Thanks to Mitch Horwood, a Grade 1 Physio at Barwon Health and attendee at our recent Part A and B courses for taking the plunge and putting together this case study on a challenging patient we saw together in our ED and Outpatient department. Given the information provided, what would you do if this patient presented to your clinic? Peter Schoch, Faculty
Part 1 – Emergency Department
A 32-year-old female presented to the Emergency Department with right lower back pain extending to right buttock, postero-lateral thigh, leg and foot. Her symptoms had commenced six weeks earlier as back pain only, possibly due to increased time spent sitting, as a result of receiving medical treatment. The patient reported her symptoms were worsening, having progressed to unilateral right thigh, leg and foot pain in the last 2 days. Lower back symptoms were constant, whereas thigh and leg were intermittent.
She reported her symptoms were always worse with sitting and bending and sometimes worse with standing. She felt better on the move and lying. Sleep was disturbed, requiring her to get up and walk 3-4 times a night. The symptoms were limiting her ability to participate in normal activities of walking her dog and cycling.
Multiple previous episodes of lower back pain had resolved within weeks and had not included lower limb symptoms.
The patient had relevant medical history of Stage 4 ovarian cancer for which she was currently receiving maintenance chemotherapy. She had known metastases in lymphatic system, lung and pelvis. A whole body PET/CT scan 2 weeks prior also described right iliac bone metastases. There were no other red flags or known health issues.
The patient reported her main concerns were loss of function due to the pain and risk of further complications from cancer.
Given this significant history and the patient’s concerns regarding the effect of her pain on her function, she consented to a physiotherapy assessment to try and ascertain whether any of her symptoms were ‘mechanical’ in nature or whether further medical referral and investigation may be required.
On examination, neurological testing showed no changes to lower limb power or reflexes. She exhibited reduced light touch sensation in the right lateral leg. She had major movement loss of both lumbar flexion and extension as well as moderate loss of right and left side glide in standing.
Repeated movement testing was commenced in lying, given the patients preference for lying as a position of comfort. Pretest symptoms in prone lying were located in back, thigh and leg. Repeated extension in lying (REIL) caused an increase in leg pain which remained worse. A relevant lateral component was considered and thus repeated extension in lying with hips off centre (HOC) to the left was trialled. This resulted in a ‘green light’ with leg pain decreasing during testing and remaining better after. The patient also reported it “felt easier” for her to walk afterwards.
Provisional classification of lumbar derangement syndrome - unilateral or asymmetrical below knee was made, with a directional preference of extension with HOC to the left. Advice was provided to continue this exercise 4-5 times daily as well as remaining active as able. Following detailed discussion with medical colleagues, they were satisfied the symptoms appeared mechanical in nature and that appropriate recent imaging had been completed; thus, there was no immediate need for further investigation. Prompt outpatient physiotherapy follow-up was organised in order to monitor and to progress the patient’s management. Click here for Assessment Form
Part 2 – Outpatient follow up
The first outpatient review occurred 1 week following the ED presentation. Symptoms and function had overall improved rapidly earlier in the week but had plateaued despite consistently completing extension in lying with HOC to left. Constant right sided back pain remained unchanged, while thigh and leg symptoms had become a ‘fuzzy’ feeling of decreased sensation rather than pain. The lower limb symptoms remained intermittent and in the same distribution. Her main functional complaint was now lack of ability to push off with the right calf and ball of foot ‘pressure’, which was continuing to limit her walking.
On assessment, lumbar range had improved to moderate loss of flexion, minimal loss of extension and no loss of left and right-side glides. On repeated movement testing extension in lying with HOC to left decreased symptoms during but was no better after, despite sufficient repetitions. Lateral forces were therefore progressed to clinician overpressure during repeated extension in lying with HOC, which also yielded a yellow light response. In consultation with the patient, it was decided that further physical assessment was warranted as treatment effects had plateaued. 2 repetitions of 2 minute sustained lumbar flexion and rotation (legs to the right) in supine abolished all symptoms during but did not remain better afterwards. As this provided a more favourable response than the previous exercise, the patient was advised to perform this (repeated) sustained positioning twice at least 4-5x daily, or more often as required and continue to remain as active as possible in relation to walking the dog.
The patient was reviewed weekly for the next 2 weeks. During this time symptoms all became intermittent. Lumbar range was improved to minimal loss of flexion and nil loss of extension and right/left side glides. The patient reported she was now getting consistent yellow light responses from the flexion rotation exercise, despite good adherence with the suggested dosage. It was decided at this point to re-test sagittal movements. REIL produced no effect. It was progressed to self-overpressure which resulted in centralising during, but no better after. REIL with clinician overpressure was therefore applied which resulted in symptoms remaining centralised. The patient was educated on completing REIL with self-overpressure with towels (or with her partner’s assistance) at least 15 repetitions 5 times daily, or more often as required.
The patient elected to continue with weekly reviews. 5 weeks after commencing physiotherapy, she reported “70% improvement” from initial symptoms. Lower back and right lower limb pain symptoms were minimal, but right ball of foot ‘pressure’ and right calf weakness whilst walking continued to be the main functional complaint. She reported good adherence with the REIL exercise program.
Physical assessment showed ongoing minimal loss of lumbar flexion, nil loss of extension or bilateral side glides. Functional testing showed right single leg calf raises lost height/power at 3 repetitions, compared to 20 on the left. Sagittal forces were further progressed gradually to therapist mobilisation in prone at 45deg extension for 2minutes was tested. This provided only slight relief during walking. Lumbar repeated extension in standing (REIS) was tested, which interestingly providing greater subjective improvements than extension mobilisation, with the patient reporting the foot pressure symptoms felt better during ‘fast walking’ after REIS.
Given the overall improvement to the patient’s lumbar and lower limb pain symptoms but ongoing restricted lumbar flexion it was decided to more thoroughly test ‘recovery of function’ exercises. Lumbar flexion in lying (FIL) was tested for 8 repetitions with no effect during or after to symptoms or mechanical baselines. This was deemed as a ‘safe’ dose to introduce 2-3 times daily, to help restore the remaining lumbar flexion range of motion. The patient was educated to cease FIL if symptoms worsened or peripheralised. Single leg calf raises until fatigue/height loss were suggested to be performed twice daily, as were the lumbar REIS (15x4 daily), given the apparent effect on her foot pressure feeling and the fact it would be much more convenient for her to do during the day. She was also advised she could choose to do REIS or REIL as symptom response dictated and what she felt was most useful at any given time.
By 8 weeks the patient reported she felt “90% improved”. Foot ‘pressure’ symptoms were only present first thing in morning and there was no limitation to fast walking. As a result she had returned to walking the dog daily. Single leg calf raise had also improved to 15 repetitions. The patient was happy to continue self-management with a final review booked for 3 weeks later.
At the final review (11 weeks post ED presentation) all symptoms had fully resolved. Single leg calf raise max was equal bilaterally and lumbar ROM was full. The patient was educated on maintaining full lumbar range and to resume reductive exercises if she felt the return of any lumbar symptoms. She could also rebook if she felt she needed further assessment of any symptoms.
Reflections:
This case challenged my clinician reasoning in a number of ways, especially as I had not yet completed a Part A: The Lumbar Spine course. Whilst I was aware of some of the basic principles of MDT, through working with Credentialed and Diplomat clinicians, it was challenging to explore and understand the full impact of a mechanical assessment, without necessarily having the full background knowledge of a Part A course.
This patient’s active cancer diagnosis and known bony metastases were immediate red flags and made me somewhat hesitant in attempting to assess and treat the patient. However, the systematic and detailed history and physical examination process of MDT, coupled with close collaboration with my senior physio colleagues (MDT Diplomats) and medical staff, where required, meant that the patient was safely able to be classified and treated using MDT principles.
The traffic light guide greatly assisted my decision making process. Clear symptomatic and mechanical baselines were required at every stage, in order to inform the use of force progressions and/or alternatives; as was the ability to recognise early, the presence of a relevant lateral component that required combined movements, to generate the initial ‘green’ light response. It was interesting and impactful to see the process of using combined movements for as long as required to decrease, centralise and abolish symptoms before retesting sagittal movements, which had previously been provocative; and for those previously provocative movements to then also contribute to a green light response.
Prior to being exposed to the MDT framework and the concepts of directional preference and loading strategies, I wouldn’t necessarily have been confident in exploring multiple movements with this type of patient, especially if symptoms or other baselines worsened in session. I may have also struggled to make clear decisions when symptoms/baselines remained the same between sessions. I suspect I previously would have been tempted to drastically change treatment or perhaps even suggest to the patient that physiotherapy may not be able to help her.
Having now completed both Part A and B courses I can reflect that whilst the patient’s presentation was complex, she was able to be managed within the framework provided by the ‘four stages of managing derangement’. Further, keeping the approach to exercise therapy simple and changing usually only one variable within session, enabled her response to be recognised both within and between sessions, thus informing the treatment progression throughout her episode of care.
This case has also illustrated to me the importance of effective communication with patients. Building and maintaining rapport and trust was critical to her remaining engaged in the physiotherapy program; especially when her improvement plateaued, and, given the multitude of other medical appointments and treatment she was attending. Establishing her priorities and goals and trying to address them in a supportive and personalised way was difficult at times but ultimately very rewarding.
This case challenged my clinical reasoning and communication skills. It taught me the value of keeping assessment and treatment logical and as ‘simple’ as possible. It also highlighted why not changing too many treatment variables at the one time, can allow monitoring the impact of a treatment program to be more effective.
Finally, this case reinforced the importance of having good clinical support networks (mentors) to be able to co-consult and / or debrief about complex cases. I realise that we don’t always have to have all the answers for every patient but having access to other clinicians can be very reassuring to ensure that all relevant options are considered, and nothing is overlooked.