Low Back Pain Case
Chiropractic Referral – Overview of Initial
Assessment
Robert Francis,
D.C.
Case History:
Samuel Cooper, 68 year old male, initial office
visit to PCP with presenting chief complaints
of low back pain and non-dermatomal distribution
of right sided buttock and posterolateral thigh
pain of insidious onset three days duration. Patient
has been using heating pad and OTC ibuprofen for
three days with no relief. Denied bowel/bladder
dysfunction, sensory or motor disturbances below
the knee, fever, and weight loss. PCP treated
with Rx of NSAIDs and narcotic medication two
weeks with instructions for gentle home exercise
and heat. Symptoms persist at two weeks follow
up. MRI study of the lumbar spine and referral
for orthopedic consultation ordered. Orthopedic
evaluation revealed upon clinical examination
no nerve root tension signs present, diagnostic
imaging reviewed and was negative for soft tissue
or bony pathology, mild broad based disc bulges
appreciated at lower lumbar levels however, no
space occupying lesion of clinical significance
identified, case determined to be non-surgical
and continued conservative care recommended. PCP
then referred for four weeks traditional physical
therapy intervention of hydroculation, electrostimulation,
soft tissue massage and passive assisted stretching.
At six weeks follow up visit, the patient’s
symptoms persist and PCP provides referral to
the chiropractic service for evaluation. Initial
evaluation includes interview regarding nature
of onset, chief complaints, Visual Analog Pain
Scale completed by the patient, history of previous
episodes, past medical history, social history,
family history, surgical history, current medications,
allergies, a review of systems, orthopedic and
neurological examination, review of diagnostic
imaging, physical examination and formulation
of diagnostic impression.
Clinical findings are positive for articular
dyskinesia of the lumbosacral spine bilaterally
and provocative tests for SI joints reveal sacroiliac
joint dysfunction. There are no true nerve root
tension signs present. There are no neurological
deficits nor contraindications to SMT. Examination
reveals decreased ranges of motion bilaterally
of the lumbosacral spine with reduced flexibility.
Due to the length of time the patient has experienced
antalgic posture and decreased range of motion,
there is decreased visco-elasticity and flexibility
of the posterior motor units, paravertebral
musculature and supporting soft tissues of the
spine. There is suggestion of fibroblastic proliferative
changes occurring of the paravertebral musculature
and peri-articular soft tissues contributing
to the restricted ranges of motion and decreased
flexibility resulting in deconditioning.
Diagnostic Impression is:
1. Lumbar Radicular Syndrome
2. Lumbosacral Segmental Dysfunction
3. Sacroiliac Joint Dysfunction
4. Fibromyofascitis/Deconditioning Syndrome
Treatment plan consists of spinal manipulative
therapy, a supervised active conditioning rehabilitation
program, nutritional supplements and continuation
of home exercise program with emphasis on postural
mechanics and lifting instructions. Treatment
objectives are to reduce symptoms, increase
functional capacity, prevent exacerbations and
recurrent episodes of LBP.
The frequency and duration of SMT and rehab
is daily for two weeks with follow-up evaluation
at the end of two weeks to determine frequency
and duration of possible continued care. Nutritional
supplementation includes Glucosamine and Chondroitin
supplements for articular nutrition specifically,
and recommendations are made for multi-vitamin
and mineral supplements to continue as general
nutritional regimen.
At the initial visit after clinical evaluation,
the patient receives pre-manipulative hydroculation
towards an effort to encourage vasodilation
of the supporting soft tissues of the spine
and SI joints prior to manipulation. This results
in greater visco-elasticity and ease of manipulation
for the practitioner and comfort to the patient.
The patient subsequently undergoes passive myofascial
release procedures using the lower extremities
as long levers to accomplish a thoracolumbar,
lumbosacral and pelvic girdle myofascial release.
Manipulation of the lumbosacral spine bilaterally
and sacroiliac joints bilaterally is performed
in the lateral decubitus position bilaterally.
The patient then is introduced to an active
supervised conditioning program consisting of
kinetic exercises beginning with 30 minutes
daily increasing to 1 ½ hour daily per
patient’s tolerance. An intake Functional
Capacity Evaluation (FCE) is performed to determine
current functional capacity and to compare with
discharge FCE.
The patient is discharged to follow up with
instructions to begin nutritional therapy, continue
home stretching program, observe postural mechanics,
and return to office per treatment plan, daily
for two weeks.
On subsequent office visits, the patient will
be assessed with range of motion evaluation
and functional assessment through motion palpation
of the lumbosacral spine and sacroiliac joints,
Visual Analog Pain Scale, and functional capacity
evaluation towards an effort to evaluate outcome
assessment of treatment objectives.
Rationale:
Spinal Manipulative Therapy is designed to restore
biomechanical integrity to areas of articular
dyskinesia due to pathomechanical factors including
loss of joint mobility, fibroblastic proliferative
changes of the supporting soft tissues and neurological
and vascular changes resulting from articular
dyskinesia.
To achieve reduction in symptoms and decrease
in pain, SMT is utilized to recruit the neurological
mechanism of collateral inhibition. Collateral
inhibition is that part of the arthrokinetic reflex
(see Lewit, Dorman, Wyke, Vernon) that inhibits
the central transmission of pain through mechanoreceptor
collateral fibers innervating the nociceptors
in the posterior motor units of the spine and
the zygapophyseal capsules.
There are three mechanoreceptors and one nociceptor
distributed from the dorsal primary ramus (DPR)
innervating each posterior motor unit in the
spine. The mechanoreceptors include kinesioreceptors,
barrorecceptors, and proprioceptors. As long
as the mechanoreceptors’ sensory input
to the cord are
within normal limits, a collateral fiber from
each mechanoreceptor inhibits nociception. However,
when for example, there is abnormal range of
motion of the posterior motor units, kinesioreception
(sensory input regarding normal or aberrant
range of motion) is abnormal and the collateral
fiber inhibiting nociception from the kinesioreceptor
no longer inhibits the nociception. The threshold
for depolarization of the nociceptor is thereby
lessened requiring fewer stimuli to depolarize
the nociceptor causing pain. If additional stimulation
of abnormal sensory input occurs such as a decrease
in synovial fluid production due to lack of
proper motion of the joint, the intra-articular
pressure is changed and the barroreceptor collateral
inhibition is interrupted thereby causing even
more sensitive state of depolarization of the
nociceptor.
The nociceptor input is through the lateral
spinothalamic tract, which carries pain and
temperature. When fully depolarized, the nociceptor
initiates an arthrokinetic reflex resulting
a state of hypertonic paraspinal muscle splinting
and pain.
An audible “pop” or “crack”
often accompanies spinal manipulation. This
is the process of cavitation. Cavitation (PV=nrt)
occurs when the intra-articular pressure changes.
Volume and pressure are inversely proportionate.
During SMT, the joint surfaces are separated
increasing the volume of the joint space and
reducing the intra-articular pressure. The reduction
in pressure causes a CO2 gas bubble to come
out of the synovial fluid. This causes the audible
“pop” much the same as removing
the bottle cap from soda pop which reduces the
pressure inside the bottle and CO2 comes out
of solution making a popping noise.
A longer resting length of the musculature
often results post SMT. This is a process of
proprioceptiveneurofacilitation (PNF). This
occurs when the spindle cell mechanism in the
belly of the muscle is stimulated to reset to
a new resting length after the actin/myosin
heads are gently stretched or pulled apart.
Proprioceptive input from the Golgi tendon organ
and the spindle cell result is less tonic muscle
contraction and compressive forces across joints
are reduced. Microadhesions in the myofibrils
are frequently reduced by this stretching resulting
in more visco-elastic, flexible and functional
musculature.
Benefits of SMT include the reduction of peri
and intra-articular microadhesions of the posterior
motor units, restoration of the pathomechanics
in the three-joint complex (two posterior motor
units and the intervertebral disc joint), increase
in ranges of motion, flexibility and visco-elasticity
of the soft tissues and a reduction of fibroblastic
proliferation, recruitment of collateral inhibition
and maintaining the pressure hierarchy of the
intervertebral foramen.
(Pa > Pc > Pv > Pf
> Pt)
The pressure in the artery is greater than
pressure in the capillary, which is greater
than the pressure in the vein, which is greater
than the pressure in the funiculus, which is
greater than the pressure in the tunnel. (Sunderland)
Definition of Manipulation:
Manipulation consists of accurately determined
and specifically directed manual forces to areas
of restriction, whether the restriction is in
ligaments, muscle or joints; the result of which
may be improvement in posture and locomotion,
improvement in function elsewhere in the body
and the enhancement of the sense of well-being.
(American Medical Association, Council on Orthopedics,
1980)
References:
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Zygapophyseal Joints. J Anat 1982; 135:795-809.
Giles, LGF. Lumbosacral zygapophyseal joint
inclusions. Manual Med 1986;2: 89-92.
Giles LGF and Taylor JR. Innervation of human
lumbar zygapophyseal joint synovial folds. Acta
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Haldeman S. The neurophysiology of spinal pain
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in the Principles of Chiropractic. New York:
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Kirkaldy-Willis WH. The relationship of structural
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Korr, I. The Neurobiological Mechanisms in
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Lewit, L. Post isometric relaxation in combination
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