sciatica, complicated case

[gcoe]

Hi anoodyPT

Wow this is quite complex! It doesn't neatly show one pattern to me but there are a number of things that you could do to lead to a more rational diagnosis.

How long has she had the symptoms?

What about red flags? - and concerns raised with a thorough array of special questions?

c/o pain at lower back referred to (R) L.L ( 9/10 according to VAS) + she can't stand or walk more than 10 min

- that is very high pain and disability. Could this be a yellow flag. Have you looked at fear/avoidance beliefs/Kinesphobia (fear/avoidance beliefs questionnaire or the TAMPA will measure this)

felt burning and electrical sensation

this is suggestive of nerve pain - but what exactly is the distribution. Does is follow a dermatome pattern? Is it bilateral? Have you completed and objective tests of conduction - sensory loss/alteration?

she has hyperlordosis[+ she can't stand or walk more than 10 min

- alternatively could she have stenosis? Teaching her to stand and walk with a rotated pelvis to decrease lordosis and increase flexion may relieve her symptoms or increase her standing and walking tolerance.

An MRI may reveal more including the presence of spinal stenosis and may be warranted given her rather extreme presentation - although if there is a high yellow flag component this may explain things better.

What actually are her neurodynamic test results SLR slump + PNB?

her muscle strength is : abd. = 2/5
back ext. = 2/5
both L.L= 3/5

The marked weakness could be due to "pain inhibition", particularly if there is a fear/avoidance component = in which case she may be unwilling to contract her muscles properly. Does she seem fearful when testing? However if this is due to true weakness this is VERY concerning. I suggest you go back and do a through muscle chart of her lower limbs. See if you can develop a myotome map for her. If this is frank weakness this is definitely grounds for further investigation. In terms of management even if there is no serious underlying pathology, I think it may suggest the relative futility of using passive manual therapy techniques when you really need to do something to build up he muscle function. She is having so much trouble with posture and movement I think that would need to be the focus of her rehab

she has hyperlordosis , hypertrophy paraspinal muscles + back ext. = 2/5

. This doesn't seem to add up does it. Can you account for this?

Movement Impairment Syndromes Approach

If you have ruled out the potentially serious underlying pathology and the yellow flag issue isn't really an issue then this may be a more useful approach. I wouldn't try to convey this over the net but Shirley Sahrmann writes well on the topic. this may be a fairly extreme case of an "extension movement impairment syndrome" of the lumbar spine. For example she seems to have overly active and shortened erector spinae and probably has weak lower abdominals. So you work on strengthening the lower abdominals, particularly in the inner range to counter the pull of the shortened and overactive erector spinae. This approach may fit the bill but it takes time and there is a quite a bit of precision in prescribing the therapeutic exercise.

Treatment

I think you need to work out more what is going on - so sharpen up your differential diagnosis. Otherwise you are just firing blanks in the air.

Finally as an intern I think this is a good case to refer on for advice from a supervisor. You are right that this is quite exceptional and seeking advice is entirely appropriate

Feel free to respond and all the best with sorting it out.

[gcoe]

Hi anoodyPT

now in reassessment her pain become 5/10 and AROM: there is little limitation in extention and (R) lateral flexion and she able to walk and stand up to 30 min
but still her burning and electrical sensation didn't improved
what can i do else for her

Sorry I didn't read this when I responded above - based on this you have achieved a significant improvement in pain and disability so well done and sounds like you are at least partly on the right track. This would tend to add weight to the movement impairment syndrome idea and possibly also the lumbar stenosis. How many treatments have you given her and over what time?

The Williams exercises (very old system but interesting to see it is in use still) is probably quite similar to Shirley Sahrmanns approach for and extension problem of the lumbar spine and both would improve the problem. However I think Sahrmann's concept is more developed and the emphasis is on permanently changing the muscle imbalance by improving both motor control and appropriate strengthening and lengthening. William's approach is relatively imprecise in this way.

I still think you should go back to your diagnosis however. Particularly ruling out red flags, possibly getting further imaging if warranted, and to sharpen up your differential diagnosis. Understanding the nature of the burning and electrical symptoms is important. And what about her muscle strength now? This maybe important to ensure you can get further improvement.