The following are real patient cases we have had just this year. For privacy reasons, identities and personal information have been removed.
Case 1: The case of the irritated banker
A 50 year old athletic female presents to clinic with pain in the low back and pain in the left leg. Patient states she feels all types of pain including numbness, tingling and just a constant pain. Patient also states that if she lays flat on her back with ice she has no pain. Pain began in March and hurts her to put on shoes. Patient states the pain got worse in April. Patient tried steroid injections with her orthopedic surgeon, but it did not work. Patient also underwent a few months of physical therapy, but the pain gradually became worse. Patient says that acupuncture helps the pain a little bit. Pain increases when she sits so she cannot drive much. It is now July and pain is still felt radiating in both legs in the thigh and calves frequently. Patient was seen by her family physician and a chiropractor prior to her visit here. Patient brought in her MRI report as ordered by her physician. MRI indicated multiple disc bulges from L1-L4 with a disc herniation at L5-S1. MRI also indicated the bulges and herniation displaced L4 and S1 nerve roots respectively.
Patient states the condition is impairing her ability to work. She has trouble sitting for more than a couple minutes and has to stand throughout the day. Driving aggravates her pain dramatically. She had to rent a car because she can no longer drive her stick shift car due to pain. Driving for more than 15 minutes causes extreme discomfort. Pain rated between a 3-7 out of 10 on a 1-10 pain scale depending on the activity. Her family doctor recommended a surgical consult but she wanted to avoid surgery unless it was the last resort.
Patient is currently taking ibuprofen and pain relievers to control the pain as recommended by her physician. No history of trauma or surgery noted.
Initial Exam Results:
Restricted Range of Motion Thoraco-Lumbar
Flexion 0/80 with pain
Extension 0/45 with pain
Right Rotation 35/35 with pain
Left Rotation 35/35 with pain
Right Lateral Bending 0/30 with pain
Left Lateral Bending 0/30 with pain
Orthopedic Tests:
Kemps positive bilateral
Straight Leg Raise positive bilateral
Braggards positive bilateral
Yeomans negative
Gaenslens positive bilateral
Valsalva positive
Reflexes: Diminished +1 on the left L4 and S1
Sensory: Decreased Dermatome L5/S1 on the left outside and bottom of the foot
Myotomes: Could not perform due to pain
Diagnosis:
Lumbar Disc Bulges L1-L4 and Lumbar Disc Herniation at L5/S1 causing Lumbar Radiculopathy, Myospasms and Restricted Range of Motion
Immediate Treatment, 3 times a week for 2 weeks followed by re-evaluation:
1. Therapeutic Ultrasound and Electrical Stimulation of Lumbar spine paraspinal muscles.
2. Trigger point therapy and myofascial release Lumbar spine paraspinal muscles.
3. Strip and Stretch Lumbar spine paraspinal muscles, left hamstrings and left calf muscles
4. Traction therapy - Cox Flexion / Distraction technique for Lumbar specific areas
Short Term Treatment Goal:
To reduce the pain level and relieve pain so that more corrective treatments can be administered. At the moment, the pain symptoms are so intense that it would be difficult to constructively perform any spinal adjustments or active therapies.
Long Term Treatment Goal:
Restore Range of motion and function.
What happened afterwards:
Patient actually followed her treatment plan religiously. She came 3 times a week for two weeks. After two weeks her pain scale reduced from a 3-7/10 depending on activity to a 4-5/10. She still had trouble sitting down for more than a few minutes and the pain was still constantly there but the severity of the pain was diminishing. We recommended continuing the same therapy for another 2 weeks or until more significant pain reduction occurred.
2 weeks later, her symptoms decreased to a dull ache in the low back and hamstring/calf muscles. Pain was now rated at a 2-4/10 on the pain scale. Pain is still aggravated by sitting, especially at work. She is no longer having pain sitting in the car but sitting at work for more than 5 minutes in the office chair causes pain. We recommended very light spinal adjustments to be added to her treatment and removal of electric stimulation therapy. We also recommended treading water in the pool to help increase motion in the lumbar spine.
The next visit later, the patient stated her pain was aggravated by her acupuncture treatment over the weekend at another clinic and rated her pain at a 6-8/10. There was no pain in the low back but the thighs and back of the legs were having burning, cramping pains very frequently. Her pain worsened slightly again next visit and it wasn't until the week after that her pain decreased dramatically. The following week she stated she was now able to sit for an hour and a half before feeling any symptoms. The pain is now an occasional dull ache rated as a 1-3/10.
It is now her 20th visit and patient states mild aggravation occurs in the morning when she wakes up. Pain remains at a 1-3 /10 in her back and legs with occasional burning. Upon further questioning we were shocked to find out that she has been taking 12 Advil a day consistently since March as recommended by her family physician. Her physician had told her that taking 12 tablets a day would be the same as prescription strength pain relievers and the choice was hers. We recommended she re-consult her physician on appropriate dosage as such a prolonged high dose could provoke serious consequences.
A week later patient states she is feeling much better and she is now able to sit and drive for a much longer time. She has also reduced her dose of Advil to 4 tablets a day and her pain level is now a 1-3/10.
30th visit, Patient is feeling much better but states she still feels the occasional burning feeling down the glutes and calf is she sits down too long. She can now sit at work for the most part with occasional breaks and driving is alright with the occasional flare up. Pain usually a 1/10 but sometimes can occasionally flare up to 5/10 for a short period of time if aggravated. Treatment is still therapeutic ultrasound and heat for chronic muscle pain, trigger point therapy and myofascial release, Stripping and stretching of lumbar spine paraspinal muscles. Flexion/Distraction traction therapy for lumbar spine with Diversified lumbar spine adjustments. Patient is also exercising on the elliptical machine for an hour a day. Treatment frequency reduced to twice a week.
October, patient reports symptoms have remitted consistently with the occasional dull ache flare up. She is no longer taking any ibuprofen as well. Once a week she states occasional aggravation in the morning or a feeling on onset after an intense workout. We added core exercises to her treatment and reduced her visits to once a week.
A month later we've seen our patient sporadically. Her condition seems to have remitted with the occasional dull ache in the morning every couple of weeks. Upon the 40th visit her treatment plan was over and we recommended wellness and follow up visits once a month.
