Today's COTW is a marathoner who presented with 3 day old onset of acute central, lower lumbar pain.
History: Pt is a 38 yo marathoner who also does yoga and pilates (see flexible). She was performing squats with a 50# rope when she heard a "pop" and felt acute lower lumbar pain, central and equal bilaterally. She had previous history of LBP, but I had not seen her since I started my own practice 1.5 years ago. She sought me out and luckily made daily appointments with me 3 days in a row. She c/o of being shifted to the right, and having difficulty standing upright first thing in the morning. The pain was constant and rated 8-10/10. Her complaints were worse with sitting and bending. Her normal repeated extension in lying exercises were not effective at reducing her complaints.
Objective:
mod lumbar lateral shift in standing to the right
- lumbar flexion: sev loss, PDM
- lumbar SGIS Left: mod loss, PDM, Right WNL, PDM
- lumbar extension: sev loss, only able to flex knees, normally able to extend like she is dodging bullets in the Matrix
- hip IR (supine): DN, sev loss left, FN on right
I did not take hip ROM in that order, after taking lumbar motion in standing, it is normal to attempt to correct the shift in standing. Shift correction SGIS to the left was severely blocked, PDM, no worse as a result. She also could not tolerate the motion very well.
We also have an office manager out and she was not scheduled as a "new patient" so she did not get a 60 minute slot, only a 30 minute slot. I decided to make the most of the time I had with her and check if she met some more criteria for the CPR for thrust manipulation.
lumbar stiffness, check, loss of hip IR on at least 1 side, check, acute, check, no pain below the knee, check, low FABQ, check!
We reviewed the informed consent for thrust manipulation. I used the non-specific lumbar roll technique I teach in my courses, not the technique used in the study, as I find this technique more comfortable on the patient. She tolerated 1 lumbar roll thrust to each side well. After the lumbar rolls, left hip IR was FN.
We rechecked her lumbar extension in standing, it was now improved to about sev loss, but no longer zero. I then placed her over heat in prolonged and gradual extension on an extension table. She felt comfortable in this position, and tolerated gradual extension every 5-7 minutes.
It is important to educate the patient when doing prolonged/gradual extension that Sx may increase at first, but should not remain worse. This is what happened with the patient. After 20 minutes, she was close to end range and her complaints had reduced to 5/10.
After getting off the table, she was no longer shifted, and felt Sx reduced to 3-4/10. Extension in standing was now only moderate loss. She was instructed on use of a lumbar roll and repeated extension in standing hourly, plus prolonged prone on elbows twice a day with pillow progression to raise into further extension for 20 minutes.
Day 2
Presented as improved to 6-7/10 central/bilateral and equal pain at baseline, but after leaving yesterday, she went to an amusement park all day with her nieces who are in town from Las Vegas. She was minimally shifted to the right. SGIS was mod loss to the left with PDM. Manual shift correction was much better tolerated and performed on/off for 10 minutes. I was able to progress her to end range, and she was able to walk without re-shifting.
Lumbar IASTM was performed on her paraspinals, QL and psoas release were performed on the right. Lumbar roll manipulation was more comfortable for her. We tried quadruped lumbar extension in lying modification - instead of pressing up from prone, the patient locks their elbows and drops the hips forward for passive lumbar extension. After doing this for 2-3 minutes, she almost had her hips to the table without pain. This is WNL for most, but still a mod loss for her. She was off from work - on vacation this week - so this quadruped repeated extension was instructed for HEP hourly.
Day 3
Min lateral shift to the right, Sx baseline 3-5/10, still central and bilateral. Shift correction to the left was minimally blocked (much less resistance), not painful, and progressed to shift correction with lumbar extension, which was severely blocked, and PDM, no worse as a result.
Lumbar IASTM was again performed along lumbar paraspinals, QL and psoas release along with diaphragm release on the right (left was normal tone/mobility). Lumbar roll was again performed.
SGIS in standing was performed with extension at end range SGIS to the left, this improved to mod loss. She was progressed to standing lumbar extension in with hips moving to the right (shoulders dropping to the left - to simulate both sidegliding and extension components of the shift correction). Upon leaving, she rated complaints as 3/10 at worst. Extension in lying from quadruped, hips met the table, but this is still a mod loss for her (normally able to backward bend almost at a right angle).
That's it for now! The case is still a work in progress!
Discussion: I had a Q&A about managing an acute "discogenic" presentation. This is my Eclectic approach. I used the best of MDT, OMPT (CPR), and some IASTM and FR of areas that were restricted due to having lumbar pain and being shifted. If I had a full hour with her the first day, I may have just done shift corrections for 45 minutes and eventually gotten a similar result.
After all, research shows that patients who are classified as lumbar derangements under MDT also fall into the CPR for lumbar thrust manipulation. Thus, both should respond equally well when presented acutely under the right condition. Recent research also would predict favorable outcome when good outcomes occur during the first two visits. I predict she should be near 90-100% by the end of this upcoming week (her second week).
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