January Journal Club Case

[Tyler France]

Hey guys, looking forward to seeing y’all this weekend. Below is my journal club case for next week.

Subjective: Pt is a 35 y/o male delivery driver who reports 3 week history of left sided LBP without referral to distal regions. He first experienced the pain when bending forward to pick up a flower pot from the ground. He received a prescription for muscle relaxers from his PCP and the pain has largely subsided since then. He reports first experiencing similar LBP in 2010 when lifting a piece of lumber. He has been experiencing similar episodes of LBP since then, but they are increasing in frequency and intensity. The patient is a former college runner that has recently gotten back into running as a way to manage his stress, but he has not tried running since the onset of this episode of pain. His primary goal is to prevent further episodes of low back pain.

Comorbidities: Bipolar I Disorder that is being managed with medication and psychiatric intervention
Aggs: Forward bending, backward bending, sitting >30 minutes
Eases: NSAIDs, frequent changes in position, lying supine
24-hour pain behavior: Best-0/10, Current- 2/10, Worst- 3/10
Severity: Min-Mod. Pt was unable to work for 3 days following the incident and has had mild interference with ADLs since then. Has been able to return to work with mild symptoms when driving for >30 minutes.
Irritability: Min-Mod. Able to reproduce symptoms easily with lumbar flexion or extension, but it returns to baseline immediately upon return to neutral position.
Nature: Mechanical/Somatic
Stage: Acute on Chronic
Stability: This particular episode is improving, but the recurrence of LBP has been more frequent since 2010

Objective:
-Increased lumbar lordosis in standing, (+) vertical compression test
-75% lumbar AROM except 25% extension (pain with flexion, extension, and L ROT)
-Aberrant movement and Gower’s sign with return to upright from flexion
-Reproduction of primary complaint with L extension and R flexion quadrants
– (+) H/I testing for poor motor control into L extension/SB, (+) prone instability test at L4/5
– (-) Hip/SIJ clearing, (-) ASLR for pain production but >90 deg bilaterally
– Symptom provocation with PPIVM/PAIVM into extension at L4/5, as well as hypermobility
-Oswestry Disability Index: 10%

Primary Hypothesis: L sided L4/5 facet pathology with clinical instability
Asterisks: (+) quadrant testing, (+) vertical compression test, Age <40, (+) Prone instability test, aberrant movement, SLR >91 deg

HEP:
-Unsupported Dead Bugs (Level 1&2)
-Child’s Pose
-Bird Dogs

PICO: In patients with recurrent low back pain, is exercise an effective intervention to prevent future episodes of low back pain compared to education/advice?

Discussion Questions:
1) Our profession is moving away from the practice of telling patients with clinical instability that their low back pain is due to a weak or “unstable” core. How do you explain to these patients why the get back pain frequently?
2) When treating a patient whose symptoms have resolved and who has a goal of preventing future episodes of LBP, what do you use as your discharge criteria?
3) Are there any prognostic factors for recurrent low back pain that you believe should be addressed with this patient?
4) Being that lumbar manipulation has been shown to be beneficial in certain patients with acute low back pain, do you feel that this patient would be appropriate for manipulation even though he may not meet the clinical prediction rule?
5) Are there any other objective tests that you think could be beneficial for this patient?

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[Katie Long]

Hi Tyler,

Good post, this is very relevant to a patient I am seeing right now, and this article was very helpful.

1. I usually try to stay away from the words “weak” or “unstable” core explanations in relation to LBP. What I explain is that our muscles and our joints work together during our day, and if one of the two is not working as much as it usually does, it causes the other part to have to work harder, and sometimes that makes us hurt. I usually emphasize that if we can get the other component to “pull its weight” so to speak, they will likely start moving (and feeling) better.
2. With these patients, I think compliance and competence with HEP (in addition to improved pain/initial symptoms) is my biggest discharge criteria. I like to make sure that they have a good pool of exercises to pull from in order to help manage their symptoms. That way if they are to notice their back starting to feel bad in the future, they are able to try some of these exercises and utilize them as a tool to help manage their symptoms before seeking care.
4. I do not think I would manipulate this patient. It seems to be a motor control issue. I would likely utilize some mobilizations for neural input if they were found to be effective, but this is not the patient I typically manipulate. He does not meet the CPR for lumbar manipulation, but he does meet the CPR for clinical instability, so I would likely focus my efforts on neuro re-ed and motor pattern training.

Looking forward to hearing more on Thursday!

[Jennifer Boyle]

Hey Tyler! This is a great case and extremely helpful being that I have been seeing a lot of patients recently with a variation of this presentation.

1) I agree that choosing our words is extremely important and what we tell patients can change their outlook on what is causing their pain. Using words like “unstable” tends to do more hard than good. I personally try to explain this by relating it to another joint that is less intimidating and giving them a personal example from myself. I would explain that as swimmer growing up I had a good amount of shoulder motion for my sport and all the muscle to back this up and now that I stopped swimming I still have that motion but no muscle to work and control for this motion. Then relate this back to him being a college runner and his back pain. I also like to emphasize that movement is not a bad thing and this will not harm him or make his back worse.

2) My discharge criteria for a patient like this would revolve around me being confident in their abilities to self manage this. A good HEP with proper progressions and regressions that they could manage their sx would help me rest easy letting this patient manage this after PT ended.

4) I agree with Katie in that manipulation is not something I would use on this patient. I would also use mobilizations and potentially some gapping/ lumbar rotation techniques working out of those painful quadrants and progress to working into those problematic quadrants.

[Sarah Bosserman]

Hi Tyler! Great case, I think we have all have patient’s with similar presentations. I agree with what Jen and Katie discussed when trying to explain recurrent low back pain to patients. I definitely do not want to make them more fearful of movement and I think using an example relevant to them/their goals helps with understanding. I agree that I would not likely use manipulation with this patient as he would benefit more from treatments focused on neuro re-education. I definitely think moving towards functional exercises as soon as possible also helps with patient buy in, especially with someone with low irritability. The more task specific (lifting, running, etc), the more likely he is to continue his HEP beyond the end of therapy and hopefully prevent future injury.

[Stephanie Roane]

Hey Tyler- just a couple questions in case I can’t make it to your journal club.

You stated his first onset of LBP was in 2010, what has his management strategies been since that time? Has he seen Ortho, been to PT/Chiropracter, injections/imaging, self managing with any other exercise program other than running?

What are his beliefs about his LBP and the recurrent nature? Learning this is key to identify the best way to educate and guide your treatments, discussions, and plan of care.

You mentioned he enjoys running to manage stress; Did you watch him run to see if running may be a contributing factor since you noted his lordotic posture? Think specificty. You may be able to go directly to these activities and clear up a majority of the contributing factors to his chief complaints.

It looks like you cleared his Hips/SI, does that include mobility? Does he have any joint limitations or soft tissue restrictions around his hips/pelvis that may be contributing to his low back posture.

You initiated his HEP in supine and quadruped. Any reason you didn’t initiate lumbar stabilization in standing since you didn’t list standing/walking (load intolerant features) as an aggravating activity? I’m aware there’s a progression to everything however if we’re thinking specificty of treatment, it may be that you can skip supine/quad stabilization and go directly to standing with education on pelvic/lumbar posturing prior to loading. May be successful, may not be but I feel with what you presented it doesn’t appear contraindicated to his symptoms.

Sorry for the last minute questions. Looking forward to discussing your case more.

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