This client’s amazing success story, occurring within 5 weeks of starting treatment, highlights the benefits of using a whole body problem solving approach that is not based on assumptions about a specific pathology.
Table of Contents
Background and History
Mrs B is a 58 year old nurse who recently presented to our clinic with a 9 month history of right buttock, posterior thigh and calf pain, as well as intermittent numbness in the calf and bottom of foot.
The pain had developed slowly without any specific incident. Of note, Mrs B had suffered a period of left heel pain 3 years prior. At the time, Mrs B had been managed in a moon boot on the left side for 8 weeks to reduce pressure on the foot for what had been diagnosed as plantar fasciitis. She had also been experiencing left hip pain, but these 2 pains had resolved before her more painful right buttock and leg pain had started.
Mrs B had trialed treatment with Physios, Osteos and had been having Pilates, the latter she felt actually aggravated her condition. She had also had cortisone injections into the facet joints of her lower back, which had not helped.
Investigations
Mrs B’s MRI, taken 5 months previously, showed forward displacement of the L4 segment, disc bulging, facet joint degeneration, as well as compression of lumbar nerve roots (see excerpt below).
How Mrs B Was Impacted By Her Condition
Mrs B’s pain was worse in the mornings, and she often waked on turning in bed. She could not sit for more than 20min before the pain worsened, and she was also unable to walk for longer than 10-15min.
She had struggled to maintain her part time nursing, and had taken afternoon shifts because the pain was not as bad at that time of day. She was not able to do as much for her family and her children were helping her out with most of her home duties (not necessarily a bad thing!).
Mrs B had also stopped her regular walks around the Maribyrnong River with her friend due to the pain.
She was taking 2-3 Panadeine daily and also 2 x Nurofen.
She rated her functional ability at 50%.
Assessment
Mrs B presented with some postural compensations, ie she was standing in an altered state due to her pain. The anterior pelvic tilt posture was placing more stress on her lower back.
She had reduced reflexes on the right side (S1), but no loss of power in the specific nerve supply areas (myotomes). Her lumbar range of movement was restricted by muscle guarding, as was her right hip flexion, hamstring range and thoracic rotation. The latter 4 movements formed the basis of her key movement signs, the tests we use to measure her response to treatment and her progress. These were all tested to the first point of reactivity, which is a more sensitive and reliable way to test movement, as it tests the protective response within the nervous system and is not reliant on a patient’s symptoms.
Mrs B also exhibited adverse nerve tension in the left upper limb, and both lower limbs.
We performed a whole body assessment (WBA) for Mrs B as part of our systematic whole body problem solving process. We found many areas of muscle knots and stiff hypomobile joints in the neck, thoracic and lumbar spines.
The Treatment and Problem Solving Process
We first needed to clear Mrs B’s adverse neural tension, so that she would then respond to treatment more readily and it would be easier to find her primary contributors to her condition.
We then performed treatment trials on all of the unhappy muscles and joints we found on the WBA, using Mrs B’s hamstring as the main movement test. That is, we released the relevant muscle or joint while Mrs B actively straightened her hamstring (hip in 90deg flexion). Any improvements in hamstring range were recorded as percentage improvements for the particular structure on which we trialing treatment. We would retest all of Mrs B’s movement signs at the start and end of each session, so that we could plot a progress graph.
Process of Elimination
We came up with a list of 16 structures which were all affecting Mrs B’s key movement tests related to her sciatica and back pain. We then worked more on each of these to release them further and test if they were still part of her condition, again using her key movement tests, until the tests reached an optimal range without muscle guarding or reactivity.
We arrived at 3 structures that were having the most effect on Mrs B’s movements. They were the left Piriformis muscle, the left plantar fascia and the T8 segment, with a left to right bias on the transverse process. These were the primary contributors to her condition as they all improved her key tests related to her sciatic condition.
We also started Mrs B on a range specific exercises for her Tr Abd, as she was not activating this well, and also the right gluteal muscles. They were also activating poorly.
Results
As we got towards the end of the problem solving process, and not earlier, Mrs B’s symptoms finally began to ease, which coincided with her movement test improvements. Her leg pain started to reduce and she was no longer experiencing the catching pain that had troubled her intermittently over many months.
She began to sleep better, then walk further without pain. She also started to reduce her medications.
On her last review, she was extremely happy with her progress and most of her pain had resolved. She was off all her medications, and had resumed walking around the river with her friend, who had commented that she was struggling to keep up with Mrs B!
She was waking up in the mornings feeling great, and was now happy to resume morning shifts at work.
She self rated her functional capacity at 85-90%!
Mrs B’s progress above shows a steady improvement in her key movement tests, with some regression between sessions.
Summary
This was a very satisfying result both for Mrs B and her Physiotherapist. The protective responses that made the most change in her condition were on the opposite leg. It was theorised that the episode of plantar fasciitis she had last year had contributed to the tension on that leg, and she was most likely placing more weight on the right side.This would have loaded the structures on the right more, leading to her pain.
This case highlights the benefits of using a systematic whole body problem solving approach, as where your pain is may not be where the problem is.
It also highlights the fact that MRI scans don not always correlate with a patient’s symptoms. If Mrs B had a repeat MRI on her lumbar spine, it is unlikely to be any different, yet her pain has resolved. Pain is an output sign created by the brain, and when we address the primary protective responses in the body, there is no need for the brain to create the pain. It is dependent on tissue pathology in many cases.
Careful and thorough assessment and problem solving is needed for each person because each case is individual. People with the same symptoms may have totally different primary sources of their pain.
To ensure the problem does not recur, we have taught Mrs B self management strategies and corrective exercises that she can do at home.
