February Journal Club Case

[Scott Resetar]

Referring diagnosis: Right lumbar radiculopathy.
Precautions written on Rx: degenerative disc disease
Outcome Measures: FOTO – 78 ( predicted discharge score = 79)

Subjective: Pt is a 54 y/o male Security Manager. Previous officer in US military, Retired as a Major (O-4) in the Army Military Police. Works out 7 days per week including deadlifts (315 lbs), squats (275 lbs), running, cycling.

Pt reports local sharp right low lumbar pain (7/10 at worst, 0/10 current), with radiating numbness and tingling from right low lumbar through buttock, wrapping around to anterior thigh to the medial side of the knee, and foot drop. Onset of lumbar pain 3 years ago, numbness/tingling 6 months ago, foot drop 3 weeks ago. He also reports he feels he is leaning to the left when he wakes up in the morning, comes “back to center” within 10-15 minutes

No treatment until 1.5 years ago, when he sought treatment at a chiropractor who performed manipulation for 5 sessions total. Patient stated the manipulations were very painful but provided relief for 2-3 weeks and symptoms would return. Last session with chiro was 4 months ago (After onset of N/T, before onset of foot drop)

Description of symptoms, Agg/Ease
Lumbar: Sharp, deep, intermittent, variable. Agg: standing up first thing in the morning, standing up after sitting for 30-60 minutes. Ease: morning: 15 minutes from rising pain and tingling will cease. exercise, running. Eases within 5 minutes of walking or moving around after inactivity throughout day

Buttock/Thigh: Described as numbness with “very little tingling”: Agg: walking ¼ mile, waking up in AM

Foot drop: described as “heavy foot”, “slapping the ground” Agg: 1.5 hour bike ride and when he gets off the bike his foot will be “floppy”, walking ½ mile. Ease: sitting, rest, standing. Will ease and “come back alive” if he just stands or sits for 5 minutes.

PMH: X-ray 2 weeks ago from PCP, arthritis, DDD, no notable findings.

Primary Hypothesis after subjective: L3/L4 radiculopathy
Differential List: L3-L5 facet joint arthritis, spondylolisthesis, Hip joint referral, SIJ

Objective: All lumbar AROM + OP is WNL and painfree, including flexion quadrants, except for extension quadrant right with overpressure and held for 15 seconds, at which point his numbness and tingling started in the L3 distribution. Eased immediately. Joint mobility testing revealed hypomobility throughout lower lumbar spine with CPAs and UPAs but equal bilaterally with no reproduction of symptoms. No step off deformity noted.

Neuro screen: 2+ patellar and achilles reflexes on the left, 1+ on the right, negative babinski
Decreased sensation anterior thigh in L3/L4 dermatomes to the medial knee, decreased sensation in R paraspinal area
Myotomes all 5/5 and strong with repeated testing

Slump: mildly positive (posterior hamstring tightness on the right, relieved with cervical extension, not present on the left)
Negative femoral nerve testing
Negative SIJ cluster
Hip AROM+OP pain free and equal bilaterally
Decreased Ankle DF bilaterally
Decreased Hip Extension bilaterally

Observation: increased lumbar lordosis in standing

Severity: Min/Mod ( Min – not affecting daily life except gym workouts, Mod – 7/10 pain, foot drop)
Irritability: (Min – goes away quickly after ceasing offending activity, takes a lot to elicit in clinic)
Stage: Chronic (3 years)
Stability: Worsening

Visit 1 Treatment:
Gapping L4 Grade III in sidelying // no posterior thigh tightness with slump post
HEP: Self lumbar gapping with arm against wall → educated to perform in AM and anytime he has the tingling/numbness or foot drop to see if it improves
Pelvic tilts in seated and standing → educated to perform when walking and during sit to stand to see if this decreases pain/ symptoms

Visit 2: Patient rescheduled due to being diagnosed with mild left ventricular bundle branch block during routine physical

Visit 3 – 3 weeks post eval. Pt reports he has made huge progress. With HEP the numbness and tingling slowly moved up his leg and disappeared. He stopped running and biking after last visit, but has resumed elliptical without any symptoms. He continues to squat/deadlift without pain. He has not felt N/T in 10 days. Still leaning left in AM with tingling in the R low lumbar area for 10-15 minutes. Foot drop still present but at ½ mile walking, not ¼ mile Due to large improvement decided to address associated factor of limited ankle DF, and looked at bike positioning

R extension quadrant +OP: did not reproduce any numbness/tingling with 60 second hold. Manual shift correction reproduced lumbar tingling only. No area of decreased sensation in anterior thigh or low back with dermatome testing. L4 myotome remains strong.

Tx: Repeated Gapping but added nerve tension positioning during. Grade III, increased duration (8-10 minutes)
B Ankle MWM w/ belt (functional dorsiflexion measure of toe from wall increased from 6.5cm to 10.5 cm bilaterally)
Bike positioning assessment on bike trainer: Patient has seat very high and he is in maximal lumbar flexion with upper cervical extension/FHP during rides.
HEP: Nerve glides, ankle stretching, hip flexor stretch

Visit 4: Continued improvement. AM tingling/pain is only in the low back, not in the leg. Still feels he is leaning in AM. Lasts 5 minutes. Resumed running, and he has tingling in the low back only with running, not in the leg. Does not notice foot drop when walking except for very long walks. Has not biked. He can run ½ mile before tingling increases, he will hop off treadmill and do core work/HEP for 5 minutes, and resume running x 4 rounds (2 miles).

Obj: No numbness/tingling with extension quadrant + OP for 60 seconds. Tingling in lumbar only elicited with manual shift correction still

Running assessment: Patient has a mid to forefoot strike that lands near his center of gravity, notable forward trunk lean, upper cervical extension noted during running.

Able to run for 2 minutes before onset of tingling, I had patient hop off and perform 20 repeated standing back extensions, and then resume running. He was able to run for 3:30 before onset of tingling. Raised treadmill incline and tingling ceased immediately

Educated patient to not run through tingling (hop off and perform back extensions, or run on incline), attempt back extensions in AM to see if this relieves his pain faster in AM.

Repeated lumbar Gapping in nerve tension position

Visit 5: Patient reports he continues to have tingling during running, but he turns up the incline and it goes away. He still has pain with sit to stand after prolong periods, but no foot drop since last visit. Still has tingling in the AM in low back and repeated extensions do not appear to have an effect

Manual shift correction did not elicit any tingling today.

Tx: Due to no tingling when closing down R facets w/ shift correction, started working on improving closing of those facets with prone UPAs in R sidebend position, and followed up with same gapping intervention.

PICO: In a patient with radiculopathy, would adding cervical positioning/postural treatment improve long term outcomes when compared to standard manual therapy?

Discussion Questions:

1. Patient had painful experience with manipulation previously, but stated that he benefited. Thoughts on attempting manipulation with this patient? Do you think it would be beneficial? How would you go about having that conversation?

2. What other things would you have measured/assessed? What did I leave out?

3. Signs of foot drop are concerning. Patient had discussed the foot drop with his PCP who referred him. Would you have referred him to a neurologist? If no, what signs/symptoms would this patient have to have in order for you to refer out.

4.Patient initially reported that his low back pain would ease with running, but now it is eliciting tingling. I admit I did not differentiate/question him on this very thoroughly. Do you think the change is due to my treatment or that he was avoiding running for a while before starting treatment and had not elicited this?

5. Patient appears to display signs/symptoms of foraminal stenosis with possible osteophytes. He also loves some high impact activities like squatting/deadlifting heavy weights and long bike rides. How would you discuss/implement activity modification with this patient who obviously loves to exercise?

6. Have you ever implemented cervical interventions on a LBP/radiculopathy patient without any neck complaints?

7.Anything else you want to ask, just shoot!

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[August Winter]

Good case Scott. I’ll start with my questions and move on to yours.

– At initial eval you mention sensation changes in the objective section, is that light touch or sharp/dull, or both?
– What nerve mobilization did you give him at visit 3? Given what we learned in the most recent course weekend, would your exercise or dosage change?
– This patient does demonstrate weakness and fatigability with prolonged activity, but no longer has hard sensory changes, is not areflexive, so are you still calling this radiculopathy? Or is this lumbar stenosis with components of neural irritation/compression?

1. I think if other techniques you were doing were not providing relief then I would think more about manipulation. He has the expectation that it will be beneficial, and maybe there are ways to adjust the positioning of the lumbar manipulation to make it more comfortable. All the being said, it might be interesting to see what manipulating his T spine in a neurodynamic position might due to his tolerance for running.

2. T spine AROM and PAIVM assessment. Extension quadrants with OP and compression in order to further load those structures and potentially provoke sx. Hip accessory mobility if extension was limited?

3. I think a cluster of worsening foot drop (time before occurring, slap versus complete drop), worsening patellar reflex, and worsening hard sensation changes would make me want to refer this patient to a spine specialist.

4. I think for a change it presentation like that I typically refer back to the cascade of degeneration that we have used in the course series for the cervical and lumbar spines. It could be that this patient had annular/discal lesions that once they became less acute actually felt better with loading like running, but now further down the cascade the loading into extension is too provocative.

6. This is not something that I have specifically done before. I definitely have done strength and mobility work in the thoracic spine for some of my patients with stenotic presentations, but I’ve never focused on neck posture or strengthening. I think that if we are giving education on posture elsewhere in the spine that providing more information on the C spine could be beneficial, and following that up with 1-2 simple exercises might be beneficial.

[Scott Resetar]

– At initial eval you mention sensation changes in the objective section, is that light touch or sharp/dull, or both?

Light touch. I did not do sharp/dull testing. In fact, I rarely do, but that is out of habit, not due to any view against sharp dull testing. Since I don’t do it, I don’t have the experience of measuring changes with it. In your patients with radiculopathy, do you see sharp/dull changes improve before or after numbness/tingling? Just curious. Like would you see N/T go away and then you can still measure sharp dull changes?

– What nerve mobilization did you give him at visit 3? Given what we learned in the most recent course weekend, would your exercise or dosage change?

Sciatic nerve in sidelying. Yes, I think I could have done supine sciatic nerve the the L leg in a tensioned position.

– This patient does demonstrate weakness and fatigability with prolonged activity, but no longer has hard sensory changes, is not areflexive, so are you still calling this radiculopathy? Or is this lumbar stenosis with components of neural irritation/compression?

At this point, no I would say he is presenting as more of a lateral stenosis with neural compression. His complaints at this point are tingling in the R side of lumbar spine present upon waking and with running, and a slight lateral shift in the morning.

2. I don’t look at the T-spine enough with lumbar dysfunction! Might be a window for manipulation as well.

[Justin Bittner]

Interesting case Scott. Thanks for posting.

1.
He doesn’t really fit the CPR for manipulation. However, as you stated, he noted improvement following manipulation. I don’t think I would have proceeded with a lumbar manipulation since your initial treatment was working. He was receiving Chiro care before and is in PT now because he possibly wants something different. (Do you think that statement is true?) Having said that, I probably would have manipulated his thoracic spine to help reduce neural irritability (in a slight SLR as we talked about this weekend) prior to working on additional direct techniques.

2.
Like August, I would have assess thoracic mobility. I would like to say I would have also assessed anterior hip articular mobility. I know you said you assessed myotomes that were negative. Did you also check INV strength in addition to DF? I would have also assessed hip FABER position.

3.
If his foot drop was worsening, I would be concerned. Additionally, if myotomal weakness arose and if N&T was reported to be worse and/or the duration was increased. Even if the physician was not informed, I would not have referred out but would have just communicated it in my evaluation findings and plan if signs/symptoms worsened.

4.
It would make sense to me that this may have been an unprovoked symptom with running since it had not previously been performed prior to starting PT. It might be worth mobilizing his hip into extension and then getting him back onto treadmill (as you have shown improvement with lumbar extension). I would be curious to see if mobilizing the his was more or less beneficial.

5.
He was in the military and works out 7 days/wk. Do you think we would be able to get him to modify his activities/routine? We could maybe discuss decreasing weight at this moment but not sure if that would work for this particular patient. Could also talk about potentially decreasing days he works out to maybe 4/7 or something to allow more healing time. Just a thought.

6.
Like August, I can’t say I’ve specifically done this. But I have seen several posters at conferences addressing cervical mobility (with manipulation) followed by neurodynamic mobilizations for patients with radicualar low back pain. It can certainly be beneficial sometimes to treat away from the irritable segment but the pt would certainly need to be educated on why it may be beneficial; particularly if you want to get buy it. For this guy in particular, it could be easy to get buy in since he likes to bike. You could take a picture of him on the bike with his phone and educate him on his cervical/lumbar positioning and the effects it can have on his overall posture or low back pain.

[Erik Lineberry]

1. I don’t think I would start with manipulation with this patient. He doesn’t really meet the typically patient characteristics that would seem to benefit from manipulation intervention with his chronic and distal(ish) symptoms. However, I would not completely give up on it at a later visit if I thought it might help, especially since the patient has already indicated they think their chiropractic intervention helps. Perceptions are powerful things and if this patient truly believes they will help then they might even if he isn’t the typical candidate for that intervention.

2. I might had assessed some hip special testing just to be sure it is not involved, but you screened for it and this may be something that would not have added much to IE and could be reassessed later if the patient is not progressing as expected.

3. This is something I would have my eye on. I would refer out if his foot drop was severe enough he was unsafe at home/work/whatever or if other neural signs popped up in eval. It looks like his neural screen shows some differences side to side, but the myotome testing shows no weakness with repeated testing. Since he was referred and didn’t report any other red flags or neural signs I think it becomes something to keep an eye on, but not refer out for immediately.

4. That’s a toughy. It would be interesting to see if his running form changed as his lateral shift did and if that affected things at all.

5. I liked that you looked at his bike posture. I feel like this is missed with a lot of folks. I would do the same with all of his exercises, modify his form if needed and make talk to his about avoiding loaded lumbar extension exercise. Try to give him alternatives to exercises that would not be safe or comfortable for his anatomy.

6. I can’t say that I have. Looking forward to hearing about this.

[Michael McMurray]

1. I agree with the overall consensus; if you are finding techniques that are leading to symptom reduction, I would stick with those. If you hit a plateau, it may be something to investigate. We talked recently this weekend about not making a manipulation an ‘event.’ Perhaps working it in as a part of treatment would be most appropriate. If he were to relate this to what was performed at the chiropractor, you could discuss it further.

2. Not quite sure if overpressure is the same as compression, but I agree with August that this may be useful if you were not able to provoke all of his symptoms during the exam. I know it is something that I do not do well, but if you have provoked all the patient’s symptoms and have a good idea of what is going on, providing the patient with symptom relief and exercises is where I would go. You can assess later down the road.

3. If there was an increase in frequency and duration of symptoms, or no change with treatment after several visits, I would rely these findings to the referral physician.

4. It would be hard to tell since there have been several changes. For instance, He could initially have not changed his running pattern. Then with worsening of symptoms, a maladaptive pattern may have created symptoms.

5. To get some buy in to change some of his activity, you could potentially have him perform some of the lifts he is doing at the gym; abet you may not have enough weight (315 lbs is a lot). While I’m not an expert on these techniques, if you were able to provide him with feedback on positioning or form, he may buy into some changes to his routine. It could give you an avenue to discuss the potential of increasing reps at lower weights or incorporating rest days.

6. I have not. Similar to August, I have utilized thoracic techniques for patients with stenosis. And similar to Erik, I’m interested in learning more.

[Myra Pumphrey]

Great discussion! A couple thoughts: I would not do a mid/low lumbar grade V with an intermittent foot drop. Remember, when discussing in relationship to previous manipulations by the Chiropractor, the presentation was different when being treated by the D.C. His symptoms have regressed.

Great points about considering adding treatment techniques for hypomobility at the hip and thoracic spine then reassess effect.

Treatment 3, please clarify your progression noted (8-10 minutes). 8-10 minutes of gapping in nerve tension position??

With running assessment/strategies, he seems to improve both with repeated extension and by running on an increased incline. Is this a consistent/expected pattern? What do you think is happening with the repeated extension vs. increasing incline which results in decreased symptoms?

In regards to communication w/ MD and/or referring out: I would first ask him if he told the MD about the foot drop and inquire about the MD’s neuro exam (to see if the MD is monitoring and will be monitoring his neurological status in the future). If the MD is not yet aware of the intermittent foot drop, I would call, tell him/her about his symptoms/clinical findings/history progression and let him/her know that I am monitoring the neuro/discuss together at what point we would recommend consult w/ a spine specialist MD. I would also discuss this with the pt., to determine the pt’s personal philosophy on seeing a spine specialist. Some feel comfortable with being monitored by their GP and PT, being referred if signs regress. Others, in light of his progression of symptoms over the past 3 years, want to establish a relationship w/ a specialist MD even if they don’t need any current intervention by an MD. Even though symptoms are not irritable, I would lean towards referral to a spine specialist MD due to the regression that has happened over the past 3 years with relative recent onset of foot drop. If he turns a corner and suddenly has a regression of neurological status, better to already have a specialist who he feels comfortable with with whom he can get seen on short notice. I would try to discuss what is in the patient’s best interest w/o elevating fear. However, the patient needs to understand that it is important to not delay in reaching out to a member of his medical team immediately if there is a progression of the foot drop.

Love the FOTO prediction – 1 point of change?

[Scott Resetar]

For that treatment, it was 2-3 minutes of mobilization, rest (for me), re-assess, and mobilize again x 3 bouts, if i’m not mistaken.

That’s a great point about the repeated extension vs incline. This doesn’t really make sense. Repeated extension makes sense if this is more of a disc issue, while the incline makes sense if this is more of a stenosis issue. He seems to present more as a lateral foraminal stenosis, but the lateral shift seems more disc-y.

It might be both. I’m glad I did both to give him more options.

Regarding MD referral to spine specialist, I like that management strategy you propose. How would you go about talking about this with the patient without making it seem like he is a ticking time bomb? I think its easy for that conversation to go terribly, haha.

[nhoover17]

1.
I would be hesitant to manip lumbar based on worsening presentation and previous use in tx by chiro. I think the benefit of our manipulations is that we add some stability component after. Did you inquire as to the tx given from chiro and if exercise was also implemented?

2.
I probably would have checked FABERs and hip derotation test and STM along nerve path. Aaron and I had a similar presentation in a pt with stenosis and found (+) gluteal tendinopathy tests that allowed us to incorporate some STM in that region with success.

3.
I think I would treat and monitor. If no improvement then consider referral.

4.
I think it is probably multifactorial. Seeing his relief with increased grade on TM, likely producing more fwd lean, I would be curious to see what his running posture was like initially and compare that to now. It is possible that he had a fwd leaning posture when running (maybe compensating for decreased hip ext/push off) which would relieve compression based on his stenotic presentation; then, after some tx, posture and hip ext improved which allowed him to run more erect, possibly eliciting some symptoms in extended positions.

5.
My initial thoughts are obviously “moderation”, decreasing load, decreasing time in activity, intervals with self mobs like you already had him do.
The devil’s advocate in me looks at squats, deadlifts and biking as having flexion components that may be relieving to an extent. Aside from the compressive loading, maybe these aren’t so bad?… which brings my thought process back to “moderation”…

6.
I have never thought to go that far away from ground zero but, based on some of the presentations this past weekend with neurodynamics and “neurophysiological cascade of events” brought about through gr V mobs, I think it holds some water.

7.
I had a patient with cervical radic that had some progressive declines similar to this patient. Also had some unclear UMN signs that became progressively more clear. Started having some fatigable weakness. Aaron and I experimented with providing manual traction and retesting Myotomes in sustained traction and strength was 5/5. Maybe traction is a different direction to explore with your patient as well?

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