Clinical decision making in a patient with secondary hip-spine syndrome

The prevalence of lumbar and hip pathology is on the rise; however, treatment outcomes have not improved, highlighting the difficulty in identifying and treating the correct impairments. The purpose of this case report is to describe the clinical decision making in the examination and treatment of an individual with secondary hip-spine syndrome. Our case study was a 62-year-old male with low back pain with concomitant right hip pain. His Oswestry Disability Index (ODI) was 18%, back numeric pain rating scale (NPRS) was 4/10, fear avoidance beliefs questionnaire (FABQ) work subscale was 0, FABQ physical activity subscale was 18, and patient specific functional scale (PSFS) was 7.33. Physical examination revealed findings consistent with secondary hip-spine syndrome. He was treated for four visits with joint mobilization/manipulation and strengthening exercises directed at the hip. At discharge, all standardized outcome measures achieved full resolution. Clinical decision making in the presence of lumbopelvic-hip pain is often difficult. Previous literature has shown that some patients with lumbopelvic-hip pain respond favorably to manual therapy and exercise targeting regions adjacent to the lumbar spine. The findings of this case report suggest that individuals with a primary complaint of LBP with hip impairments may benefit from interventions to reduce hip impairments.     

Classification, treatment and outcomes of a patient with lumbar extension syndrome

The purpose of the current report is to describe the classification, treatment, and outcomes of a patient with lumbar extension syndrome. The patient was a 40-year-old female with an 18-month history of mechanical low back pain (LBP). The patient reported a history of daily, intermittent pain (mean intensity of 9/10) that limited her ability to sit, stand, walk, and sleep, as well as perform work-related activities. Symptom-provoking movement and alignment impairments associated with the direction of lumbar extension were identified and modification of these impairments consistently resulted in a decrease in pain. Treatment was provided in 3 sessions over a 2-month period. Priority of treatment was to train the patient to restrict lumbar extension-related alignments and movements during symptom-provoking functional activities. Exercises to address the extension-related impairments also were prescribed. The primary change in outcome was a decrease in the mean intensity (2 months: 2/10; 6 months: 1/10) and frequency of pain (2 months: decreased pain with standing and walking; 6 months: additional decrease with sitting, standing and walking). She also reported a decreased duration and number of LBP episodes. Classification directed treatment resulted in improvement in short and long term impairment and functional-level outcomes.     

Classification,treatment and outcomes of a patient with lumbar extension syndrome

The purpose of the current report is to describe the classification, treatment, and outcomes of a patient with lumbar extension syndrome. The patient was a 40-year-old female with an 18-month history of mechanical low back pain (LBP). The patient reported a history of daily, intermittent pain (mean intensity of 9/10) that limited her ability to sit, stand, walk, and sleep, as well as perform work-related activities. Symptom-provoking movement and alignment impairments associated with the direction of lumbar extension were identified and modification of these impairments consistently resulted in a decrease in pain. Treatment was provided in 3 sessions over a 2-month period. Priority of treatment was to train the patient to restrict lumbar extension-related alignments and movements during symptom-provoking functional activities. Exercises to address the extension-related impairments also were prescribed. The primary change in outcome was a decrease in the mean intensity (2 months: 2/10; 6 months: 1/10) and frequency of pain (2 months: decreased pain with standing and walking; 6 months: additional decrease with sitting, standing and walking). She also reported a decreased duration and number of LBP episodes. Classification directed treatment resulted in improvement in short and long term impairment and functional-level outcomes.     

Use of a classification system to guide nonsurgical management of a patient with chronic low back pain

BACKGROUND AND PURPOSE: This case report describes the use of a classification system in the evaluation of a patient with chronic low back pain (LBP) and illustrates how this system was used to develop a management program in which the patient was instructed in symptom-reducing strategies for positioning and functional movement. CASE DESCRIPTION: The patient was a 55-year-old woman with a medical diagnosis of lumbar degenerative disk and degenerative joint disease from L2 to S1. Rotation with extension of the lumbar spine was found to be consistently associated with an increase in symptoms during the examination. Instruction was provided to restrict lumbar rotation and extension during performance of daily activities. OUTCOMES: The patient completed 8 physical therapy sessions over a 3-month period. Pretreatment, posttreatment, and 3-month follow-up modified Oswestry Disability Questionnaire scores were 43%, 16%, and 12%, respectively. DISCUSSION: Daily repetition of similar movements and postures may result in preferential movement of the lumbar spine in a specific direction, which then may contribute to the development, persistence, or recurrence of LBP. Research is needed to determine whether patients with LBP would benefit from training in activity modifications that are specific to the symptom-provoking movements and postures of each individual as identified through examination.     

Effect of the Individual Strengthening Exercises for Posterior Pelvic Tilt Muscles on Back Pain,Pelvic Angle,and Lumbar ROM of a LBP Patient with Excessive Lordosis: A Case Study

[Purpose] The purpose of this study was to document the effect of individual strengthening exercises for posterior pelvic tilt muscles on back pain, pelvic tilt angle, and lumbar ROM of a low back pain (LBP) patient with excessive lordosis. [Subjects] The subject was a 28 year-old male with excessive lordosis who complained of severe LBP at the L3 level. [Methods] He performed individual strengthening exercises for the posterior pelvic tilt muscles (rectus abdominis, gluteus maximus, hamstring). [Results] Pelvic tilt angles on the right and left sides recovered to his normal ranges. Limited lumbar ROM increased, and low back pain decreased. [Conclusion] We suggest that an approach of individual resistance exercises is necessary for the effective and fast strengthening of the pelvic posterior tilt muscles in case of LBP with excessive lordosis.Key words: LBP, Lordosis, Posterior pelvic tilt     

Effect of Individual Strengthening Exercises for Anterior Pelvic Tilt Muscles on Back Pain,Pelvic Angle,and Lumbar ROMs of a LBP Patient with Flat Back

[Purpose] The purpose of this paper is to report the effect of individual strengthening exercises for the anterior pelvic tilt muscles on back pain, pelvic tilt angle, and lumbar ROM of a low back pain (LBP) patient with flat back. [Subject] A 37 year-old male, who complained of LBP pain at L3-5 levels with flat back, participated. [Methods] He performed the individual strengthening exercises for anterior pelvic tilt muscles (erector spinae,iliopsoas, rectus femoris). [Results] Pelvic tilt angles of the right and left sides were recovered to normal ranges. His lumbar ROMs increased, and low back pain decreased. [Conclusion] We suggest that individual resistance exercises are a necessary approach for effective and fast strengthening of pelvic anterior tilt muscles in LBP with flat back.Key words: Anterior pelvic tilt, Flat back syndrome, LBP     

The relationship of lumbar flexion to disability in patients with low back pain

BACKGROUND AND PURPOSE: Physical therapists routinely assess spinal active range of motion (AROM) in patients with low back pain (LBP). The purpose of this study was to use 2 approaches to examine the relationship between impairment of lumbar spine flexion AROM and disability. One approach relied on the use of normative data to determine when an impairment in flexion AROM was present. The other approach required therapists to make judgments of whether the flexion AROM impairment was relevant to the patient's disability. SUBJECTS: Fifteen physical therapists and 81 patients with LBP completed in the study. METHODS: Patients completed the Roland-Morris Back Pain Questionnaire (RMQ), and the therapists assessed lumbar spine flexion AROM using a dual-inclinometer technique at the initial visit and again at discharge. RESULTS: Correlations between the lumbar flexion AROM measure and disability were low and did not vary appreciably for the 2 approaches tested. CONCLUSION AND DISCUSSION: Measures of lumbar flexion AROM should not be used as surrogate measures of disability. Lumbar spine flexion AROM and disability are weakly correlated, suggesting that flexion AROM measures should not be used as treatment goals.     

Intertester reliability of judgments of the presence of trigger points in patients with low back pain.

The purpose of this study was to determine the intertester reliability of assessments of the presence of trigger points in the region of the lumbar spine of patients with low back pain (LBP). A total of six trigger points described by Travell and Simons were studied. The trigger point examination procedures described by Travell and Simons were used by 12 physical therapists. Randomly paired therapists examined 50 patients for 197 trigger points. The Kappa coefficient, percent agreement, the observed proportion of positive agreement (Ppos), and the observed proportion of negative agreement (Pneg) were used to describe reliability. Kappa values ranged from .29 to .38. Percent agreement ranged from 76% to 79%. Ppos ranged from .43 to .52. The low Kappa and Ppos values suggest different therapists are unable to reliably determine when a trigger point is present in a patient with LBP. This study suggests the usefulness of examining for the presence of trigger points in patients with LBP should be questioned.     

Clinical diagnosis and treatment of a patient with low back pain using the patient response model: A case report

The medical management of low back pain (LBP) can be approached in a multitude of ways. Classification via subgrouping is increasingly common in orthopedic literature. Clinical diagnosis and treatment of LBP using the patient response model (PRM) can assist clinicians in hypothesizing the origin of pain and providing beneficial interventions unlike the widely used pathoanatomical model. This case report involved a 52-year-old female with sudden onset of right-sided LBP that radiated to the foot. These symptoms were accompanied by occasional paresthesias in bilateral lower extremities. Magnetic resonance imaging (MRI) confirmed disc bulges at levels T11-T12 and T12-L1. On the first of seven visits, she reported 9/10 on the Numeric Pain Rating Scale (NPRS), scored a 24/50 on the modified Oswestry disability index (mODI), and demonstrated lumbar flexion range of motion (ROM) of 10°. Using the PRM, the patient was classified as an extension responder and was instructed to perform 10 repetitions of standing lumbar extension every 2 waking hours. After 4 weeks of therapy, the patient reported a 1/10 pain localized to the low back, scored 20/50 on the mODI, and improved flexion ROM to 45°. Classification using the PRM yielded positive outcomes with this patient’s symptoms and daily function.     

Application of a classification system and description of a combined manual therapy intervention: a case with low back related leg pain

Low back pain and leg pain commonly occur together. Multiple factors can cause low back related leg pain; therefore, identification of the source of symptoms is required in order to develop an appropriate intervention program. The patient in this case presented with low back and leg pain. A patho-mechanism based classification is described in combination with the patient’s subjective and objective examination findings to guide treatment. The patient’s symptoms improved marginally with intervention addressing primarily the musculoskeletal impairments and with intervention addressing primarily the neurodynamic impairments. Full functional improvements were attained with a manual therapy intervention directed at both mechanisms simultaneously. The approach described in this case address a mixed pathology utilizing passive accessory and passive physiological lumbar mobilizations in combination with lower extremity neurodynamic mobilization. The patient reported complete resolution of symptoms after a total of seven visits over a period of 6 weeks. While specific guidelines do not yet exist for treatment based on the classification approach utilized, this case report provides an example of manual therapy to address low back related leg pain of mixed pathology.     

Classification, intervention, and outcomes for a person with lumbar rotation with flexion syndrome

BACKGROUND AND PURPOSE: The purpose of this case report is to describe the classification, intervention, and outcomes for a patient with lumbar rotation with flexion syndrome. CASE DESCRIPTION: The patient was a 22-year-old man with a medical diagnosis of low back strain. Impairments in lumbar flexion and right rotation and lateral bending were identified. Daily activities and positions associated with these actions were associated with increased low back pain (LBP). Instruction focused on modifying lumbar rotation and flexion movements and alignments in daily activities. Exercises to address the direction-specific impairments were prescribed. OUTCOMES: The patient participated in 4 visits and completed a questionnaire 1 year after intervention. The patient reported a decrease in symptoms, disability, and frequency of recurrences. DISCUSSION: Repetition of specific strategies (alignment and movement) during activities may result in specific impairments that contribute to LBP. Modification of the strategies and exercises to change contributing factors are proposed to help alleviate symptoms, disability, and recurrences.     

Flexibility and velocity of the normal and impaired lumbar spine

Trunk mobility, as defined by trunk angle, has long been considered an acceptable means to evaluate the degree of impairment in patients with low back pain (LBP). However, biomechanically, there is reason to believe that patients with LBP may exhibit significant sensitivity to trunk velocity of motion as well as angular mobility factors. An experiment was performed to study the trunk action of patients with LBP and of a normal control group. A lumbar monitor was used to monitor both trunk angle range and trunk velocity. The results indicate significant differences between the two groups for both angle and velocity measures. However, the velocity measure revealed more dramatic difference between groups and was the only parameter that was capable of distinguishing between the particular experimental tasks for both LBP and normal groups. Thus, it is suggested that trunk velocity be used as a quantitative measure of low back disorder and that it be used as a means to monitor the rehabilitative progress of patients with LBP.     

Congenital ‘butterfly vertebra’ associated with low back pain: a case report

The butterfly vertebral defect is a rare congenital anomaly of the spine, which is generally considered benign. In this report we present the case of an active young man who presented with recurrent low back pain (LBP), and was found to have a butterfly vertebral defect at the symptomatic L4 lumbar spinal level. We describe the genesis of the butterfly vertebral defect, in the context of normal embryological development of the human vertebra and intervertebral disk. We report the clinical examination findings and therapeutic interventions undertaken prior to the radiographic discovery of the vertebral defect, and discuss the impact that the presence of a butterfly vertebral defect presented to therapeutic decision-making.     

Treatment of subacute low back pain with a novel device for continuous passive motion of the spine: a report of three cases

Patients experiencing subacute low back pain (LBP) represent a challenge for the physical therapist. There have been few studies on the use of continuous passive motion of the lumbar spine for the treatment of LBP. Three patients with symptoms of subacute LBP without radiculopathy were treated using a novel device for continuous passive motion of the lumbar spine. The protocol consisted of 12 sessions of lumbar continuous passive motion at 30 minutes per session two to three times per week for 4 to 5 weeks. Outcomes were assessed at baseline and after 12 sessions at 4 to 5 weeks by Oswestry score and active range of motion measurements by a blinded investigator. Clinically significant improvements in Oswestry score and consistent improvements in range were observed. A supervised protocol using a commercial device can benefit some patients with subacute LBP if supervised by a knowledgeable practitioner.     

Differences in end-range lumbar flexion during slumped sitting and forward bending between low back pain subgroups and genders

Patterns of lumbar posture and motion are associated with low back pain (LBP). Research suggests LBP subgroups demonstrate different patterns during common tasks. This study assessed differences in end-range lumbar flexion during two tasks between two LBP subgroups classified according to the Movement System Impairment model. Additionally, the impact of gender differences on subgroup differences was assessed. Kinematic data were collected. Subjects in the Rotation (Rot) and Rotation with Extension (RotExt) LBP subgroups were asked to sit slumped and bend forward from standing. Lumbar end-range flexion was calculated. Subjects reported symptom behaviour during each test. Compared to the RotExt subgroup, the Rot subgroup demonstrated greater end-range lumbar flexion during slumped sitting and a trend towards greater end-range lumbar flexion with forward bending. Compared to females, males demonstrated greater end-range lumbar flexion during slumped sitting and forward bending. A greater proportion of people in the Rot subgroup reported symptoms with each test compared to the RotExt subgroup. Males and females were equally likely to report symptoms with each test. Gender differences were not responsible for LBP subgroup differences. Subgrouping people with LBP provides insight into differences in lumbar motion within the LBP population. Results suggesting potential consistent differences across flexion-related tasks support the presence of stereotypical movement patterns that are related to LBP.     

椎间盘突出临近退变节段是否导致腰痛

背景：椎间盘突出症患者腰痛原因很难判断,一直以来,认为突出的椎间盘是椎间盘突出症患者腰痛及腿痛重要原因,椎间盘突出临近退变节段是否导致腰痛需进一步研究证实。目的：通过椎间盘造影判断突出临近退变节段是否是椎间盘突出症患者腰痛原因,并报告经椎间盘镜摘除椎间盘后残留腰痛在临近退变疼痛椎间盘经亚甲蓝注射治疗的效果。方法：20例同时具有腰痛和腿痛椎间盘突出症患者行椎间盘造影检查,这些患者腰椎MRI表现为有1个突出椎间盘外至少合并1个或1个以上的临近退变的椎间盘,全部患者均经椎间盘镜摘除椎间盘切除突出的椎间盘,5例临近退变椎间盘造影阳性患者在椎间盘镜切除后经椎间盘内注射亚甲蓝治疗。腰痛、腿痛采用目测类比评分评定。结果与结论：20例患者总共64个椎间盘行椎间盘造影,共11个椎间盘造影阳性,其中6个位于椎间盘突出临近退变节段,5个位于引起神经根性痛的椎间盘突出节段。全部病例腿痛行椎间盘镜切除突出椎间盘后明显缓解,腰痛有部分缓解,6例临近椎间盘造影阳性患者经椎间盘镜摘除椎间盘后腰痛明显,影响日常生活,其中5例行临近疼痛椎间盘亚甲蓝注射后腰痛缓解,1例患者拒绝亚甲蓝注射治疗仍有明显腰痛。结果显示椎间盘突出症患者腰痛可能来源于突出临近退变节段。