Mr W (consent form in file) is a 25 year old male roadside technician. He spends most of his time at work bending forward and does a lot of heavy lifting. In his spare time he has been preparing himself for next season’s amateur football consisting of bike riding and running. On the day of his initial consultation Mr W presented with acute low back pain. The pain was located centrally in the L2-3 region. The low back pain was described as dull aggravated by lifting and prolonged sitting and standing. He also stated that he occasionally had a sharp referral of pain into the left posterior thigh usually after long sessions of kicking the football. He found relief by lying flat on his back or stretching the low back with forward bends (touching toes).
He said that he had suffered numerous episodes of low back pain over the past 7 years. The pain has gradually worsened over this period but has been largely ignored. He had a previous history of trauma – a fall from a motorbike where he slid on his back and into a tree also 7 years ago. X-rays were taken immediately after the accident and revealed no abnormality. Initial Examination Findings: Postural examination revealed a level pelvis and significant lower right shoulder. He also had rounded shoulder posture and forward head carriage His range of motion was normal with no aggravation of pain. Achilles reflex was grade I on the left.
Kemps test was performed and revealed ache in L3 region on the left. Hypertonicity and tenderness was noted in Paraspinal, Quadratus Lumborum and Piriformis muscles bilaterally and L2/3 and L3/4 joints were restricted and painful on joint play. X-rays were performed and revealed slight retrolisthesis of L2 on L3. Differential Diagnosis: Working diagnosis was chronic facet syndrome with sub acute exacerbation with associated hypertonic Paraspinal and Piriformis muscles. Other possibilities included: Piriformis syndrome, L2/3 subluxation, Sacroiliac Joint Dysfunction, myofacial pain
syndrome of Erector Spinae, Quadratus Lumborum muscle (in order of increasing likelihood). Treatment: Soft tissue therapy was applied to the QL, ER Spinae, Gluteal muscles followed by side lying adjustments were applied to L2/3 fixation. Gentle stretches and postural advice were recommended as home treatment. By the fourth visit the low back pain “was not as soar” (subjective reporting). The 4 Point Kneeling Abdominal Drawing-In Test was performed and revealed the umbilicus deviating cephalad (using Rectus Abdominis). Hip Abduction and Hip Extension testing was performed and revealed no abnormality. Why Rehabilitation?
His hamstring flexibility was poor and he was keen to improve it as it would help in his kicking action. He had pendulous abdomen and was unable to voluntarily contract the transverse abdominis. The main tender points seemed to be over the region of the lumbar erector spinae more so on the left. The hamstrings were very tight and due to this mans occupation, it could be expected that decreased flexibility in forward flexion would result in significant strain in the erector spinae, eventually leading to overload. Rehabilitation Plan: Mr W. was prescribed Transverse Abdominis contractions in pain free supine position on the fourth visit.
Treatment continued with STT and stretching to the ER Spinae and QL muscles was initiated and chiropractic adjustments to the L3/4 fixation (2x per week for 3 weeks). He was also prescribed Brugger Relief Position for when ever his neck was feeling stiff and to combat the forward head posture. During the fourth week I would like to reassess Mr W condition and if there has been improvement I would like to continue to see him 1x per week.
I would graduate the Transverse Abdominis contractions by asking him to hold it for 15secs. Once that can be done effortlessly I would telling to try to breathe while holding the Transverse Abdominis contraction. Then incorporating the contractions when ever he had to lift a heavy object or change a tyre. Response to Care: I have only seen Mr W four times but he seem to be responding well to the treatments. He is very compliant and is determined to get back into shape and out of pain for next seasons football competitions.