Therapeutic interventions for a patient with bilateral cervical and lumbar radiculopathy: a case report.

Transcription

1 Therapeutic interventions for a patient with bilateral cervical and lumbar radiculopathy: a case report. Steven Schmidt, SPT Mark Erickson, PT, DScPT, MA, OCS Carroll University Physical Therapy Program, Waukesha, WI

2 TITLE: Therapeutic interventions for a patient with bilateral cervical and lumbar radiculopathy: a case report. ABSTRACT: Background: Low back pain (LBP) is the second leading cause of disability in the United States. Lumbar radiculopathy is often associated with LBP and can be caused by multiple pathologies, mostly by degenerative spondyloarthropathies. The prevalence of lumbar radiculopathy is approximately 3% to 5%, distributed equally in men and women. Cervical radiculopathy is a disorder of a cervical nerve root and is common in the general population. Evidence suggests that patients who are treated conservatively for cervical or lumbar radiculopathy may experience superior outcomes to those who undergo surgery. The purpose of this study is to demonstrate therapeutic interventions in the treatment and management of a patient with both cervical and lumbar radiculopathy. Case Description: The patient was a 57 year old male with a history of osteoporosis and chronic low back and neck pain with radiating symptoms to both upper and lower extremities referred to an outpatient physical therapy clinic. He was diagnosed with bilateral cervical and lumbar radiculopathy consisting of impaired posture, decreased lumbar ROM, pain, and decreased muscle flexibility; impacting the patient s activity tolerance to perform ADLs. Interventions consisted of manual therapy, therapeutic exercise, patient education, and posture re-education and focused on the primary impairments affecting his function. Outcomes: The patient attended 9 treatment sessions over the course of 6 weeks and reported an average pain of 6/10 that decreased to 1/10 by the end of therapy. The Oswestry Disability Index score improved from 33/50 to 29/50. The patient also reported >75% decrease in radiating symptoms in both upper and lower extremities, and standing tolerance improved from 10 to 30 minutes, walking from ¼ mile to ½ mile, sitting from 30 to 45 minutes, and shoveling from 15 to 30 minutes. Objective outcomes indicate an increase of >15% in lumbar AROM flexion, extension, and lateral flexion without being limited by pain. Patient attributed impairment outcomes and improved functional abilities to physical therapy. Discussion: These findings suggest that physical therapy may play a significant role in the management of patients with lumbar or cervical radiculopathy. Improvements were noted for symptom frequency and intensity, lumbar ROM, posture, and activity tolerance of ADL s. Keywords: lumbar radiculopathy, cervical radiculopathy, osteoporosis

3 Purpose The purpose of this case report is to describe therapeutic interventions and outcomes for a 57 year old patient with severe osteoporosis, fibromyalgia, cervical and lumbar radiculopathy. Patient History and Review of Systems The patient is a 56 year old male referred to outpatient physical therapy for massage and myofascial release, diagnosed with osteoporosis and fibromyalgia approximately six years ago. Imaging from six months ago revealed degeneration of lumbosacral interveterbral disc, grade 1 chronic spondylolisthesis of L5 on S1, and lumbar foraminal stenosis. Medications for pain management included pregabalin and celecoxib. PMH was significant for myoclonic spasms which were managed effectively with clonazepam. A systems review was performed indicating no abnormal findings of the cardiopulmonary and integumentary system. His chief complaint was neck and low back pain with symptoms radiating into bilateral upper and lower extremities, with occasional numbness into his hands. Symptoms began within the past few years; however, symptom frequency and intensity of low back pain had increased within the past few months. Initially, the patient rated the average low back pain 6/10 (0-10 scale) with least rated 2/10 and worst 8/10. The pain was described as continuous, deep, and aching, generalized to the lumbar spine and occasionally radiated into bilateral posterior legs and calves, right worse than left. Aggravating factors included prolonged sitting, standing, walking, bending, and cold weather; whereas, alleviating factors included massage, myofascial release, and lying supine. For prior management of symptoms, patient had received massage, myofascial release, and injections all which he felt were helpful. His functional limitations included difficulty: 1) lifting, 2) standing >10 minutes, 3) sitting >30 minutes, 4) walking >½ mile, and 5) shoveling >15 minutes; all limited by increasing pain when performing the activity. His goals for therapy were to stay active and independently manage pain through exercise and stretching. Examination Disability Index: The Oswestry Disability Index (ODI) 10-item questionnaire was administered to determine the patient s functional disability related to his low back pain. The ODI is considered the gold standard of low back functional outcome tools due to its high reliability and validity. 1 The ODI score was 33/50 or 66% at the initial evaluation and indicated his back pain interfered on all aspects of his life and that positive intervention was required. The patient reported

4 moderate limitations on all items with increased difficulty relating to lifting, standing, and changing degree of pain. Posture and Palpation: Sitting and standing posture was impaired with a significant protraction of shoulders, forward head, thoracic kyphosis, lumbar lordosis, and anterior pelvic tilt. Lower extremity posture was normal and no muscle atrophy was observed. Tenderness with moderate palpation was noted at the bilateral posterior superior iliac spine (PSIS). Light to moderate gross palpation of the bilateral lower extremities and low back revealed no abnormal response. Visual assessment indicated increased muscle tension of the right lumbar paraspinals. Palpation revealed decreased skin extensibility near the thoracic spine in all directions. Visual assessment of the patient s bilateral leg length in supine was also negative. Three sacroiliac (SI) tests were performed to rule in or out SI involvement including the SI compression, distraction, and Gaenslen s Test, all with negative results in replicating the patient s symptoms. 2 The patient was negative for sacral torsions, iliac innominate rotations, and iliac up-slips. SI joint and leg length tests were performed as described by Magee. 3 Although the validity and reliability of palpation remains questionable, it is a useful tool in providing diagnostic information in patients with long-standing musculoskeletal pain. 4 Range of Motion: The patient demonstrated decreased mobility with pain in the low back during the range of motion assessment. Lumbar active range of motion (AROM) was measured in standing and results are specified below in Table 1. Extension passive range of motion (PROM) was assessed with the patient moving from prone to prone on elbows, with approximately 50% range. Within this position the patient reported a mild decrease of pain in the low back and bilateral lower extremities. Flexibility of the bilateral lower extremities was performed with PROM of the hip, knee, and ankle with the patient in supine. The Thomas test was used to assess rectus femoris and iliopsoas flexibility. 3 All results had no limitations except those outlined in Table 2 and are demonstrated as percent of normal. Reliability and validity for measuring ROM for a percentage of normal is not established; however, it provided insight into relative limitations that could be used to guide diagnostic and intervention reasoning. Strength: Strength assessment of the bilateral lower extremities was performed with manual muscle testing (MMT) in sitting as described by Reese. 5 Results are outlined in Table 3 and

5 revealed no abnormal weakness, neurological deficits, or symptom reproduction. Functional Mobility: The patient demonstrated increased bilateral hip external rotation throughout gait and increased left lateral trunk flexion during right heel strike. Stride length and stance time during gait were symmetrical and the patient demonstrated no deficits in performing transfers or stairs. Special Tests: Neural tension testing, using the seated slump test described by Slater et el. 6 was negative. The slump test is used to detect altered neurodynamics or neural tissue sensitivity. 7 Additionally, the patient tested negative for the Straight Leg Raise (SLR) and Crossed SLR (X-SLR) test. The SLR has high sensitivity (91%) and low specificity (26%) in diagnosing herniated discs whereas the X-SLR has low sensitivity (52%) and high specificity (89%). 8 Table 1: Lumbar Spine AROM (% of normal) Flexion 75 (pain in low back 5/10) Extension 50 (pain in low back 5/10) Lateral Flexion Left: 50 Right: 50 Rotation Left: 75 Right: 75 Lower Extremity Table 2: Flexibility (% of normal) Left Right Iliopsoas Rectus femoris Piriformis Hamstring Table 3: Lower Extremity MMT Left Right Hip Flexion (L2) 4+/5 4+/5 Knee Extension (L3) 5/5 5/5 Ankle Dorsiflexion (L4) 5/5 5/5 Great Toe Extension (L5) 5/5 5/5 Ankle Plantarflexion (S1) 5/5 5/5 Ankle Eversion (S2) 5/5 5/5 Clinical Impression Examination findings supported the initial clinical impression of mechanical low back pain associated with impaired posture, decreased lumbar ROM, pain, and decreased flexibility of lower extremity musculature. The diagnosis provided was bilateral lumbar radiculopathy. An extension directional preference that alleviated and centralized lower extremity symptoms into the low back was identified supporting the diagnosis. The patient s postural deficits were most likely related to osteoporosis and decreased flexibility of the iliopsoas and rectus femoris causing asymmetry of the lumbo-pelvic-hip complex (LPHC). Imaging results (see

6 Case Description) indicated abnormal lumbar alignment and degenerative changes as potential sources of dysfunction. SI joint dysfunction was ruled out based on the negative findings. Systems review ruled out cardiopulmonary, integumentary, and other system involvement. Finally, neural compression was ruled out from negative slump, SLR, and X-SLR tests. Based on these findings, the next plan of action was to proceed with intervention. The patient would be seen twice weekly for 45 minute appointments for 4-6 weeks and the plan of care would include manual and soft tissue mobilization to improve ROM and reduce muscle tone. Planned interventions included patient education, therapeutic exercise, and neuromuscular re-education to improve posture, muscle imbalances, muscle flexibility, and reduce pain in the low back and lower extremities. Pain level and symptom behavior were assessed each session. Goals were assessed every other session, whereas the ODI was reassessed at the final session. The following short term goals (STG) were established to be achieved by week 3, the patient will: 1) report being able to sit >45 minutes without pain as a limiting factor, (2) demonstrate improved body mechanics during sitting, and (3) demonstrate a 50% improvement in pain frequency and intensity down the legs. The following long term goals (LTG) were established to be achieved by week 6, the patient will: (1) improve by 7 points on the ODI, (2) report independent management of myofascial pain symptoms, and (3) demonstrate an understanding of safety to prevent injury including compression fracture. Despite the chronic nature of the patient s symptoms, a good prognosis to benefit from physical therapy and meet these goals was assigned. Intervention Patient education was used during the initial visit to inform the patient of his diagnosis, prognosis, impairments, and functional limitations found during the examination. He was also instructed in proper sitting and standing posture and the modification of aggravating activities. The patient was also informed of resources that included specific exercises designed for patients with osteoporosis. According to Dupeyron 9, therapeutic patient education reduces the negative consequences of fear-avoidance behavior and promotes treatment compliance in patients with low back pain. The patient was instructed in therapeutic exercise and a home exercise program (HEP) on his first visit to complete twice daily, and exercises were added each week to address additional impairments. Prior to each session the patient performed a low-intensity active warm up on the stationary bike to improve the effectiveness of stretching 10. Treatment for the patient s cervical radiculopathy was incorporated at week two based on additional examination findings consistent with bilateral thoracic outlet syndrome. The exercise descriptions, purpose, and the week the exercises were initiated are listed in Table 4.

7 Table 4: Therapeutic Exercise Exercise Description Purpose Prone extension* Hip flexor stretch* Piriformis stretch* Abdominal isometric bracing* Abdominal bracing with heel taps* Isometric hip flexion in hooklying* Cervical retraction* 1 st rib/middle scalene stretch.* Core stabilization on foam roller. Thoracic spinal mobilizations with towel.* *Given as part of HEP Patient in prone and extend trunk by propping up on forearms. 5 repetitions, 60 seconds Patient in supine at edge of mat, flex knee and hip while opposite leg slowly lowered, allowing the hip and knee to extend. 2 repetitions bilaterally, 30 seconds Patient in supine, knee flexed and crossed over the other. Stretch performed gently pulling knee toward opposite shoulder. 2 repetitions bilaterally, 30 seconds Patient in hooklying and asked to draw lower abdomen inward toward the spine and hold an isometric contraction. 5 repetitions, 10 seconds Abdominal bracing as above. Patient in supine with hips flexed to 90. Alternate with lower extremities by tapping heel to mat. 10 repetitions bilaterally Patient in supine with hips flexed to 90. Isometric force applied with hands to the top of the thighs. 5 repetitions, 10 seconds Patient supine and slowly nods head and draws chin towards the mat. 10 repetitions Patient seated and using towel to depress 1 st rib. Laterally flex neck to the left. 2 repetitions, 30 seconds Patient supine with spine supported on foam roller. Abdominal bracing as above with: Alternating sliding heel away from gluteals Alternating heel taps to mat, as above. Alternating points of contact of UE and LE. 10 repetitions bilaterally Patient supine with rolled towel perpendicular to spine. Hands behind head and shoulders protracted, lean backwards on towel. Hold for 10 seconds. Move towel along spine and repeat. Week Initiated Centralize symptoms and 1 improve lumbar ROM 11,12 Increase flexibility and ROM 13 1 Increase flexibility and ROM 13 1 Improve core endurance, strength, and posture 14 Improve core endurance, strength, and posture 14 Improve core endurance, strength, and posture 14 Centralize symptoms and improve cervical ROM and posture 15,16 Increase flexibility and decrease cervical radicular symptoms 13,17 Improve core endurance, strength, and posture 14 Increase thoracic extension Manual therapy techniques such as soft tissue mobilization (STM), nerve mobilizations, PROM, joint mobilizations, and kinesio-taping were also implemented throughout therapy to address impairments. The cervical joint mobilizations were performed using mobilization with movement (MWM) as described by Mulligan. 19 For example, the therapist applied cervical lateral glide mobilizations while the patient performed cervical retractions.

8 The first rib joint mobilizations were performed with standard techniques with the addition of proprioceptive neuromuscular facilitation (PNF) movements called Functional Manual Therapy (FMT). Functional Manual Therapy is an integrated intervention developed by Gregory and Vicky Johnson in 1973 which combines active movements and resisted contractions with a specific directional pressure of the joints or tissues to produce efficient mobility. 20 The concept evolved from incorporating functional PNF techniques as described by Kabat 21 with soft tissue and joint mobilization techniques. Joint mobilizations of the right 1 st rib were performed while the patient was performing hold relax and contract relax movements with the left upper extremity. This theoretically allows manual therapy techniques to be more effective as they are integrated while the patient is performing movement. The efficacy of FMT is not established, but in some cases allowed for effective interventions to be simultaneously combined. The manual therapy descriptions, purpose, and the week the interventions were initiated are listed in Table 5. Table 5: Manual Therapy Exercise Description Purpose STM PROM cervical spine Median nerve flossing Kinesio taping for shoulder retraction. 1 st rib mobilization with neuromuscular facilitation Mastoid process mobilization Prone thoracic and lumbar paraspinals, latissimus dorsi, trapezius, rhomboids, Supine sub occipitals, upper trapezius, sternocleidomastoid, scalenes, levator scapulae Mild to deep pressure minutes. Supine, PROM by therapist into flexion, bilateral lateral flexion, and bilateral rotation, and cervical distraction into gentle end-range stretch for seconds. Supine, therapist passively brings patient into 90 abduction, elbow extension, wrist extension. Patient laterally flexes cervical spine away from involved arm while therapist passively moves wrist into flexion. Tape applied while patient standing with shoulders flexed. Strip applied bilaterally at 45 angle perpendicular to medial scapular border at 50% pull. Patient in supine with left shoulder flexed 90, slightly horizontally adducted, and elbow flexed. Therapist mobilizes right 1 st rib grade 3-4 in an inferior and lateral direction while providing isometric extension force against patient s left UE for 10 repetitions. Therapist stops mobilizations and provides resistance against LUE while patient actively flexes and extends shoulder. Supine, grade 4 mobilization applied to left mastoid process for 1 minute while patient performs repetitions of cervical retraction. Decrease pain, promote relaxation, decrease muscle tension, improve tissue extensibility and mobility. 22,23,24 Week Initiated 1 Increase ROM 22 2 Increase nerve mobility 2 and decrease pain 25 Improve scapular retraction and posture 26 Increase joint mobility 27 3 Increase joint mobility

9 Lateral mobilization to C3, C4, C5, T1, T2 Supine, grade 3-4 mobilization applied medially to cervical or thoracic vertebrae for 1 minute while patient performs repetitions of cervical retraction. Increase joint mobility 20,28 4 Outcomes The patient presented with pain and limitations in posture, lumbar ROM, lower extremity flexibility, and activity tolerance. These impairments and functional limitations were significantly reduced at the conclusion of therapy, which included nine visits within six weeks. The patient met all three STG after three weeks and two of three LTG by discharge. The patient reported a 75% improvement in pain frequency and intensity at discharge that allowed him to perform daily tasks such as sitting, standing, lifting, shoveling, and walking for greater durations of time. Standing tolerance improved from 10 to 30 minutes, walking from ¼ mile to ½ mile, sitting from 30 to 45 minutes, and shoveling from 15 to 30 minutes. Average pain decreased from 6/10 to a 1/10 and no more than 5/10 at worst, and the ODI score improved from 33/50 (66%) to 29/50 (58%) with improvements in pain intensity, walking distance (>1/2 mile), social life, and traveling. The minimum clinically important difference for the ODI to show improvement was six points. 29 Measurements of lumbar AROM and lower extremity flexibility are outlined in Tables 6 and 7 and revealed improvements from initial evaluation to discharge. These improvements increased his ability to bend forward and lift objects with limited pain and enhanced his standing and sitting posture with decreased anterior pelvic tilt and increased thoracic extension. This provided a more ideal spinal alignment to reduce the risk of injury by a compression fracture. Manual muscle test scores of the bilateral hip flexors increased from 4+/5 to 5/5 by discharge. Table 6: Lumbar Spine AROM (% of normal) Initial Discharge Flexion 75 (5/10 pain in low back) 90 (1/10 pain in low back) Extension 50 (5/10 pain in low back) 75 (0/10 pain in low back) Right Lateral Flexion Left Lateral Flexion Right Rotation Left Rotation Table 7: Lower Extremity Flexibility (% of normal) Left (Initial) Left (Discharge) Right (Initial) Right (Discharge) Iliopsoas Rectus femoris Piriformis

10 Hamstring Reflection As part of my first outpatient orthopedic clinical experience, I believe I did a good job in examining and developing a plan of care for this patient. Despite the patient s complex history and symptom presentation, I was able to thoroughly address the patient s primary complaints of low back and neck pain. Things that were done well included manual therapy and therapeutic exercise to address the patient s impairments with the focus of improving activity tolerance for functional limitations. Although evidence states that a specific pain source cannot be identified in patients with low back pain, I did a sufficient job in using evidence based examination procedures and reasoning to synthesize my findings and develop a plan of care. Evidence based interventions for treating lumbar radiculopathy included core strengthening, extension exercises, and soft tissue mobilization of low back musculature. These interventions were then incorporated into the home exercise program for long term management of symptoms. I could have improved on advancing the basic interventions related to the lumbar radiculopathy by making them more challenging; however, the initial interventions appeared to be successful in addressing the patient s impairments. Additionally, I should have added trunk and hip extension exercises as these are important to include. As far as examination procedures, I should have assessed lumbar strength at initial evaluation and discharge as well as continually assessing SI joint involvement. Likewise, assessing cervical strength and additional impairments would have guided exercise intervention and long term management of the neck symptoms and radiculopathy. Finally, with pain being the primary factor of concern, little focus was put into weight bearing tasks to address his osteoporosis. In conclusion, I feel I could have done a better job with evidence based practice. Some of the things above should be included in all patients with low back pain. On the other hand, due to the dynamic presentation of symptoms and continually changing of the plan of care, it made it extremely difficult to keep up with frequent evidence based interventions and examinations. Although some were based on research I performed specifically regarding the diagnosis, others were treating impairments in which I feel were still an evidence based approach to treatment. Looking at the project as a whole, I was very disappointed in the entire experience. I was hoping to use a unique intervention on a unique patient, but it simply did not work out that way. The patient s uniqueness had very little effect on the plan of care. Additionally, a unique intervention was simply not warranted for him. Hoping to change to a more unique patient, it was already too late and I needed to commit to simply describing my practice on this particular patient. Dr. Erickson was very helpful in providing good feedback in the writing and editing process, responding in a relatively prompt fashion. Still, I felt this project provided more

11 experience to writing professionally and concisely much like an English class with a touch of evidence based practice. If I ever plan to write a case study, then I feel this assignment has significantly prepared me; however, I feel time would have been better spent researching information on several patients on a more consistent basis. I would most likely feel different if I knowingly contributed to a literature gap, but I cannot say for certain. But who knows, this project may help a therapist treat a patient sometime in the future.

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