This patient was first assessed in our office three months following discectomy. She just bought a business and was worried she would not be able to perform work or life tasks as a mother due to limited mobility from chronic low back pain. Difficult tasks included: sitting for long periods at a desk and computer, bending and lifting pots and watering cans, as well as normal activities of daily living, such as walking and sleeping.
Physical assessment was based on the Selective Functional Movement Assessment (SFMA) from Functional Movement Systems(Cook, 2010) (Honarbakhsh & Rose, 2017). Orthopedic, neurologic, and motor tests were also included as well as functional attributes from First Principles of Movement and the text Rehabilitation of the Spine: A Practitioner’s Handbook (Liebenson, Rehabilitation of the Spine - A Practitioner's Manual, 2007) (Liebenson, Prepare, 2019). Positive Orthopedic Tests included: Straight Leg Raise (right) with radiating pain from the lower back continuously into the mid-calf just prior to 70 degrees, same results with Well Leg Raise, Milgram’s with moderate pain increasing into stopping the test at ten seconds due to pain and radiating symptoms into the right calf, Ely’s bilateral greater on the right during right sided testing in the lower back, Patrick Faber’s bilateral with the pain on the lateral hip describing an impingement type feeling, Jack’s test (assessment of dorsiflexion of the metatarsophalangeal joint of the great toe) showing significantly decreased ROM on the right in supine both active and passive with associated tenderness in the right plantar area and none on the left. Motor testing showed decreased strength bilateral in the Quadratus Lumborum and Gluteus Medius worse on the right with pain associated only on the right. Full strength findings were demonstrated in the Gluteus Maximus, but pain in the low back testing bilateral, with leg pain on the right with right sided testing.
Significant findings during the SFMA included: (1) A functional non-painful multi-segmental flexion test (she was able to touch toes, had posterior weight shift, and smooth spinal curve), (2) dysfunctional painful multi-segmental extension test across the L-S junction, bilateral dysfunctional non-painful multi-segmental rotation (unable to reach 100 degrees rotation standing bilateral), (3) Left single leg stance with eyes closed (patient was unable to stand more than 2–3 seconds with eyes closed), and (4) dysfunctional non-painful deep squat arms in front (knees fall far in front of the toes and cave inward). An assessment of rotation at the joint level revealed decreased internal rotation bilateral of the hips actively, but full ROM past 30 degrees passive with pain in the lower back during right side moving. She demonstrated bilateral decrease in thoracic ROM actively in “reach back” position, but full passive ROM passively reaching 45 degrees bilateral (Honarbakhsh & Rose, 2017). Light touch evaluation of the lower extremities revealed NAF bilaterally.
An Oswestry Disability index was used on the first visit which resulted in 62% disability (crippled) (Fairbank JC, 2000). Single leg glute bridging showed the inability to keep pelvis level bilateral with worse drop of the right pelvis during left leg testing. She was unable to perform shin box (seated with one hip in external rotation and the other in internal rotation) testing unless laying on her opposite elbow, and inability to hold torsional buttressing (single arm planking) unless she was on her knees. Gait visualization showed a relatively normal gait pattern during left swing phase. During right swing phase the patient pulled her entire hip and body through the motion essentially twisting the right side to step through.
Her initial treatment plan consisted of in office adjustments twice weekly for 3–4 weeks, then weekly for 2–4 weeks depending on both progress and compliance to the prescribed therapeutic plan. A reassessment was performed following one month of care using an ODI and functional. Passive treatment consisted of Sacro-occipital Technique blocking of the pelvis with the use of drop table adjusting, and P-A high velocity low amplitude adjusting in the T-L junction. Soft tissue treatment consisted of post-isometric relaxation of the quadratus lumborum, erector spinae, psoas on various appointments based on tight muscle findings. Early on the patient did have radiating symptoms into the right leg with pain in the lumbosacral junction on the right. “Hip scouring” was also performed periodically.
Active treatment exercises included: press up exercise based on McKenzie protocol, single leg standing in Brugger’s relief position with the goal of eyes closed for a minimum of 10 seconds working to 30 seconds. She was taught how to activate short foot through modeling and Vele forward lean, Bird dog hold 8-10 seconds at 6, 5, 4 reps 1-3 times per day (McGill, 2017), and shin box with activation of gluteus medius. As a side note on Bird Dog: with the patient having her main dysfunctional pattern in the transverse plane, it was extremely difficult for her to level out her pelvis in this pose. After multiple visits, modeling, and trying to have a family member observe, we discovered the best “cue” was external with some type of object on her low back. In the office we used a yoga block. Following this, she made the most progress with motor control in this plane. See photos (1-3).
The patient underwent the prescribed in-office therapy and reported compliance with active at home rehabilitation exercises. After one month we noted remarkable improvement in her ODI, decreasing to 36% (moderate disability). Reassessment and functional testing following one month of therapy, showed decreased pain, resolution of radiating leg pain, and reduction in the feeling of being “twisted”. She required external input (yoga block) to fully level the pelvis during Bird Dog exercise but was able to self-correct. Single leg gluteal bridging improved with pelvis un-leveling. At this point, and to expedite active treatment to a more real-life situation, she was given vertical loading exercises to help her improve her daily activities. These included a farmer’s carry exercise and a single leg squatting exercise with a doorknob or other object to help stabilize, an isometric hold was used with the opposite leg behind her to “kickstand” for 6–8 reps while holding the single leg squat position. Due to Covid-19, her Chiropractic treatment was on hold, but email communication allowed us to know her function was much better at work and regular life. During her visit following the hiatus from care, we were able to reassess the ODI to find that her self-care strategies were enough to continue to improve to 16% disability (minimal). Complaints include flares of low back pain when sitting, carrying, and/or lifting for long periods throughout the day. The night prior she began to get some radiating pain into her right leg.
Supplementation and general dietary advice were also given to the patient to maintain healthy diet of anti-inflammatory foods along with fish oil at roughly 2,500 mg per day, since this has been shown to “be the floor for anti-inflammation” (Murphy, 2005).