Clinical diagnosis and treatment of a patient with low back pain using the patient response model: A case report

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1 Physiotherapy Theory and Practice An International Journal of Physiotherapy ISSN: (Print) (Online) Journal homepage: Clinical diagnosis and treatment of a patient with low back pain using the patient response model: A case report Michael Robinson PT, DPT, OCS To cite this article: Michael Robinson PT, DPT, OCS (2016): Clinical diagnosis and treatment of a patient with low back pain using the patient response model: A case report, Physiotherapy Theory and Practice To link to this article: Published online: 06 Apr Submit your article to this journal View related articles View Crossmark data Full Terms & Conditions of access and use can be found at Download by: [Laurentian University] Date: 07 April 2016, At: 14:12

2 PHYSIOTHERAPY THEORY AND PRACTICE CASE REPORT Clinical diagnosis and treatment of a patient with low back pain using the patient response model: A case report Michael Robinson, PT, DPT, OCS University of North Carolina Division of Physical Therapy, Department of Allied Health Sciences, Chapel Hill, NC, USA ABSTRACT The medical management of low back pain (LBP) can be approached in a multitude of ways. Classification via subgrouping is increasingly common in orthopedic literature. Clinical diagnosis and treatment of LBP using the patient response model (PRM) can assist clinicians in hypothesizing the origin of pain and providing beneficial interventions unlike the widely used pathoanatomical model. This case report involved a 52-year-old female with sudden onset of right-sided LBP that radiated to the foot. These symptoms were accompanied by occasional paresthesias in bilateral lower extremities. Magnetic resonance imaging (MRI) confirmed disc bulges at levels T11-T12 and T12-L1. On the first of seven visits, she reported 9/10 on the Numeric Pain Rating Scale (NPRS), scored a 24/50 on the modified Oswestry disability index (modi), and demonstrated lumbar flexion range of motion (ROM) of 10. Using the PRM, the patient was classified as an extension responder and was instructed to perform 10 repetitions of standing lumbar extension every 2 waking hours. After 4 weeks of therapy, the patient reported a 1/10 pain localized to the low back, scored 20/50 on the modi, and improved flexion ROM to 45. Classification using the PRM yielded positive outcomes with this patient s symptoms and daily function. Background Over the course of a lifetime, 65 85% of adults will experience low back pain (LBP). In addition, considerable practice variation exists in the medical management of this patient population (Gellhorn, Chan, Martin, and Friedly, 2012). LBP is a multifactorial ailment for which approximately 45% of cases are discogenic in origin, approximately 13% originate from the sacroiliac joint, and 15 40% arise from facet joint dysfunction (Schwarzer et al, 1994). Each of these anatomic structures is innervated and potentially noxious. Mechanical or chemical stimulation of these structures can cause LBP (Hancock et al, 2007). The pathoanatomical model of diagnosing LBP has traditionally been the primary model. Even though this model is used widely, it has provided a definitive diagnosis in less than 10% of cases (Fritz, Cleland, and Childs, 2007). Other authors have grouped heterogeneous low back conditions into one singular group or classified the conditions into timebased categories as follows: acute, 0 7 days; sub-acute, 7 days to 7 weeks; and chronic, greater than 7 weeks (Cook, Hegedus, and Ramey, 2005). Physical therapists employ a wide variety of conservative treatments for LBP, which include, but are not ARTICLE HISTORY Received 20 January 2015 Revised 16 May 2015 Accepted 31 July 2015 KEYWORDS Centralization; directional preference; low back pain; McKenzie method; MDT; sciatica limited to: manual therapy; therapeutic exercise; traction; modalities; and functional training (Delitto et al, 2012). Other medical practitioners employ treatments such as non-steroidal anti-inflammatory drugs and muscle relaxants, both of which may have a positive effect on LBP (Koes, Van Tulder, and Thomas, 2006). On the other hand, evidence on more invasive interventions is not as supportive. For example, the use of facet joint, epidural, trigger point, and sclerosant injections has not clearly been effective. For those who fail to respond to the aforementioned options, surgical discectomy is typically considered (Koes, Van Tulder, and Thomas, 2006). Given the elusiveness of diagnosing LBP, a superior method of treatment has not yet been determined. An intervention strategy based on an organized, patient-centered, and evidence-based system may be beneficial in the management of LBP. The patient response model (PRM) is an approach that uses a patient s response to singular or repetitive movements for diagnostic and treatment information. Responses typically include pain provocation, reduction, or both (Cook, Hegedus, and Ramey, 2005). One of the goals of this assessment is to determine the directional preference (DP) of the patient, if one exists. CONTACT Michael Robinson, PT, DPT, OCS m.t.robinson2013@gmail.com Austin Orthopedic Physical Therapy Resident, University of North Carolina Division of Physical Therapy, Department of Allied Health Sciences, 101 Manning Drive, Chapel Hill, NC 27599, USA Taylor & Francis

3 2 M. ROBINSON Werneke et al. (2011) defined a DP as, a mechanical response in which movement in one direction improves pain and limitation of ROM, and movement in the opposite direction causes signs and symptoms to worsen. The phenomenon of centralization, sometimes improperly used interchangeably with DP, is an emerging concept in physical therapy. Fritz, Cleland, and Childs (2007) define centralization as, when a movement or position results in abolishment of pain or paresthesia, or causes migration of symptoms from an area more distal or lateral in the buttocks and/or lower extremity to a location more proximal or closer to the midline of the lumbar spine. Documented as a positive prognostic indicator (Werneke et al, 2011), centralization is a desirable finding when utilizing this model. Delitto, Erhard, and Bowling (1995) presented the treatment-based classification system for the management of LBP with the objective of yielding positive outcomes faster, more efficiently, and cost-effectively. The algorithm allows practitioners to classify patients into categories determined by information gathered via examination procedures. The system then matches patients with evidence-based treatments. This original classification system described PRM principles and recommended direction-specific exercises that decrease pain as the primary therapy intervention (Delitto, Erhard, and Bowling, 1995). Since the formation of this system, Fritz, Cleland, and Childs (2007) have presented a more concise and updated version of the original algorithm as evidence on LBP evolved over the years. This group termed the PRM portion of the system, Specific-Exercise. The primary difference between these models and the widely used pathoanatomical model is matched intervention. This integral piece sequentially leads clinicians to potential interventions to address their patients problems. The McKenzie method, also known as mechanical diagnosis and treatment (MDT), is a more specific classification approach that enables differentiation between discogenic LBP and non-discogenic LBP based on patient response (Cook, Hegedus, and Ramey, 2005). MDT is a heavily researched type of PRM that is sometimes construed as an extensionbased treatment protocol despite evidence demonstrating improvements with flexion-based and lateral flexion-based programs (Long, Donelson, and Fung, 2004). Though interexaminer reliability of clinical testing and classifying LBP patients with this specific approach is good, this is only when examiners are trained in MDT (Kilpikoski et al, 2002). The PRM simplifies the diagnostic process by categorizing the patient based on patient s responses to movement rather than categorization based on tissue pathology. Donelson, Aprill, Medcalf, and Grant (1997) found a strong correlation between disc morphology and spinal motions used in clinical movement assessments. When considering the efficacy of this evidence in practice, clinicians can more confidently determine the integrity of a disc by using patient response as an identifier for abnormalities. This model uses direction-specific exercises with the goal of centralization to reduce pain and improve ROM (Southerst et al, 2013). The purpose of this case report, therefore, was to explore the diagnostic utility and treatment efficacy of the PRM for a patient with sub-acute LBP and radicular symptoms. Case description The following case involved a 52-year-old morbidly obese female bank teller who reported to outpatient physical therapy with a sudden onset of right-sided LBP with symptoms radiating distally and posteriorly to the foot. These symptoms were also felt on the left side in the same pattern with significantly less frequency and intensity. This injury occurred approximately 6 weeks prior to the patient s initial visit with physical therapy. While working at the drive-through station, the patient reached forward toward the deposit chute and instantly felt the aforementioned symptoms. She described her pain as a constant dull ache with intermittent sharp and burning pains that radiated from her low back to her right foot. She was placed on medical leave for 1 week and prescribed hydrocodone by an urgent care physician. She was instructed to apply ice to her low back and walk 30 minutes a day. She returned to work after 1 week. Upon bending forward to reach below a counter, her symptoms returned with increased intensity. That same week, the patient was evaluated by an orthopedist who identified two bulging discs at levels T11-T12 and T12-L1 via magnetic resonance imaging (MRI). Her complaints included low back and leg pain when she sat longer than 30 minutes, stood longer than 10 minutes, and with forward bending and lifting activities. She managed her pain by changing positions when: sitting; weight shifting when standing; and use of the prescribed pain medication, ibuprofen, and acetaminophen. She denied bowel and bladder changes; however, she reported having instances of bilateral lower extremity (LE) paresthesias, as well as unusual clumsiness with gait (i.e., tripping). Her ultimate goal for physical therapy was to eliminate her symptoms so that she could return to work pain-free. The injury was not a workers compensation case.

4 PHYSIOTHERAPYTHEORYANDPRACTICE 3 Measures As can be seen in Figure 1, pain was mapped by the patient using a body diagram. The diagram showed a distribution of pain in the low back and bilateral LEs symbolized by the marked areas. Pain mapping has been reported as a reliable method for recording pain location and distribution specifically in the acute and chronic LBP population (Southerst et al, 2013). The Numeric Pain Rating Scale (NPRS) was administered to gauge the patient s pain intensity. This scale ranges from 0 to 10, where 0 equates no pain and 10 equates the worst pain imaginable. An NPRS score was recorded on every visit, with her initial score measured at 9/10 throughout the marked pain distribution. Active range of motion (ROM) of the lumbar spine in the directions of flexion and extension was measured with a single inclinometer, and bilateral lateral flexion was measured using a goniometer. Though the correlation between lumbar ROM and function may be weak (Parks, Crichton, Goldford, and McGill, 2003), this measurement was recorded to determine the effect of treatment on ROM limitations. Repeated movements into these planes were also tested to classify the patient using the PRM (Fritz and Irrgang, 2001). The patient demonstrated a reduction in symptom intensity and visual increase in lumbar ROM with 10 repetitions of repeated standing lumbar extension and an increase in symptom intensity with one repetition of standing lumbar flexion. A neurological screen consisting of LE dermatomes, myotomes, and deep tendon reflexes was administered. At dermatome levels L2-S1, the patient reported a hypersensitivity of the right LE compared with the left LE with the application of random light touches by the therapist. Myotomes for the same levels were normal bilaterally. Deep tendon reflexes of the Achilles and patellar tendons were 1+ bilaterally. Special testing consisted of the straight leg raise (SLR), slump, Patrick s (FABER), sacroiliac compression, and sacroiliac distraction tests. The positive results of these tests were a right-sided SLR test yielding right-sided LBP, a rightsided slump test yielding right-sided buttock pain, and a right-sided Patrick s test yielding right-sided buttock pain. All other tests administered bilaterally were negative for pain provocation. The modified Oswestry disability index (modi) was the primary outcome utilized to measure the patient s perceived level of function in terms of disablement. The self-rated questionnaire consists of 10 items addressing different aspects of function. These aspects include: (1) pain intensity; (2) personal care; (3) lifting; (4) walking; (5) sitting; (6) standing; (7) sleeping; (8) social life; (9) Figure 1. Pain mapping by the patient at the initial physical therapy visit using a body diagram. Marked areas reflect the locations of the patient s pain.

5 4 M. ROBINSON traveling; and (10) employment/homemaking. Each item is scored from 0 to 5, with greater values representing greater disability. Despite the minor differences between the modified and original ODI, similar levels of test retest reliability and internal consistency exist between the two (Fritz and Irrgang, 2001). The patient s initial score was 24/50, which reflects severe disability. Differential diagnosis Given the patient s subjective report and objective examination, diagnoses of somatic and radicular origin such as facet joint and nerve root irritation were considered plausible since referred pain can be characteristic of these two sources. When considering a discogenic diagnosis, the debate of a nociceptive irritation versus radicular irritation can be made. Afferents from a disc share pain referral patterns with irritated nerve roots at the lumbosacral spine (Kallewaard et al, 2010). Within the PRM, movement testing of the trunk serves as the most valuable tool, especially in cases where a disc lesion is suspected. Donelson, Aprill, Medcalf, and Grant (1997) have suggested that repeated end-range spinal movement testing in multiple directions could identify a lesion-specific direction of asymmetrical disc loading which simultaneously stimulates the underlying symptom-producing pathology Without the need of imaging or diagnostic injection, movement testing allows for a gross assessment of spinal osteokinematics while assessing the integrity of the annulus fibrosus and the ability of a potential disc prolapse to reduce itself (Donelson, Aprill, Medcalf, and Grant, 1997). Collectively, clinical findings such as the dermatomal discrepancy, unilateral positive neural tension testing, and negative sacroiliac joint testing increased the likelihood that the source of pain was radicular. The patient denied bowel or bladder changes and deep tendon reflexes were hyporeflexive, decreasing the likelihood of an upper motor neuron concern. These findings were consistent with the reported mechanism of injury and suggest that the patient s pathoanatomical diagnosis was lumbar radiculopathy due to the disc bulges at T11-T12 and T12-L1 that had been documented on MRI. Based on the patient s positive response to extension-based movement and negative response to flexion-based movement, the patient would be classified as an extension responder in terms of the PRM. Treatment The patient demonstrated a DP of extension at the initial evaluation, as repetitions of standing lumbar extension to end-range reduced pain intensity and repetitions of standing lumbar flexion increased pain intensity (Werneke et al, 2011). Therefore, the patient was prescribed the same pain-reducing movement of standing lumbar extension as a home exercise. This sole exercise was provided to allow the process of centralization to continue and to confirm that the selected movement was therapeutic. The patient was instructed to perform 10 repetitions of this direction specific exercise every 2 waking hours, based on previous research on DP interventions (Long, Donelson, and Fung, 2004). Standing extension, as can be seen in Figure 2, was used instead of prone extension, primarily due to the patient s size and related difficulty assuming the prone position. She was also instructed to use a stable object, such as a countertop, for balance assistance, if needed. The patient was instructed to cease exercise if symptoms worsened or migrated distally to the low back. Recommendations were provided to the patient regarding workstation modifications to promote a neutral lumbar spine during her work shift and to avoid pain-provoking movements to supplement her direction specific exercise. She returned for followup visits 2 times per week. Her DP was either reconfirmed or reestablished at the start of each visit. Within each treatment session, the patient was guided through end-range pain-reducing movements in bouts of 10 repetitions. As symptoms and trunk range of motion ceased to produce further positive responses, the therapist assisted in providing overpressure to ensure maximum end-range movement with each repetition. The patient established a DP of right lateral flexion on the fourth visit only. A plausible explanation for this change, in terms of the PRM, is that coronal plane movements were the only movements to decrease symptom intensity and increase trunk ROM upon reassessment. On the other hand, a pathoanatomical explanation may determine a lateral disc derangement as the reason for change in DP. The home program was modified to the single exercise depicted in Figure 3. The sagittal plane exercises were resumed upon reassessment at the fifth visit less than a week later. Outcomes The patient was treated for seven visits over 4 weeks. As can be seen in Figure 4, a body diagram was administered on the final visit attended by the patient. This version depicts a pain distribution localized to the low back. This demonstrates the pain was centralized and supports the idea of direction-specific exercise yielding a positive effect on an individual with sub-acute LBP and radicular symptoms.

6 PHYSIOTHERAPYTHEORYANDPRACTICE 5 Figure 2. Repeated extension in standing. Direction-specific exercise used at visits 1 3 and 5 7. Figure 3. Repeated right lateral flexion in standing. Direction-specific exercise used at visit 4. The NPRS score was assessed at the beginning of every visit to determine the current pain status. Over the course of seven treatment sessions, the patient demonstrated an improvement in pain intensity from 9/10 to 1/10. As can be seen in Figure 5, a spike in pain intensity midway through treatment was attributed to the patient s inability to have her workstation modified coupled with a subsequent symptom exacerbation.

7 6 M. ROBINSON Figure 4. Pain mapping by the patient during her final physical therapy visit using a body diagram. The marked area reflects the location of the patient s pain. Figure 5. The patient s numeric pain rating over the course of seven visits. Education on body mechanics and avoiding lumbar flexion was emphasized to the patient during this treatment to prevent future exacerbations. Childs, Piva and Fritz (2005) reported that a 2-point change in NPRS scores was a meaningful improvement in LBP. The patient displayed an 8-point improvement in her NPRS score from the initial evaluation to her final visit. This result also supports the idea of directionspecific exercise yielding a positive effect for an individual with sub-acute LBP and radicular symptoms. The patient s lumbar ROM was measured at each visit for flexion, extension, and bilateral lateral flexion. As can be seen in Figure 6, the most significant improvement was 35 more degrees of flexion. Though no strong studies were identified regarding the significance of change in lumbar ROM values as they relate to function, an overall

8 PHYSIOTHERAPYTHEORYANDPRACTICE 7 Figure 6. The patient s lumbar flexion ROM over the course of seven visits. improvement in lumbar ROM was demonstrated for this patient from initial evaluation to final visit. The modi was assessed on a weekly basis. The patient scored 34/50 at week 3 before improving to 20/50 at week 4. This spike in modi score at week 3 was also attributed to the aforementioned symptom exacerbation. Education on body mechanics and avoiding lumbar flexion was emphasized to the patient during treatment to prevent future exacerbations. The change in scores from initial evaluation to final visit was not large enough to exceed the MCID of the modi. Although minimal change was noted on the modi, the patient s final survey exhibited a 2-point improvement in lifting ability. In addition, 1-point improvements were noted in the sitting and travel ability sections while all other aspects of the modi were unchanged over 4 weeks. These specific changes are important to highlight as each of these sections relate to the patient s ultimate goal of returning to work pain-free. The final outcome of 20/50 reflects moderate disability despite decreased pain intensity and location as well as increased lumbar ROM. Discussion Subgrouping patients for diagnostic and treatment purposes is becoming the focus of musculoskeletal back pain research (Long, Donelson, and Fung, 2004; Fritz, Cleland, and Childs, 2007). Data from this case report supports the use of the PRM. The body diagram is a clinically useful tool to document the phenomenon of centralization when using this model. Similarly, the NPRS and improvements in lumbar ROM are clinically useful tools in the documentation of DP. According to subjective reports and body diagrams, the patient in this case had complaints indicative of lumbar radiculopathy despite MRIs revealing potential nerve root involvement at levels T11-T12 and T12-L1. Though rarely reported, lower thoracic disc involvement may mimic radicular symptoms, paresthesias, and weakness in the LEs (Benson and Byrnes, 1975; Lyu, Chang, Tang, and Chen, 1999; Tokuhashi, Matsuzaki, Uematsu, and Oda, 2001). Lyu, Chang, Tang, and Chen (1999) proposed that this inconsistency exists due to the lumbar enlargement of the spinal cord at lower thoracic levels and subsequent compression of exiting lumbar spinal nerves. Alternatively, disc bulges are prevalent in asymptomatic patients and may be unrelated to the patient s symptoms in this case (Jensen et al, 1994). Despite an uncertain correlation between her MRI findings and symptoms, this patient achieved a positive outcome with clinical management based on the PRM. In taking an organized, patient-centered, and evidence-based approach to managing LBP like the PRM, this patient was classified and treated, and yielded favorable outcomes for multiple measures. On a larger scale, Long, Donelson, and Fung (2004) identified that the prevalence of a DP was 74% in a population of 312 acute, sub-acute, and chronic LBP patients. In addition, good prognoses have been predicted in individuals

9 8 M. ROBINSON treated with the matching DP exercise (Werneke et al, 2011). After determining the patient exhibited a DP for extension, she became part of the significant subpopulation of LBP patients who respond favorably when managed with the principles used in the PRM. These high levels of evidence further validate the effectiveness of the PRM in physical therapy practice. Clusters of signs and symptoms have been established for patients who would benefit from the PRM and patients who would benefit from other treatments such as manipulation, stabilization, and traction (Fritz, Cleland, and Childs, 2007). Examples of criteria that typically have favorable outcomes with PRM include: DP; symptoms distal to the buttock; centralization; and age greater than 50 years for flexion-based DP (Fritz, Cleland, and Childs, 2007; Long, Donelson, and Fung, 2004). Limitations to this approach include contradictory progress for patients who are not appropriately classified. For example, if a patient s DP is not correctly interpreted, the potential for improvement becomes limited. Long, Donelson, and Fung (2004) reported a significant difference in improvement between subjects prescribed exercise matching their DP versus subjects prescribed exercise opposite of their DP. In a poststudy interview of the first patient randomized to the treatment group opposite of her extension DP, the subject reported consistent increases in her pain intensity with flexion-based daily activities (Long, Donelson, and Fung, 2004). Second, the absence of determining a DP would limit the application of this approach. If an improvement in symptoms or ROM is not elicited, a matching treatment protocol cannot be assigned. Therefore, awareness of a patient s subjective and objective responses to movement testing is essential in utilizing the PRM. This case report was not without limitations. First, the patient self-discharged due to financial difficulties. Comprehensive data, therefore, could not be collected. Second, the exacerbation of the patient s symptoms attributed to the patient s inability to modify her work environment was not adequately addressed. From the perspective of the widely used International Classification of Functioning, Disability and Health (ICF) model, contextual factors like the environment can affect the status of a health condition (Steiner et al, 2002). A more concentrated effort could have been made to assist with this matter. Two examples include initiating communication with her direct supervisor or having the patient bring in photos of her workstation to make a more comprehensive ergonomic assessment to supplement the plan of care. Lastly, compliance was not recorded in this report. Self-management via home exercise is vital in this model. The frequency of performing prescribed exercise every 2 walking hours of the day was adhered to based on patient report. However, documentation of each exercise session would assist in confirming protocol compliance. Accordingly, the PRM is optimal for patients who display the ability to routinely carryout a home exercise protocol. This case study supports the use of patient classification using the PRM for a patient with sub-acute low back and radicular symptoms. Such an approach can be implemented clinically for diagnosis and treatment purposes while being cognizant of all environmental factors that may affect a patient s outcome. Acknowledgments Special thanks to Michael T. Gross, PT, PhD, FAPTA, and Carla H. Hill, PT, DPT, OCS, Cert. MDT, for their assistance in writing this report. This case study was written by a resident of the Orthopedic Physical Therapy Residency Program at the University of North Carolina, Chapel Hill, in partial fulfillment of the program requirements. Declaration of interest The author reports no declaration of interest. 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