MANUAL THERAPY TREATMENT FOR LUMBAR STENOSIS …...The patient completed the Revised Oswestry...
Transcript of MANUAL THERAPY TREATMENT FOR LUMBAR STENOSIS …...The patient completed the Revised Oswestry...
MANUAL THERAPY LUMBAR STENOSIS
MANUAL THERAPY TREATMENT FOR LUMBAR STENOSIS AND
ACCOMPANYING RADIATING PAIN
A Case Report
Presented to
The Faculty of the Marieb College of Health and Human Services
Florida Gulf Coast University
In Partial Fulfillment
of the Requirement for the Degree of
Doctor of Physical Therapy
By
Ryan D Emery
2017
MANUAL THERAPY LUMBAR STENOSIS
APPROVAL SHEET
This case report is submitted in partial fulfillment of the requirements for the
degree of
Doctor of Physical Therapy
_________________________
Ryan Emery
Approved: April 2017
Dr. Arie J. van Duijn, EdD, PT, OCS
Committee Chair
Dr. Eric Shamus, DPT, PhD, CSCS
Committee Member
The final copy of this case report has been examined by the signatories, and we
find that both the content and the form meet acceptable presentation standards
of scholarly work in the above mentioned discipline.
MANUAL THERAPY LUMBAR STENOSIS
Acknowledgments
Firstly, I would like to that my independent study committee members, Dr.
Arie van Duijn and Dr. Eric Shamus for all of their assistance, feedback, and
guidance during the independent study and case report process.
I would also like to extend my gratitude to Dr. Tom Zeller for the
opportunity, as well as, his assistance and advice during the selection process
and treatment of my case report patient.
I am very thankful to the entire Florida Gulf Coast University Doctor of
Physical Therapy faculty and staff for their patience, guidance, and mentoring
during this doctoral program.
I would like to thank the members of my cohort for their continued support
and work that we completed together over the last three years.
Finally, I would like to thank my family for supporting me through this
graduate process and my life in general. Without you I would not be where I am
today.
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Table of Contents
Abstract 5
Background and Purpose 6
Case Description 7
Patient History and Systems Review 7
Clinical Impression #1 9
Examination 9
Clinical Impression #2 11
Intervention 14
Outcome 17
Discussion 19
References 25
Appendix A: Numerical Pain Rating Scale 29
Appendix B: Revised Oswestry Disability Index 30
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Abstract
Background and Purpose: Patients with lumbar stenosis and radiating pain are
frequently treated using various forms of manual therapy. This case report study
describes a single patient case and the treatment of lumbar stenosis and
radiating pain using manual therapy techniques. Case Description: A 53-year-
old female presented to outpatient care with 10/10 left lumbar pain and radiating
pain present to posterior lateral mid-calf. The patient was in a motor vehicle
accident three weeks ago. Symptoms were provoked during right rotation and
left lateral flexion of the lumbar spine as well as during prolonged sitting or
walking. A multi-modal manual therapy based treatment approach was utilized
which included: lumbar spine rotation (Grade II, III) mobilizations, soft tissue
mobilization, and therapeutic exercise for lumbar pelvic stabilizer muscle
strengthening and neuromuscular control. Outcome: After 12 visits over 5
weeks of treatment, the patient displayed significantly improved strength, range
of motion, level of disability, centralization of pain, and reduction of pain.
Discussion: While the results described in this case report cannot be
generalized, it does depict a successful outcome of a patient with lumbar
stenosis and radiating pain using manual therapy techniques and therapeutic
exercise.
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Background and Purpose
Radiating pain or radicular pain from the spine involves inflammation and
chemical changes that will cause increased sensitization of the nerve root or
spinal ganglion that results from compression, irritation, or pinching of the spinal
nerve root. The radiating pain may be due to disc protrusion, osteophyte
formation into the intervertebral foramen, or any local degenerative disorder that
compromise the intervertebral foramen including spinal stenosis (Hengeveld &
Banks, 2014). Radiculopathy may cause neurological signs or symptoms
including: myotomal weakness, changes in sensation in dermatomal patterns,
and pain that is described as lancinating, shocking, burning, or of electric
qualities (Hengeveld & Banks). Referred pain is perceived at a site other than
the painful stimulus. Pain perceived along the distribution of the sciatic nerve in
the posterior aspect of the lower extremity is a common referred pain pattern
resulting from nerve compression in the lumbosacral spine (Longo, Ropper, &
Zafonte, 2015). Conservative treatment including various forms of manual
physical therapy management have been demonstrated to be effective in the
management of lumbar pain by improving pressure pain thresholds (Willet,
Hebron, & Krouwel, 2010). A comprehensive clinical practice guideline was
constructed utilizing evidence based research. It was determined that manual
therapy interventions are indicated in patients with acute low back and back
related lower extremity radiating pain to improve spine and hip mobility as well as
reduce pain and level of disability (Delitto et al., 2012). Manual therapy
techniques including spinal mobilization have demonstrated positive effects on
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the presentation of lumbar radiating pain through pain modulating effects through
neural analgesic mechanisms (Dorron et al., 2016). Spinal manipulation has also
been demonstrated to address local hypomobility with reduction of compression
in the intervertebral foramen (Vieira-Pellenz et al., 2014). It is suggested that
conservative management of lumbar radiating pain should be attempted prior to
surgical management in the absence of worsening neurological signs or cauda
equina syndrome (Valat, Genevay, Marty, Rozenberg, & Koes, 2010). Research
has demonstrated that there are positive effects on both range of motion of the
lumbar spine as well as pain reduction with various grades of Maitland lumbar
manipulation techniques (Bhushan et al., 2016; Shum, Tsung, & Lee, 2013).
Likewise, there has also been research concerning the use of soft tissue
mobilization on decreasing pain and increasing tissue extensibility (Furlan,
Imamura, Dryden, & Irvin, 2009). A recent systematic review of literature also
demonstrated that there is evidence for the use of mobilization and soft-tissue
manual therapy techniques combined with exercise for both short and long term
pain and disability management (Hidalgo et al., 2013). This case report
demonstrates the positive effects of conservative physical therapy management
with use of manual therapy techniques and interventions in the treatment of
lumbar stenosis and accompanying radiating pain.
Case Description
Participant History and Systems Review
A 53-year-old female presented for physical therapy treatment with severe
(10/10) left lumbar spine pain and radiating pain in the left lower extremity that
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began after being in a motor vehicle accident. The patient first began having
pain after a motor vehicle accident approximately 3 weeks prior to physical
therapy evaluation. Diagnostic imaging including a MRI and radiographs were
completed after the motor vehicle accident which displayed left L4-L5 spinal
stenosis, L4-L5 facet arthropathy, disc bulges on L3-L5, and L4-L5 degenerative
disc disease. The patient described her pain as sharp and shooting pain and
rated it at 10/10 on the 11-point Numerical Pain Rating Scale (NPRS). She also
reported pain into the left lower extremity in the posterior thigh that extended to
the posterior lateral mid-calf. No associated numbness, paresthesia, weakness,
or cauda equina syndrome symptoms were reported. As a result of this lumbar
pain and radiating pain the patient was unable to sleep uninterrupted as well as
unable to complete many functional activities without severe increase of pain.
Activities that were limited included: prolonged standing, ambulation of
community distances, transfers, lifting or carrying objects required for household
activities, and recreational activities. The patient was only able to sleep on her
right side and her sleep was frequently disturbed by low back pain resulting from
turning, rolling, or moving while in bed. The current episode of pain also
prevented her from sitting upright at work as an office worker or moving about as
needed while at work. The patient felt that she was unable to perform her job
adequately due to pain and difficulty with moving secondary to pain. She was
anxious concerning her condition and how it may negatively impact her
professional, social, and personal life as well as the potential of long-term
disability. The patient’s goals for physical therapy were to return to prior level of
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function, to resolve her low back pain, and to allow for return to work at the level
of previous capacity.
Clinical Impression #1
The patient reports severe (10/10) low back pain with radiating left lower
extremity pain of spinal origin. There are significant functional limitations
secondary to this pain. Due to mechanism of injury as well as the radiating pain
pattern there is several potential differential diagnoses including: facet
dysfunction, intervertebral disc herniation, spinal stenosis, piriformis syndrome,
and sacroiliac joint dysfunction.
The examination plan included: neurological testing, postural assessment,
lumbar range of motion, passive intervertebral motion, strength of the lumbar
pelvic stabilizers, determination of a flexion or extension directional preference of
movement, and neurodynamic testing. Due to the patient presentation of low
back pain with mobility deficits it was determined that, based on evidence based
research, there was likely to be functional improvements through the use of
manual therapy techniques including spinal and soft tissue mobilization as part of
a multi-modal conservative approach.
Examination
The patient completed the Revised Oswestry Disability Index (ODI). She
scored 70%, which indicates complete disability. Physical examination of the
patient was limited due to the severity of the patient’s pain and irritability of
affected structures. She was observed to have forward flexed posture, increased
lumbar lordosis, rigid posturing, and antalgic motions secondary to severe low
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back pain. There was an increase of localized left lumbar pain at end range
motion in all directions of the lumbar spine. Right rotation and left lateral flexion
also increased left lower extremity radiating pain. Range of motion was
significantly limited in all directions secondary to pain at end range with greatest
limitations in right rotation and left lateral flexion. Pain was most severe with right
rotation and left lateral flexion with recreation of radiating lower extremity pain to
posterior lateral mid-calf. The patient reported a decrease in pain with slight
flexion, right lateral flexion, and left rotation. Palpation of the left lumbar erector
spinae, upper gluteal region, and quadratus lumborum also recreated localized
pain with significant tenderness to palpation. Palpation testing also revealed
that the patient had significant muscle guarding and tightness of left erector
spinae, paraspinals, and quadratus lumborum. Passive bilateral and left
unilateral posterior-anterior accessory range of motion also recreated pain in
lumbar spine and buttocks region. Passive intervertebral motion was determined
to be 2/6 in left L3-S1 segments with slight joint limitations of movement. There
was significant weakness of the lower abdominals and lumbar pelvic stabilizers,
2/5, with rapid fatigue and inability to maintain neutral spine position during
supine manual muscle testing. Neurodynamic testing using a straight leg raise
test caused local lumbar pain at 15 degrees of flexion of her left hip and at 30
degrees of flexion of her right hip. There was no increase or change in left lower
extremity pain or symptoms. The localized lumbar pain was reported to be sharp
and pulling. The pain descriptors reported during straight leg raise testing
differed from previous pain reported and fit the descriptors of pain of a muscular
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origin. However, neither increased peripheral pain symptoms in the left lower
extremity and no change was noted with increasing dorsiflexion. Straight leg
raise was determined to be negative due to no recreation of lower extremity pain
and symptoms. This test has a sensitivity of 0.91 and specificity of 0.26 for
lumbar disc herniation with a positive likelihood ratio of 1.2 and negative
likelihood ratio of 3.5 (Deville et al., 2000). Neurological testing revealed no
determinable myotomal weakness, sensory abnormalities, or abnormalities in
deep tendon reflexes.
Clinical Impression #2
The patient described was likely to have intermittent nerve root
compression with neurogenic claudication as a result of spinal stenosis. Left
lumbar referred pain to the lower extremity due to irritation of the nerve root due
to stenosis was suspected due to limitations in lumbar range of motion, preferred
posture, and joint restrictions. Significant muscle guarding and tightness due to
the motor vehicle accident is likely to further decrease inter-vertebral spacing and
increase localized inflammation causing additional lumbar and referred pain
symptoms. MRI impressions included: left L4-L5 spinal stenosis, L4-L5 facet
arthropathy, disc bulges on L3-L5, and L4-L5 degenerative disc disease. These
findings would further indicate potential irritation of the lower lumbar nerve roots
with narrowing of the intervertebral disc space, bulging of the disc, and
degeneration of the facet joint causing stenosis of the lateral intervertebral
foramen. Due to the presence of lateral stenosis as well as movement limitations
it was decided to initiate a plan of care including manual therapy spinal and soft
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tissue mobilizations and therapeutic exercise to improve strength and
neuromuscular control within the lumbar spine to reduce pain, inflammation,
functional limitations, and level of disability. This is based on the clinical practice
guidelines for low back pain (Delitto). The patient’s response to intervention and
her associated outcomes were evaluated and recorded every 3 visits to
determine appropriateness of interventions and progress toward short and long
term goals (Table 1).
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Table 1 Short and long term goals
Goal type and number Goal description
Short term goal (STG) #1 Improve lateral flexion to 20 degrees, flexion to 50 degrees, and rotation to 25 degrees bilaterally to allow for improved ability to complete ADLs including household chores, self-care tasks, and work related activities within 3 weeks.
STG #2 Improve strength of transverse abdominis and lower abdominals to 4-/5 to improve lumbar stabilization to allow for improved ability to transfer, bend, lift, carry, ambulate, stand, and sit for prolonged periods of time within 3 weeks.
STG #3 Patient will be able to sit for 15 minutes without increase of lumbar or radiating pain to improve ability to complete work tasks within 3 weeks.
Long term goal (LTG) #1 Improve lateral flexion to 30 degrees, flexion to 70 degrees, and rotation to 40 degrees bilaterally to allow for improved ability to complete ADLs including household chores, self-care tasks, and work related activities within 6 weeks.
LTG #2 Improve strength of transverse abdominis and lower abdominals to 5/5 to improve lumbar stabilization to allow for improved ability to transfer, bend, lift, carry, ambulate, stand, and sit for prolonged periods of time within 6 weeks.
LTG #3 Patient will be able to sit for 1 hour sessions without increase of lumbar or radiating pain to improve ability to complete work tasks within 6 weeks.
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Intervention
At the initial treatment session, manual therapy techniques were utilized to
address generalized lumbar hypomobility with emphasis on L4-L5 joint as
passive intervertebral motion testing, palpation, and diagnostic imaging
determined this segment displayed increased reactivity and left lateral stenosis.
Various manual therapy techniques and lumbar pelvic stabilization exercises
were completed (Table 2). After mobilization was completed, pain free lumbar
rotation range of motion was retested during the same treatment session. Range
of motion had improved and the patient reported decreased focal pain,
tenderness to palpation, and centralization of radiating pain to left buttocks.
Further education was given to the patient to reduce patient anxiety and to
reduce strain through the lumbar spine causing exacerbation of symptoms.
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Table 2 List of interventions
Intervention Parameters Position Target structure
Maitland Grade II and Grade III left rotational mobilization
60 seconds, 30 movements/minute 10 sets
Right side lying L4-L5 spinal segment
Maitland Grade II and Grade III flexion mobilization
60 seconds, 30 movements/minute 10 sets
Right side lying L4-L5 spinal segment
Soft tissue mobilization
15 minutes Seated in manual massage chair
Erector spinae, thoracolumbar fascia, gluteus medius, gluteus minimus, and quadratus lumborum
Lumbar pelvic stabilization exercises
See Table 3 Hook lying Transverse abdominis and neutral spine posture
Patient education regarding ergonomics and spine safety to avoid further exacerbation
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Table 3 Progression of lumbar pelvic stabilization exercises
Intervention Parameters Position
Transverse abdominis (TA) activation with posterior pelvic tilt
10 second isometric hold 10 repetitions 2 sets
Hook-lying
Alternating marching with TA activation
30 seconds 2 sets
Hook-lying
Straight leg raise with TA activation
30 seconds 2 sets per leg
Supine with non-moving leg in hook-lying
Side lying clam shell with TA activation
30 seconds 2 sets per leg
Side lying with hips at 60 degrees and knees at 90 degrees
Side lying straight leg raise with TA activation
30 seconds 2 sets per leg
Side lying with legs extended
Standing hip abduction with TA activation
20 repetitions 2 sets
Standing
Standing marching with TA activation
20 repetitions 2 sets
Standing
Patient response to initial plan of care was assessed and at the second
physical therapy session, the patient reported reduced pain to 9/10 and improved
motion and tolerance to activity. Patient reported that her radicular pain in left
posterior lower extremity extended only to the popliteal fossa. The interventions
(Table 2) were applied at this and each subsequent physical therapy visit with
progression of conservative lumbar pelvic stabilization exercises (Table 3). With
a reduction of muscle guarding the presence of directional preference was noted
with a flexion directional preference with further reduction of pain. The patient
had twelve total physical therapy visits following the aforementioned protocol.
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Reassessment of pain and associated neurological signs were made at each visit
to determine progress and appropriateness of selected interventions. Due to
improvements of neurological signs and symptoms using conservative physical
therapy management and manual therapy techniques, the referral of the patient
to a neurosurgeon for surgical management was not considered necessary.
Outcome
After twelve visits after their initial physical therapy evaluation the patient
reports their pain reduced to 5/10 levels and their lower extremity pain symptoms
have resolved at rest and with all activities except prolonged upright sitting.
There was also a significant centralization of pain with the most distal radiating
pain being present to the buttock region. The patient’s tolerance for sitting
improved with being able to sit upright for 30-minutes prior to increase of pain,
and ability to sit in a reclined or forward flexed position for greater than 1-hour
without increase of pain. The Revised Oswestry Disability Index (ODI) was
completed again and the patient reported a score of 46% indicating reduced level
and severity of disability resulting from current low back pain and dysfunction
(Table 4). The patient also was able to return to previous work and household
duties including those that required bending, carrying, lifting, and repetitive
motions. The patient reported that she could once again sleep through the night
and sleep on her left side without disruption due to low back or lower extremity
referred pain. The patient displayed significantly improved ROM throughout the
lumbar spine (Figure 1). The only remaining site of muscle guarding and
tenderness to palpation was present at the left lower lumbar paraspinals.
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Table 4 Progression of objective measures
Initial Evaluation (left/right)
Visit #3 (left/right)
Visit #6 (left/right)
Visit #9 (left/right)
Final (left/right)
Revised Oswestry Disability Index (ODI) 70%
46%
Pain level (NPS) 10/10
8/10
7/10
6/10 5/10
Most distal radiating pain Mid-calf
Popliteal fossa
Popliteal fossa
Buttock Buttock
Lumbar flexion 30°
40°
45°
52° 62°
Lumbar extension 10°
10°
10°
12° 15°
Lumbar lateral flexion 5°/10°
8°/15°
10°/20°
16°/22°
20°/25°
Trunk rotation 15°/5°
20°/5°
25°/10°
32°/20° 35°/30°
Figure 1 Lumbar Range of Motion (ROM) throughout physical therapy
0
10
20
30
40
50
60
70
Initial Evaluation 3 6 9 Final
Deg
rees
Visit #
Lumbar Range of Motion (ROM)
Lumbar flexion Lumbar extension
Lumbar lateral flexion (right) Lumbar lateral flexion (left)
Trunk rotation (right) Trunk rotation (left)
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Discussion
Spinal stenosis, degenerative disc disease, and disc related pathologies
can cause diminished space within the intervertebral foramen causing
compression on the spinal nerve root or spinal ganglion. Localized pain as well
as radiating pain into the lower extremity may present from compression,
irritation, or pinching of the neural tissue as well as accompanied inflammation
and chemical factors. This combination of factors can cause increased neural
sensitization (Latremoliere & Wolf, 2009).
MRI and routine advanced imaging are not associated with improved
patient outcomes and may demonstrate abnormalities that have a limited
relationship to the patient’s symptoms. The patient’s MRI displayed disc bulging,
however studies have shown that up to 81% of asymptomatic individuals will
demonstrate bulging of intervertebral discs (Jarvik & Deyo, 2002). Within the
case report patient’s age group, 80% of asymptomatic individuals will show signs
of disc degeneration and 60% will show signs of disc bulging on MRI imaging
(Brinjikji et al., 2014). Because of false positives as well as the costs of
diagnostic imaging it is suggested to treat conservatively for 4 to 6 weeks prior to
advanced diagnostic imaging should the symptoms be unable to be relieved
(Lateef & Patel, 2009).
There are various prognostic factors that predict the outcome of lumbar
spine disorders. The presence of radiating lower extremity pain is a poor
prognostic factor, as is high intensity of pain (Schistad, 2013). Anxiety related to
condition and pathology is also another poor prognostic factor that further
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complicates the conservative treatment of lumbar spine disorders (Campbell,
Foster, Thomas, & Dunn, 2013). This case study patient had radiating lower
extremity pain that was severe in intensity combined with anxiety. A positive
outcome with significant reduction of symptoms, functional limitations, and level
of disability was demonstrated even with this combination of poor prognostic
factors.
Placebo effect as well as natural spontaneous resolution of low back pain
can influence reported pain intensity level (Puhl, Reinhart, Rok, & Injeyan, 2011).
Further testing throughout the plan of care including manual muscle testing of
lumbar pelvic stabilizers and lumbar range of motion was conducted in addition
to pain reporting to demonstrate affects, beyond any placebo effect, on pain
intensity level and outcomes. This additional testing was utilized to determine
the effects of manual therapy and conservative treatment as well as the value of
the specific techniques being utilized for this patient. Lumbar range of motion,
reported pain level, and strength of the lumbar pelvic stabilizers all improved
significantly with this case report patient throughout the plan of care.
The use of spinal mobilization has been shown through evidence-based
research to decrease pain and disability associated with lumbar pain (Shum,
Tsung, & Lee, 2013). There is a hypoalgesic effect of spinal mobilization due to
stimulation of the dorsal root horn, descending pain pathway, or systemic release
of neurotransmitters (Bialoskey et al., 2009; Potter, McCarthy, & Oldham, 2005).
Manual therapy and spinal mobilization can be used to address hypomobility of a
spinal segment and has been shown to improve the accessory mobility and
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increase the mobility of the surrounding tissue to reduce compression on the
sensitive neural tissue (Olson, 2015). The use of manual therapy techniques
including flexion-distraction mobilization has shown to significantly increase disc
height (Choi et al., 2014). Also, research concerning mechanotherapy indicates
that movement of pathological structures cause increases of healing factors and
allow for proper alignment and reorganization of tissue (Khan & Scott, 2009). It
is possible that mobilizations of the L4-L5 segment served to move the
mechanical interface around the affected nerves that would serve to reduce
inflammation and compression surrounding these neural structures (Shacklock et
al., 2005). This case patient displayed an improvement in lumbar range of
motion as well as disability level and pain levels. Restriction of pain free range of
motion in the direction of foraminal closing within the lumbar spine remained,
however, the amount of range of motion restriction was greatly reduced.
Soft tissue mobilization has been shown to reduce focal points of pain due
to increased muscle compliance, decreased stiffness, improved circulation,
decreased neural excitability, changed parasympathetic activity, and promotion
of systemic release of endorphins. It has also been shown to decrease anxiety
that can also have a positive predictive effect on the patient’s pain level
(Weerapong, Hume, Kolt, 2005).
Initially, due to the mechanism of injury and associated muscle guarding
and strain, all motions of the lumbar spine were painful at end range of motion.
However, after the acute period ended the patient then fit into the directional
preference category with reduction of pain with flexion and opening of the left L4-
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L5 spinal segment. There is strong evidence for the use of mobilization
procedures in order to reduce pain and disability in patients who are experiencing
subacute or chronic low back and back related lower extremity pain (Delitto et al.,
2012). In addition to this there is evidence of centralization and reduction of
symptoms with the use of repetitive directional preference movements to
“improve mobility and reduce symptoms in patients with acute, subacute, or
chronic low back pain with mobility deficits”. This patient largely fit into the
“subacute low back pain with mobility deficits” ICF-based category. Because of
the classification of the patient into this ICF-based category, the emphasis of
treatment was to utilize manual therapy and therapeutic exercise to improve and
maintain spinal, hip, and lumbopelvic mobility and preventing further episodes of
pain therapeutic exercise for active stabilization and patient education (Delitto et
al.).
The 11-point Numeric Pain Rating Scale (NPRS)(Appendix A-1) was
utilized to track current pain levels of the patient. This survey has been studied
and utilized in patients with low back pain. There is an associated Standard
Error of Measurement (SEM) of 1.02. The Minimum Detectable Change (MDC)
in cases of lower back pain is 2 points based on a 95% confidence interval. The
Minimally Clinically Important Difference (MCID) at 4 weeks of physical therapy
treatment of lower back pain is 2.2 points (Childs et al, 2005). The patient
displayed a reduction of 5 points on the NPRS which is beyond the MDC and
MCID indicating a significant positive change throughout the course of
conservative physical therapy treatment in the severity of pain.
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The Revised Oswestry Disability Index (ODI)(Appendix A-2) is a survey
based on questions regarding the severity of low back pain and the functional
limitations and disability associated with that pain. Studies have shown that the
MDC of this survey is 15.35 in populations with sub-acute low back pain and a
MCID is 9.5. The sensitivity of this survey is 76% and the specificity is 63%
(Monticone et al, 2012). This test also has excellent test retest reliability and
excellent correlation between improved vs nonimproved patients (Frost et al,
2008; Grotle et al, 2012). The patient displayed 24% reduction of the Revised
Oswestry Disability Index score which is greater than the MDC and MCID
indicating a significant positive change in level of disability related to low back
pain and dysfunction.
It is suggested that lumbar stenosis and accompanying radiating pain be
treated conservatively (Valat, Genevay, Marty, Rozenberg, & Koes, 2010).
Additional research regarding the use of alternative manual therapy techniques in
the treatment of lumbar stenosis and lumbar spine disorders as part of physical
therapy treatment is indicated as these techniques utilized are only a small
portion of the techniques available. Other techniques may demonstrate differing
results in the outcomes of each individual patient. Although the results of this
case report cannot be generalized, it does depict the successful outcomes of one
patient using manual therapy techniques and therapeutic exercises as part of a
conservative physical therapy treatment. The treatment plan implemented
addressed severe lumbar spine pain and radiating lower extremity pain and
related functional limitations with positive outcomes including: centralized
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radiating pain, reduction of low back pain, reduction of physical disability,
improved pain free range of motion, resolution of various physical limitations, and
return to prior level of function.
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Appendix A: Numeric Pain Rating Scale
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Appendix B: Revised Oswestry Disability Index
Revised Oswestry Disability Index
This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability
to manage everyday life. Please answer every section and mark in each section only the ONE box that applies to you.
We realize that you may consider that two of the statements in any one section relate to you, but please just mark the
box that most closely describes your problem.
Section 1: Pain Intensity o The pain comes and goes and is very mild.
o The pain is mild and does not vary much.
o The pain comes and goes and is moderate.
o The pain is moderate and does not vary much.
o The pain comes and goes and is very severe.
o The pain is severe and does not vary much.
Section 2: Personal Care o I would not have to change my way of washing or dressing in order to avoid pain.
o I do not normally change my way of washing or dressing even though it causes some pain.
o Washing and dressing increases the pain, but I manage not to change my way of doing it.
o Washing and dressing increases the pain and I find it necessary to change my way of doing it.
o Because of the pain, I am unable to do some washing and dressing without help.
o Because of the pain, I am unable to do any washing and dressing without help.
Section 3: Lifting o I can lift heavy weights without extra pain.
o I can lift heavy weights, but it causes extra pain.
o Pain prevents me from lifting heavy weights off the floor, but I manage if they are conveniently positioned (e.g., on a
table).
o Pain prevents me from lifting heavy weights off the floor.
o Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently
positioned.
o I can only lift very light weights at the most.
Section 4: Walking* o I have no pain on walking.
o I have some pain on walking, but it does not increase with distance.
o I cannot walk more than one mile without increasing pain.
o I cannot walk more than 1/2 mile without increasing pain.
o I cannot walk more than 1/4 mile without increasing pain.
o I cannot walk at all without increasing pain.
Section 5: Sitting o I can sit in any chair as long as I like.
o I can only sit in my favorite chair as long as I like.
o Pain prevents me from sitting more than one hour.
o Pain prevents me from sitting more than 1/2 hour.
o Pain prevents me from sitting more 10 minutes.
o I avoid sitting because it increases pain right away.
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Appendix B: Revised Oswestry Disability Index (continued)
Section 6: Standing o I can stand as long as I want without pain.
o I have some pain on standing, but it does not increase with time.
o I cannot stand for longer than one hour without increasing pain.
o I cannot stand for longer than 1/2 hour without increasing pain.
o I cannot stand for longer than 10 minutes without increasing pain.
o I avoid standing because it increases the pain right away.
Section 7: Sleeping o I get no pain in bed.
o I get pain in bed, but it does not prevent me from sleeping well.
o Because of pain, my normal night’s sleep is reduced by less than 1/4.
o Because of pain, my normal night’s sleep is reduced by less than 1/2.
o Because of pain, my normal night’s sleep is reduced by less than 3/4.
o Pain prevents me from sleeping at all.
Section 8: Social Life
o My social life is normal and gives me no pain.
o My social life is normal, but increases the degree of pain.
o Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc.
o Pain has restricted my social life and I do not go out very often.
o Pain has restricted my social life to my home.
o I have hardly any social life because of the pain.
Section 9: Traveling o I get no pain while travelling.
o I get some pain while travelling, but none of my usual forms of travel makes it any worse.
o I get extra pain while travelling, but it does not compel me to seek alternative forms of travel.
o I get extra pain while travelling, which compels me to seek alternative forms of travel.
o Pain restricts all forms of travel.
o Pain prevents all forms of travel except that done lying down.
Section 10: Changing Degree of Pain o My pain is rapidly getting better.
o My pain fluctuates, but is definitively getting better.
o My pain seems to be getting better, but improvement is slow at present.
o My pain is neither getting better nor worse.
o My pain is gradually worsening.
o My pain is rapidly worsening.