Healthy Life: Diagnosis & Treatment (1) (871)

Healthy Life: Diagnosis & Treatment (1)

蘇鎮邦 (Christopher So)：
舒整物理治療師 (Manipulative Physiotherapist) 人類工程師 (Ergonomist)

Understanding the process of diagnosis and treatment will help patient to have a correct view and expectation from the physiotherapist. The trust of patient towards the physiotherapist has great importance to treatment success.

The following case is a twenty three year old arborist. His dad has been my patient for over twenty years and came to me a lot in the past. However, he has retired from the front line for the last few years. Now he has no back pain or very mild back pain that can be managed by exercises. I have not seen him for a few years.

His son had a big job three months ago. He hurt his back and came to me for treatment. After two treatments, he was 80% better. We decided to leave it and continue with back exercises to get the last 20%. Yesterday, he moved house and lifted a very heavy piece of furniture. He had sharp pain but he had to finish it. However, his back pain started to get worse at night. He found it very hard to get up the next morning. There was pain during walking and he was limping when he came to me. His right leg had numbness and pain which indicated right sciatica. The right foot especially the toes could not pull up as compared to the left. The low back movements were restricted, especially bending forward. Luckily, he had been my patient for 7-8 years since he was a teenager. He has full confidence in me. Also, his father has complete confidence in me and accepted my suggestion that he should be rested for at least 4 weeks.

I was extremely careful in examining him. His straight leg raising test (SLR), with R only 10 degrees and L 70 degrees, confirmed the diagnosis of right sciatica. His ankle and knee reflexes were normal. For the initial treatment, I applied very gentle mobilisation, ultrasound and interferential therapy (IFT). After I established the effect of the mobilisation, I replaced the IFT treatment with intermittent lumbar traction attempting to decompress the pinged nerve. I began with 15 kgwt and increased by 0.25 kgwt till it reached 25 kgwt and stayed there for the rest of the course of treatment.

After 4 treatments, he had definite improvement but it was slower than my expectation. I referred him to a doctor for MRI. Fortunately, after the 5th treatments, he began to respond quicker. There was much less pain on walking and limping had reduced by 60%.

At the 7th treatment, he came with the MRI report and confirmed that the 4th and 5th discs were bulging into the intervertebral foramen. I started to see him alternate days and let him do more exercises himself. I added combined movement mobilisation. It greatly improved his forward bending movement. After 12 treatments, subjectively he reported 80% improvement. In my own judgment after further examination, it might be 50-60% at the most. There was slight pain in walking but limping had decreased substantially. There was no pain during sleep. His SLR increase to 40degrees. The strength of his right foot and toes had improved by 50%.

(Herniated Disc)

I predicted he might improve to 70% in 2-3 weeks. In the fourth week, he might start to go back to light duty work. It was extremely fortunate that his dad is his boss. He was allowed to do whatever he could without over exerting himself. His mum is an occupational therapist. She arranged for him to continue rehabilitation in the community centre where she worked. I left him in the 7th week with toes strength improved by 60%, SLR to 50 degrees. He seemed to cope with his work for 2 days. I did not hear from him.