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:

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:

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

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