decreased

tightness

(3) self stretching ex to L piriformis mm

Future Plan

• Back stretching and strengthening exercises for correction of kyphotic convexity of spine

• Reinforce piriformis mm stretching ex and self Rx

• Self back care and ergonomic advice to prevent injury

Learning Issues

• Clinical presentation of piriformis syndrome

• Make Differential diagnosis between hip joint problem and piriformis syndrome

Discussion Time