group 2 presentation lumbar spine. overview history preliminary diagnosis exam diagnosis treatment...

Group 2 Presentation

Lumbar Spine

Overview

• History

• Preliminary Diagnosis

• Exam

• Diagnosis

• Treatment

• Outcome Assessments

History

• 49 yr. old African American

• Male

• 6 ft. 240 lbs.

History

• Previous onset of injury was 4 years ago in 2006. He was changing a tire when he felt a “pop” lifting up the tire. He had some pain and could not finish changing the tire. About one week later the pain was minimal but he noticed some tingling sensations in his foot and a little leg weakness.

Consultation

• ONSET: It happened 3 days prior to initial visit. He was in his attic pulling out Halloween decorations when he fell over from a squatted position, while reaching for a fake skull, and heard a loud “pop.”

Consultation

• Provocation: Going from a seated to standing position causes pain. Twisting movements, and walking and standing are aggravative. Coughing, sneezing and baring down.

Consultation

• Palliative: Ibuprofen offers some relief but “not enough.” The pain is tolerable when sitting in his favorite recliner at home. In bed at night sleeping on his back with his feet elevated is the only position he can fall asleep in.

Consultation

• Quality of Symptoms: A sharp, electrical type of pain accompanied by a feeling like his foot and sometimes up in his leg is “asleep.”

• Radiating/Region: The pain starts in his Right leg just below the knee and travels down into his foot and toes.

Consultation

• Severity/Site: Pain scored as a 10 out of 10 for right lower leg and back.

• Timing: Daily; constant and gets worse as the day progresses.

Consultation

• Previous Treatment: Ice and NSAIDS

• Past Medical History: Has a 60 pack/year history, and drinks on the weekends. His father has Diabetes type 2

Consultation

• Activities of Daily Living Affected: Virtually all activities are affected from previous state of the patient. His wife helps him dress and takes him to work. He can’t participate in household chores. Can’t participate in outside activities with his kids because walking and standing are difficult.

Consultation

• Adverse Environmental Activities: Working at a desk all day talking on the phone.

• Medications: NSAIDS 5 times per day

Red Flags

• Have you had a previous history of cancer or unexplained weight loss, and is your pain relieved by bed rest?

• Cancer would be suspected if history of cancer, unexplained weight loss, or pain unrelieved by bed rest were reported.

Red Flags

• Have you had recent urinary tract infections or skin infections and is there a fever?

• Fever and previous infections help to rule out a possible spinal infection.

Red Flags

• Are you having difficulty with urination, stopping and starting?

• To consider prostate cancer.

Red Flags

• Does the pain radiate below the knee?

• Pain above the knee is more indicative of a lumbar facet or sacro-iliac problem. While radiating pain into the groin can mean kidney problems.

Red Flags

• Does coughing, sneezing and defecating make symptoms worse?

• Indicates possible space occupying lesion, or disc lesion.

Red Flags

• How severe was the trauma and did you fall directly on your buttocks?

• To consider possible coccygeal fracture and others depending on mechanism of injury.

Differential Diagnosis

PRELIMINARY DIAGNOSIS

• Lumbar disc protrusion

• Canal stenosis• Radiculopathy• Lumbar Sprain• Upper Cross• Lower Cross• Lumbosacral

plexopathy

• Postural Paresis• Motor Weakness

Exam• Basic Vitals

– Height: 6’– Weight: 240 lbs– Radial Pulse: 85 bpm at rest– Post Tib & Dorsal Pedal Pulse: strong and

symmetrical– Respirations: 18

• Lines Of Menstruation– Lt quad 18” Rt quad 15” – L calf 16,” R calf 13”– Upper extremities were symmetrical

• Neurological Assessment– Reflexes: diminished on the Rt leg +1 for

Patellar, Med hamstring and Achilles. Lt leg demonstrated +2

– Joint position: Unaware of position of toes 3-5 on Rt; NAD for Lt. toes

– Pin wheel: Couldn’t feel on dermatomes L4- S1 on Rt; Lt dermatomes were felt and defined as prickly

– Vibration sense: Not felt on Rt leg regardless of intensity of vibration In L3-S1. Lt leg was felt at lowest level of stimulation at all points.

Exam• Orthopedic Tests

– (+) Kemps to R, – (+) Braggard’s at 60 degrees, – (+) SLRat 65 degrees, – (+) Valsalva– (-) FABERE– (+)Goldthwait’s at lumbar movment level

Exam• Postural analysis

– Anterior head carriage– Bilateral internal rotation of shoulders, – shoulder and pelvic unleveling, – Hyperkyphosis of T-sp, – Protruding Abdomen , – hyperlordotic L-sp.

• ROM – Cervical lateral flexion decreased (bilaterally) – Cervical extension decreased. – Rt. Cervical rot. decreased – Cervical Flexion was full but ataxic– Lumbar Lat-flexion (Bilaterally) decreased– Flexion and extension were all considerably

compromised– Patient was reluctant to do L-sp flexion due to pain

in low back.

• Fixations– Fixation C4-C7 L1-L5; Sacral Base Posterior on Lt;

Rt Post Ilium

Exam• Functional Movement Assessment

– Sit and Reach • Unable to touch toes, Limited movement of lumbar spine -

Restriction of lumbar erector- Restriction of Quadratus Lumborum and Medial hamstrings

• Excessive motion of the Thoracic spine indicative of hypermobility of the thoracic erector spine

– Sit to Stand• Excessive torso flexion (>40°) Weakness of Transversus

abdominis & Excessive swaying / wobbling d/t inability to use Rt leg. Pt. pushed off with arms indicating weakness of Quadriceps muscles

– Lunge• Patient attempted Lunge, but was unable to d/t balance and

weakness in Rt leg

– Gate Analysis • shortened swing phase while dragging Rt foot

DIAGNOSIS

• Radiology

• MRI

• Electrodiagnostic

Testing

Diagnosis

• Lumbar Disc Protrusion 722.10

Complicating DiagnosisLower Cross secondary to Upper CrossPostural Paresis 781.92Motor Weakness 728.87Radiculopathy 724.4Lumbar Segmental Dysfunction 739.3Disuse Atrophy 728.2

Treatment

• Goal: alleviate pain, decrease inflammation, strengthen weak muscle groups and stretch restricted muscle groups in order to restore pre-tire incident ADLs.

Treatment Defined

• Interferential for pain and inflammation • Decompression table for pain • Therapeutic exercises to strengthen upper/ lower cross inhibitions Multifidi, Abdominals, Glut maximus/ med, Deep neck flexors, Lower traps and Serratus anterior. • PIR stretches for upper cross/lower cross restrictions. Erector spinae, Iliopsoas, QL, SCM, Upper traps, Levator scap, Pectoralis.• Adjustments of lumbar and cervical spine. To restore motion with equivalent fast stretch of the muscle spindles to restore protein alignment in the restricted muscles.• Therapeutic Vacation Time away from treatment in which the body will either maintain or lose treatment gains, allowing the Dr to create a more complete treatment plan.

Phase IWeeks 1-4

• Interferential 3xwk for 2wks Cycle time: 5/5. Sweep: 3-5hz. Time: 20mins

• Decompression 3xwk for 4wks DTS pull pattern: Reverse Gradient Weight: 75lbs Time 20mins

• Therapeutic exercises 5xwk for 4wks Vibe plate with hand bike Wobble chair Core: Tummy hollowing Time: 15mins Time: 7mins 3 sets hold for 15secs. ATM2 exercises into muscle weakness 3sets holding for 30secs.

• PIR stretches for upper cross/lower cross restrictions 5xwk for 4wks

• Adjustments of lumbar and cervical spine. 3xwk for 4wks

Phase IIWeeks 5-8 (RRU)

• Therapeutic exercises 5xwk for 4wks Recumbent bike w/ CC Wobble chair Core: Tummy hollowing Time: 15mins Time: 7mins 3 sets hold for 30secs. ATM2 exercises into muscle weakness 3sets holding for 45secs.



Weeks 9-12 (RRU)• Therapeutic exercises 2xwk for 4wks Elliptical machine w/ CC Wobble chair Core: Tummy hollowing Time: 15mins Time: 7mins 3 sets hold for 45secs. ATM2 exercises into muscle weakness 3sets holding for 60secs.



Weeks 13-14 (RRU) • Therapeutic Vacation

Phase IIIWeek 15-19 (RRU)

• Therapeutic exercises 2xwk for 4wks Elliptical/Recumbent bike w/ CC Wobble chair Core: Tummy hollowing Time: 15mins Time: 7mins 3 sets hold for 30secs. ATM2 exercises into muscle weakness 3sets holding for 45secs.



Week 20- 23• Therapeutic exercises 2xwk for 4wks Elliptical w/ CC Wobble chair Core: Plank Time: 15mins Time: 7mins 3 sets hold for 15 secs. ATM2 exercises into muscle weakness 3sets holding for 45secs.



Week 24-25 (RRU)• Therapeutic Vacation

Phase IVWk 26-37 (RRU)

• Therapeutic exercises 1xwk for 12wks Elliptical/ treadmill (footbrace) w/ CC Wobble chair Time: 15mins Time: 7mins. Core: Plank ATM2 exercises into muscle weakness 3 sets hold for 15 secs 3sets holding for 30secs.



Wk 38-39 (RRU)• Therapeutic Vacation

Wks 40- Lifetime • Continue above care 1-2x Mnth for lifetime

NUTRITION

• 1st goal: to reduce inflammation

• What causes inflammation? Nuclear material in epidural space.

Forms &Tests

• Seven day food diary

• Health appraisal

• NutrEval By Genova Diagnostics

•

• Hb A1C and C- reactive protein tests

Nutrition Recommendations

• Anti-inflammatory diet

• Linoleic acid converted to arachidonic acid

• Meats, dairy fats and shellfish

• Diet should be of less grain and seeds, more vegetables, fruit and fish

USDA Food pyramidpro or anti-inflammatory?

Dietary support

• Glucosamine and probiotics

• Vit C and bioflavinoids(anti oxidants)

• Boswellia 600 mg

• Magnesium 1000 mg

• Turmeric 200 mg

• Malic acid 2400 mg

• Vit B1 and B6 600 mg

Clinical Outcomes

From To

QVAS

Initial Exam:

10/10

Goal:

8/10

Re-Exam:

7/10

OSWESTRY

Initial Exam:

44

Goal:

32

Re-Exam:

30

Neurological Tests• Initial Exam (all Rt leg)

– Plantar flexion = 3/5– Dorsiflexion = 5/5– Inversion = 3/5– Eversion = 3/5– Achilles/Med

Hamstring/Patellar Reflexes = +1

– L4-S1 decreased dermatome sensory w/ pinwheel

– No vibratory sense– No jt perception of 3-5 toes– Tandem gate & Romberg’s

positive to the Right

• Re-Exam– Plantar flexion = 4/5– Dorsiflexion = 5/5– Inversion = 4/5– Eversion = 4/5– Achilles/Med Ham/Patellar

Reflexes = +2– L4-S1 dermatome sensory

still decreased– Slight improvement w/

vibratory sense & jt position– Tandem gate and Romberg’s

still positive to the right

Other Outcomes• Increased ROM in cervical & lumbar spine.

• Increase in AROM in lower extremities.

• Improvement in pelvic unleveling.

• No longer drags right foot while walking.

• Increased feeling of stability.

• Increased bowel movements.

• Improved urinary continence.

• Increased sexual activity.

• Increased ability to perform activities of daily living.

group 2 presentation lumbar spine. overview history preliminary diagnosis exam diagnosis treatment...

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