April Journal Club Case

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    • #3697
      Laura Thornton
      Moderator

      Referral from PCP: Low back pain

      Demographics: 58 year old female, works as a travel consultant. Plays tennis multiple times a week, cycles (5,000 miles a year), skier

      PMH: SLAP repair in 2012, otherwise none. Previous episodes of mild back pain in the past. Was treated in 2012 with physical therapy for back pain.

      MRI 2012: Grade I anterolisthesis L4 on L5 (brought imaging results with her)

      Chief complaints:
      • dull, aching central low back pain
      • “electricity” in bilateral posterior thighs from gluteal crease to knees
      • sharp pain from left hip down lateral thigh into lateral lower leg (stops at ankle, nothing into foot)

      History of Present Complaint:
      • In Early February, patient was playing tennis and fell when running to get a ball. She noticed some soreness in her low back after, however it wasn’t excruciating so she finished the tennis match. Two to three weeks later, she woke up in the morning feeling like she had pulled her back. However, she didn’t change her activity level and continued with tennis and normal exercise. The first week in March went to Vail with her family and noticed her low back pain started to get worse during skiing and started having the pain down her leg that was worsening throughout the week. She got back from Vail and continued with normal exercise, like running up bleachers and playing tennis multiple times that week. Low back wasn’t getting better, so went to a Chiropractor and got “adjusted”. She felt small amount of relief, however two days later she woke up and could barely walk. She went to OrthoOnCall and took x-rays, same result of Spondylolisthesis at L4-5. She was placed on a steroid pack and has gotten much better. She has returned to exercise including cycling, however is not playing tennis yet.

      • Aggravating factors:
      • Turning in bed in the middle of the night brings on the bilateral electricity feeling in posterior thighs, immediately diminished upon rest and stopping the movement
      • Low back dull, aching pain is brought on by driving greater than 1 hour or sitting for a long time, alleviated within several minutes of changing postures. This is particularly troublesome because she travels so much for work.

      • Left leg sharp pain is brought on by walking greater than 10 minutes, will take several minutes to decrease once in seated position

      • Easing factors: sitting (but will start to ache if sitting for greater than 1 hour), cycling

      • Patient denied weakness, change in balance or gait, saddle paresthesia, bowel or bladder dysfunction.

      Hypothesis after Subjective Examination: Left L5 radiculopathy
      Rule Out: Red Flags due to bilateral symptoms, direct trauma, and hx of spondylolisthesis – Myelopathy?, L4-5 Facet/Disc, Hip, Gluteal tendinopathy

      Physical Examination “Asterisks” Signs and Symptoms:
      Observation: Patient stands in increased lumbar lordosis. No lateral shift present. Increased lateral thigh pain with SL stance on L. Ambulates in increased lumbar lordosis and forward trunk lean, had increased pain in lateral thigh after 10-15 feet of ambulation.

      Lumbar ROM: Flexion 100%, painfree, no aberrant motion
      Extension: 25%, painfree, although mostly performs movement through hips and thoracic spine
      Right Sidebending: Fingers to knee joint line, painfree
      Left Sidebending: Fingers to 3 inches above knee joint line, pain increases down lateral thigh and lower leg at end range, diminishes upon return to upright standing

      Neurological Screen:
      Myotomes: 5/5 all
      Dermatomes: Normal to light touch
      Reflexes: 2+ L4 and S1 B
      Straight leg raise: Negative on the R with dorsiflexion and cervical flexion, Positive on the L for low back and left lateral thigh pain at 70 degrees hip flexion with cervical flexion (but not dorsiflexion)
      UMN: Negative Babinski, Negative ankle clonus, Negative Inverted Supinator reflex, Positive Hoffman’s bilaterally

      Conclusions after Physical Examination: Lumbar radiculopathy (L5) with possible underlying lumbar instability. The positive Hoffman test, MOI, bilateral paraesthesias were of concern to me and I would have recommended a consult if she hadn’t already scheduled an appointment the next day. She presented in a directional preference of flexion, therefore as initial treatment I gave her low level flexion-biased exercises including pelvic tilt, all fours lumbar flexion to neutral spine (cat/camel exercise just into flexion), and prayer stretch. I agreed that cycling would be okay for her to continue, hold off on tennis for the time being, and gave her education on avoiding provocative activities such as prolonged walking. She also wanted to do quadruped alternating UE and LE extensions, which I reviewed and ensured that she was performing with proper core activation and not going into lumbar extension.

      Discussion Questions:
      • Would you send this patient for further medical consult if she hadn’t already had an appointment with the neurologist?

      • I think at the time I was too conservative with my examination because of the MOI, positive Hoffman’s, history of spondylolisthesis, and I knew she would have an appointment with the neurologist the next day. Looking back, I wish I would have done lumbar instability testing to confirm underlying instability. Would you have continued with the examination or have kept this for later sessions?

      • She’s very active and was eager to start exercising again, including tennis. What do you think her prognosis is in terms of returning to an extension-biased sport? What would you all suggest in terms of explaining if and when she is to return?

      • Would you have done anything differently in the initial treatment?

      Some questions to consider when reviewing the article for next week:

      • What are your thoughts on the study authors prescribing the same physical therapy protocol to all patients, regardless of their predominant clinical presentation of mechanical back pain, radiculopathy, or neurogenic claudication?

      • The frequency of visits of 1x/month is uncommon in orthopedic practice, although the response was positive. What are the pros and cons of this frequency and what is the feasibility of implementing this?

      • Were the results surprising to you? Why or why not?

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    • #3709
      omikutin
      Participant

      Great case Laura!
      During the observation you said SL stance on her L increased her lateral thigh pain. Did the pain radiated down to her lateral leg? Turning in bed brings on her B electric feeling, does it matter if she turns from supine to side-lying or side-lying to supine? What was her resting position? As well, when she was standing did you try to correct her posture (decreased lumbar lordosis) and see if that made a difference?

      How would you list her irritability level? If patients are low, I like to perform the vertical compression test (very slight gradual pressure) and show her where she buckles, correct it and redo the test. It has been a great patient buy in for me.

      I would first consult with a coworker about the + Hoffman finding and if we had similar findings then I would like to follow up with her/the neurologist after the appointment.

      Deciding a plan of care has always been a challenge for me. I would see how she would respond to her HEP and consult with the neurologist if there were any abnormal findings.

    • #3710
      Laura Thornton
      Moderator

      Thanks for your responses Oksana! Great points.

      No, when she started to stand on her left leg, she reported that she felt start of mild pain in her lateral thigh, not into her lower leg.

      She reported that she could feel the “electricity” feeling when she rolled from supine to side-lying. I didn’t ask what her resting sleeping position was, but that will be a good question to ask where she starts out at the beginning of the night.

      I didn’t try to correct her static standing posture, as she didn’t have any symptoms in standing but I definitely want to incorporate the vertical compression test and standing postures into treatment at adjacent sessions. I think that will be a crucial piece as we start working into load bearing postures.

      I apologize, I did not write what her irritability and severity levels were. This is reflecting her current state, which has definitely improved since onset. Her left radicular pain and dull, aching pain were not severe. Her low back pain takes awhile to provoke with sustained postures and easily subsides with change in position, therefore mild in severity and irritability. Her radicular pain is easy to provoke with activities but again, easily subsides with getting out of certain positions. It’s not affecting her sleep and she is able to function, but is avoiding her regular amount of exercise due to pain. I would say her severity is mild to moderate for the radicular pain and mild in irritability. This would make me think that I could have been more firm with my examination, however, there were some indications of caution so I was more gentle.

      Update: I saw this patient yesterday morning again for her follow up. She saw the neurologist who wrote an updated prescription for lumbar radiculopathy and stabilization exercises. She was significantly improved and had been doing the exercises 2-3 times a day. She reported she had not felt the electricity feeling since before the last session. I re-did her neuro and she presented with negative Hoffman’s B, similar SLR on the L, and improved L sidebending ROM. We progressed her stabilization exercises to include:
      – Supine marches from table top
      – Supine alternating leg press
      – Sidelying clam into leg abduction/extension
      – Quadruped forward rocking (had increased L lateral thigh pain with plank, therefore modified)

      We also discussed strategies to use during bed mobility to reduce excessive lumbar rotation.

    • #3711
      Nick Law
      Participant

      Thanks so much for posting Laura!

      A few things I would have added: slump testing (just to supplement SLR), thoracolumbar rotation (rotation towards decreases the size of the foramen, at least on dead people, and I have consistently seen this reproduce radicular symptoms), possibly quadrant depending on how irritable she seemed, recognizing you already reproduced her left sided LE symptoms – at least I may have checked right posterior quadrant as nothing else was reproducing her R LE symptoms.

      Given the Hoffmans I would have done a quick cervical screen – rotation with OP/quadrant/spurlings, UE reflexes, would have asked about if she had any complaints of neck pain following her recent fall or if she has had any other cervical symptoms.

      If above was all negative, seeing that she only has 2/5 for cervical myelopathy, lack of UE symptoms, no hyperreflexia, R LE symptoms seem more infrequent than L LE which seem to have a clear reproducible mechanism and pattern, I don’t think I would have been concerned about the Hoffmans. I may have picked up the phone and called the MD just to inform, but I think in this case you can move forward with relative confidence in treating.

      I wouldn’t let the presence of the spondylolisthesis deter you from your examination otherwise, especially because the image hasn’t changed over the past several years. Research has shown very little to no correlation between spondylolisthesis and LBP, and has found it to be as high as 20% in an asymptomatic population (see attached).

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    • #3714
      Laura Thornton
      Moderator

      Thank you for posting those articles Nick. Honestly, when I went into the initial examination I didn’t know if spondylolisthesis, like other degenerative changes in our bodies, was correlated with LBP or not, especially with athlete certain extension-biased sports. That was also one of my reasoning questions to ask and search in the literature for and that’s one of the reasons why I went more gentler with my initial examination. But, it’s much more clear to me now and one thing that I was ecstatic about was not only did the patient and I get to have a conversation about MRI findings and the lack of correlation between symptomatic and asymtomatic individuals at the second visit, but the neurologist and the chiropractor had the same conversations with her. She’s getting consistent information from all angles so she was completely on board for what we’ll do in PT.

      Yes, I agree with you on adding in quadrants at future sessions but I felt at that time, I had a pretty good concordant sign so I held off. I did perform thoracolumbar rotation with her, she was painfree bilaterally with about 75% of the range each way so it wasn’t an asterisk sign for me but I agree, I’ll have to do more specific movements with her because she’s already improved with L sidebending.

      That is an excellent point with cervical pain/ROM/Quadrants/full cervical DTR testing. Would have been a great thing too add in to affirm or deny the caution that I had with her. I’m really glad I posted this case, good learning experience for me. Thanks for your input!

    • #3715
      omikutin
      Participant

      I would definitely agree with fully ruling out cervical myelopathy: 1) gait deviation, 2) + Hoffman, 3) inverted supinator sign, 4) + Babinski test 5) age >45 yo. (I had to review them for my sake) It’s good that you checked other UMN tests just to lessen the muddy waters.

      Having a stability program for patient with spondylolisthesis sounds like a solid plan. However, tailoring a program for the patient is vital. They maybe uniformed treatment per patient to see the effectiveness of this particular stability program. For example, the bridging exercise might be aggravating for a patient like yours due to her extension sensitivity which I would cue her to extend from her hips without lumbar extension (common mistake that I see with my patients).

      Having treatment once a month does not seem frequent enough. I’m sure patient’s form could be faulty and I would definitely encourage seeing them more frequently. As well, 15 patients dropped out due to various reasons. I’m sure motivation probably dwindled as time went on. However, just getting the person moving is better than “bed rest” which is why I can perceive positive results. It might be more helpful if this study had a comparison group.

    • #3717
      sewhitta
      Participant

      Thanks for posting Laura
      I agree with Nick. I would need more supporting evidence to refer this patient out after your initial eval. The Hoffman’s test, from what I have been reading, is not reliable as a stand-alone test for a cord compression, and having bilateral symptoms is not as concerning as unilateral symptoms (correct me if I’m wrong). It also appears her symptoms are very mechanical. Going back to your physical exam, you mentioned you would add prone instability testing. Prior to this, I would palpate as specific as I could throughout the lumbar spine to develop an appreciation for muscle tone and any deformities in the spine (possible step deformity with spondylolisthesis). I would add PPIVMS, PAVIMS and PA’s, again to get as specific as possible to the area in question if you are thinking the spondylolisthesis could be the source of her symptoms. If it’s not provocative, great! That’s a great opportunity to educate her further on the lack of correlation between the exam and the MRI findings, which could potentially set her mind at ease if she is having any sort of fear of this “deformity” in her spine.
      As far as her prognosis, this is always tough for me to address with these patient’s. At this point in my clinical reasoning I try to explain back injuries by comparing it to other tissue injuries, such as an ankle sprain. Depending on the tissue involved and the severity of the initial injury, the tissue could take months to remodel and longer to restore strength and motor control. I think it’s important to convey that expectation if it’s necessary. According to the LBP Practice Guideline, there is a high recurrence of episodes of LBP after an acute LBP episode, and 60% of those episodes occur 2 months after the initial episode. When I sprained my ankle, I tried to play basketball 3 months later and sprained it again (3 times in one year, most likely because I did nothing to rehab it). I think patients often are discouraged when they feel they’re not getting better because their expectation is not realistic and they lack knowledge of the physiology of tissue healing. In addition to that, it can be tough for us as therapist to tell someone who is very active that they may have to stop doing something they really love and we really want them to get back to activity as quickly as possible. However, I feel it’s necessary to plant the seed at times and let them know, this may take a while. For the appropriate patient, therapy once per month with quality patient education sessions may be the best route and all they need. I mean, how many times do people come back each week, 2 or 3 times each week and tell us “nothing has changed”? Well, it may need more time to change. I have also found that less frequent visits seems to hold the patient more accountable to take charge of their care and not rely on coming to therapy visits to be “fixed” by their therapist.
      I think it’s also awesome as well that she received consistent information from multiple sources regarding her condition. Can you imagine how much that would affect outcomes if that were always the case?

    • #3718
      ABengtsson
      Participant

      Thanks for posting Laura!
      Lots of great points already and I fully agree with some of the mentioned additions like slump, quadrants (maybe not day 1 since you already reproduced her pain; I tend to include quadrants regardless, to check for combined motion and with suspected instability, move to H-I test from there) and the more specific palpation and mobility assessment Sean mentioned. I def like the idea of using standing compression and if positive, working on neuro re-ed right away.
      I’d also include prone instability test on day 1. It seems that her irritability is low enough to tolerate PAs and I’ve found that the PIT helps tremendously with buy-in because it shows the pt a way to instantly decrease their symptoms. That also allows for a great transition into therex education and could help with HEP compliance. Did you clear the hips? I wouldn’t be surprised if her EXT and PAs would be limited considering the mechanism/biomechanics.

      I wouldn’t have been too concerned with the Hoffman’s alone. I was in class with Aaron the other day (cervical eval) and one of the PT students had a positive Hoffman’s (and Aaron had way too much fun with that) and it opened my eyes to how this can be a (+) in completely asymptomatic individuals. 2 weeks ago, I definitely would not have been as certain. If cord compression or UMN signs would really be a significant concern, I’d probably add cervical ligament testing as well, especially in a pt like that who likely has more ligamentous laxity as it is.

      I don’t think that once a month is a great idea initially, especially in more acute cases. Considering how much neuro re-ed and motor learning is involved, especially at the beginning, I wouldn’t consider the idea. Also, I’d want to make sure that I can progress the treatment as needed, which would be difficult to do. If an exercise gets too easy after 1-2 weeks, I also have a hard time expecting the pt to be fully compliant. If it were a patient with chronic pain/limitations, where I know that the tissue healing time etc. is considerably longer, I think it can definitely work. I have a few patients I see on a very low frequency, but that’s always later in the course of care.

    • #3720
      Laura Thornton
      Moderator

      Oksana – you hit the nail on the head when you mentioned tailoring the program to the patient. Absolutely, I agree. Stabilization is taught as a standard treatment approach, but I think looking at her movement patterns and seeing why she is getting more stress to her low back is the ultimate goal. One of the main topics I want to discuss during journal club tomorrow is the question of does it really matter if there is a spondy or not and looking at them individually with movement patterns.

      Sean – good to hear about your thought process and what you have continued with in the examination. You’re right, it would have been a great educational tool to supplement the concept of not concentrating solely on anatomical abnormalities. We also had a brief discussion this past weekend on the trend of decreasing the frequency of visits for patients and the potential benefit of allowing more time between sessions to see change and increasing accountability. I tend to do this for the patients that I do less manual therapy with and I am much more satisfied with progression of treatment (and also seem to get less frustrated myself). I think my patient is a great candidate for decreasing frequency to 1x/every other week or 1x/every 3-4 weeks as she progresses since she’s responding so well to exercise prescription. Especially when we do get to that point of introducing tennis back into her program and incorporating more swing analysis and response to return to sport.

      Alex – Clearing the hips is in my plan. I think its fair to say that what’s going on with this patient is not just at her lumbar spine, but up and down the chain as well and in terms of returning to her sport specific movements, I am looking at hip extension/rotation, thoracic extension/rotation, shoulder ROM, and even ankle ROM. That’s interesting about the + Hoffman’s sign with the PT student, and I’m sure that more cases like this exist. The research supports Hoffman’s sign as a test for cervical myelopathy. I wanted to know if the cord was being compressed at ANY region of the spine, could the UMN tests that we know (Babinski, clonus, reflexes, Hoffman’s, etc.) be positive regardless of region. BUT, at the region of low lumbar, if you’re getting central compression doesn’t that constitute as peripheral since the conus meduallis ends at L1-2? My other question was that if you even had slight irritation or sensitivity of the central nervous system structures that is minimal irritability and was reversible, would those tests still be affected. I didn’t really get an answer to that through the literature but I think it’s fair to say that at least I have a little bit more awareness of the ambiguity and variance that can be found with them as well. I loved getting all of your guy’s thoughts because it helps with organizing all of the information and planning what to do next if you see an abnormal finding.

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