Back dominant pain aggravated by flexion
A pleasant middle-aged male decided to use CareChain services due to a predominant complaint of severe, unrelenting, left leg pain of approximately 8 weeks duration. He reported experiencing similar, less intense episodes of leg and back pain over the course of the last 15 years that resolved completely with conservative management – physiotherapy and exercise.
Unlike his previous episodes, this current episode had not responded to physiotherapy, exercise or acupuncture. He continues to work at his job which is comprised of heavy lifting, bending and twisting albeit with significant modifications. Despite continuing to work he has all but given up his recreational activities and has significantly limited his social activities due to his unrelenting symptoms. To date, he has not been referred for diagnostic imaging or for a surgical consultation. His family doctor has instead referred him to a CareChain physiotherapist for a comprehensive assessment in an effort to get expert answers for his patient, rapid access to services and an evidence-based personalized plan of management.
At his CareChain physiotherapist appointment, the patient underwent an advanced back assessment. During his assessment, the CareChain PT noted that the patient had some difficulty with toe walking on his left side, a positive left straight leg raise, diminished left S1 reflex, slight weakness in the left calf with motor testing and altered sensation in the left S1 distribution. Accordingly, he was diagnosed with a left S1 radiculopathy (also known as constant leg dominant pain).
The patient was provided with a personalized plan of management which included an exercise program emphasizing walking, swimming, extension type exercises, and core stability.
In addition, the CareChain physiotherapist took the time to educate the patient on the specific aspects of his condition including prognosis, activity limitations and postural advice. At the end of the consultation, the CareChain physiotherapist faxed a consult note to the referring family physician which included an outline of the patient’s personalized plan of management as well as recommendations for ongoing treatment.
The patient was advised to touch base with his family physician to discuss pain-relieving medications such as Lyrica or Gabapentin and to review his plan of management within one week’s time. In addition, he was advised to undertake physiotherapy to support him in executing on his CareChain plan of management.
Over the course of the next four weeks, the patient attended several physiotherapy sessions. He elected to attend treatment at his CareChain physiotherapist’s office. He was seen once per week and was instructed to perform his home exercise program on his days away from the clinic. Each week, his condition was re-evaluated by his physiotherapist and his exercises progressed as per his CareChain plan of management. He remained employed and slowly started reintroducing social and recreational activities.
- Complete resolution of left S1 radiculopathy
- Improvement of lower back pain
- Normal functioning and return to regular activities
- Better knowledge of his condition and how to manage it
At his follow-up appointment with his CareChain physiotherapist approximately 6 weeks later he reported complete resolution of his left S1 radiculopathy (constant leg dominant symptoms) and that his main complaint was now localized to his low back and aggravated by flexion (discogenic low back pain or back dominant pain aggravated by flexion). He was educated on his back dominant pain and that his current symptoms were due to his resolving disc herniation. Nonetheless, the patient indicated that this too was improving with the prescribed exercises and activity recommendations. Additionally, he reported that overall he was functioning quite normally and was eager to return to all his regular activities.
Physical examination at the time of his follow-up was unremarkable. There was no evidence of calf weakness or his S1 sensory deficits. The patient was further educated about his condition and the importance of staying active, avoiding aggravating factors until asymptomatic and the continued importance of managing his condition through core stability exercises.
As is the case with so many radiculopathies, this patient’s symptoms resolved through conservative management. Key to this was a comprehensive assessment, rapid access to a CareChain physiotherapist and an evidenced-based personalized plan of management.
Had his symptoms persisted, worsened or if surgical intervention was warranted, as can be the case in 15% of patients, then he would have been provided rapid access to a CareChain networked spine specialist as well as advanced imaging. Instead, his symptoms are now almost resolved, and he has been able to return to most of his recreational activities without having to wait months or years for an appointment with a spine surgeon.
Do you have back problems?
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