CASE 5: Right L5/S1 Acute LBP with Somatic Referral Flashcards
Prognosis
- The prognosis is good (outline reasons why – no major trauma, only acute, no leg or nerve symptoms).
- State normative data/what we know – most people improve rapidly and we expect an improvement in these symptoms within the next week. However, most make a full or close to full recovery in 4-6 weeks (50% recover in 1-2 weeks, 80% in 4-6 weeks)
- Really helps to give two-time frames – 1st time frame to see improvements (quickly <1week) and then when to expect more of a full recovery to normal activities.
What will you advise the patient to do around managing at work? Be specific
- Sitting – can he modify chair – use a support on the chair temporarily like a cushion or towel. Make sure he is using the back support to enable him to relax his back. Frequent changes of position.
- Re-educate about how to go from sit to stand – keeping spine in neutral – shuffle to front of chair, lean body weight forward to come over feet and use momentum to come up.
- Can he minimise his time in sitting at work? Can he stand for short periods? Can he take more regular breaks temporarily?
- Support in the car – raising the seat height in the car if possible
- What exercises can he do at work – walk around? Repeated extensions in standing (if tolerated)? Frequent ROM and directional preference exercises
Diagnosis + Prognosis
From the physical examination, I have found that you have not sustained any major injuries to your back and are experiencing some symptoms around the L5/S1 region of your back (show on model):
- You didn’t have any major trauma and you aren’t experiencing any symptoms down your legs.
We can expect a drastic decrease in your symptoms in the next 2 weeks:
- 80% of patients recover completely in 4-6 weeks.
What can the Pat do?
- Some initial rest until your symptoms settle down slightly and then we want to get you moving as soon as possible.
- Then we want to get you moving and back to work as soon as possible.
- Discuss potential temporary work modifications – minimize prolonged amount of time in any positions.
- Repeated movements into extension have been found to relieve your symptoms, so we can use that as part of your management.
Ax priorities
- Observation + Functional
- AROM + repeated movements
- Manual Exam
Ax Observation + Functional test/results
Standing with acute loss of lordosis – he notices that he is standing this way slightly (see picture)
Sit to stand – needing to use edge of chair to brace back - pain 6/10 but once into upright standing – 3/10 – very slow to get upright.
Sitting:
- Sitting in neutral – pain 2/10
- Pain on posterior pelvic tilt – pain 5/10
- No increase in pain on anterior pelvic tilt
Ax AROM + repeated movements tests/results
- Flexion: pain 6/10 fingers reach knees - pain 6/10 on return to upright
- Extension: only slight extension – pain 5/10
- Repeated extension in standing 10x – increased range extension and reduced pain to 2/10
- Side flexion in standing – 3/10 pain – fingers to 3cm above knee L=R
Ax Manual Exam tests/results
Prone
Significant difficulty getting into prone
Palpation
Very Tender L QL and Iliac Crest (5/10 pain) Increased tone/tension L QL and ES muscles
PAIVMs:
↓ L4 – 3/10 back pain
↓ L5 – reproduced back pain (6/10)
L4/5 and L5-S1 L unilateral PA - also reactive (6/10 in back) All others normal
Significant difficulty getting back out of prone
Tx Priorities
- Advice + Education
- Reduce pain
- Initiate movement/exercise
Tx Advice + Education
b) Outlining what has happened – why the high levels of pain? You might consider explaining that there has been a mild injury or sprain (you could use an anatomical model to show where this has been in the spine) but the area + nervous system is very sensitive
c) The importance of staying active and at work for better recovery – but how he can modify these things
d) Options rather than long walks with the dog – a few 10 min walks instead? – breaking the walking to twice a day and shorter is a good idea.
e) Discussion about how to modify work and home requirements to keep up a normal routine or responsibilities
f) Focus on the most difficult functional tasks = sitting and transitions = talk about/find ways of getting these being done more effectively
Tx Reduce pain
a) Manual therapy – rotation or reverse lateral flexion – if successful, consider increasing the grade of the rotation mobilisation (and use manipulation). Consider MWM to extension in prone.
b) Directional preference – gentle repeated extension in standing if tolerated but preferably prone repeated extension onto hands if he can get into prone.
Tx
ROM exercises in supine and 4 point kneel (if he can get there) – show him progressions to do over the next few days as he is expected to improve significantly over the next few days – this might be pelvic tilts in sitting or prone onto elbows (repeated extensions).
