Case study series
Limp & Wasting From Lumbar, 48 yr
This is a very interesting case I would like to share with you and I hope more of such patients could be helped. A 46-year-old housewife developed a limp of her right leg 8 years ago. She was thoroughly examined by an Orthopaedic surgeon and was diagnosed to have nerve impingement at the low back at L4/L5 or L5/S1. She was then referred for physiotherapy to have traction, electrotherapy and back exercises. Despite persisting with her treatment, her limp gradually worsened. Three years ago, she was hospitalized to have further examinations by Orthopaedic surgeons, Neuro-surgeons and Neurologists who concluded the same diagnosis. Unfortunately, surgery was not suggested as x-ray and scan results were negative. She therefore continued to seek other forms of treatment such as acupuncture and massage. However, her limp continued to worsen and had begun to affect the left leg. By the time I saw her, she was limping badly left worse the right. Her complaints were mainly weakness and tiredness butnever the usual aches and pain and paraesthesia such as pins and needles and numbness.On examinations, her limp was mainly due to her drop foot (unable to lift foot upward)left worse than the right. The related muscles had no power at all or rather weak with obvious muscle wasting. Normal lordosis (forward/inward S-curve of the low back) was reduced and backward bending was restricted to 1/2 range. Specific low back joint movements were very stiff left worse than the right with surrounding soft tissue thickening (scarring) but without pain. Buttock and calf muscles were very tight. No other related signs were found otherwise. Her very stiff low back was found most likely be the cause of her weakness due to nerve pinching. Although the source of her symptoms was clearly identified by her doctors, treatment had never been effective enough to restore her function. Since surgery was not suggested, the full responsibility should be on us as physiotherapist to provide the best possible treatment to the patient. The good old lumbar (low back) traction had always been the first or even the only treatment of choice for any low back condition, especially in nerve impingement cases. With the advance in manipulative assessment and treatment techniques, we now prefer direct palpation or mobilization to the affected levels to restore any local mechanical dysfunction such as soft tissue thickening and restriction of spinal motions. The patient felt fine after the examination, suggesting low irritability and that subsequent treatment could be more aggressive such as deep frictions, mobilizations and localized manipulations, stretches and mobility exercises to restore her normal low back S-curve and backward bending movement. In addition to all the wonderful manipulative techniques, the patient´s home exercises and awareness of her condition was crucial to her recovery. She was told to do a lot of forward bending exercises to stretch her back muscles and to open up the spine but not understanding the possible damaging effect of such movements to the disc. After a course of 7 treatments, she was walking a lot more confidently and muscle power was gradually recovering.