A 34-year-old man named Miguel consulted an MSR-supported physiatrist after he sustained a low back injury in a motor vehicle accident, as he was a seat belted driver that was rear ended by another motorist while stopped at a traffic light.
Miguel had low back pain with no appreciable radicular findings. The physiatrist placed him on conservative physical therapy treatment for his lumbar spine strain/sprain consisting of ultrasound and electric stimulation, followed by range of motion exercises (as tolerated). Miguel returned about eight weeks later, after his back pain worsened and he had complaints of pain traveling into the leg.
Clinical evaluation revealed that Miguel had weakness in the right leg with a positive straight leg raise test. The physiatrist referred him for an MRI of the lumbar spine that revealed a disc herniation at the L5/S1 level. Based on this finding, the physiatrist placed him in lumbar spine traction to alleviate the intradiscal pressure causing back pain; he also prescribed a muscle relaxant for Miguel and enccouaged him to continue physical therapy treatment. At re-evaluation, Miguel continued to have low back pain with further radicular complaints down the right leg concordant with radicular clinical findings consisting of motor weakness in the right leg with diminished sensation and reflex, as well as a positive straight leg raise test. Miguel also had a lower EMG/NCS test to confirm lumbosacral radiculopathy, which revealed a right SI radiculopathy.
Based on this finding, the physiatrist modified Miguel's physiatric treatment to incorporate TENS unit application to the lumbar spine followed by progressive prone lumbar isotonics with isotonics to right S1 myotome (ankle everter, ankle plantar flexor) and placed on him on Lyrica, a commonly used anti-epileptic drug for neuropathic pain. Throughout the course of treatment, the Lyrica dose was upwardly titrated to 300 mg at nighttime, which he noted alleviated his complaints of pain down the leg.
The physiatrist treated Miguel with conservative treatment, incorporating lumbar spine traction, followed by progressive prone lumbar isotonics with isotonics to the right S1 myotome. He also prescribed a commonly used analgesic Ultram ER 200 mg daily which Miguel believes had helped his back pain. After a nearly a year of persistent treatment, Miguel noted that his back pain had diminished significantly. He also denied any further radicular pain (i.e., numbness, tingling, pins and needles sensation). A clinical evaluation revealed improved lumbar spine range of motion with no residual weakness or reflex asymmetry in the lower extremities. Miguel had full sensation to light touch and pin prick.
Miguel improved gradually with conservative physical therapy treatment, as objective MRI and electrodiagnostic testing revealed the etiology of his low back pain and radicular symptoms that allowed "a fine tuning" of his physiatric rehabilitation medicine treatment. Ultimately, Miguel showed good recovery, and the physiatrist recommended that he continue with a home exercise program that included McKenzie low back extension exercises and William's low back flexion exercises to maintain lumbar spine strength and hygiene.
The physiatrist also advised Miguel to return to the office if his radicular symptoms resumed. He also strongly recommended that Miguel wean himself off the Lyrica and the Ultram over the next two weeks.
The ability of a specialist in Physical Medicine and Rehabilitation (PM&R) to provide multidisciplinary and multimodal care, as well as the ability to focus on patient function and the patient as a whole separates the physiatrist from other medical specialties. It is what makes the physiatrist a unique provider of medical care.
Case study by Joseph Gregorace, D.O.
Sports Medicine & Spine Rehabilitation, P.C.