Peer Reviewed by the American Chiropractic Rehabilitation Board
Michael W. Mathesie, DC, CCSP, DABFP, DACRB*
*Chiropractor; Private Practice
10617 West Atlantic Boulevard
Coral Springs, Florida 33071
Structured Abstract: A Retrospective Treatment/ Management Case Report
Objective: To document and describe a multi-modal treatment method approach, that can be utilized in resolving a case of long term recurrent exacerbations of a lumbar disc herniation, resulting in low back pain and sciatica in a 39 year old construction worker.
Methods: The review of the literature suggests numerous methods for the treatment of lumbar disc herniation; this is including: spinal manipulation, physical therapy methods, rehabilitation, NSAIDS, steroid epidural injections, and surgery. The methods used in this case include non pharmaceutical and non surgical methods available to the chiropractor. Nutritional advice included elimination of corn syrup and sugar drinks, an increase in water intake, a reduction of breads and grains, the addition of supplements (including niacin and omega 3 essential fatty acids) and a daily general supplement pack with enzymes. A heel lift was fit for the patient for an anatomical short right leg. During the passive phase of care, modalities including High Volt Electrical Muscle Stimulation @ 80-150Hz, Interferential Electrical Muscle Stimulation @ 1-10Hz, Ice, breathing exercises, and 910nm LASER, were utilized in the acute stages of treatment along with Chiropractic Spinal Manipulation for the first 8 visits. During the transitional phase of care Post Isometric Relaxation Muscle Energy Techniques progressing to Post Facilitation Stretch, Manual Therapy Soft Tissue Techniques, Foam Roll Maneuvers, Posture Stretches, Side Bridges Progression, Cat-Camel, Dead Bug and Quadruped Bracing Progressions, were introduced with continued 910nm Laser Therapy and PRN Chiropractic Spinal Manipulation over the next 9 visits. During the active phase of care, after a full functional assessment, the patient began a 20 minute cardiovascular training program and continued progressions of the previous transitional program exercises. Additional rehabilitation was initiated consisting of: Deep Neck Flexion, Push-ups, Scapulo-Thoracic Facilitation, McGill Curl Up Lumbar Stabilization Exercises, Cook Hip Lift Lumbar Stabilization, Side Bridge McGill Lumbar Stabilization Exercises, Prone Bridge McGill Lumbar Stabilization, Supine Bridges with Progressions to Gym Ball, Standing Lunges, Superman with Gym Ball, Bird Dog, Wall Squat with Gym Ball, and Balance Training on Rocker Board for an additional 10 visits, which were performed for a total of eight weeks. A one month follow-up visit occurred for a total of 28 visits. In this case, the visits were completed within a three month period.
Discussion: Considering that the cause of low back pain is so complex, it would not be efficient to limit the treatment option to one mode. In this case, the patient was brought through the passive, transitional, and active phases of chiropractic rehabilitation. The patient also followed simple nutritional recommendations for weight loss, general health, and to lower blood pressure, inflammation, triglycerides, and cholesterol levels. He was given a heel lift for an anatomical short leg, to balance the lumbar spine and improve a lumbar convexity. He improved his cardiovascular fitness in the office and at home, and was taught to strengthen his spinal stabilizing core while being treated with a 250 Watt peak power; this included a 2 Watt average power, and a 910nm wavelength LASER that would have the ability to reach the target tissue of the lumbar facet and discs.
Conclusion: The patient responded well with treatment in a two month time frame, and then with a one month follow- up. There was no longer any residual chronic low back pain or sciatic radiculopathy, which has not been able to be accomplished in nearly 20 years for this patient. A normal strength and flexibility level was reached, using referenced Physical Performance Ability Test Methods and Measurements. There was a near normal BMI accomplished from previous obesity, normal cholesterol ￼￼￼￼ from previous hypercholesterolemia, normal glucose from borderline hyperglycemia, 33 pounds of weight loss, a decreased resting heart rate, and a decreased blood pressure. Common outcome assessment tools were utilized, and scores were dramatically improved including: Roland–Morris Low Back Pain and Disability Questionnaire (RMQ), Revised Oswestry Back Pain and Disability Questionnaire, and Health Status Questionnaire/SF-36/Rand 36.
Keywords: Lumbar Disc Herniation, Chiropractic Rehabilitation, 910nm Superpulsed Laser, Weight Loss, Heel Lift, Outcome Assessments, Chiropractic Spinal Manipulation
This case is an example of a common type of patient presenting to a chiropractic office, which includes: a nutrient deficient, obese, de-conditioned, early middle aged male physical laborer, with signs of pre-diabetes, hypercholesterolemia and elevated blood pressure. Along with a chief complaint of nearly 20 years of recurrent exacerbations of a lumbar disc herniation, resulting in chronic low back pain and acute episodes of sciatica. The objective, in this case, is to document and describe a wellness model of care using a multi-modal treatment method; an approach for a portal of entry chiropractor that could be utilized in resolving the presenting musculoskeletal conditions of the patient as well as the underlying additional health conditions that are co- morbidities affecting the healing process and the future health of the patient.
Case Report Presentation:
History of Present Illness (HPI) and Chief Complaint/ Symptoms: The patient entered the office explaining that at 8:30 AM he had bent over and lifted a small generator at a construction site, turned, and felt a pop in his lower back. He immediately felt pain in his lower back region, and it progressively got worse throughout the day. The pain eventually began to radiate to his right buttock and posterior thigh, his girlfriend had to drive him to the office. The symptoms remained to be constant; 100% of the time, they were severe in intensity, rated as an 8 to a 9 on a Quadruple Visual Analog Scale, with 8 being the best and 9 being the worst. His current and average pain levels were at a 9. The symptoms were further described as low back pain, from the bilateral ribs to the top of the crests, and then pain in the right butt cheek, under the butt cheek, and down the back of thigh stopping right before the back of the knee. The patient also described his back as being swollen. He said the pain he felt was sharp, dull, deep, burning and achy. The pain diagram filled in by the patient matched the description. He stated that lying on his back decreased the pain by a little, and putting weight on the right leg, including any movement, increased the pain. Prior to this episode, he has suffered from chronic low back pain, on and off, for 20 years, since high school sports. He also expressed, that he always feels stiffness and tightness in his body, even in the mid back region and neck, but those regions were not as painful in comparison to the pain he felt in his lower back. The patient revealed that 2 years ago he went to a pain doctor who ordered him a lumbar MRI; the patient brought in the results of the MRI for my review.
Activities of Daily Living Form revealed that there were no activities that could be performed except sedentary items and those not related to movement.
Outcome Assessment Forms, Red Flag and Risk Factor Assessments: These questionnaires were filled out to assess risks and set up baselines for future comparisons, and to determine levels of improvements; the results can be evaluated below in Table 1.
Past Medical History: The patient revealed a history of an appendix and tonsil surgery as a child: a broken right middle finger in high school, lacerated thumb requiring 20 stitches a few years ago, an automobile accident five years ago with no treatment, many traumas to the spine and extremities from high school sports, and he admitted to 8 episodes of this similar problem over the last 10 to 20 years. There was no other history of major illnesses, hospitalizations, or traumas revealed. His last physical examination was approximately two years ago, when he went to the pain doctor for pain medication and had injections. There was no blood work-up performed, according to the patient at that time, and he thinks it has been over 5 years since he’s had blood taken. Current Medication: He took 2 unknown pain pills from a co-worker this morning. For many years, he has been regularly taking two Motrin (400mg) every day, for his low back pain. Allergies: Pollen; Codeine; no other known allergies were listed.
Family History: The patient revealed that there was no heart disease, blood pressure conditions, cancer, or strokes in his immediate family. However, he revealed that his father has just been diagnosed with diabetes, and his father and mother both have high cholesterol. Since the patient had not had a blood work-up in over five years, further evaluation will occur regarding serum cholesterol and glucose levels.
Social/Occupational History: This patient is divorced, has an occasional two cigarettes a week, and consumes two alcoholic drinks a day with an occupation as a self employed carpenter/construction worker. His duties include construction, carpentry, form work, and framing which is often very strenuous. The highest level of education reached, is the completion of high school. The patient reveals that he does believe he has stress in his life, with some financial worries and trying to find work all the time, but not too high. He rarely takes a multi vitamin and often has fast food, processed food, and soda/sugar drinks at work all day. Prior to this injury, he had exercised less than moderately. He occasionally participates in other sports and activities, and he states that he usually does not get 6 to 9 hours of sleep each night.
Review of Systems: There were no symptoms of weakness, fatigue, fever, night sweats, weight loss, or any indication of vision, hearing, nasal, or throat disorders, coughing, difficulty breathing, chest discomfort, difficulty or loss of bladder or bowel control, rashes, numbness, major mental or hormonal disorders, or other blood, immune, or lymphatic abnormalities. However, he mentioned the feeling of pins and needles in his right leg. There was stuffiness mentioned for the nasal system, contributed to the allergies and construction dust, but there were no other additional symptoms noted to indicate additional organ dysfunction, except muscle/joint pain/back pain/stiffness was listed. However, this is part of the chief complaint, because he also has a chronic intermittent lower back condition.
Clinical Impression/Working Diagnosis: Based on the history, the patient most likely has a sprain/strain in the lumbar spine, with sciatic neuritis and possible disc herniation aggravation. A comprehensive examination will be performed to confirm this working diagnosis.
Physical Findings: This was a 39 year old, 5′ 11″, 225 pound, slightly disheveled appearance, endomorph body type, afebrile, Caucasian male with blood pressure of 138/89, and a pulse rate of 90 bpm with normal rate, rhythm and amplitude, and respiration rate of 19 breaths per minute. He would be considered obese based on the Body Mass Index calculation of (225 #/71 inches2) X 703 = 31.4 BMI. This would be considered within the “30 BMI and above” which would be the obese category; 18.5 to 24.9 would be normal category. Observation/Inspection of the skin, revealed no rashes or major scars of the head, neck, trunk, back, or extremities, except the hands, fingers, and forearms had multiple scars from working in construction. The fingernails were normal, there were no tattoos, no contusions, cuts, or discolorations noted on the spine or pelvis regions.
Percussion of the bony structures around the spine and pelvis, using a reflex hammer, revealed all normal findings except that the lower lumbar spinous processes were very tender when being struck with severe levels of increased pain. This was a suspicious finding, although hitting the painful areas would typically increase the pain, this level was more than would be expected.
Palpation/Inspection of the head, neck, trunk, back, and extremities (including skin, lymph nodes and thyroid gland) revealed all to be within normal limits except the bilateral lumbar paraspinals, and right quadratus lumborum were in spasm—rated at a 2— which is a spasm existing without provocation. Tenderness of this area would be graded as +4; thus, the patient complained of severe tenderness and withdraws immediately in response to the test pressure, and was unable to bear sustained pressure. The right Gluteals and piriformis muscles were in spasm, rated as a 1, which is triggered with movement or external pressure. These areas would be graded a +3 for tenderness, which is considerable tenderness, and withdraws momentarily in response to test pressure. The hamstring muscles were very tender to palpation, rated as a +2, which is moderately tender. The cervical paraspinal muscles revealed mild trigger points that were tender, graded as +1, which would be mildly tender or annoying.
Peripheral Vascular Evaluation consisted of auscultation of the carotid, subclavian, abdominal aorta, and femoral arteries for which there were no bruits heard. There was no swelling distally in the ankles or feet.
Specialized Testing consideration was appropriate at this point, because there was significant provocation upon percussion of the spinous processes of the lumbar spine, suggesting a possible fracture of the spinous processes, which could occur with some lifting injuries. This was considered in order to prevent further damage to the patient, from performing more strenuous testing. AP, lateral, left and right posterior oblique x-ray views of the lumbar spine, was taken on this patient before the exam was continued, in order to rule out the red flag of fracture of the spinous processes. The films did not reveal any fractures or other pathology; thus, the examination proceeded. The x-ray findings will be listed in a subsequent paragraph.
Range of motion of the cervical spine using dual inclinometer method reveals Flexion 45/50, extension 50/60, right lateral flexion 40/45, left lateral flexion 40/45, right rotation 65/85, and left rotation 70/85. There was no pain reported in the cervical spine, just stiffness. The lumbosacral spine ranges of motion were measured at flexion 30/65 (reached 24 inches from the toes) and pain in lumbar and right gluteal/posterior thigh, extension 10/30 with pain at lumbosacral region/right SI joint, and upper gluteal, right lateral flexion 10/25 right gluteal/hamstring pain, and left lateral flexion 20/25 with no increase in pain. Thoracic ranges of motion were flexion 40/60, right rotation 15/30, and left rotation 20/30. These movements increased low back pain. Range of motion of the hip joints, using goniometer revealed flexion to be 120/135 on the left and 50/135 on the right with both movements, resulted with increasing pain in the lower back and down the right posterior thigh. The Extension was 20/30 on the left and 10/30 on the right; both caused low back pain. Abduction and Adduction were too painful for him to complete. Internal rotation was 30/35 on the left and 25/35 on the right, with an increase in pain in the right gluteal. External rotation of the hip revealed 30/45 on the left and 20/45 on the right with increased pain in the right buttock with movement. Knee flexion was 115/135+ on the left and 105/135+ on the right. There was only a mild increase in low back pain upon knee flexion, no knee pain. The knee could be fully extended and there was obvious abnormal movement patterns noted in the spine.
Posture evaluation revealed: anterior head translation, a left head tilt, a high left shoulder, bilateral internally rotated shoulders, an increase in thoracic kyphosis, a high left ilium, mild left torso translation, a pendulous abdomen, and flattened Gluteals. Gait revealed a mild limp with the patient putting more weight on the left leg, no pronation of the feet, a mild right external rotation of the foot, and a slow cadence of gait were all noted.
Chiropractic evaluation, utilizing motion palpation of spinal joint play, was performed. Ligamentous fixations were noted at C1/C2, C5/C6 and C7/T1, T5/T6 and T12/L1, L4/L5, and Bilateral SI joints were fixated to a moderate degree. These fixations indicated kinesiopathology components of the subluxation complex. There was no crepitation or hypermobilities noted. No contusions were visually evident in these regions. There was obvious hypertrophy of the lower thoracic musculature and tenderness of the lumbar paraspinals as noted above, as well as additional right sided hypertrophy apparent from a lumbar spinal right convexity. There was also inflamed muscle tissue noted with mild edema, palpated along the paraspinals and right iliac crest.
Neurological Examination: The patient was oriented to time, place, and person. The mood was normal. A normal review of the cranial nerves was noted. Peripheral vascular system revealed normal skin temperature, and normal pulses of the upper and lower extremities. The Muscle tone in the upper and lower extremities was normal with no atrophy, fasciculations, spasticity, or flaccidity noted. Dermatome sensation to light, touch, and sharp stimulus was normal bilaterally along both upper and lower extremities (except S1 on the right would be considered hyperesthesia) because it was perceived as an increase in sensation compared to the left S1 dermatome, as well as the right L5 dermatome above, and S2 dermatome below. Muscle strength was 5/5 for all major upper and lower extremity muscle groups. Deep tendon reflexes of the upper and lower extremities were 2+, normal. Tandem Gait was difficult and not completed due to pain. Babinski’s Sign was absent with the toes going into plantar flexion. Rhomberg Sign was absent. Coordination testing of finger to nose was normal. Cerebral function was assessed with the patient being able to count backwards from 35 in intervals of 7. He was able to rapidly move his hand to his thigh, chest, and other hand. The girth of his left calf was 15 inches and the right calf was 15 inches.
Orthopedic Examination: In addition to the above findings, a musculoskeletal examination including inspection and palpation of the bilateral joints, bones, muscles, and tendons with stability/provocative testing revealed the following: Vertebral Basilar Artery Functional Maneuver was negative for vertebral artery insufficiency. Thoracic outlet syndrome testing was negative. Cervical foraminal compression, Maximum Compression, and Soto-Hall/forced flexion were all negative for any increase in cervical pain or radiation of pain. Shoulder depressor testing was negative but did cause a mild pulling sensation of the trapezius muscles, not pain. Jull’s Test with the patient asked to hold their head off the table for 10 seconds, resulted in chin jutting indicating weak deep neck flexors. An increase in intrathecal pressure caused an increase in lower lumbar spine pain. Straight Leg Raise Test caused an increase in low back pain bilaterally and also radiation to the right posterior thigh above the knee at 50° of right passive hip flexion. The hamstrings were shortened bilaterally with 70 degrees on the left and 50 degrees on the right. Bowstring Sign was negative bilaterally. Patrick’s Test was performed causing pain on the right side indication a possible right hip lesion and indicating very tight groin muscles bilaterally. Milgram’s Test was performed causing pain in the lower lumbar spine almost immediately and revealed very weak abdominals and/or hip flexors. Thomas’ Test revealed shortened Iliopsoas muscles bilaterally. Pelvic compression testing revealed pain in the right SI joint and surrounding regions. Nachlas’ Test caused pain in the right lumbosacral region and Sacroiliac Joint. Hibb’s Test revealed pain in the right SI joint and deep gluteal region when pushing away the right leg, also causing the left pelvis to rise, indicating piriformis shortening. There was no pain on the left Hibb’s Test. There was tight quadriceps muscles noted bilaterally with the patient unable to reach the heels to the buttocks with a passive stretch. Yeoman’s Test was positive on the right for SI joint pain. Kemp’s/Quadrant Test caused local low back pain and radiation of pain on the right when rotating the patient posteriorly on the right. Passive Scapula Approximation Test was negative for interscapula pain. There were no deformities, step offs, masses or instabilities noted.
X-rays: The views that were taken included the upright AP lumbopelvic, AP spot, lateral, and left and right posterior oblique x- ray views of the lumbar spine. As discussed previously, the physical exam was discontinued until fractures were ruled out and then the examination proceeded. The films did not reveal any fractures, on any of the projections, within any portion of the spinous processes or vertebral bodies. The AP lumbopelvis view revealed a lumbar convexity with an 11 degrees Cobb’s angle to the right, with a pelvic deficiency of 9 mm on the right side, measured at the heads of the femur, indicating an anatomical short leg on the right side. The L4/L5 and L5/S1 facets showed mild arthrosis. There was mild global left spinous rotation noted of the lumbar spine. The lateral projection revealed mild L5 disc space narrowing. The intervertebral foramens were patent. A mild loss in the lumbar lordosis is evident. Mild anterior spondylosis is evident on the vertebral bodies of L2/L3 and L5/S1. The oblique projections show no separation of the pars.
MRI: The patient brought in with him a copy of a lumbar spine MRI report, and compact disc from a local MRI Center dated 12/18/09, 15 months ago, which was ordered during his last episode of pain similar to this. The report written by a medical radiologist, who was considered reputable in the community, revealed a right paracentral herniation L5-S1 with loss of lumbar lordosis and a very mild dextroscoliosis. These findings were compared to the images and were accurate, thus the report was initialed.
No physical performance testing was attempted on this visit, to establish a baseline or weak link, because of the acute inflammatory phase or stage of the patient’s condition.
Diagnostic Impression/Assessment: This is an acute new injury over a pre-existing chronic weakness.
1. 847.2-Lumbar Spine Sprain/Strain
2. 724.3-Sciatic Radiculitis/S1
4. 728.85-Muscle Spasm; Piriformis
5. 739.3-Lumbar Joint; 739.4 SI Joint; Dysfunction/
Non-Allopathic Lesion/Subluxation Complex
1. 722.10-Lumbar Disc Herniation/L5
2. 739.2-Thoracic Joint Dysf./Non-Allopathic Lesion/ Subluxation Complex 3. 728.87 Muscle Weakness
4. 719.7-Difficulty Walking
5. 781.92-Abnormal Posture
Complicating Factors: The patient had co-morbidities noted; he was de-conditioned, had a pendulous abdomen, had a 9mm right short leg contributing to a mild right convex lumbar curvature, he was obese by at least 40 pounds, worked a laborious job, had an alcohol intake of two drinks per day, and occasionally smoked.
Prognosis: Fair. He has had this condition for many years, with on and off flare-ups every one to two years. He has never truly addressed the underlying weaknesses contributing to the problem. He works in a job that requires the use of his back. He has a confirmed L5 disc herniation that appears moderate in size. This condition could become more stable with proper methods applied. If he chose to follow my directions and treatment plan, this prognosis could be elevated.
Discussion, Decision Making, Treatment Goals and Initial Treatment Plan: The initial treatment plan was recommended to consist of short term, one to three weeks of ice with compression on the lumbar spine. This includes electrical stimulation of the lumbar spine and right piriformis/gluteal region to decrease pain and tissue swelling, starting with high volt galvanic at 80 to 150 Hz (encephalon release) and then after several visits, interferential at 1-10 Hz (endorphin release). He was instructed to wear an all elastic lumbar support brace for the next five days; it was to be worn only when moving and traveling places, and not when in bed or sitting at home. The brace is not rigid, but semi-flexible. He was required to return the back brace support to the office to assure he did not wear it past five days. The use of this brace was for short term only, to protect the injured area from re- injury while it was healing, to rest the injured tissue and to compress the injured tissue. At the same time, there was an attempt to prevent further weakness and disuse atrophy of the small spinal muscles of the spine. Also recommended, was LASER therapy to the lower lumbar region, L5 and SI joint, and right piriformis muscles for the reduction of pain, inflammation, and for the biostimulatory effects on the joint and soft tissue. To reach the facet and disc, which is at least 3.5cm to 5cm deep, a 910nm LASER must be used. Chiropractic Manipulative Treatment/Adjustments/Manipulation was recommended to the thoracolumbar region, lumbosacral and sacroiliac subluxation complex kinesiopathophysiological components as indicated during this initial stage of care. He was also given a soft tissue supplement pak, containing 660 mg of turmeric root extract, 705 mg of an enzyme blend of protease, amylase, papain, lipase, bromelain and others, quercetin, GABA, vitamin C, B-6, calcium, and magnesium for the inflammation and tissue repair. This would be taken as directed on the box and brochure given, and would immediately be stopped if any nausea occurred. If this occurs try to take it with food. The patient would then be re-evaluated within approximately 3 weeks unless indicated earlier or later. Treatment frequency would be three times a week, but he could be seen daily for the first few days in result of the severity of pain. He was treated on the day of this initial examination.
The clinician would be evaluating for improvement of symptoms and function. Short term treatment goals, by two to four weeks, will be a 50% decrease in the symptoms intensity, elimination of the majority of tissue swelling, the ability to sit, drive, and stand for more than one hour without an increase in pain, and the ability to walk without a limp, and to be able to perform basic functional testing maneuvers to assess his baseline. An additional goal for this patient was to lose 15 pounds in 30 days. He wanted to finally get rid of the chronic back pain that kept returning. The patient was concerned about his elevated blood pressure and wanted his cholesterol checked, and he agreed to listen to my recommendations. The patient would also utilize ice on the lumbar spine and right gluteal region with compression at home; applying a bag of crushed ice on a moist towel over the complaint area for 15 minutes, and then re-apply when the skin is normal to touch. The patient was given a requisition form to go to Quest Labs and have blood drawn for a comprehensive metabolic panel, thyroid panel, CBC, and Lipid Panel to evaluate the fatigue, thyroid, cholesterol levels, and glucose levels; it was done with the consideration of the borderline elevated blood pressure, obesity, and scores on the health status questionnaire.
This was an acute injury/condition with multiple components to the diagnoses. It required a low to moderate complexity of medical decision making, including the reviewing of diagnostic images and reports, low risk of morbidity, as well as the length of time spent face to face with the patient of over 75 minutes, with at least 25 minutes involving counseling. However this was regarding the options for him, including the referral for pharmaceutical intervention or epidural injection consultation, or the following up with a rehabilitation program with this office over the next 3 to 15 weeks. The risks of treatment and the risks of not getting treatment, were discussed with the patient and listed on the separate signed informed consent form, and the patient stated that he understood all elements and wanted to start the treatment plan that day.
The patient was able to stand on the platform of a hi-lo table, and the table was then lowered to the prone position. Four adhesive electrode pads were attached to the four lead wires, and placed over the left and right L5 paraspinal/quadratus regions and the right upper and middle buttock. The high volt galvanic (HVG) (G0283) was set at 80-150 Hz for encephalon release and pain relief to slightly more than patient perception for 20 minutes. Ice (97010) was also applied to the same region with compression for no longer than 15 minutes to prevent an increased reaction of blood flow. After the ice and HVG therapy was complete, a 910nm 250W peak, 2W average power, superpulsed LASER device (S8948) was applied to the patient while in a side lying position at the right side of the interspinous space between L5/S1, the right top of the sacrum, the right SI joint, and the right piriformis muscle with 1344 Joules in a total area of 90 cm2 for a dose or energy density of 15 J/cm2 at the surface over 15 minutes. The use of ice prior to using LASER is often beneficial because less blood in the capillaries will allow better transmission of photons through the tissue. The patient was given an adjustment/spinal manipulation in the side posture position to the Left SI joint, and T11 fixations/subluxation complex. The right SI joint was too acute to manipulate on the initial visit. He tolerated the adjustment (98940) very well. The patient was fitted with an all elastic lumbosacral support brace to protect from re-injury, rest, and compress the lower back to assist in the reduction of swelling and pain. This is a loan to the patient to assure that he returns it and does not wear it for more than 5 days. He agreed to return it within the recommended time period. The patient was instructed not to wear it when sleeping or when sitting for long periods; he was only required to wear it when standing and walking. He understood that it was the goal to not have him become dependent on the brace, and would be utilized short term during the first phase/inflammatory phase. He was instructed to use ice at home with a moist towel on the skin, use a zip lock bag of crushed ice cubes on top of the wet towel for 15 minutes at a time, and then apply the ice again when the skin returns normal to touch (up to four times a day). The patient was given a three page handout on McKenzie self treatment/stretching and sciatica by Liebenson that he should read and attempt to put his body into the positions on the sheets. His breathing patterns were reviewed, also demonstrated and instructed him that while doing the exercises (even when standing or lying down) he must practice inhaling with his abdomen and ribs coming outward, and breathing out/exhaling with his abdomen and ribs coming inward; his shoulders and chest should not rise with breathing. It was explained to him that this could be a great exercise for him to start, and that it is not strenuous for his back and will help him have a head start when additional exercises begin in the weeks to come. The patient was instructed to return the next day. This treatment was performed for 4 visits over the next 7 days.
On the third visit the lab results came back. The results are available in Table 2. In addition to the soft tissue support vitamin/mineral/enzyme pak he was already taking. He was recommended to go to the health food store and purchase additional 100 mg capsules of niacin (B3) in the form of nicotinic acid. The patient was informed about the flush sensation which feels similar to a sunburn, but disappears in approximately 30 minutes. He should start with 100 mg three times a day for a week if tolerated. Then slowly titrate up to 500 mg three times a day. A slight flush, is the maximum he should feel. If it is more than that, he should back off. After three months, he should decrease the amount gradually and just include it in a multiple vitamin or other supplement packs or B-complex. This is to lower the triglycerides and increase his HDL levels and lower his LDL. He was also recommended to take 3000 mg of molecularly distilled Omega 3 essential fatty acids per day (in 1000 mg separate doses) to help lower triglycerides and possibly blood pressure, LDL cholesterol and increase HDL. He should increase his walnut and almond intake every day with at least a handful of each. Since he requested assistance with weight loss and fatigue; dietary recommendations included the complete elimination of all sugar drinks including electrolyte “ade” type, Cola, Iced Teas, and every other drink with sugar and corn syrup. No diet, energy, or vitamin water drinks, or artificial sweeteners were allowed either. He was instructed to drink as much water as he wants to for thirst. He may have plain green or black teas (cold or hot) with no sweeteners. He was able to use squeezed lemon in liquids. He may have two eggs for breakfast. He may also have a mixture of steel cut oats, shredded coconut, sliced almonds, walnuts, pecans, cinnamon, chia seeds, pumpkin seeds, and a banana with almond milk. He may have up to four servings of real beef/chicken/fish a day, but no processed cold cuts or jerky. He can have as much fresh or frozen vegetables (salads or steamed vegetables) as he wants to eat in a day, but can only use extra virgin olive oil, vinegar, lemon, Himalayan Salt, pepper, curry, hot sauce, or other seasonings on them. No other liquid dressings or oils were permitted. He may have one sweet potato or white potato a day if he wants and one serving of bread a day (two slices) if he must. For example, he can have a sandwich for lunch but not a full hero/hoagie roll. He may have four handfuls of fruit a day, (i.e. one whole fruit like an apple, orange, banana is each a handful, a big handful of blueberries is a handful) no more. He was permitted to cheat on his diet only one day a week (a Saturday night). Although this was a big change for him, he understood the parameters and promised to stick with it. He understood his lab results and understood that if the levels did not change in three months, he would need to see a medical doctor for pharmaceutical intervention. On the 5th visit over a 9 day span, the type of EMS was changed to interferential therapy. Interferential therapy (G0283) was applied with four adhesive electrode pads with the leads placed properly in a criss-cross pattern over the lower lumbar muscles/quadratus region and the upper gluteal/piriformis with most of the L5 region pain in the center of the pads vectors attempting to reach deeper in the tissue. The interferential machine was set to 1-10 Hz for endorphin release and continued pain relief, but also to increase circulation and reduce spasm, and set to patient comfort/tolerance for 20 minutes. Ice (97010) was also continued; to be applied to the same region with a compression wrap, but for only 15 minutes because of the tissue thickness and to prevent an increased reaction of blood flow. After the ice and interferential therapy application, a 910nm, 250W peak powered, 2W average powered LASER device (S8948) was applied to the lower lumbar/L5/and Right SI structures, delivering 1344 Joules in a total area of 90 cm2 for a dose or energy density of 15 J/cm2 at the surface over 15 minutes. He was given a side posture adjustment (98940) to the right and left SI joint fixations/subluxations, and supine adjustment to the lower thoracic segments. Light, passive range of motion was applied to the lower extremity to all muscles and all planes of his tolerance levels, and they were done to not aggravate the sciatica on the right, and just to relieve tension on the left side. He was instructed to try to walk a little more during the day and avoid sitting or lying down at all. He can continue to use ice at home as directed. This treatment was performed from the 5th to the 8th visit in slightly over two weeks. On his 6th visit, wall angel exercises were instructed, and performed to assist with the weak scapula stabilizers, tight pectoralis, and thoracic kyphosis. On the 7th visit, since his short right leg measurement was 9mm on the standing x-rays previously taken, he was given a 5mm heel lift to put into his right shoe. He walked around and did not have any problems with the lift. The patient is instructed to always remember to wear it in all his shoes. The pelvis appeared more balanced with the heel lift in the right shoe. On the 8th visit he was re-assessed/examined and functional and physical performance evaluations were performed, provocative tests were less severe regarding positive signs; some of the functional measurements and findings were noted in Table1, Table 2, and Table 3. The patient then began transitional care on the 9th visit to the 17th visit, for which the next goal was to continue with correct breathing patterns, stretching strategies, and stabilizing strategies. He continued to receive spinal adjustment/manipulations on a needed basis as well as the LASER therapy more regularly each visit. He continued on the diet and nutrition regimen, home exercises previously given, and additional ones. The transitional sessions consisted of breathing exercises for 6 to 8 minutes in the office, while stretching supine on a gym ball with the patient’s arms extended above his head, and then out to the sides stretching the pectoralis muscles and extending the thoracic hyperkyphosis. He was explained that with all exercises, the object is to never do a bad repetition to prevent creating a bad motor pattern. Stop at a bad rep and do more sets of fewer repetitions. Next the patient stood looking in the mirror (for awareness) holding perfect posture and abdominal hollowing with a “small foot” for 10 seconds at a time and this was repeated for three sets. He was then instructed to lay supine on a foam roll in the vertical position with arms to the side for 2 minutes and then up above the head for 2 minutes. He was then instructed to lay supine on a foam roll in the horizontal position and roll back and forth on the thoracic spine working the myofascial adhesions of the lower thoracic, and the hyperkyphosis of the upper back for 2 minutes. He was instructed that cavitation may occur and that would be fine. Next the Cat-Camel was performed for 6 to 8 minutes accentuating the correct breathing and reinforcing the tightening of the core, and assisting the form by holding the low back and abdomen for the patient and having him hold the positions. Quadruped Bracing:-on all fours-with chin tucked and neutral spine with a stiffened trunk/core using the “end cough contracted position” technique, and challenging the patient with perturbations when able, was performed. Next a Side Bridge on knees was held for 10 seconds each side for three sets. Then the Dead Bug Beginner: with arm above head, supine with same leg bent with foot on floor, other knee comes up and touches opposite hand coming from above, then switch, all while abdominal bracing and not holding the breath. 10 times three sets. Then Post Isometric Relaxation (PIR) was performed on the quads-hams-adductors- gastrocs-soleus-iliopsoas piriformis and gluteals, with the patient comfortable, with muscle passively lengthened to the slight resistance barrier, patient contracts the muscle with minimal effort against resistance for 10 seconds while breathing in, and then let out and relax. This was repeated 3 to 5 times until no new barrier was met for each group. In addition, Deep muscular manual therapy techniques of ischemic pressure, and stroking massage using the elbow, was applied to the right piriformis and gluteus muscles, and QL for up to 7 seconds. It was then released and repeated at different locations of the tightened trigger points of these muscles. The patient was explained that this deep pressure may be very painful and to not allow the level to pass their tolerance threshold. LASER therapy was applied on the right piriformis muscle, QL on the right and left trigger point areas at L4 and L5 region, and medial superior right SI joint region using a 910nm Superpulsed system, with a 250W peak and 2W average power to stimulates growth factors effecting gene expression, which is necessary for remodeling and formation of healthy tissue. This device also has the ability to penetrate deeper into the tissue because of its power density, wavelength, and delivery properties. 1344 Joules were delivered in a total area of 90 cm2 for a dose or energy density of 15 J/cm2 at the surface over 15 minutes. (S8948). He is recommended to attempt to do all of these routines and stretches gently at home. He was given a roll for the mid back to take home so he could work on the mid back at home. The patient was confident in doing the perfect form and repetition and was given my cell phone number for any questions. He should use ice as directed previously for any pain or flare-ups. At the 12th visit-no spinal adjustment was needed, and the patient was ready for additional intensity but still in the transitional phase of care. PNF techniques of Post-Facilitation Stretch (PFS) were initiated on the quads-hams/biceps femoris-gastrocs-soleus-iliopsoas-glutes and TFL/ITB. Care was used to assure patient comfort, and although he was instructed to contract with near maximum effort, pain should not increase past his average pain levels of 4. He promised not to go too hard with this stretch technique to avoid straining himself. The patient was then instructed to push against my body on each muscle treated, and breathe in slowly (respiratory synkinesis) while resisting on my count of 10 seconds, and have his eyes look (visual synkinesis) into the direction of his contraction. He then was told to completely relax and let go, as the muscle was stretched to the new barrier for 15-20 seconds, and he had his eyes look into the direction of the stretch. He relaxed for another 20-30 seconds and repeated each muscle 4 times. He continued then with breathing exercises for 6 to 8 minutes in the office, while stretching supine on a gym ball with the patient’s arms extended above his head, and then out to the sides stretching the pectoralis muscles and extending the thoracic hyperkyphosis. Again, the importance of proper breathing methods through the abdomen extending outward on inhaling, and that the ribs should come out laterally on inhaling and the shoulders should be relaxed with breathing and not be rising, were all reviewed. He was explained that with all exercises, the object is to never do a bad repetition, in order to prevent creating a bad motor pattern. Stop at a bad rep and do more sets of fewer repetitions. Next the patient stands looking in the mirror (for awareness) holding perfect posture and Abdominal Hollowing with small foot for 15 seconds at a time and this technique was repeated for three sets. This began with expected and unexpected perturbations while standing in this position. Then this was performed with the eyes of the patient closed, trying to assist him with proprioception, and balance while standing on two feet with awareness and perturbations trying to maintain the posture. He was then instructed to lay supine on a foam roll in the vertical position with arms to the side for 2 minutes, and then up above the head for 2 minutes. Next, He was instructed to lay supine on a foam roll in the horizontal position, and roll back and forth on the thoracic spine working the myofascial adhesions of the lower thoracic, and the hyperkyphosis of the upper back for 2 minutes. The patient also began rolling with perfect form, and breathing and bracing on the TFL to release some trigger points and tightness of this soft tissue for 2 minutes. Next the Cat-Camel was performed for 6 to 8 minutes accentuating the correct breathing, and reinforcing the tightening of the core as described previously. Quadruped Bracing was performed as described previously with expected and unexpected perturbations for 4 minutes. Next, a Side Bridge on the feet (instead of the knees) was held for 15 seconds each side for three sets. Dead Bug Second Progression was performed with the arm above head, supine with both knees at 90 degrees, other knee comes up and touches opposite hand coming from above, then switch, all while abdominal bracing and not holding breath, 10 times bilaterally; three sets. Deep muscular manual therapy techniques of ischemic pressure and stroking massage (using the elbow) was continued to be applied as previously described. LASER therapy was continued and performed as described above. A re-evaluation of previous positive maneuvers, as well as a reassessment of functional performance, was performed on the 17th visit of 03/09/11. Some of the results are included in Table1, Table 2, and Table 3. In addition, a Par-Q Form was filled out by the claimant to assess cardiovascular risks for which, allowed us to proceed with the YMCA 3 minute Bench Step Test. He was able to complete the assessment for which, the total visit took 2 hours to complete. On the 18th visit, 03/11/11-we began Active Care. The patient was instructed to continue to perform all the previous exercises at home during the off days. He is also asked to continue the cardio routine at home on his off day that was started today in the office, with the same level of intensity and time. He is also to attempt—with perfect form—the new exercises he was taught. The patient started at a 5 minute slow pace on the bicycle, and then increased the pace for 20 minutes maintaining his target heart rate of 142 bpm and then a 5 minute cool down. He was rated as below average on the YMCA 3 minute Bench Step Test on the assessment. Therefore, he was started at 60% for aerobic training for 20 minutes, and will be progressed up slowly to 80% for 20 minutes over the next several weeks as his fitness levels allow. The Karvonen Method Formula: (220 – age) – (RHR) X (% intensity) + (RHR) = HR target. This patient: 220 -39age = 181HRmax 181HRmax – 83HR rest =98 98 X 60% = 58.8 58.8 + 83HRrest = 141.8 HR target
By this time, the patient had mastered the Cat-Camel, Dead Bug, Mirror Image Posture, Side Bridging, Quadruped Bracing, Breathing Techniques, and has improved in his flexibility; he was able to explain that with all exercises, the object is to never do a bad repetition in order to not create a bad motor pattern. Stop at a bad rep and do more sets of fewer repetitions. He was instructed to continue this routine and use it as part of his warm up before entering the office, and also to perform this routine and all stretches daily. The active rehabilitation routine utilized is listed in Table 4. This rehabilitation routine was progressed slowly over each visit from the 18th visit to the 27th visit, with increased repetitions, sets, and/or resistance. It includes other increases in challenges such as, eyes being closed as indicated in the routine. He stretched and performed one hour of the exercises, and 20 minutes of cardio on his off days from this office, and used ice after all sessions for 15 minutes as previously directed. He was seen 3 visits a week of Monday, Wednesday and Friday until the 27th visit.
On the Final Evaluation, which was the 27th visit, the patient was discharged from active care and told to return in one month. He was stronger and thinner; had better posture and had nearly no back pain. At this point, it was deemed that he would do very well continuing to strengthen his back on his own. The patient should continue to perform all the exercises he was taught in this office, 3 times a week, as a home maintenance program. This would also include his cardio exercise as well. He was also prescribed a general multiple vitamin pack. This is in addition to the fish oil and niacin that he was still taking. He was no longer taking the soft tissue support pack for the last four weeks. He was instructed to reduce one fish oil capsule per day that he has been taking, because this new pack has one in it. He will reduce the niacin in four weeks, titrating down. He will visit his MD within the next four weeks, and have a complete physical and blood workup performed. He returned to work, and was recommended to return here in four weeks for a check-up to see how going back to work affected his back. He may also return to the office PRN (as needed) for any flare-ups, regressions, or reoccurrence of his lumbar condition. On the one month follow- up, the 28th visit, the patient was released and discharge. The patient has done a great job keeping up with the exercises. He looks great and he should return as needed for any tune-ups or flare-ups of any pain. If his condition deteriorates and functions decrease, if his symptoms reoccur, or after his home treatment fails to give relief, he may return for any nutrition purchases. The patient understood the importance of continuing the home plan of exercises with perfect form and proper breathing.
Results/Outcome of Care:
|Key: *right now, average, best, worst listed, PF=Physical Function, BP=Bodily Pain, EF=Energy Fatigue|
|Quadruple Visual Analog Scale*||9,9,8,9||6,6,5,7||2,3,2,5||0,1,0,2|
|Health Status Questionnaire-(Rand)/SF 36||PF-60||PF-90|
|Roland-Morris Disability Questionnaire||18/24||11/24||6/24||1/24|
|Revised Oswestry Back Disability Quest.||39/50||22/50||13/50||5/50|
|Motrin Medication Intake||14x’s/week||2x’s/week||1x/week||0x’s/week|
|Height||71 inches||71.75 inches|
|Resting Heart Rate||90bpm||83bpm||75bpm|
at 60% and then 80%
|*Lumbar Spine Mobility Listed as Flexion, Extension, Lateral Bending Right, Lateral Bending Left (AMA normal values)|
|**Normal Values referenced from Rehabilitation of the Spine, A Practitioner’s Manual, 2nd Ed., Craig Liebenson, Lippincott Williams & Wilkins|
|YMCA 3 Minute Bench Step Test||116bpm; below average||101bpm above average|
|Lumbar Spine Mobility/ROM*||30, 10, 10,10||40, 15, 15, 20||45, 20, 20, 25||55, 25, 25, 25||60+, 25, 25, 25|
|Over Head Squat Test||Score: 0; Fail; Pain||Score: 1; Difficult||Score 3|
|One Legged Standing Test||Score: 0; Fail; 4 secs /open; 0 sec/closed||Score: 1; Difficult; 15 secs /open; 6 secs /closed||Score: 2; some compensation; 30 secs /open; 20 secs /closed|
|Lunge Test:||Score: 1; Difficult||Score: 1-2; Borderline||Score: 3; No Compensation|
|Janda Hip Extension Test||Score: 0; improper sequence; twisting/weak||Score: 1; Weak Glute||Score: 3; Correct Sequence/Normal Glute Max Strength|
|Janda Hip Abduction and Coordination Test||Score: 1; Severe Hip Hike; ext. Rotation||Score: 2; Overactive QL/Piriformis||Score: 3; Normal|
|Side Bridge Endurance Test||Score: 0; Pain; 10 secs||Score:2-35 secs/no LBP/Compensation||Score: 2; held 75 secs; slight compensation **/84.5 ave.|
|Sit and Reach Test||Score: 2; 7 inch mark||Score: 2; 9 inch mark||Score: 3; 12 inch mark/10-16 mark|
|Trunk Flexor||2/50||10/50||35/50reps ; Ave. 27 +/- 14|
|Repetitive Arch Ups||6/50||15/50||30/50reps; Ave. 28 +/- 14|
|Squat Endurance/Repetitive||9/50||18/50||40/50reps; Ave. 37 +/- 12.5|
|Sorenson’s/Static Trunk||30/240||65/240||99/240sec; Ave. 97 +/- 56|
|Deep Neck Flexion||Retraction of chin in the prone, seated or standing position to assist with forward head posture; with nodding the head without and then with resistance with a small gym ball and or head harness or band||Sets of 10 to 20 reps to patient abilities|
|Push Ups||On fists, chin tucked, neutral spine, protraction of shoulders, activate all stabilizers, feet dorsiflexed||5 reps; add reps, add rocking, rotation, and tripod|
|Scapulo-Thoracic Facilitation||In the side lying position, activate scapula stabilizers, patient brings back scapula and shoulder to where the doctor directs||Start with 10 reps each side and then increase|
|McGill Curl Up Lumbar Stabilization||No head jutting, only perform after activation of abdominal bracing, breathing and bracing concurrently, hold and breath multiple times starting with the one leg bent, elbows on the floor, hand behind lumbar spine, upper spine moves only, no lumbar spine movement; progress to elbows off floor and/or both legs bent; then fingers curled next to ears, then adding trunk rotation.||Start with 10 reps and increase to multiple sets of higher reps|
|Cook Hip Lift Lumbar Stabilization||Supine; The focus should be on engaging the hip extensors. Pull one knee towards the chest as much as possible to engage the opposite hip extensors (as opposed to overusing the lumbar extensors)||Hold 10 secs each side; increase secs held /sets|
|Side Bridge McGill Lumbar||Side lying on feet (top in front) and propped up with forearm, square pelvis so no sag, abdominal brace||3 sets of 10 secs with Roll Over and increase|
|Prone Bridge McGill Lumbar||Prone; propped up with both forearms, square pelvis so no sag, abdominal brace, chin tuck; progress from two feet to one foot, and lift other leg up and hold||3 sets of 10 secs and then increased over time|
|Supine Bridge||Maintaining co-contraction including glut max, raising buttocks off the floor, then sacrum, lower lumbar, and upper lumbar spine. Then lower the spine down to the floor with the coccyx last to touch||Hold 10 secs, longer; 2 legs to 1 leg, then ball|
|Superman||On floor, both feet supporting on wall/floor, brace, keep spine neutral, extending the hips, not spine and lift arms up; both hands out, also sideways; hold 3 seconds/10 reps/3 sets||Progress in hold time, reps, sets, and then to gym ball|
|Gym Ball Lumbar Extension||Lay prone on ball, feet on floor, torso hanging off; lumbar extensions, 3 sets of 10 reps, hold each rep for 3 secs.||Progress in reps and sets and hold time|
|Bird Dog||Quadruped; chin tuck, breath, brace and hold, check for abnormal external rotation of hip and lumbar hyperextension, should be neutral then one arm/other leg; hold 3 secs; progress to under touches/ball||3 sets of 10; increase sets, reps, hold time; touches|
|Standing Lunges||Patient steps forward onto Stability Trainer-(green-firm then blue and then black) with perfect erect posture; knee &hip at 90 degrees, then returns to stand; alternate legs; progress to weights on shoulders||3 sets of 15; progress in sets/ reps/colors/lb’s|
|Wall Squat with Gym Ball||Abdominal Brace; Stand with back, shoulders, and head even and straight, leaning against the ball and look straight ahead. Keep shoulders relaxed and feet 1 foot away from the ball and a shoulder’s width apart. Keep head straight, roll down the wall with the ball, lowering the buttocks toward the floor until the thighs are almost parallel to the floor. Hold this position for 10 seconds. Make sure to tighten the thigh muscles while slowly sliding back up to the starting position.||3 sets of 10; progress with time in lowered position, sets, reps, and dumbbells on shoulders|
|Balance Training on Rocker Board||Small foot and subtalar neutral maintained, abdominal hollowing, patient should maintain controlled rocking on the board with ankle joint without bending at the waist; start with 3 minutes and increase.||Progressing to multiple angles eyes closed and round board|
The fact that obesity contributes to higher levels of inflammation and to causing additional abnormal forces on the motor and biomechanical systems, cannot be ignored. A leg length deficiency contributes to uneven forces on the spine structure; often a convexity of the lumbar spine on the same side; and in many cases should be progressively leveled to prevent or slow down the process of boney deformation, osteophytes and syndesmophytes. Joint and tissue mobility and flexibility is the foundation of any rehabilitation protocol and must be attained in order to progress into restoring stability to a weakened and unstable lumbar spine. Chiropractic Manipulative Treatment/Chiropractic Adjustments/Spinal Manipulation is the most researched mode of treatment for low back pain. This of course is the staple of the practice of chiropractic in restoring joint mobility and reduction of the kinesiopathophysiological component of the subluxation complex. Proper functional testing and measurements are key components to the documentation process. This testing and measuring will validate that conservative chiropractic rehabilitation protocols is cost effective with outcomes that not only produce resolution of the abnormal spinal condition, and progress a patient to normal status compared with referenced normal data, but also for the resolution of systemic health conditions that if ignored may require the inveterate use of medications. These outcomes will then possibly confirm that chiropractors are more than qualified to be primary care physicians, not only on health plans but on workers’ compensation plans, including wellness models of healthcare. Nutritional supplementation and cardiovascular fitness is also imperative when attempting to improve a patient’s general health. Proper circulation to the soft tissue with oxygen and micro and macronutrients is required for any successful rehabilitation and conditioning protocol. Finally, with the advances in technology, there are LASER devices which are FDA cleared in the United States that are available with a 910nm wavelength that have the ability to penetrate into the deeper target tissues of the spine with adequate power density to initiate the biostimulatory effects and accelerate the healing process. The practicing chiropractor, depending on his or her practice style, philosophy of practice, state regulatory practice acts, and education have the ability to utilize more than one modality to assist the patient to become well, not just in the spine, but the whole body, and without the need of pharmaceuticals.
This clinical case study did not have a post MRI performed after the treatment was finished. This would have been beneficial to access if the chiropractic manipulation/adjustment, rehabilitation protocols, and laser therapy assisted in the reduction of protrusion size. Thus, resulting in the beneficial results that were seen or if it was just from the improved stability, mobility,
strength and global alignment. Since this patient was self paying for his treatment, ordering another MRI in a pain-free subject may have been difficult. There are also limitations in general when treating this type of chronic condition, because of the amount of treatment time required each visit to accomplish the goal. The typical physician or therapist does not always get reimbursed by third party payers adequately for the hour or more that these visits actually lasted to make it financially feasible to perform on all patients. Furthermore, instead of being impressed with the provider, the third party payer may interpret the amount of effort by the provider as overutilization, making the documentation of the case much more important. Dedicating an hour of time one on one with the patient can be very difficult in a typical practice, which is why so many therapists and physicians often utilize more passive modalities which do not require constant attendance, but do not usually give a long lasting result.
In general terms, case reports should not be generalized beyond the context of a particular case for a larger population of patients. Also, the natural progression of a condition or dysfunction may also explain the results experienced in patient care. This case study submitted, that happened to have stellar results for only one patient with long term reoccurring low back pain and sciatic radiculitis from a documented disc herniation, will hopefully stimulate more large scale studies and utilize multi-mode procedures instead of a single mode procedure. Most of these types of case studies attempt to establish the “best” single treatment; however, the “best” treatment may actually be performing everything that will restore the patient to whole body full function and wellness, not just treating the pain or the assumed source of pain.
This case study was completed in part for the purpose of a requirement for board certification by the American Chiropractic Rehabilitation Board. The learning process and the assistance from the instructors such a George Petruska, DC was invaluable to me. The professionalism of the testing process and the staff and members of the ACRB was an example for all to follow. I am grateful for the opportunity to be a part of it.
Funding sources and potential conflicts of interest:
No funding sources or conflicts of interest were reported for this study.
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