Case Example 1 – Lumbar Pain

Sorry for the delay in this post………

Looking forward to feedback/thoughts regarding this patient, and the layout of the case report.

Enjoy.

Key Subjective Findings:
  • 26 year old male.
  • Original Lumbar Injury in November 2011 whilst lifting a piece of concrete (approx.  20kg) from the floor. Received a week of physiotherapy management. Outcome being full recovery.
  • Re-injury in March 2012 as result of reaching forwards to reach a spanner in toolbox (on the ground).
  • Ongoing aggravations since then (related to lifting bending) but symptoms are gradually improving.
  • Currently off work (trades assistant – full-time). Work can involve lifting up to 4okg from the floor (although this is infrequent).
  • Current treatment nil apart from pain medications from GP (NSAID’s and panadeine forte)
  • Patient specific functional scales
    • Sitting – 3/10 (30 mins tolerance)
    • Lifting – 1/10 (pain immediately with light weight)
    • Normal work duties – 1/10
  • Body chart:
cs2
  • Pain is constant (VAS 4 to 8/10). Aching to sharp in quality
  • No leg symptoms. No pins and needles/numbness.
  • Nil red flags.
  • General Health – normal
  • Imaging
    • MRI – Large central disc protrusion at L4/5
  • Diurnal Pattern
    • PM – some slight discomfort but no significant sleep disturbance
    • AM – mild lumbar stiffness (5 to 10 mins)
    • Day – activity dependent.
  • Patient Beliefs
    • Feels his back is weak and needs strengthening.
    • Feels positive about his recovery and that he will be able to return to normal work.
    • Is motivated to return to work and feels his workplace is supportive.
    • Enjoys his work.
    • Is unclear what the cause of his pain is.
Key Objective Findings:
  • He has relatively good range in his lumbar spine. Pain increases throughout flexion, but he has full range.
  • Squat – full range, pain at end of range.
  • Neurological exam – not assessed
  • Straight leg raise (70 degrees) and prone knee bend non-provocative.
  • Sacroiliac joint testing is negative.
  • Muscle length (hips/lumbar spine) normal.
  • Hip joints non-provocative and normal range.
  • Slump test is provocative for lumbar pain.
  • Tender centrally over L2 and L4 (he reports his lumbar pain is reproduced palpating both of these segments).
  • PPIVM’s L4/5 is hyper-mobile into flexion. L2/3 slightly hyper-mobile into flexion.
  • No allodynia or widespread hyperalgesia.
  • Motor Control:
    • When lumbar spine is loaded (e.g. simulated lifting) his pain is increased.
    • When he actively posteriorly tilts his pelvis in this position his pain increases.
    • When he controls his lumbar lordosis (via an active anterior pelvic) in this position his pain is significantly lessened (60% less), but not completely i.e. suggestive of a flexion control impairment component. This active anterior pelvic tilt requires a significant amount of therapist assistance. Patient  unable to independently perform this movement correctly in standing or sitting. He has reasonable control in crook lying.
Neuropathic Pain Assessment:
  • DN4 Neuropathic Pain Questionairre – 2/10. Result suggests neuropathic pain is unlikely.
Questionairres:
  • Orebro Musculoskeletal Pain Screening Questionairre- 88
  • Oswestry Disability Questionairre- 34% (moderate disability)
Diagnosis:
  • Subacute Non Specific Lower Back Pain
    • Non-specific in nature given:
      • pain was equally reproduced on central palpation of both L2 and L4.
      • MRI findings inconclusive
Classification:
  • Dominant Mechanical Pain – Flexion Motor Control Impairment L4/5 > L2/3.
    • See motor control findings above and:
      • Full range in functional activity (reported aggravating factors).
    • No movement impairment evident
  • A likely inflammatory component is present (constant pain, morning stiffness that is better once moving) but this appears to be resolving.
    • This is likely to be why pain could not be completely abolished with correction of motor control strategy. i.e. the patient had constant symptoms suggestive of inflammatory pain.
    • Inflammatory pain is the most likely cause of the constant symptoms given the unlikely involvement of Neuropathic and Dysfunctional pain types (see below).
  • A Neuropathic Pain component is unlikely given DN4 result.
  • Dysfunctional Pain element is unlikely given:
    • General health is clear
    • Mechanical nature of pain
  • Central sensitisation is unlikely given:
    •  lack of widespread pain
    • nil allodynia
    • dominant mechanical nature of pain
  • Peripheral sensitisation is possible, given inflammatory aspects (mild) of the disorder but is not a dominant pain mechanism in the presentation.
Prognosis:
  • Overall prognosis is positive due to:
    • the dominant mechanical nature of the pain.
    • the ability to improve pain significantly with correction of motor control
    • symptoms appear to be resolving/improving.
    • patient is motivated and positive about his recovery.
    • low Orebro score.
  • The only negative aspects of his prognosis are:
    • Ongoing constant nature of his pain since March and frequent aggravations since.
    • Patient’s work can require heavy lifting below knee height (?up to 40kg).
    • Moderate disability on Oswestry.
Treatment
  • Patient has been progressed through a 3 week program consisting of:
    • Development of ability to independently anteriorly tilt, and maintain, the lumbopelvic area in:
      • Crook lying
      • Sitting
      • Standing against wall
      • Standing
    • Trained to anteriorly tilt lumbopelvic area and maintain control during:
      • sit to stand
      • simulated lifting from floor to waist (no weight)
      • lifting from floor to waist
        • gradual increase in weight (currently up to 15 kg in weight and able to achieve pain free for 20 repetitions)
Most recent review – Key Findings
  • Subjective
    • Pain now intermittent (VAS 0 to 3/10)
    • No PM or AM symptoms
    • PSFS
      • Sitting – 6/10 (90 minute tolerance)
      • Lifting – 5/10
      • Normal Work Duties – unknown.
        • Scheduled to return to modified work duties – 2 week trial. Will continue with exercise program whilst at work.
    • Nil medications needed.
  • Objective
    • Full, pain free lumbar range.
    • Pain free lifting 15kg floor to waist if correct motor control strategy utilised. Independent control achieved. Able to achieve 20 repetitions pain free.
    • Nil tenderness on palpation of lumbar spine.
    • Slump test negative.
  • Physiotherapy review scheduled on return from work trial.
    • Plan
      • Review
        • key subjective/objective findings
        • PSFS’s
      • Re-assess Orebro and Oswestry
      • Progress treatment as indicated

Will keep you updated…..

Any thoughts/feedback? I have tried to include as much info as relevant. Happy to clarify anything.

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Branch Councillor on the Western Australian Branch of the Australian Physiotherapy Association.

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