Diagnosis and exercise recovery program for acute lower back pain with sciatica

Diagnosis of Injures and Development of Exercise Recovery Program

What has occurred?

James lifted a stretcher while forward bent and twisted to the right. James says he felt his back pull at the time, but he continued with his shift, and after work went home to bed. He woke this morning with low back pain, greater on the left than the right, with some shooting pain into his left buttock and the posterior aspect of his left thigh. He says his left leg feels "a bit wobbly."

Predisposing factors and biomechanics of injury

Incorrect lifting technique

Genetical predisposition?

In biomechanical terms what muscles, bones and joints were involved?

Investigate the effects of poor sleep patterns, diet and fatigue.

Differential Diagnosis

To identify the physiology of the injury complained of in terms of location of injured region on the anatomy.

Primary muscle groups involved or at risk in the region, e.g. Erector spinae, multifidus

Secondary muscle groups being recruited to compensate or that may be injured. Proximal, distal, superior, inferior, posterior, anterior, superficial, deep, medial or lateral to the injury site e.g. rectus abdominus, external obliques, transverse abdominus, gluteus maximus, medius, minimus, Iliopsoas major & minor and other hip flexors and extensors including ligaments and nerves (sciatica).

Possibility of skeletal damage -- Explain referred pain, muscular and neurological

Any deficiencies outside our scope of practice will require a referral to another specialist e.g. Nutritionist, physiotherapist, chiropractor etc.

3. Determining a prognosis for lower back pain.

Physical tests can be conducted to give us a more thorough history of injury and associated complaints. Testing in sequences will drill down on the sections of the lower body that are causing pain or discomfort. Testing should help us to identify problem areas and to discount non-problematic areas.

Inspection- what can actually be seen anatomically. Is the person symmetrical? Is there any asymmetry?

Movement- Range of movement e.g. trunk flexion, extension, lateral flexion. Causes any pain/discomfort?

Physical tests- Making sure the line of the iliac crest is symmetrical. If asymmetry this is a sign of the iliac crest involvement in the injury. This can suggest posture issues.

Lumber quadrant test- Person in extension lateral flexion and rotation of the trunk. This will load the axial which attempts to recreate patient's pain. If positive, sign for prolapsed disc or disc involvement.

Slump tests- Patient slumps forward seated on a couch, flexes the neck, straightens one leg and dorsiflexes the foot. If pain in buttocks or hamstring when neck is flexed this is positive sign for neurological involvement. This could indicate nerve impingement.

The Faber test: Pressure on externally rotated hip and knee when patient lying supine. Positive for hip pathology if pain reproduced. Hip pathology can contribute to lower back pain.

Fadlong test: Patients flexed hip and knee, applying pressure towards patient's head. Reproduction of buttock or lower back pain indicated a positive sign for sacroiliac dysfunction.

Palpation of spinous processes of lumber spine posteriorly or unilaterally can indicate pathology if pain/discomfort is the reproduced.

MRI- To show injured areas that won't show up on the x-ray. Particularly good for imaging the spine as it also shows all the soft tissue components.

X-ray- may indicate any fractures (only if healed) or any broken bones.

Summary of care and diagnosis

Upon examination, the patient had swelling in the left lower back and muscle were knotted up tightly.

Patient as x-rayed to check to the lower spine and the pelvic / hip region.

Patient was told to use ice on the injury for the first 48 hours and after that the use of heat was recommended.

Pain medicine, muscle relaxers, and anti-inflammatory pills were prescribed to help with the pain and swelling.

Patient was given list of exercises to help loosen up and strengthen the back and nerves affected.

Patient will be referred to an Orthopedic Specialist for further evaluation and determination as to the severity of the damage and the course of treatment needed.

Assessment of iliac crest symmetry lumber quadrant test

The slump test Faber test

The Fadlong test Palpation of L5 spinous process

Pictures courtesy of: http://www.racgp.org.au/afp/200406/20040601jensen.pdf

4. ROLES OF EXERCISE IN TREATMENT & RECOVERY

How to apply 4 principles of program maintenance incorporating FITT and SMART goal principles as well

We want to design a program that pt will commit to.

F.I.T.T - Frequency (how often), Intensity (how hard in % of max HR or max VO2), Time (duration), Type (what type/s of exercise to isolate specific improvement need)

S.M.A.R.T -- Specific, Measurable, Achievable, Results oriented, Time specific.

Is there any ability to take time off for recovery & rehab?

Does pt have access to suitable facilities to undertake safe rehab exercises?

What level of compliance can we expect if longer term lifestyle changes are required (especially if underlying morbidities are discovered such as obesity, inadequate health & fitness lifestyle, chronic or degenerative diseases, lost desire or adverse mental state of mind)

For example, 4 principles method will consider:

Specificity - what areas of fitness or rehab are we designing a program for? What will it achieve?

Individuality - program must aim at recovering pt specific injuries and must be acceptable to the pt according to his fitness level and interests.

Overload - be aware that pt is in slow rehab and therefore avoid a program that introduces too much too soon

Reversibility -- if patient stopped regular exercising after returning to work how long would it take to lose the fitness gains ?

5. Suggested exercise and therapy plan

Listed are 10 exercises the patient can perform at work or home to help with the lower back region. (Rogers,2010).

Hip extension- Get down on all fours and keep your neck straight so that you are staring at the floor. Simultaneously lower the top of your head toward the floor while bringing your right knee in toward your head. Then, tilt your face up toward the ceiling and extend your leg out behind you until it is parallel to the floor. Return to the starting position and repeat with your other leg. Repeat three times on each side.

Side bend- Stand up straight with your arms at your sides and your feet shoulder-width apart. Lower your right shoulder to the side, running your hand down the outside of your thigh and bending your entire trunk at the waist as far as you can without straining. Hold for five seconds and slowly straighten up. Repeat three times on each side.

Rag doll- Sit in a chair with your feet flat on the floor and your knees shoulder-width apart. Look straight ahead and relax your neck and shoulders. Slowly curl your neck, then your upper back, then your lower back forward until your chest is between your thighs. Let your palms rest on the floor and hold for 10 seconds. Straighten up by doing the same movement in reverse, lifting your head up last. Repeat three times.

Spread eagle- Lie on your back with your arms stretched above your head, palms facing up. Make sure not to bend your neck so you don't strain it and pay attention to your lower back throughout the exercise. Tilt your pelvis toward the sky and push your belly in, so the entire surface of your lower back is touching the floor.

Simultaneously reach above your head with your right hand and push down (into the "air" below your foot) with your left leg. Hold the position for four seconds, then change sides (left hand up, right leg down). Repeat three times on each side.

Pelvic lift- Lie on your back with your knees bent and your feet flat on the floor. Keep your legs together and cross your arms over your chest. Tilt your pelvis up and push your lower back to the floor, then slowly lift your buttocks off the floor as far as you can without straining. Maintain the position for five seconds, then lower your buttocks to the floor. Repeat three to five times. Breathe normally throughout.

Good Morning Exercise

Keep a bar with some weight on your shoulders. Bend at the waist with your knees bent a little and the back straight till the trunk is parallel to the ground. Relax in the upright position and repeat

Piriformis Stretch

Lying on your back, cross the right leg over the left knee, grasp the back of the left thigh and pull the knee close to the chest. This stretch helps in the overall flexibility of the pelvic region.

Psoas Stretch

Lying on your back, bend the knee close to the chest and clasp it just below the knee.

Lumbar Extension Stretch

Lie on your abdomen and slowly use your forearms to raise your upper body above the ground, and then lie down again. This back arching is important to help in stabilizing the spine.

Hamstring Stretch

Lie on your back and hold on the back of your thigh, lift the knee 90* above the ground and straighten it until it exerts a mild stretch on the back of the thigh. This exercise helps increase the muscle flexibility and reduce the stress on the lower back exerted through the pelvis.

BIBLIOGPRAPHY

Heyward, V. (2007). Advanced Fitness Assessment and Exercise Prescription. 5th ed. Human

Kinetics, IL, USA.

Olds, T., Norton, K. (1999). Pre-exercise Health Screening guide. Human Kinetics, IL, USA.

Sports Medicine Australia. (2006). Sports Medicine for Sports Trainers. 9th ed. Mosby

Elsevier, Sydney, Australia.

Jensen, S . (2004). Back pain -- clinical assessment. Australian Family Physician, 33(6), 393-

401. Available from http://www.racgp.org.au/afp/200406/20040601jensen.pdf

Rogers, Sabrina. (2010). Top 10: exercises for back pain. Available from http://www.askmen.com/top_10/fitness/26c_fitness_list.html

Maisie, M. (2010). Exercises to Release Sciatic Nerve Pain. Available from http://www.buzzle.com/articles/exercises-to-release-sciatic-nerve-pain.html