Back Pain in an Adult with Cerebral Palsy
A 50 year-old female full-time student was referred to Physical Therapy by a family practice physician who diagnosed the patient with "back and hip pain." This is her first episode of back pain. The condition commenced due to lifting a heavy object and has been worsening in intensity and frequency overall. Initially, she reports the pain in the back and then her thigh.
Past Medical History: She has congenital spastic diplegia, with movement impairment that affects her lower extremities more than her upper extremities. The patient reports her symptoms are not affected by coughing and sneezing. Bladder function is normal. She states that her gait is "stiffer and slower" because of the back pain. Currently, she is not taking any medication.
It should also be noted that the patient communicates with total communication (sign and speech) due to congenital sensorineural hearing loss and chooses to not use hearing aids. (Note: The clinician is functionally conversant in this mode of communication.)
Observation: The patient presents with poor sitting posture. Posture correction lessened her thigh symptoms. In standing, lumbar lordosis appeared exaggerated. No lateral shift was noted.
Pain: The patient reports intermittent right anterior thigh pain to mid-thigh, and constant back pain. All symptoms have been present for 4 weeks. (Fig. 1)
Figure 1. Symptoms diagram
Function: The patient reports that the pain interferes with long-term sitting while in class, driving, donning her slacks and footwear, and turning in bed. Initial self-rating on the Oswestry Low Back Disability Index is at 34% (Moderate Disability).
Pain Behavior: Her symptoms are aggravated with sitting for prolonged time periods and rising from sitting. Walking for short periods and lying supine alleviates symptoms.
Neurological Testing: There was bilaterally generalized weakness in the hip extensors, knee extensors, and dorsiflexors. Reflex testing results showed hyper-reflexia of all knee and ankle reflexes and negative straight leg rise testing. The patient reported no changes in sensation in the lower extremities since the onset of the back pain episode.
Lumbar Movement Loss: There was minimal loss of lumbar flexion in standing with report of sharp, increased back and thigh pain. There was moderate loss of extension in standing with no effect on her symptoms. No loss in side-gliding to the right or left was noted.
Repeated Movement Testing of Lumbar Spine
In standing: Baseline symptoms: back pain, right anterolateral hip pain to mid-thigh.
Lumbar flexion in standing: increased back and right anterior thigh pain, increased with repetition, and remained worse.
Lumbar extension in standing: decreased right thigh pain with repetition, but did not remain better.
Baseline symptoms: back pain, right anterolateral hip pain to mid-thigh.
Lumbar flexion in supine (knees-to-chest): no effect on symptoms.
Lumbar extension in lying (press-up): decreased back or thigh pain, production of upper extremity fatigue, and no better as a result.
Hip provocative testing (e.g. hip scour test): negative
She has undergone diagnostic radiography that was reportedly "negative in results."
Suggest TreatmentIndicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.
Reversible lumbar disc pathology
Initial Treatment: Postural correction, avoidance of flexion and lifting, and to perform repeated lumbar extension in lying because repeated passive extension reduced and abolished the patient's symptoms.
Figure 2A. Prone
Figure 2B. Extension
Repeated end-range extension (Figure 2A, 2B): 50 repetitions of repeated passive trunk extension decreased, abolished back and thigh pain, better as a result symptomatically and functionally.
The patient was instructed to (1) perform repeated lumbar extension (10 repetitions) in lying 4 to 6 times per day, (2) avoid flexion-biased activity (e.g., sitting, bending), (3) maintain proper posture (with maintenance of lumbar lordosis), and (4) return 2 days later for reassessment.
During the second session, her thigh symptoms ended and back symptoms were occasional. The patient required further instruction on proper performance of repeated extension in prone.
Reassessment of her symptomatic and mechanical responses to movement testing was reassessed over that visit, the third session, and 2 days later.
The results of the tests were as follows:
(1) Lumbar extension in standing was full and painless.
(2) Lumbar flexion in standing was full but slowly performed.
At the conclusion of the third session, the patient claimed she was more aware of assumption of proper posture and able to sit in school without pain. She could roll over in bed with "a little soreness" but, all symptoms ended with regular extension exercises, which she would periodically perform throughout the day. Gait had improved in quality and cadence.
The patient accomplished treatment goals after 3 visits over a period of 5 days. She was discharged from physical therapy.
This patient's symptoms centralized and ended with repeated movement testing in extension. She was classified as a rapid responder, likely due to reversible disc pathology (reducible derangement). This method of examination, Mechanical Diagnosis and Therapy (MDT), has been shown to reliably and quickly identify patients whose back and/or leg pain emanates from the spine and who are capable of responding to conservative care. Also, this case shows that those with upper extremity weakness need repeated extension in lying (via REPEX) to effectively reduce mechanical back pain may benefit from repeated end-range extension. This case presents good evidence of the ability for specially-trained physical therapists to manage most activity-related spine disorders, including those with unrelated congenital movement impairment, such as cerebral palsy. Like the vast majority of people who experience mechanical back pain, this patient responded rapidly to appropriate mechanical therapy and required no further intervention. References
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This case represents an example of an adult low back pain patient who is probably suffering from injury of a lumbar intervertebral disc. The most common source of low back pain in adults under age 55 years is a disc with L5-S1 and L4-L5 commonly affected. Lifting is a common event precipitating injury of and subsequent symptoms from a disc. Typically discogenic low back pain is located in the midline and may arise due to frank herniation or just annular fissuring without nuclear herniation.
Mechanical Diagnosis and Therapy (MDT) is a viable manual evaluation to assist in determining which low back pain patients will experience improvement in their symptoms facilitated by an extension biased physical therapy regimen. The authors of this case nicely illustrate how extension in the supine position for the patient was necessary given the patient's reduced upper limb strength. Regardless of the reason, patients with limited ability to actively extend while in a prone position can utilize the technique outlined in this short report.
If this patient's lower limb pain was more prominent reflecting radiculopathy and her symptoms did not rapidly respond, recent evidence has been presented demonstrating improvement of peripheral symptoms by combining transforaminal epidural steroid injections with the MDT paradigm.
In short, adult low back pain patients are likely suffering from injury of an intervertebral disc but application of MDT can select which patients will rapidly respond. Furthermore, it appears that even a subset of radiculopathy patients, who do not rapidly respond, eventually achieve good results upon addition of transforaminal epidural steroid injections.
Thank you for Dr. DePalma's discussion. There are three points I wish to raise. One, the case study shows that even those with neurologic co-morbidity like cerebral palsy can be effectively assessed and treated for back pain and related symptoms. Secondly, this patient most likely had mechanical back pain that responded to mechanical assessment and treatment because she rapidly responded to mechanical treatment, and treatment by injection was unnecessary. And, lastly, in this case, repeated extension exercises were performed in either the prone or standing positions. It should be pointed out, however, in cases where the patient could benefit from repeated extension but were unable to assume the prone position (e.g., 2nd to 3rd trimester of pregnancy) that use of the REPEX in supine can be a viable option for treatment.