Management of Low Back and Hip Pain with Leg Weakness – Choosing the Proper Technique: A Case Report

Original Article

Management of Low Back and Hip Pain with Leg Weakness – Choosing the Proper Technique: A Case Report

Rebecca Warnecke, DC1

1Private Practice – Grand Rapids, MI

[email protected]

Published: March 2018

Journal of the Academy of Chiropractic Orthopedists

March 2018, Volume 15, Issue 1

This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: http://www.dcorthoacademy.com. © 2018 Warnecke and the Academy of Chiropractic Orthopedists.

Abstract

Objective: The purpose of this study is to report the management of a patient with insidious onset of low back pain and bilateral iliofemoral pain. There was no history of trauma reported or evidence of trauma upon examination.

Clinical Features: A 26-year-old male presented to the clinic with low back pain, bilateral iliofemoral pain, bilateral thigh weakness and pain, bilateral groin pain, and urinary incontinence.

Intervention and Outcome: The patient was treated with two separate trials of chiropractic care resulting in 20 visits over the course of 12 weeks. The chiropractic care consisted of Sacro-Occipital Technique (SOT) treatment applied to the pelvic region, but traditional spinal manipulation was also utilized during one visit. In addition to chiropractic care, the patient also participated in exercise rehabilitation for a total of 7 visits and 4 sessions of kinesiology taping to the lumbar spine.

Conclusion: This study demonstrates a favorable response to SOT of the pelvis as an alternative to traditional techniques of spinal manipulation more commonly seen in chiropractic care. It also reveals the importance of coupling spinal care with exercise rehabilitation.

Background

There are multiple ways to perform spinal manipulation. In chiropractic, the different variations are known as “techniques”. Estimates vary regarding the number of chiropractic techniques employed around the world. In a survey performed by both Australian Chiropractic Associations involving 280 doctors of chiropractic, the most common techniques used in practice were diversified, activator, flexion-distraction, and soft-tissue therapies.1 Three techniques for the low back that are the most widely studied in research include side-posture high velocity low amplitude (HVLA) manipulation, flexion-distraction, and general mobilization.2 In general, traditional chiropractic treatment focuses on manual manipulation of the spine. Sacro-Occipital Technique (SOT), another chiropractic technique, was developed in the 1920s by Dr. Major Bertrand de Jarnette3 after appreciating a reduction in pain while lying on a traditional chiropractic table with certain elements elevated. He reasoned that by applying specific biomechanical forces to the pelvis, one could resolve pelvic asymmetry. SOT differs from traditional chiropractic techniques because it does not involve manual manipulation, providing a less invasive approach to the treatment of low back pain. De Jarnette performed many experiments to identify the optimal instrument for application of SOT and ultimately selected wooden wedges, also known as “blocks”, that are to be positioned beneath the patient’s pelvis. In 1964, he published the results of his experimentation.3 SOT has since been taught at various chiropractic colleges. Several case studies have been published describing increased range of motion and improved pelvic biomechanics following utilization of SOT.4

It is estimated that low back pain affects 80% of people over the course of a lifetime.5 Due to the prevalence of this musculoskeletal complaint, research much be done to determine how best to individualize treatment for each patient. Per the American College of Physicians, spinal manipulation was strongly recommended as a form of non-pharmacologic treatment for acute, subacute, and chronic low back pain.6 Classification of the most common chiropractic techniques regarding varying patient presentation of low back pain is essential in providing congruent evidence-based care to the estimated 700 million people world-wide affected by low back pain at any given moment.7

Case Presentation

A 26-year-old Asian-American male presented to a private practice clinic with chief complaints of iliofemoral pain, low back pain, lower extremity pain, foot pain, and thigh weakness, all presenting bilaterally. His symptoms began a year and a half prior to the initial appointment but had worsened over the past five months. It was then that he started to use a cane to assist with ambulation. Upon deeper questioning, the patient reported struggling with urinary incontinence that began at the start of this condition. With no known history of trauma, the patient attributed his symptoms to long hours of working on his feet at a restaurant job, rarely having a day off to rest. The patient stated that the original pain was confined to his left iliofemoral joint but had recently begun to affect the contralateral side. In addition to the main complaints, he reported upper back pain as well as neck pain. On the Numeric Pain Rating Scale (NPRS), he rated his pain in both iliofemoral joints, low back, mid back, neck, bilateral feet, and bilateral thighs as an 8/10. The pain was temporarily relieved by massage, stretching, and ibuprofen but always returned, especially after long work days. The patient stated that the pain at the initial appointment was no different in character or intensity than it had been over the last five months. Via patient history intake, the patient reported difficulty sleeping, sitting in a chair for more than one hour, and prolonged car riding. He also reported experiencing numbness and tingling of the thighs, muscle and joint pain, and fatigue. The family medical, surgical and pharmacological histories were not pertinent to the treatment of this patient. The patient visited a primary care physician five months prior due to the exacerbation of the condition and was then diagnosed with piriformis syndrome. The patient also reported receiving several chiropractic treatments four months prior with minimal results.

Radiographic examination of the lumbar spine, both anterior-posterior and lateral lumbopelvic views were negative for serious pathology. The only finding present was facet tropism of L5/S1.

Figure 1: Radiographic Lumbar Series

The initial physical examination revealed a slightly elevated blood pressure of 134/99 mmHg with a pulse of 76 beats per minute. Grip strength was recorded at 110 lbs. on the left and 105 lbs. on the right. Significant hypertonicity and spasms were noted at the left trapezius and levator scapula, right thoracic erector spinae, and right gluteus medius and piriformis musculature. Thoracolumbar range of motion was measured using dual inclinometers. Thoracolumbar flexion was minimally decreased at 55 out of 60 degrees but provoked sharp left iliofemoral pain. Thoracolumbar extension was decreased at 17 out of 25 degrees but did not cause pain or discomfort at any location. Thoracolumbar right lateral flexion was decreased to 14 out of 25 degrees and caused sharp left iliofemoral pain. Thoracolumbar left rotation was within normal limits of 30 degrees but also provoked the left iliofemoral joint pain. All other thoracolumbar ranges of motion were non-provocative and were within normal limits. Restricted right sacro-iliac fluid motion was noted upon examination with exquisite tenderness on palpation. Palpation of the right lower posterior rib cage and right piriformis muscle provoked localized pain, as well. Muscle testing of the hip flexors, hip abductors, hip adductors, and knee flexors was a 3/5 on the right and 4/5 on the left. Muscle testing of the right lower extremity provoked right iliofemoral pain but muscle testing of the left lower extremity did not.

Both patellar and achilles deep tendon reflexes were rated 2+ bilaterally. Nachlas test was positive on the left for both thoracic and lumbar pain and negative on the right. The patient experienced difficulty bilaterally with both heel and toe walking but pain only on the left. Straight Leg Raise (SLR) was positive on the right with reproduction of low back and posterior thigh pain radiating to the heel; SLR was negative on the left. Patrick Test was positive on the left for iliofemoral pain and negative on the right. Prone Leg Extension Test was positive bilaterally for imbalanced muscle activation and caused severe pain in the left sacro-iliac joint while raising the left leg; however, the patient experienced greater difficulty elevating the right leg (without pain). Valsalva maneuver was negative for pain and discomfort.

Following this examination, the patient was diagnosed with bilateral L2-L4 radiculopathy, mechanical low back pain, sacro-iliac joint dysfunction, and muscle strain of the left hip flexor musculature.

Patient was referred for MRI evaluation. The MRI was negative and revealed a normal lumbar spine.

Figure 2: Magnetic resonance imaging of the lumbar spine

Management and Outcome

Management consisted of two trials of chiropractic care totaling 20 visits over the course of 12 weeks. After the initial visit, the patient was no longer using a cane and reported a 50% reduction in bilateral hip pain (4/10), left thigh pain and weakness (4/10), low back pain (4/10), and upper-mid back pain (4/10) as measured by NPRS. He endorsed a 12.5% reduction in right thigh pain. He also reported an 87% reduction in both neck and bilateral foot pain (2/10), as well as resolution of urinary incontinence. Chiropractic treatment included prone high velocity-low amplitude (HVLA) spinal manipulation of the thoracic spine, supine Diversified technique of the cervical spine, and passive SOT of the pelvis, a technique chosen due to the severity of the patient’s pain in that area. Initially, the patient was seen for chiropractic treatment 2-3 times per week for 3 weeks. Re-evaluation was performed at the 8th visit. The second physical exam showed resolution of initial right thoracic erector spinae muscle hypertonicity and the pain during palpation of the lower right posterior rib cage. The patient’s blood pressure was 138/98 mmHg with a pulse of 64 beats per minute. The following orthopedic examinations remained positive for pain in the low back and/or hip area: Nachlas on the right, Ely on the right, Kemps on the right, and SLR on the right causing radicular symptoms down the right thigh and leg. SLR was positive on the left for low back pain only. The patient endorsed complete resolution of left lower extremity pain, left hip pain, and left lower extremity weakness. He rated his right lower extremity pain at 6/10, low back pain at 3-4/10, right hip pain at 6/10, neck pain at 1/10, and mid-back pain at 3/10 on the NPRS. The patient subjectively reported that standing and working had become easier since initiation of care, and that his gait had improved. He also reported feeling stronger, especially in the left leg, and endorsed better sleep.

At this point of care, a new chiropractic technique was chosen for the treatment of the low back and pelvis due to the improved but plateaued results in the low back and iliofemoral joints. For one visit, the HVLA drop table mechanism (Thompson technique) was utilized instead of SOT for the pelvis with instrument assisted manipulation (Activator instrumentation) utilized in the lumbar spine. The patient returned two days later having regressed to symptomatic baseline, rating his pain at 8/10 on the NPRS and endorsing a recurrence of bilateral lower extremity weakness. Patellar and achilles deep tendon reflexes were again performed and remained +2 bilaterally. The patient denied recurrence of urinary incontinence and denied any new issues with bowel function. After two additional visits with application of SOT, the patient reported 3/10 on NPRS in all areas and feeling “90% better.” Pelvic SOT was continued throughout the remainder of the treatment plan. Upon resolution of the exacerbation, the patient was referred to an exercise rehabilitation specialist in the same private practice clinic for therapy involving lumbo-pelvic stabilizing exercises and stretching in addition to kinesiology taping.

Rehabilitation exercise sessions occurred once per week for 4 weeks followed by every other week for 8 weeks and included both strengthening exercises and stretches. The first phase of exercises included calf raises, donkey kicks, and standing hip abduction. The first phase of stretches included modified child’s pose, runner’s calf and achilles stretch, standing quadruped stretch, sitting figure 4 stretch, and the sitting hamstring stretch. After the second visit of exercise rehabilitation and two sessions of kinesiology taping of the lower back, the patient reported greater ease during exercises and less pressure on the low back during work hours. During phase two of exercise rehabilitation, new exercises and stretches were introduced including the cat/camel stretch, single leg bridges, ball squats, flutter kicks, air bicycles, crossed-leg piriformis stretch, side lunges, supine hip flexor stretch, and the knee hug stretch.

For the remaining 6 weeks, the patient was seen once per week. During the last three visits, drop table spinal manipulation of the left iliofemoral joint was also administered. By the end of this phase of care, the reported NPRS scores were as follows: 0/10 in bilateral legs and feet, 2/10 in bilateral iliofemoral joints, 1/10 in both the mid back and neck, and a 2/10 in the low back. Thoracolumbar flexion was decreased to 50/60 degrees and no longer provoked pain in the left iliofemoral joint but merely affected tight bilateral hamstring and calf muscles. Thoracolumbar extension caused minor right iliofemoral pain and had increased to 19/25 degrees. Thoracolumbar right lateral flexion greatly increased to 24/25 degrees and only produced mild thigh soreness. Thoracolumbar left lateral flexion was recorded at 20/25 degrees and produced mild leg soreness and slight low back pain. Thoracolumbar bilateral rotation produced no pain and were both within normal limits at 30/30 degrees. The patient’s blood pressure decreased to 126/85 with a pulse of 60 beats per minute. Nachlas and Ely were negative bilaterally for pain. The patient’s grip strength had increased to 125 lbs. on the left and 117 lbs. on the right. SLR was positive bilaterally for slight low back pain but no longer caused radicular symptoms. Kemps was positive bilaterally for minor low back pain. Prone leg extension was positive on the left for suboptimal muscle activation, but the patient continued to struggle to elevate the right leg more. Patellar and achilles deep tendon reflexes remained a +2 bilaterally. The patient reported NPRS scores of 2-3/10 in all previous areas. He also stated that riding in a car and sitting had also become better tolerated.

After his final visit of the second trial of care, he denied pain in any thoracolumbar range of motion. As of the time of publication, this patient continues to be seen every 2-3 weeks, as needed, for management of his low back and iliofemoral complaints, as well as his muscle weakness. He continues to perform his home exercises and stretches approximately 3-4 times per week while keeping a six-day work schedule where he is on his feet for 8 hours or more at a time.

 

Table 1

Range of motion exam results in degrees with reported pain exacerbation before and after treatment.

Range of Motion

(Normal)

Initial Examination (Degrees)

Pain Present (Initial Exam)

Final Examination (Degrees)

Pain Present (Final Exam)

Thoracolumbar Flexion

(60)

55

Left iliofemoral joint

61

None

Thoracolumbar Extension

(25)

17

None

15

None

Thoracolumbar Right Lateral Flexion

(25)

14

Left iliofemoral joint

22

None

Thoracolumbar Left Lateral Flexion

(25)

25

None

23

None

Thoracolumbar Right Rotation

(30)

30

None

30

None

Thoracolumbar Left Rotation

(30)

30

Left iliofemoral joint

30

None

 

Discussion

This study demonstrates success in the management of low back pain and iliofemoral pain with concomitant bilateral lower extremity weakness. This course of treatment also resulted in resolution of long-lasting urinary incontinence after the initial visit. Due to bilateral leg weakness and urinary incontinence, imaging was necessary to rule out more serious pathology, such as a space occupying lesion. The MRI revealed no contraindications to spinal manipulation.

The urinary tract is controlled by a complex neurological relationship involving sympathetic and parasympathetic nerves of the autonomic nervous system.8 Nerves exiting from the thoracolumbar region of the spinal cord are associated with the sympathetic function of the urinary tract; parasympathetic and somatic innervation arise from the sacral segments of the spinal cord.9 This well-established concept of neuroanatomy provides a valid hypothesis as to how neurological interference or dysfunction at a particular spinal level could potentially cause associated visceral symptoms in a patient. There is, however, very limited research currently on the treatment of these symptoms with spinal manipulation.

Although this study produced many benefits for this patient, it is important to emphasize that further research is necessary to determine the validity of the treatment rendered. Until a larger body of evidence exists to suggest which chiropractic techniques should be provided for various patient presentations of low back pain, the results of this study may not be generalized to the overall population.

This case study suggests that not all chiropractic techniques are appropriate for all patients with low back pain. Chiropractors must be diligent and thorough during initial examination to determine the best course of treatment possible for each patient. Although other techniques, such as side posture HVLA, have been more thoroughly researched, it is important to identify which chiropractic techniques are more suitable for each patient being treated.

Limitations

Due to the uncontrolled nature of case report studies, this study had several limitations. Causation may not be determined in this study as it could, in comparison, from a randomized control trial. It is important to note that only NPRS, range of motion, and general patient subjective measures were the main identifying factors in determining patient outcomes. More objective measures, including a rated outcome assessment questionnaire such as the Back-Bournemouth Questionnaire, would have generated more validity and objective results in this study.

Consent

Written consent for this publication was obtained from the patient.

Competing Interests

The author declares no competing interests.

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