Hey guys, what are your thoughts on some of these questions? Lets see if we can get some good pre-presentation discussion going!

1) By reading this patient summery what would your primary hypothesis be? What are some differential diagnoses that cross your mind? Is there anything that I did not look at during the IE that I should have to have made this a more comprehensive evaluation?
2) What are some manual techniques/ HEP that you would apply to this patient day 1?
3) What are some early indications seen in this case that would lead you to think the use of mechanical traction would be effective or ineffective?

Hi Jen, thanks for sharing!

I would think that with this case as presented, the steroid dose pack would have helped. It is unfortunate that it does not seem that it has made much of an improvement, and additionally seems to be worsening from what your assessment says. I think my primary hypothesis according to what you have presented would be an injury to the disc with subsequent nerve root involvement, potentially a neuritis. I am wondering, did she get the LE sx immediately with the LBP? Or did they take longer to become apparent?

With patients who are highly irritable, my goal day one is usually sx relief. It sounds like your patient is somewhat familiar with comfortable and uncomfortable positions for her, but I am wondering if you were able to educate her on potential positions/movement strategies for relief of her sx? I think that leads into your question about traction. Did you try any manual traction day one? I would want to assess that before initiating mechanical traction.

Looking forward to hearing more this weekend!

Hi Jen,

Primary Hypothesis: L5-S1 disc pathology.
Differential Diagnosis: L5/S1 facet w referred pain

Some questions that come to mind that you may have checked: Observationally, is there any type of lateral shift in standing? Is her gait normal? Do her symptoms peripheralize or centralize with AROM? Repeated motion? Any LE weakness?(did you mean weakness with heel raises?) I know she reported numbness/tingling intermittently – Is dermatomal sensation intact?

Manually, I may try uni or central p/a’s above the painful segment depending on how she tolerates it. I may try some extension PPIVM’s in sidelying.

Hey Jen,

After reading your case, my primary hypothesis would be L5-S1 disc pathology. I’m a little unclear on your neuro screen. By “MMT: Heel raises” did you mean that she had weakness with heel raises? Was it bilateral or only on the involved side. I would also have screened dermatomes and DTRs at some point even if you missed it at the initial evaluation so that you have a baseline. One of the criteria I would use for determining if a referral is necessary at any time for this patient would be worsening neurological symptoms. If you test reflexes at visit 8 and find out they are absent, you will not know if that was the same as the eval or if they are worsening. If you eventually decide to refer, it is imperative that you have those data points to provide to the physician. I’m also interested to hear your reasoning for performing overpressure with lumbar flexion during your active ROM assessment due to the fact that you rated your patient’s irritability as mod-severe and that you had already elicited her primary complaint with active movement. What did you hope to gain by overpressing?

As far as manual techniques I would try, I usually try some nerve flossing in the SLR position and UPAs to see if I can make a change in their SLR. I’ve found that that is a really powerful tool for increasing patient buy in. I’m curious to hear if you attempted any repeated extension to see if her symptoms changed at all because it seems that extension positions (standing, lying prone, etc) helped relieve her symptoms. If she responds to repeated extension, that gives you a pretty clear path to follow with the initial HEP.

Looking forward to seeing everyone this weekend!

I agree with tyler in that a thorough neuro assessment would be high on my list and I would be monitoring frequently to ensure that symptoms were not further deteriorating. Similar questions also come to mind in terms of if you were able to centralize her symptoms, how irritable she was with nerve tension testing, and your thought process when using OP with someone who is more irritable.

Hey Guys!
These are all great points and I do have some answers for you. I honestly was so focused on posting the positive Objective * I neglected to post the things that helped me rule out my differential diagnosis. Here are some other things I looked at during the IE. I hope this helps clarify!
ROM: Repeated Ext centralized sx (Sessions 1-3)
Gait: Antalgic in nature
LE dermatomes: Intact and equal B to light touch (Increased sensitivity to palpation along the S1 neurodynamic pathway)
LE Myotomes: Fatigable weakness with L PF (heel raise) All others strong and pain free
SIJ: (-) Thigh thrust, Sacral thrust, compression and distraction
Hip: (+) FABER (Pain in L low back), (-) FADDIR but painful in LB getting into this position