Low Back Pain and Mechanical Diagnosis Treatment: A Case Report

Transcription

1 University of North Dakota UND Sholarly Commons Physial Therapy Sholarly Projets Department of Physial Therapy 2017 Low Bak Pain and Mehanial Diagnosis Treatment: A Case Report Aliia Bullinger University of North Dakota Follow this and additional works at: Part of the Physial Therapy Commons Reommended Citation Bullinger, Aliia, "Low Bak Pain and Mehanial Diagnosis Treatment: A Case Report" (2017). Physial Therapy Sholarly Projets This Sholarly Projet is brought to you for free and open aess by the Department of Physial Therapy at UND Sholarly Commons. It has been aepted for inlusion in Physial Therapy Sholarly Projets by an authorized administrator of UND Sholarly Commons. For more information, please ontat zeineb.yousif@library.und.edu.

2 ,("-) \., LOW BACK PAIN AND MECHANICAL DIAGNOSIS TREATMENT: A CASE REPORT By Aliia Bullinger Bahelor of Siene in Kinesiology Otober 2016 A Sholarly Projet Submitted to the Graduate Faulty of the Department of Physial Therapy Shool Of Mediine University of North Dakota In partial fulfillment of the requirement for the degree of Dotor of Physial Therapy Grand Forks, North Dakota May 2017

3 n \ This Sholarly Projet, submitted by Aliia Bullinger in partial fulfillment of the requirements for the Degree of Dotor of Physial Therapy from the University of North Dakota, has been read by the Advisor and Chairperson of Physial Therapy under whom the work has been done and is hereby approved. Graduate Shool Advisor ii

4 Title: Department: Degree: Permission Low Bak Pain Treated by Mehanial Diagnosis Treatment: A Case Report Physial Therapy Dotor of Physial Therapy \~ ~-~ In presenting this Sholarly Projet in partial fulfillment of the requirements for a graduate degree from the University of North Dakota, I agree that the Department of Physial Therapy shall make it freely available for inspetion. I further agree that permission for extensive opying for sholarly purposes may be granted by the professor who supervised my work or, in her absene, by the Chairperson of the department. It is understood that any opying of publiation or other use of this Sholarly Projet or part thereof for fmanial gin shall not be allowed without my written permission. It is also understood that due reognition shall be given to me and the University of North Dakota in any sholarly use whih maybe made of any material in this Sholarly Projet. Date II/CO II ~ ~r/~/~ L, iii

5 Table of Contents Title...'"...i Submission...ii Permission....iii Table of Contents...iv List of Tables... v Aknowledgments... vi Abstrat... vii Chapter One: Bakground and Purpose... 1 Chapter Two: Case Desription and Examination... 6 Intervention...11 Outomes Chapter Three: Disussion Chapter F out: Refletion...19 Referenes L iv

6 List of Tables Table 1... page 8 Table 2... :... pages 12 v

7 n Aknowledgements I would like to thank my professors at the University of North Dakota Physial Therapy Department for teahing me the examination and evaluation skills neessary in treating this patient. I would like to inlude a speial thank you to my instrutors Shawnn Deker and Mihelle Labreque for sharing their knowledge and expertise in the development of this ase report. My fellow Physial Therapy students Melanie Fuller, Brianna Gustafson and Joe Perry are more than deserving of my express gratitude for ollaborating on this ase study with me. Lastly, I would like to thank my fiane, family and friends for their never ending support while I pursue my eduation and areer as a Dotor of Physial Therapy. It is to all these people that lowe my urrent and future suess. ( ',-, vi

8 Abstrat: Bakground and Purpose: Aute low bak pain is one of the most ommon and expensive reasons for adults to see a family physiian and is ommonly treated by physial therapists. Although most patients reover quikly with minimal treatment, patient eduation and exerises direted by a physial therapist may derease reurrent pain and need for health are servies. The purpose of this ase study is to determine if the MKenzie Method is effetive treatment for aute low bak pain in the medial workfore using evidene based pratie. Case Desription: Patient was a 37-year-old Cauasian female who worked as a registered nurse in a rural hospital. She experiened aute low bak pain injury when attempting to transfer a patient. Patient stated there was an audible "pop," in her bak at time of injury. Patient was presribed Flexeril and Peroet in the emergeny department and was experiening high levels of pain with radiating symptoms from her right low bak into her right foot. Outomes: The patient responded well to initial treatment. Patient was able to meet her short term and long-term goals while using the MKenzie Method with only 4 treatment sessions. Disussion: Overall, the patient responded well to the MKenzie treatment approah. It seems that further researh needs to be ompleted on the effiay of MKenzie treatment despite the positive outomes in this ase study. Limitations exist due to the lak of funtional assessment appliation. vii

9 Chapter One: Bakground and Purpose Aute low bak pain (LBP) is one of the most ommon and expensive reasons for adults to see a family physiian l,2. This ondition is ommonly and effetively treated by physial therapists. Researh has shown little to no support for the effiay of ultrasound, laser, tration, thermal modalities, eletrial stimulation, and aupunture or bed rest in the treatment of mehanial LBP 3,4,5,6. However, evidene does show support for short-term benefits aquired through exerise, non-steroidal anti-inflammatory drugs, patient eduation, behavioral modifiation and joint manipulation 7,8,9, 10. The spine is made of a ombination of bones, ligaments, tendons, musles and highly sensitive nerves and nerve rootsll. Its purpose is to protet these highly sensitive nerve roots while still providing a wide range of mobility in many different planes ofmovement l2 Most people take this versatility for granted exept for those who suffer from hroni or aute low bak pain. These people are driven to seek treatment to relieve their pain and prevent a reurrene. Many different strutures in the spine an ause bak pain inluding: irritation of the large nerve roots, irritation of the smaller nerves that innervate the spine and subsequent musulature, strain on the eretor spinae musles, and injury to the bones, ligaments, joints or the intervertebral dis 13. The lower bak has more motion than the rest of the spine and also arries all the weight of the torso. Inreased motion and body weight make the low bak the most frequently injured area of the spine l4 1

10 r \ ) The lumbar segment of the spine onsists of the faets and the posterior and anterior longitudinal ligaments along with the lumbar dis. The faets are sagittal in orientation and promote flexion and extension of the lumber spine l5. The posterior longitudinal ligament is narrow but provides some stability to the posterior wall of the dis and helps protet the anterior side of the spinal anal. The anterior longitudinal ligament is broad and thik. It primarily resists hyperextension of the lumbar spine but also provides good anterior dis wall stability. The lumbar dis ontains the nuleus pulposus and the annulus fibrosus. The nuleus pulposus is the shok absorber of the spine and allows the vertebral segments to pivot. It is non-innervated and non-vasular in nature l6 The annulus ( fibrosus is omposed of tough, fibrous onnetive tissue and provides strutural integrity of the dis while ontaining the nuleus. It differs from the nuleus as it does have noieptive and proprioeptive innervation l7. Aording to the dynami internal dis model lumbar flexion ompresses the anterior portion of the dis ausing the nuleus to move posteriorly while extension auses the posterior setion to ompress and the nuleus to move anteriorly. Lateral flexion and rotation result in ontralateral movement of the The motion in the lumbar spine is divided between the LI-LS vertebral segments. The lower segments (L3-LS) possess more motion than the upper segment (LI-L3). The lower two segments are the most likely to result in injury. L The two lowest diss (L4-LS and LS-Sl) take the most strain and are the most 2

11 likely to herniate. This an ause low bak pain and numbness that an radiate down the leg and into the foot. Most patients reover quikly with minimal treatment, patient eduation and exerises direted by a physial therapist. The MKenzie Method, now known as Mehanial Diagnosis Treatment (MDT), may derease reurrent pain and the need for health are servies 19. MDT is a reliable assessment proess intended for all musuloskeletal problems inluding LBP using a well-researhed, exerise-based approah of assessment, diagnosis and treatment to reate a omprehensive evaluation of patients without the use of expensive diagnosti. imaging20. The treatment priniples of MDT promote the body's potential to repair itself and do not involve the use of mediation, heat, old, ultrasound, needles or surgery. This ultimately empowers patients to learn the priniples and ontrol their own symptom management that in turn redues dependeny on medial intervention. MDT is omprised of four primary steps: assessment, lassifiation, treatment and prevention. Most musuloskeletal pain is mehanial in origin. This means that a position, movement or ativity aused the pain to start. The MDT system is designed to identify the mehanial problem and develop a plan to orret or improve the mehanis and thus derease or eliminate the pain and funtional problems 21. Robin MKenzie identified three syndromes primarily assoiated with L MDT. Those syndromes are Postural, Dysfuntions and Derangements. The 3

12 Postural Syndrome is the response of normal tissue to abnormal loading and pain results from mehanial deformation of soft tissues or vasular insuffiieny from sustained positional or postural stresses. The Dysfuntion Syndrome is pain that is aused by mehanial deformation of abnormally shortened soft tissue suh as sar tissue, ontratures, adherene or adaptive shortening. This pain is only felt when the abnormally shortened tissues are on streth. Lastly, the Derangement Syndrome is an internal hange in the normal resting position of affeted joint surfaes. It is the displaement of artiular tissue of any origin and that auses pain or obstruted movement until the tissue has been returned to its normal position 22. Studies have looked at prognosti fators in the literature that may help predit those at risk of poor reovery from work related low bak pain 23. Those whose symptom duration was greater than 6 months had signifiantly less funtional improvement than those whose symptom duration was less than 1 month 24. The funtional improvement sore is influened by age, symptom duration, and inlusion of mobilization/manipulation, strengthening and flexibility exerises. The treatment of low bak pain (LBP) is also heavily influened by ost and poses an enormous eonomi burden to soiety25. These osts are diret and indiret ranging from medial osts to loss of produtivity. Mean diret and indiret osts for LBP are are about twie as high for patients with hroni LBP ompared to autely ill patients 26. Indiret osts aount for more than 52% to I "---' 54% of total osts and about 25% of diret osts refer to therapeuti proedures 4

13 and hospital or rehabilitation are. Patients with high disability and limitations in daily living show a 2- to 5-fold hange for subsequent high healthare osts. In a study with 1,843 partiipants, nearly 14% were reeiving work disability ompensation after 1 year 27 Physial therapists familiar with the MDT use spinal stabilization exerises to identify a subgroup of patients with LBP. These patients have pain that is rapidly reversible allowing return to full funtion 28 This method uses a single patient-speifi diretion of preferene using simple end-range low bak exerises and some posture modifiations. Studies targeting MDT have foused on patients whose persisting pain had led to reommendations of dis surgery where 50% were then found to still have a rapidly reversible dis problem with high rates of nonsurgial rapid reovery. Using this form of evidene-based MDT an result in tremendous ost savings and greatly improved linial outomes. Based on logisti regression analysis there was a lower risk of subsequent medial servie usage among patients who reeived physial therapy early after an episode of aute low bak pain relative to those who reeived physial therapy at later times 29 The purpose of this ase study is to determine if the MKenzie Method is the appropriate treatment for aute low bak pain in the medial workfore using evidene based pratie. L 5

14 .f\ \ Chapter Two: Case Desription and Examination The patient was a 37-year-old Cauasian female with a Body Mass Index (BMI) of27. She worked midnight shifts as a registered nurse in a rural hospital and was a single mother of a 10 year old boy. She enjoyed partiipating in a rereational fitness program at home and reported no previous LBP inidenes. The patient was in a lot of pain from lifting and transferring a 350-pound patient at work. Patient stated that she heard her bak "pop," at time of injury but thought that she was fine to ontinue working. After three days of ontinued work she finally sought medial attention at the emergeny room due to intolerable pain. The patient was presribed Flexeril and Peroet from the emergeny department's physiian and was referred to her primary are physiian who subsequently referred her to physial therapy. On her initial visit to physial therapy, patient desribed her pain using the visual analog sale (V AS) (with 0 being no pain and 10 being the worst pain possible) as a with omplaints of radiating pain from her right low bak into her right foot ontinuously sine the time of injury. She stated that her low bak pain was daily and onstant with brief alleviation by repositioning. However, her radiating symptoms into her foot were intermittent and desribed as numbing, tingling, shooting and burning sensations whih worsened after prolonged periods of sitting (lumbar flexion) suh as driving. Patient also reported loss of sleep due to pain and symptoms. Patient's self-reported prior level of funtion was independent with ativities of daily living (ADL) and transfers. Her ADL requirements inluded 6

15 working as a nurse, lifting, arrying or pulling objets greater than fifty pounds. Patient lived in a manufatured home with a five step entry and bilateral hand rails. Patient reported taking T opamax, Claritin, Albuterol and a multivitamin prior to injury onset. Patient denied a relevant past medial history other than migraines from nek pain and hip problems but no previous episodes of low bak pain. There were no diagnosti tests performed or ordered from either the emergeny department or the patient's primary are physiian. The patient displayed a guarded posture favoring the right low bak and leg while seated and standing. This posture was typial of a relevant lateral omponent in MDT, a derangement that does not respond in the sagittal plane, but responds to appliation of fore lateral. She also displayed an exaggerated lumbar lordosis and an antalgi gait favoring the right lower extremity. Upon physial therapy evaluation and palpation, it appeared that the patient's pain and symptoms were radiating from level L4-L5 and L5-S1 of the spine. The patient had greatly inreased point tenderness in this region making it diffiult to fully assess her mehanial problems. The patient's range of motion (ROM) was limited in forward flexion with patient's fingertips able to reah her knees using a ratheting motion due to inreased pain. Patient displayed the same ratheting motion with lumbar extension, but was only limited by 25% of motion due to pain. Her pain dereased with lumbar extension when hips were laterally shifted to the right. During right side bending the patient was able to reah fingertips to mid thigh with a guarded 7

16 () posture and omplaints of pinhing in her low bak. She was able to reah to her knee during left side bending while displaying the same guarded p~sture. Patient's hamstring, anterior tibialis, fibularis, and extensor hallius strength were equal bilaterally while quadrieps strength was diminished on the right. Results of patient's manual musle testing are listed in table 1. Table 1 Right Lower Extremity Manual Musle Testing Hip Flexors: 3/5 Quadrieps: 3/5 Anterior Tibialis: 4/5 Extensor Halluis: 4/5 Fibularis Musles: 4/5 Hamstrings: 4/5 Table 1 depits the results of manual musle testing. Left Lower Extremity Manual Musle Testing Hip Flexors: 5/5 Quadrieps: 515 Anterior Tibialis: 515 Extensor Halluis: 515 Fibularis Musles: 515 Hamstrings: 515 Patient's lower extremity sensation and tone was normal bilaterally. Patient was hypoflexive bilaterally for L3 and S 1 reflex testing of the quadrieps and ahilles tendons respetively. Patient was positive to the right and negative to the left for a supine straight leg raise (SLR) test. Patient displayed a positive jump sign (an involuntary reation to stimulation of a tender area or trigger point) with palpation of the posterior superior ilia spine and L4-S 1 regions. She was tender to palpation at right paraspinals and saroilia joint with musle spasms noted. The physial therapist was unable to assess the patient's segmental mobility due to pain and point tenderness along with other ommonly used speial tests. These other tests, or onordant signs in MDT inlude, the Slump, Prone Knee Bend, and Segmental Instability. L' 8

17 The SLR test is onsidered a routine test during the examination of the lumbar spine among patients who present with siatia as it tests the lumbosaral plexus by stressing the siati nerve 30 An ipsilateral SLR has 72-97% sensitivity but 11-66% speifiity for a herniated intervertebral dis. A leg elevation of less than 60 degrees is abnonnal and suggests ompression or irritation of the nerve roots. A positive test reprodues the symptoms of siatia with pain that radiates below the knee, not merely bak or hamstring pain. A myotome is defined as a musle or group of musles served by a single nerve root. Myotome testing onfirmed patterned weakness for an L4-LS and LS- S 1 nerve root due to the right lower extremity weakness ompared to the left. lower extremity. The right lower extremity weakness was greater for the L4 nerve root affeting hip flexion, knee extension and hamstrings the greatest with mild defiits in the tibialis anterior, extensor hallius longus, and fibularis longus and brevis. Dynami testing involves repeated movements in speifi diretions. Repeated movements an give the liniian some valuable insight into the patient's ondition. Internal derangements tend to worsen with repeated motions while the symptoms of postural dysfuntion remain unhanged. Repeated motions an indiate the irritability of the ondition, as well as indiate to the liniian the diretion of motion to be used as part of the intervention. If pain inreases during repeated motion in a partiular diretion, exerising in that diretion is not indiated. If pain only worsens in part of the range, repeated motion exerises an be used for that part of the range that is pain-free, or whih does not worsen 9

18 symptoms. Pain that is inreased after the repeated motions may indiate a retriggering of the inflammatory response, and repeated motions in the opposite diretion should be explored. Forward flexion or the fingertip-to-floor test (FTF) was performed in onjuntion with the SLR during examination. The FTF has good validity in patients with aute/subaute LBP, and even better validity in those with radiular pain as ompared to the SLR at 1 month and 1 year post treatmentti;n. Range of motion defiits and the positive SLR on the right were onsistent with a right L4-LS, LS-Sl dis herniation. Following these [mdings the physial therapy diagnosis was doumented as a dis herniation at the level ofl4-l5. Aording to MDT, this patient would be diagnosed having a lumbar dis derangement with a signifiant lateral omponent. (,. I "-..., 10

19 Intervention It was deided to use the MKenzie Extension Pattern for treatment. Treatment suesses using the MKenzie method an be predited using ertain demographi and linial fators inluding: age, gender, pain duration, pain loation, spine region, MKenzie lassifiation, therapeuti fore, and entralization/abolition of symptoms 33 Typially patients with pain duration less than 12 weeks had 7 times greater suess rates than patients with longer pain duration and patients with bak pain had odds of suess about 3.5 times greater using the MKenzie method. Patients with entralization or abolition of pain had odds of suess about 2.7 times greater than those without these symptom responses. Following the physial therapy examination it was evident that the patient favored an extension pattern for AROM whih seemed to entralize her symptoms. Her treatment is desribed in table 2. L 11

20 Table 2 Initial Treatment: VAS 7/10 Seond Treatment: VAS 6/10 Extension in lying with hips plaed laterally to Extension in lying with hips plaed laterally to the right: 3 sets x 5 reps x patient's tolerane the right: 3 sets x 5 reps x patient's tolerane Extension in lying with hips in neutral: 3 sets Extension in lying with hips in neutral: 3 sets x 5 reps x patient's tolerane x 5 reps x patient's tolerane Extension in lying with hips plaed laterally to the right PT overpressure at L4-S 1: 3 sets x 5 PT overpressure in prone at L4-S1: 3 sets x 30 reps x patient's tolerane se x grade 1-2 Cold paks x 15 minutes to patient's low bak Prone hip extension: 1 set x 5 reps x patient to alm inflammation tolerane Cold paks x 15 minutes to patient's low bak with pillow plaed under the hips to redue right radiular symptoms and to alm inflammation Third Treatment: VAS 4/10 Final Treatment: VAS 0/10 Extension in lying: 1 set x 10 reps x 5 se Forward flexion: 1 set x 1 rep x 3 se Extension in lying with PT overpressure at Extension in standing: 1 set x 7 reps x 2 se L4: 3 sets x 10 reps x 5 se with last rep produing right radiular Extension in lying with patient overpressure: 1 symptoms set x 10 reps x 5 se Extension in lying: 1 set x 15 reps x 3 se Prone hip extension: 2 sets x 10 erps x 5 se Extension in lying with PT overpressure: 1 set Bird dogs: 2 sets x 10 reps x 5 se x 15 reps x 3 se Prone plank: 1 set x 2 reps x 30 se Prone hip extension: 1 set x 15 reps x 3 se Hot pak with interferential urrent x 20 min Bird dog in quadruped: 1 set x 15 reps x 3 se to right lumbar paravertebrals PA glides x 2 min to lumbar spine followed by extension in lying with PT overpressure: 1 set x 5 reps Hot pak with interferential urrent x 20 min to right lumbar paravertebrals Table 2 desribes the treatments provided to patient in treatment sessions 1-4. L 12

21 The patient was informed that treatment frequeny and duration would work best at two times per week by three weeks for a total of 6 treatment sessions. Patient stated understanding and agreed to this treatment shedule. The patient was also instruted in a home exerise program onsisting of extension in lying and extension in standing to help alleviate pain at work and at home. Patient stated she understood the home exerise program and was able to demonstrate the exerises prior to leaving the initial appointment. L 13

22 Outomes The patient responded well to initial treatment. She was able to stand more omfortably and walk more easily following the initial treatment. The subsequent treatments had good outomes with her pain entralizing eah visit. The patient stated that she was satisfied with the results of her treatment and impressed with how quikly they took effet. Despite the good results from the initial treatment, the patient failed to adhere to the treatment frequeny and duration. Four treatment sessions were held over the ourse of 4 weeks at whih point the patient self-disharged. It is diffiult to understand what led to the failed adherene and abrupt disharge. ' It is diffiult to fully disuss the patient's outomes due to the selfdisharge. A funtional outome measure suh as the ODI should have been distributed at the initial evaluation in order to doument progress and satisfation in quality of life. Due to the doumented redution in pain and addition of more diffiult exerises it would appear that the patient had self-disharged due to the lak of severe symptoms. Patient was able to meet her short term goals inluding: return to work with 4/10 or less, log roll mobility, ambulate 250 feet with 4/10 or less, lifting 50 lbs, return to her preferred fitness routine and inrease in ROM by 50%. She was also able to meet most of her long term goals inluding: return to work with 1110 pain or less and return to her preferred fitness routine. Long terms goals of ROM 14

23 If\ and bed mobility within nonnallimits, ambulation of 500 feet with 1 II 0 pain or less, and elimination of lifting restritions were not yet met at the time of selfdisharge. L' 15

24 ~ ( \ Chapter Three: Disussion Overall, the patient responded well the MKenzie treatment approah. This patient presented similar to patients in other MKenzie researh with aute LBP and seemed to respond quikly to this approah. The treatment premise and method was easy to explain to the patient. She was more able to omplete her exerises at home and at work beause she understood the ourse of treatment. This also made patient eduation easier. The AROM measurements were useful in narrowing in on the patient's. problem. Pain or restritions with forward flexion and side bending are often indiative of a dis problem in patients who present with low bak pain. The ratheting motion exhibited by this partiular patient is also a good indiator of a dis problem as the return to standing plaes more pressure on the dis and auses pain. The patient was able to feel relief when in extension position whih also follows a typial pattern and presentation of a lumbar dis protrusion or herniation. An Oswestry Disability Questionaire (ODQ) was not performed. Researh suggests that in omparison with nonspeifi LBP, the visual analogue sale (VAS) and ODQ sores were signifiantly higher and the pain duration was signifiantly longer than speifi LBP (p < 0.05)34. Others have researhed the L responsiveness of a Patient Speifi Outome Measure (PSAQ) ompared with the Oswestry Disability Index v2.1 (OeJ) and Roland and Morris Disability 16

25 Questionnaire (RMDQ) for patients with subaute and hroni LBP35. They found the PSAQ was highly sensitive to improvement but not to deterioration and it was less speifi to hange than the ODI or RMDQ. Overall, the ODI was the most responsive measure for patients with mild to moderate low bak pain disability. In ontrast with previous researh we reommend the ODI v2.1 rather than the RDMQ for patients with mild disability. This infonnation onludes that an Oswestry assessment should have been administered to more properly trak linial hange and quality of life. It is apparent how useful a funtional assessment would be in this ase to properly doument and disuss the patient's progress and linial outomes. A quality of life measure would also have been useful to determine how satisfied the patient was with her outomes even if she was yet not bak to her pre-injury abilities. Current literature is on the fene in regards to the effiay of the MKenzie Method. Some researh states that a pure MKenzie approah is best for treating all types of bak pain, both aute and hroni, while other researh states it is best for aute ases only. Despite the positive outomes in this ase study, the overwhelming onensus in the literature is that MDT does not yield appreiable short tenn results 36,37,38. Researh foused on the nursing population may prove promising as there is a higher inidene of low bak pain in this population relative to patient transfer methods. There is potential for LBP 17

26 ,~ I I prevention in the medial and nursing ommunities with patient eduation ombining proper body mehanis and lifting tehniques with the premise of the MKenzie extension treatments. Limitations exist due to the lak of fufltional assessment appliation. It is diffiult to disuss the patient's outomes without an objetive measure having been distributed. Other limitations are due to the patient's abrupt self-disharge and diffiulty adhering to a treatment shedule. These limitations made it inreasingly diffiult to reassess and doument patient's progress in a meaningful manner. 18

27 (\ Chapter Four: Refletion I piked this patient for my ase study primarily beause she was the only patient I saw in lini for more than one or two visits before disharge or in this ase self-disharge. In the rural setting when I performed my linial it was very ommon for patients to only ome for one or two visits in order to meet their PT threshold for pain mediation presriptions. This partiular patient wanted no part in pain mediations but wanted to return to work as quikly as possible in order to support her son. This patient primarily worked midnights or an overnight shift at the ( hospital, whih also played a huge role in her adherene to PT. It was diffiult for her to omply with treatments that were both immediately after work or just before the lini losed due to fatigue or lak of sleep. This is an important onsideration in future patient management so that I an enourage patients to ome at times that are most feasible for them and times when they will get the most out of their treatment versus simply being physially present. Overall, this patient had a very typial presentation regarding low bak pain and dis protrusion or herniation. The patient's mehanism of injury inluded a loaded position and twisting motion, whih seems very relevant in the general population. This position and motion seems even more prevalent in nursing and healthare related work beause a large portion of those jobs revolves around 19

28 transferring patients and aiding them while standing, walking, or sitting often putting those workers in a loaded and rotated position. Team ommuniation ould have helped to prevent this partiular injury as the patient was unaware of the size or dependeny of the person she was trying to help. As in most jobs, training in proper body mehanis and work plae ergonomis ould help to prevent similar injuries in the future. It is a physial therapist's job to help implement these programs in the ommunity to help teah safety and health promotion in the work plae. As far as MDT goes, it showed fast results with this patient and is seemingly well supported by literature but I would like to treat patients with more body awareness and strength related exerises in the future. I think MDT does a great job at handling pain upfront but very little for preventing pain in the future. I did try to mix in some stabilization exerises with this patient as seen in Table 2 but my knowledge at the time was very limited in hindsight. Now, I would prefer to treat a patient with MDT maybe 1-2 visits to help them move more freely and then zero in on pelvis position, ore/abdominallhip stabilization and lifting mehanis to provide a patient with a well rounded treatment plan. (, \... 20

29 Referenes 1. Kosloff TM, Elton D, Shulman SA, Clarke JL, Skoufalos A, Solis A. Conservative Spine Care: Opportunities to Improve the Quality and Value of Care. Population Health Management. 2013;16(6): doi: pop United States Bone and Joint Initiative: The Burden of Musuloskeletal Diseases in the United States (BMUS), Third Edition, Rosemont, IL. Available at Aessed on (Deember 8, 2016). 3. Bekkering GE, Hendriks HlM, Koes BW, Oostendorp RAB, Ostelo RWJG, Thomassen lmc, van Tulder MW. Duth Physiotherapy Guidelines for Low Bak Pain. Physiotherapy. 2003;89(2): doi: 1O.1016/S (05) Airaksinen 0, Brox n, Cedrashi C, Hildebrandt J, Klaber-Moffett J, Kovas F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G. Chapter 4: European guidelines for the management of hroni nonspeifi low bak pain. European Spine. 2004;15(Suppl. 2):SI92-S300. ( 5. Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK. Diagnosis and Treatment of Low Bak Pain: A Joint Clinial Pratie Guideline from the Amerian College of Physiians and the Amerian Pain Soiety. Annals o/internal Mediine. 2007;147(7): doi: / Delitto A, Georgr SZ, Van Dillen L, Whitman lm, Sowa G, Shekelle P, Denninger TR, Godges JJ. Low Bak Pain. Clinial Pratie Guidelines Linked to the International Classifiation of Funtioning, Disability, and Health from the Orthopaedi Setion of the Amerian Physial Therapy Assoiation. Journal of Orthopaedi & Sports Physial Therapy. 2012;42(4):AI-A57. doi: /jospt Al. 7. The human movement system: our professional identity. Sahrmann SA Physial Therapy Jul; 94(7): Effet of ative limb movements on symptoms in patients with low bak pain. Van Dillen LR, Sahrmann SA, Norton BJ, Caldwell CA, Fleming D, MDonnell MK, Bloom NJ Journal o/orthopedi Sports Physial Therapy Aug; 31(8):402-13; L 9. Further examination of modifying patient-preferred movement and alignment strategies in patients with low bak pain during symptomati tests. Van Dillen LR, MalufKS, Sahrmann SA Manual Therapy Feb; 14(1):

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