sciatica, complicated case

hey everboody
gd evening :)

i am PT intern now :o
and i have complicated case
she is 54 y/o female has LBP and her xray is shown degenerative superior and anterior end plate multiveretebral
c/o pain at lower back referred to (R) L.L ( 9/10 according to VAS) and felt burning and electrical sensation
that cause decrease functional activities , she cann't stand or walk more than 10 min , and she change her position every 30 min.

in observation :
she has hyperlordosis , hypertrophy paraspinal muscles and flat sacrum , it's really strange back :eek:
she has also sever tightness in paraspinal lumbar and multifidus and i think quadratus lumborum

AROM: it was little limitation in all directions + EROMP

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

now after 6 sessions i used with her manual trigger point technique to relief pain and tightness
and P.U.S on lumbar muscles and cold pack to relief sciatica pain
and p.A superior facet joint mobilization
and i did neurodynamic sciatic nerve mobilization but that exacerbate her referred pain and burning sensation so i told her to stop it bacuse the problem centrally not prepherally
and also i did william ex's and core stability ex's and advice her to stay in forward bending position from short sitting to increase space between vertebra and avoid compression on nerve root

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 :(

thanx everybody :o

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?

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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

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- 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)

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felt burning and electrical sensation

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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?

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

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- 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?

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

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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

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

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. 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.

Hi anoodyPT

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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

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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.

hey again
thanx alot gcoe , ur guidance was helpful so much
btw there is something i don't know about it , Shirley Sahrmanns approach ?? what's this approach , i searched about it but i can't find any thing helpful !!

Hi AnoodyPT

Glad you found there this helpful

The idea of muscle imbalance is not new However Shirley Sharmann has taken it to a new level She puts forward a "Kinesiopathological model" that it is the adoption of suboptimal motor control (such as the adopting of poor postures and inefficient movements) over a long time that leads to maladaptive changes in muscles (shrtening of some muscles, lengthening of others, over development of some and weakening of others ) which in turn stress other soft tissues and joint structures. in the case of an acute injury the pathokinesiological model accounts for damaged structures (damaged structure causes abnormal movement/pain. But in most things we see the Kinesiopathological model it is the the abnormal movement that that stresses the locomotor system and this model is posited for such problems as overuse and process injuries, degenerative joint changes, tendonopathies.

Here are a couple of things to look at:

YouTube - Ann Kaleckas Lecture April 22 2008 Shirley Sahrmann.

This lecture gives an overview of Dr Sahrmann and where she is coming from.

Here text book is:

Amazon.com: Diagnosis and Treatment of Movement Impairment Syndromes (9780801672057): Shirley Sahrmann PT PhD FAPTA: Books

To really get skilled at her method you really need to attend one of her courses But the books is very detailed and covers what you need to do

Courses on Diagnosis and Treatment of Movement System Impairment Syndromes

Her methods don't have much evidence for it but personally I think it is a very fruitful area of research and it would be great to see some clinical trials on this approach. In the mean time it provides a rationale for preventing and managing these more chronic and difficult-to-treat problems where one addresses the underlying mechanisms rather than just offering symptomatic treatment.