A Challenging Case

A patient unexpectedly showed up to the CIC today with an antalgic posture, one hand holding the left lumbosacral region and in very obvious pain.

The history revealed a lifting injury suffered 3 days prior. At the time of the interview, the symptoms had reached a peak in the 3 day duration and nothing made it better or worse. The physical exam was positive with a left unilateral Kemp's, negative resisted muscle tests and a normal neurological exam. Active straight leg raise was positive on the left with severe pain/spasm in the left sacroiliac joint. Yeoman's was positive bilaterally with left causing greater pain than the right. Farfan's was positive on the left, especially in the lumbosacral region. Nachlas, Ely's and left Hibb's were negative. Right Hibb's induced a left SI joint spasm.

Muscular palpation exhibited severely spasmed QL's, tight gluteus medius muscles and spasmed thoracolumbar paraspinals. Rising from a chair was very painful as well. The left ilium had a flexion restriction which was confirmed with provocation in both flexion and extension as well as leg length. Where extension of the SI joint reproduced the patients symptoms and flexion relieved the symptoms on the left and the left leg was about 1/4 of an inch longer.

Dr. Roberts confirmed the diagnosis of a left-sided sacroiliac sprain with associated myospasm, myalgia and related joint dysfunction. Quite the issue.

She advised we start on the flexion-distraction table. Immediately during the first minute of care, the patient spasms worsened when the table pulled into flexion. The pain was primarily in the left SI joint. I put the table back to neutral and reassessed. I decided to stop trying to fix it and go get the inferential current modality to hopefully fatigue the muscles into relaxation.

Ten minutes go by and we venture into a drop maneuver to free up the SI joint. First drop, the patient spasms and releases nicely after holding flexion pressure in the left SI joint for about 20 seconds. Second drop, no spasm. The patient is feeling a bit better, reporting no pain in the prone position, where before during the physical exam, prone was not comfortable at all.

I have the patient helicopter to a standing position and BAM another spasm happens. The patient slowly sits down and I reassure that it is okay and that the muscles are just a bit confused as to what is normal. A minute goes by and the spasm dies down. Thank goodness! The patient tries to stand again and BAM, spasms up again. I am thinking, what the hell, the person was fine on the table and reported relief from the work I just did. Dr. Roberts enters the room...

I get her up to speed as to what the patient is feeling. She says that the muscles are confused as to what to think right now and this is to be expected during the acute phase of an injury. She then says we should put the patient back on inferential current at the 80/120 level to help retrain the brain as to what it feels.

We cart the patient to another room and hook up the device. Fourteen minutes later and the machine beeps, I detach the cables and clean off the patients back hoping that this pain killing modality did the trick. I K-tape the lower back in an H-pattern with a horizontal band at 50% tension across the injury site and two vertical strips on each QL. I tell the patient to slowly get up using the helicopter move.

The back spasms again! I am thinking, oh man, I wish I could prescribe medicine right about now. We slowly rise again and with the aid of a walker, yes, a walker, I assisted the patient to their car. I ran back into the clinic, snagged an ice pack and advised further treatment tomorrow. Yikes!

Tonight, I reviewed the treatment protocol for such a case and in recollect, icing down the back during the last IFC modality would have been better versus using a luke warm heat pack to weigh down the electrodes. This would have reduced the inflammation and perhaps allowed greater mobility in the standing/walking position. All other therapies were correct and Dr. Roberts felt confident that we did the right thing. That doesn't help the fact that this patient left feeling a bit worse, despite the greater segmental movement we facilitated and reduced palpable tissue tone in the prone position.

Acute cases suck. I had one earlier this quarter where a patient strained/sprained their upper back/lower neck. The first treatment is always a make or break situation. It is a delicate balance between applying too much and not enough therapy. I struggle to know the right recipe for such cases because for the most part, we are largely working on asymptomatic patients or chronic conditions that need adjusting and soft tissue work and my experience with acute conditions consists of about 6 hands-on cases. Thank goodness there is a Dr. Roberts nearby.

Tomorrow, if the patient returns and if I can get to sleep here soon, we will reassess the situation and decide the best course of action. I will probably advise pulsed ultrasound at a very low level, mobilization versus manipulation with a flexion emphasis and utilize post-isometric relaxation stretches to trick the tight muscles into relaxing.

Hopefully, we will have a favorable outcome that has some subjective loss of pain involved versus objective changes only.

All for now