Clinical interventions for Low Back Pain: A Multifaceted Based Approach
Chronic lower back pain is one of the leading causes for outpatient physical therapy referrals 1. The incidence of lower back pain in accounts for approximately 30 % of the all cases treated in our physical therapy clinic. For many of these patients, this is not the first time that they are receiving skilled physical therapy services. Lower back pain with intermittent radicular symptoms is a common clinical presentation with patients suffering from chronic lower back pain 2. Clinical presentations often include loss of AROM, radicular symptoms, decreased flexibility, gait deviations and loss of function 3.
Jaime Caceres PT
The purpose of this case study is to present the treatment approach of a young patient with history of chronic lower
back pain with intermittent radicular symptoms in the right lower extremity. The physical therapy initial evaluation, intervention, clinical reasoning and functional outcomes used to treat this patient will be presented. Patient has history of lower back pain which returned every 12-18 months causing pain and significant functional limitations. Modified Oswestry Low Back Pain Disability Questionnaire was (56% Disability) at the time of initial evaluation. Significant functional limitations included forward bending ADLs (dressing of lower body, reaching inside the dryer, picking up objects from floor level) prolonged sitting ADLs (watching TV, sitting at work in front of his computer, driving, toileting).
Patient is a young male with a history of lower back pain with intermittent right lower extremity radicular symptoms. "I have 2 herniations at L3/L4 and L4/L5. I've had back problems for 20 years. The pain is not too bad, but a month ago I bent down and I was stuck and the pain was 8/10. My doctor wants me to have PT again before we think about injections". Patient has history of lower back pain which returned every 12-18 months causing pain and significant functional limitations.
Treatment to focus on patient's chief complaints:.
The patient reports lower back pain to be 2 out of 10 at best and 8 out of 10 at worst.
| Functional Status | Prior | Current |
|---|---|---|
| Activities of daily living | Within normal limits | Moderate limitations |
| Bed mobility | Within normal limits | Moderate limitations |
| Bending activities | Within normal limits | Moderate limitations |
| Mobility | Within normal limits | Moderate limitations |
| Picking items up off the floor | Within normal limits | Moderate limitations |
| Walking on flat surfaces | Within normal limits | Moderate limitations |
| Walking on variable surfaces | Within normal limits | Moderate limitations |
Work Status: Part-time
Ability to Work: is able to perform all duties
Oswestry Low Back Disability Index Score: 56% - Moderate Impairment
| Lumbar ROM | Repeated Movements | Hip ROM |
|---|---|---|
| Flexion = 30 degrees | RFIS = End range pain, No W after 10 reps | Right Hip = WNL |
| Extension = 12 degrees | FEIS= ERP, no significant change after 10 reps | Left Hip = WNL |
| Right SB = 7 degrees | FFIL = pain during movement, no W after 10 reps | |
| Left SB = 5 degrees | REIL= ERP, better after 10 reps |
| Right Hip Flexion = 4/5 | Left Hip Flexion = 4+/5 |
|---|---|
| Right Hip Extension = 4/5 | Left hip Extension = 4/5 |
| Right Hip ER = 4/5 | Left hip ER = 4/5 |
| Right Hip IR = 4/5 | Left Hip IR = 4/5 |
| Right Hip Abd = 4/5 | Left hip Abd = 4/5 |
| SLR Right = 35 degrees |
|---|
| SLR Left = 60 degrees |
Tender to palpation over right L3 to L5 paraspinals
Tender to palpation over spinous process L4/L5
Tender to palpation over right Piriformis
Tender over right Quadratus Lumborum
Slump Test
Right = Positive
Left = Negative
The patient posture was observed as forward head, rounded shoulders, increase in thoracic kyphosis, and decrease in lumbar lordosis.
Over a period of six weeks, patient was treated two times per week. His program consisted of Hamstrings, Piriformis and ITB stretching, PA mobs to Lumbar spine to facilitate recovery of pain free lumbar extension, core stability exercises, postural training, conditioning exercises, instructions in body mechanics and a detailed home exercise program. Modified Oswestry Lower Back Pain Disability Questionnaire improved to 10% disability. This study demonstrates the need to correlate the physical impairments identified in the initial evaluation with the functional limitations noted in outcome measures in order to improve functional outcomes. Patient participation in the home program and understanding of functional postures and body mechanics were key factors in improving functional outcomes.
When treating lower back pain patients, understanding frequency, intensity, triggers and functional limitations gives us an idea on how to design an appropriate physical rehabilitation program. When patients present with lower back pain and radicular symptoms, the McKenzie Method for treating lower back pain can be a very useful tool as part of the treatment approach 4. Understanding when to add Mechanical lumbar traction as a modality to assist in centralization of radicular symptoms is something we probably underutilize in our clinic. We often start with stretching and strengthening exercises, but until we are able to decrease the subjective reports of radicular symptoms with functional activities, we have not properly dealt with a symptom causing functional limitations with prolonged posturing in sitting, standing or lying. Improvements in objective measurements are great for documenting progress as long as those measurements have a correlating decrease in pain and increase in function. Over the past 10 years, insurance companies have slowly increased their requirement in the use of functional scales along with objective measurements to assess the efficacy of our treatments and authorization for payment 55. Our goals in physical rehabilitation need to be individualized and based on a combination of objective measurements and functional impairments. Failure to understand specific functional limitations may lead to patient dissatisfaction and possible treatment abandonment by patients 6. Once we are able to improve pain, patients are more likely to follow an exercise program to improve flexibility, core strength and overall functional endurance.
Low back pain, back pain, lumbar radiculopathy, treatment, therapy, pain, radicular symptoms.
