Low Back Pain – Diagnostic Evaluation Case Study

Case History: Patient continued with low back pain; FCE for return-to-work performed on 11/13/2008 completed successfully. Functional Diagnostic Assessment ordered to objectively measure and evaluate for potential underlying causes to explain delayed recovery and current functional limitations and report of pain limiting her ability for a successful rehabilitation outcome. This evaluation was completed on 4/29/2009.

Incident History: Mrs. Worker was hit by a car in 1986 on the right side and was hospitalized for one week. In 2002, she slipped and fell at work landing on a concrete floor in a puddle.

Previous Labs and Studies: She reports that she had a MRI and an EMG for the lumbar spine Right Hip and Right Lower Extremity. The MRI was (+) for fluid on the L4-5 vertebral space.

Relevant Medical History: Reports that after her FCE on 11/13/08 she received a shot in her lumbar spine by Dr. S.

Findings: Motion analysis-based functional diagnostic assessment revealed during ambulation the Left hip falls during Right lower extremity single leg stance. This is consistent with the weakness seen in the physical evaluation in the hip abductors. These muscles are used to stabilize the pelvis during ambulation.

During dynamic lifting analysis confirms that the Right side of the pelvis is anteriorly rotated forward farther than the Left side of the pelvis. This is consistent with the leg length discrepancy seen during the physical evaluation where the Right Low Extremity was found to be shorter than the Left Low Extremity via use of the Weber-Barstow Maneuver.

This was observed and measured during waist lifting. Motion Analysis measured the anatomical reference markers on the Right side of the body were moving forward versus the markers on the Left side.

During dynamic movement testing, the right side of the pelvis demonstrates starting in a position of increased flexion versus the left side of the pelvis.

This pattern is consistent throughout the testing and during the gait cycle, in which there is a ten degree difference in the two sides of the pelvis.

 

Conclusions:

The overall conclusion of this evaluation is that Mrs. Worker demonstrates pelvic instability that causes a leg length discrepancy resulting in changes in the pelvic tilt putting increased pressure on the lumbar spine. This leads to altered pulling in the musculature of the hips demonstrated by the (+) Ely test for the hip flexors.

Summary/Outcome:

Mrs. Worker received focused physical therapy to the sacroiliac joint and pelvis using manual therapy and muscle energy techniques with targeted strengthening of the lumbar spine. Mrs. Worker's case resolved in 3 weeks and she called Case Manager thanking her for helping to get her life back.

This is a great example of the value of motion analysis-based functional diagnostic evaluations early in medical case management when treatment has stalled and recovery is delayed. By way of illustration - had a referral been made and evaluation performed within the first 4-6 weeks post injury (estimated cost - less than $2,500) when rehabilitation was not resolving “back” pain, the underlying cause or actual source of pain, once identified would have provided her physician with timely, relevant information to revise the diagnosis and treatment plan leading to case closure within the first 4-6 weeks versus 6 years later and costs likely exceeding $30,000. (PDF version)