MSc in Manipulative Physiotherapy

Case Presentation

D Chan

Physiotherapist

Patient Information:

• Miss C, 50/F. housewife

• Reason of referral: LBP for pain management / relief

S/E:

C/O: gradual onset of deep central LBP (P1), simultaneously increase R LL stretching pain with P’s and N’s (P2) since 6/2010

Behaviour of symptoms:

• P1: – ＊↑ with activities (shopping in market), VAS 8/10– ↓ with self exercise, VAS 4/10; intake of painkillers; be

d rest– 24-hour pattern: better in the morning. morning stiffne

ss0. ↑ after daytime activities (around 18:00). night pain0/sleep disturbance0

• P2:– ＊↑ with sitt. x 15 min, VAS 8/10– ↓ with ex. (walking) VAS 5/10; intake of painkillers; be

d rest– 24-hour pattern: same as P1

Special Qs

• GH: good. • Medication: painkiller twice daily (8:00 and 20:0

0)• X-ray: mild anterolisthesis of L4 relative to L5• Cough Sneeze↑ P2 (P’s and N’s)• No previous PT Rx• Bowel / bladder disturbance0

• saddle anaesthesia0 / gait disturbance0

• hobbies0 weight loss0 surgery0. • PHx: no previous episode of LBP. trauma0.

O/E

• Posture: • Standing (resting): P10, P2: 5/10 • Lx:

– ＊ F: base of patella. P10, P2: 8/10 to mid post. thigh – ＊ E: . P20, P1: 8/10 on recovery – SF L: 1” below knee joint line. ↓P2 to VAS 2/10– SF R: knee. ↑P2 to VAS 6/10– Rot L: with OP– Rot R: with OP

O/E

• Muscle spasm0

• R gluteal palpation: P2 (local) VAS 8/10

• R hip Q: usual gluteal pain

• SIJ TxVAS 8-9/10, not usual. Stiff+. No P2

O/E

• MMT: R: L2: grade 4 (?limited by pain)

• Sensation: NAD

• Jerk: NAD

• SLR: – R +ve at 15 degrees with DF – L: -ve

Learning Issue: where were the distal symptoms referred from?

• Physiological movement tests, SLR also move hip and back

• From the Back or the Hip?

•＊ Slump test: ↑P2 (VAS 10/10) with Cx F in slumped sitt, ? ↓ with Cx E

• Canal Slump test: ? ↑P2 in both Cx F and E (irritable)

Points to consider

• are the s/s constant/ vary?

• What is the irritability?

• What are the hypotheses from SE and OE?

hypothesis

• Acute severe Nerve root pain (irritation)– R LL stretching pain with P’s and N’s– Complained more in distal symptoms– Sneeze↑ P2 (P’s and N’s)– SLR: R +ve– Slump test: ↑P2 (VAS 10/10) with Cx F in slu

mped sitt

hypothesis

• Hip with referred pain– R gluteal: P2 (local) VAS 8/10– R hip Q: usual gluteal pain

conclusion

• This case is likely Nerve root irritation

• Quite adequate information from the 1st session

• Need to differentiate whether the hip is involved/ extent of involvement

Learning Issue: Choice of technique in the 1st session

• IVLT

Go to P1 only, or short of it if severe

Constant Low (3-5kgs) poundage to startGentle, 5-7 minutes, rest 10-15 minutes

Warn of severity and latencyRecheck neuro-dynamic

Advice: rest in bed, avoid sitt

technique used in the 1st session

• IVLT, 20lb, 15/15, 15

• during Rx:↓ P2 to almost 0/10; mild ↑P1

• just after Rx: P2 returned slowly. No P1

• Warned. Note results

Learning Issue

• Reassessment

C/O: How are you? ( 點呀 ?)

If there was a change, ask:

What is the change?

Changed by how much?

When was the change? ( 由當日離開到現在 )

Any unusual labour, activities or treatment?

What do you think that caused the change?

2nd Visit

• Reassess the asterisks• S/E:

– P1: ↑just after Rx, ↓next day and maintained (in general VAS from 8 to 4/10 )

– P2: ↑just after Rx, ↓next day. Now VAS 8/10 (same) on sitting

– No unusual activities• O/E:

– Lx: • F: knee. P2 VAS10/10• E: . P1 VAS 5/10

– Slump test: same

Learning Issue: Decision on grading and rep

S/E O/E

P1 ↑ ↑

P2 same same

Same Rx to P1, with SAME grading and dosage

ADD one treatment to P2.

(ONE treatment to EACH problem)

Learning Issue: Choice of technique

To the hip, shaft rotation, though it is a physiological movement, can be used as

an accessory movement to treat hip pain

R hip caudad glide, III (short of pain), 3 lots

(rationale: significant reduction in hip pain after trial )

Learning Issue: change of repetition

• S/E: – P1: much improvement and lasted to today– P2 improved next day (the best was VAS 5/10), impro

ved sitting tolerance to 30-45min.– gradual return of pain to today 7/10 (previous 8/10)

• O/E: – P1: improved– P2: (add gluteal palpation as asterisk after last Rx)

• Same/mildly improved

What was the plan?

Learning Issue: change of repetition

S/E O/E

P1 ↑ ↑

P2 same

(↑ then ↓)

same

Same Rx to P1, with SAME grading and dosage

Treat time with time: ↑hip caudad glide

rep. to 5 lots, with SAME GRADING

Learning Issue: condition got worse

• S/E and O/E of P1 and P2 got worse

• Actually better the next day. ↑P1 and P2 after unusual activity (heavy carrying and much walking)

What was the plan?

• KEEP EVERYTHING THE SAME

• The condition seemed to be improving, but aggravated by unusual activities

• Same Rx to see the effect

• Back care education done

Learning Issue: condition got worse

Learning Issue: condition got ‘MUCH’ improvement

• S/E: – 60% reduction of P2. 40% reduction of P1

• O/E:– P2 improved; P1 slightly improved

Need to do a full neurological assessment. Why?

Learning Issue: condition got ‘MUCH’ improvement

Dramatic/ unexpected reduction

in pain /numbness (esp. distal s/s) may be due to

complete loss of sensation (anaesthesia).

(The nerve is dead!)

Full neurological exam include

(1) Sensation

(2) Muscle Power

(3)Reflexes

Learning Issue: Retrospective Assessment

• 30/9/2010

• 10 Rx sessions received

• 2 incidences of getting worse after unusual activities within this period

• P1(back): improving trend

• P2 (buttock and RLL stretching pain): similar

Need to do the retrospective

assessment for the Hip. Why?

Learning Issue: Retrospective Assessment

Aim to find anything in the treatment that

helped or not helped the patient

Usually when:

(1)Condition static despite treatment

(2) confusions++. Lots of unknown,

uncertainties and gaps

(3) take over Rx from another PT

Learning Issue: Retrospective Assessment

• Am I treating P2 well?• Aim: differentiate whether P2 was from the back

or from the hip • Findings:

– 30-40% improvement of P2 till now– She c/o ↓P2 when she kneeled– ＊ SLR : R: 700 +ve with ankle DF, usual leg pain at ni

ght

• Concluded that her R leg pain likely more contributed from her back

Conclusion:

• Bear in mind the learning issues– Traction for nerve root pain– Change of grading or repetition with respect

to change of S/E and O/E– Beauty of retrospective assessment