Clinical Problem Solving: Chronic Low Back Pain Case

What do you see?

Another PT/blogger referred me a case of an active skier and distance runner who had chronic low back pain and feelings of "instability" for one year.

OMPT Channel subscribers can see her first two online consults on The Assessments Channel. I wanted to share with you a key aspect of her case between follow up 2-3.

On the evaluation, we found that her directional preference was for lumbar extension and bilateral sidegliding in standing was even. After 1-2 days of repeated extension in standing and lying and using a lumbar roll in all seated positions, she was almost completely pain free and even did some resistance training.

On visit 2, I decided to tackle some of her right shoulder pain that cropped up from the press-ups. It turns out she had limitations in

cervical retraction with SB right
thoracic rotation right

Repeated cervical retraction with SB right had no effect on her shoulder pain with elevation and MRE. However, thoracic whips to the right made MRE FN and also prone press-ups were also FN. At the time, it also eliminated a perception of "pinching" at end range lumbar extension in standing. We both figured this was win/win.

Three weeks later, she contacted me via email and stated the REIS and REIL were no longer helpful with alleviating her low back pain, her "instability" came back, and the LBP was now left sided.

If all else was equal, there is really no reason why an exercise that was helpful with eliminating pain and feelings of instability would randomly stop being effective. She said stopped doing the thoracic whips, as she felt like that may have caused the flare-up.

notice anything?

Her standing posture looked like this. See anything? She is mildly shifted to the right. Upon checking her extension in standing and sidegliding in standing, I saw the common Clinical Practice Pattern for unilateral Lumbopelvic complaints

extension in standing there was moderate deviation to the right
SGIS had moderate loss to the left

Straight REIS stopped being effective because she was not able to load the involved (now left) side. Repeated SGIS to the left helped alleviate some of her left LBP. After several sets her shift improved someone, but she was still limited. She was instructed to perform this hourly or more for the next 2 days and follow up. She followed up 2 days later stating she was feeling much better.

Why did this happen?

possibly the thoracic whip rotation to the right unloaded her left lumbar spine too much, thus making her lose the ability to REIS and REIL without right deviation
this was discontinued as her shoulder was either not painful or negligable for loss of function in ADLs, workout, and lifting patients at work

What's the takeaway from this? Remember to rescreen for asymmetries in lumbar/thoracic/cervical loading if the bilateral loading strategy stops working "randomly." Just because they passed the screen the first time, does not mean that all things remain equal and they will pass the next time, especially if Sx are more unilateral and the previous loading/unloading strategies become ineffective.

If you found this case interesting, OMPT Channel subscriptions are on sale for 1 week from 11/24/14 to 12/1/14 for Black Friday/Cyber Monday Week! Half off the first month, or $10 off the first year. After subscribing, you will be reimbursed.

Also, most EDGE Mobility System items from The EDGE Tool, EDGEility Tool, EDGE Mobility Bands/Ball, Mirror Box and more are on sale through amazon.com!

Keeping it Eclectic....