The low back pain was of an aching quality at the L2-L4 region. She finds relief from laying down and resting after activity. Prior to the accident she experienced a similar low back complaint after long runs however not as bad.
X-rays where ordered and revealed right sagittal facets at L5/S1 on the right and diffuse scoliosis to the right in the thoracic and lumbar spine. No other significant bony or soft tissues abnormalities was demonstrated.
Initial Examination Findings:
Postural examination revealed an increase lumbar lordosis. Her range of motion was good in all movements however right rotation revealed pain in the L2-L4 region. Kemp’s test was performed and revealed local pain in the L4 region. Sacroiliac provocation tests revealed pain in the sacroiliac joints. Hypertonicity and tenderness was noted in Paraspinal, Quadratus Lumborum and Piriformis muscles bilaterally and L2/3 and L3/4 joints were restricted and painful on joint play. Physical examination and neurological tests of the lower limb revealed no abnormalities.
Differential Diagnosis:
Working diagnosis was chronic facet syndrome with sub acute exacerbation with associated hypertonic Paraspinal muscles. Other possibilities included: L3/4 subluxation, Sacroiliac Joint dysfunction, myofacial pain syndrome of Erector Spinae, Quadratus Lumborum muscle (in order of likelihood).
Treatment:
Soft tissue therapy was applied to the QL, ER Spinae, Gluteal muscles followed by side lying adjustments were applied to L3/4 fixation. Gentle stretches and postural advice were recommended as home treatment. By the third visit the low back pain “was not as soar” (subjective reporting). The Prone Abdominal Drawing-In Test was performed and revealed the umbilicus deviating cephelad (using Rectus Abdominis).
Why Rehabilitation?
Ms C. was unable to voluntarily contract the Transverse Abdominis and probably wasn’t able to prior to the accident explaining why she experienced similar yet milder low back complaints. Other large stabilizers QL, and ER Spinae were tight from the strain sustained from the accident. Inadvertently weakening the core stability of the low back even more.
Rehabilitation Plan:
Ms C. was prescribed Transverse Abdominis contractions in pain free supine position on the third visit. Treatment continued with STT and stretching to the ER Spinae and QL muscles was initiated and chiropractic adjustments to the L3/4 fixation (1x per week for 3 weeks). She has not returned after the third treatment (due to insufficient funds however she feels her low back complaint was within tolerable levels now) however I would have liked to gradually progress the TA contraction to a seated position followed by adding in a breath whist holding the contraction.
Response to Care:
On telephoning 2 weeks after the last treatment her low back condition had improved to a tolerable level. She could sit for longer periods before the aching (of a lower intensity than prior treatment) would start. I suggested the two progressions as stated above and recommended ongoing treatments if funds allowed.