December review/discussion

[omikutin]

Happy Late Thanksgiving,
This is the patient that I will be presenting this weekend and I would love to hear your thoughts and/or ideas.

Subjective:
54 yo female presents with chronic low back pain for 7 years with several episodes of for the last 4 years with an occasional numbness and tingling sensation down lateral left thigh. First episode in 1995 when she was reaching for a remote, second 2003 bending down and reaching, 2015 stepping down from a stair step and current symptoms began last week after going form sit to stand at work and felt a sharp pain. No symptoms distal to knee or radiating/ sharp shooting pain. Pain is greatest in the evening and feels stiff in the morning, occasional popping/ clicking. Reports history of visiting chiropractor and symptoms improved and then got worse.
•Aggravating Factors: driving and rotating left, prolonged standing, reaching, sitting on a soft couch, putting on shoes
•Reliving Factors: previously exercising, changing positions, resting, activity modification

Objective Exam:
•Observation: sway back, hypertonic erector spinae, hangs on “Y” ligaments, hypertonic erector spinae
•Neuro: sensation intact, reflexes B 2+, – Hoffman, myotome/ dermatome cleared
•Lumbar ROM: + extension, SBL, flexion, extension/ SBL quadrant (walks up thigh from flexion)
•Lumbar AROM: FB: 75% grower’s sign, BB: 50% pain in low back, SBL: 50% pain, RR: 50% pain, RL: 25% pain at end range
•(-) neurodynamic testing: – SLUMP, – SLR
Hip and SIJ cleared:
•Hip ROM: Ext R/L -8/ -5, Flex R/L 60/65
•SI: – compression, – distraction, -gaslens, – sacral thrust, – thigh thrust
•Joint mobility: PA hypermobility L4/L5 (pain) and L5/S1, hypomobile T7-T11

Looking at the body chart, there’s some numbness in the lateral thigh. Earlier we’ve talked about meralgia paresthetica. My patient is a female and she’s min-moderately overweight, classic meralgia paresthetica. My patient fits the prevalence for MP but what are some test to help rule out MP? My thoughts were Ely’s test, putting the femoral nerve on tension and slightly ADD the leg to further stress that nerve. So let’s say we rule out MP. Why do you think there’s numbness in the lateral thigh? From my objective and subjective data I’m thinking lumbar hypermobility. Do you see typically or have you seen paraesthesia with hypermobile lumbar patients? Why would you think so?

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[sewhitta]

Oksana –
Femoral nerve tension testing is a good way to help with your diagnosis of meralgia paresthetica, as you said. I would also palpate the area to see if you could possibly manually compress the lateral femoral cutaneous nerve as well. Is she able to recall any position or activity she is in when she feels the numbness?

Were you able to reproduce or exacerbate the lateral thigh pain/numbness? Did PA pressure to the lumbar segments change the symptoms in her thigh? Also, the glute min could refer pain to the lateral thigh. I would palpate and apply fair pressure to tender areas of the glute min and hold for maybe 15 secs or so, if tender, and see if that reproduces it.

[Laura Thornton]

Are you thinking upper lumbar at all? The numbness in the lateral thigh, the stiffness in lower thoracic. Was her joint mobility normal and pain-free?

[Nick Law]

To me, it just doesn’t seem to have as many features that fit with MP vs. lumbar pathology. No sensation loss, I think, would weigh heavily against MP. However, if you wanted to test further the article we posted earlier this year mentioned 3 tests – pelvic compression, a sidelying neural tension test, and tinels.

If you go back and look at the referral patterns for L spine, it sure looks to me that in patients with symptomatic LBP, facet stimulation caused lateral thigh symptoms. Does the patient use the word numbness to describe actual loss of sensation/tactile touch, or just a form of peristhesia?

Several features may fit with L spine instability. Did you do a prone instability test? What was her SLR ROM? Also, the hip flexion ROM you gave was extremely limited – was this due to pain or what was your end feel/take on that?

[omikutin]

I’ve only seen this patient once and she hasn’t come in since her evaluation. It’s been very difficult trying to get in touch with her.

Sean- Great idea on manually compressing the lateral cutaneous femoral nerve and glut min! I put some stress on her ASIS/ inguinal ligament and did not get a numbness response. However, she was tender. The numbness comes and goes, she does not recall a certain activity that brings on the numbness and tingling. I asked about sitting/ standing/ laying down/ putting on shoes and we still could replicate the cause of her numbness. She was hypermobile on L4/L5 with tenderness that did not reproduce numbness. I also applied pressure to her glut min/med and it was tender but also did not reproduce her lateral thigh numbness. I also did not hold it for 15 seconds. I applied gradual pressure for about 10 seconds. Do you think holding for 15 seconds I would have a different response? Given the opportunity, I would love to try it again.

Laura- I checked upper lumbar and she was not as tender as PA L4/L5. However, upper lumbar facets could potentially refer to lower back so I can’t rule out upper lumbar. I would definitely put her in the pain catastrophizing category due to her fear of movement/pain. Her hip mobility was decreased and an empty end feel due to pain in flexion.

Nick- Thanks for brining up those test, that would have been ideal! I completed a neuro exam and she appeared to have sensations intact B. I believe she uses the term numbness to describe a form of peristhesia. I didn’t even think about that! Earlier when I was questioning her numbness feeling she wasn’t able to distinguish a certain position that would increase her symptoms. I could have done a better job of digging further. I also asked her to pay attention to when she gets those lateral thigh numbness sensations and what position she is in. We also did not do a prone instability test, H or I test. I would like to perform them but she highly irritable and decided not to. I think it hurt me due to not being specific with my hypothesis of “lumbar hypermobility” but I was thinking to try those test next time. Sadly, there has not been a follow up. Her SLR passive was R/L 60/65 with pain in her low back, SLR active was worse and she had pain with initiating movement. No lateral thigh peristhesia from active or passive SLR. End feel for hip flexion was empty (pain) and limited due to pain and ext there was a muscular end feel (pain).

I was also thinking of a potential facet referral due to the pattern distribution. My hypothesis for the lateral thigh peristhesia might be referred from a facet due to lumbar hypermobility and constant stress and lack of stability. I chose this patient because her lateral thigh pain was interesting for me. I wanted to further explore more during her next visit if she calls back. Due to her apprehensiveness would you guys continue to gather more objective data during her initial visit?

Thanks so much for everyone’s input! Intervention: I classified her in Chronic Low Back pain with movement coordination impairments per Dellito. I decided a lumbar stability program would be the best way to go. I found an article comparing motor control to a graded activity approach (attachment). The graded activity approach uses a cognitive behavior approach. This approach “involves encouragement of skill acquisition by modeling, the use of pacing, setting progressive goals, self-monitoring of progress, and positive reinforcement of progress.” It was found that motor control exercises and graded activity exercises have improved outcomes however there is no difference between both interventions. Moral of the story treat patients with the skills you have.

RCT with 173 participants. Inclusion criteria: chronic nonspecific low back pain > 3 months with or without leg pain, currently seeking care for low back pain, between 18-80 yo, clinical assessment indicated the patient suitable for active exercises, score of moderate or greater on question 7 (“How much bodily pain have you had during the past week?”) or question 8 (“During the past week, how much did pain interfere with your normal work, including both work outside the home and housework?”) of the 36-Item Short-Form Health Survey questionnaire (SF-36). Exclusion criteria: known or suspected serious pathology, previous spinal surgery, health condition that would prevent exercises programs. Treatment provided by 10 PTs with 2 years of clinical experience who received training in motor control and graded exercise training (2-day workshops and a series of interactive seminars).

Do you prefer motor control or graded activity exercises for chronic nonspecific back pain? Have you used graded activity exercises in your practice? Any other ideas of the hypotheses of lumbar hypermobility potentially causing a lateral thigh peristhesia? Would you like to test anything else? Which treatment protocol do you think my patient would benefit more from motor control or graded activity?

[sewhitta]

Hey Oksana – 15 secs was just an arbitrary hold time. I’ve been told it needs to be a noxious stimulus to a trigger point to reproduce and refer the symptoms. I’m sure 10 secs was fine

[omikutin]

Thanks Sean!

[omikutin]

Nick- Thanks for pointing this out, I looked over my data again and hip flexion was limited to pain and objectively R/L 95/100.

[Laura Thornton]

Interesting point with the hip. I’d also be interested in looking more into her hip since she had an empty end feel and significant limitation in ROM. I probably wouldn’t rule this out yet. Was the pain she felt with hip flexion or extension HER pain? Doesn’t exactly explain the numbness, but might be a contributory factor. What’s her gait look like?

[omikutin]

She had pain with hip flexion and extension. However, I don’t know how much of her pain catastrophizing characteristics played into her pain level and lack of mobility? Gait: decreased B hip extension, anteriorly tilted pelvis, decreased stride length, B LE was externally rotated (L>R).

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