I was just speaking about this case to one of the PTs that works with me this week, and felt it a good learning opportunity to post to the inter webs.
78 year old male was referred to me from another PT. The patient underwent 6 weeks of PT with another therapist also certified in MDT.
I helped train that PT and she felt that the patient should be referred to me to see if there was anything missed during the appointments.
The patient had an extrusion at L3, affecting quad strength. He also had a loss of light touch sensation at the anterior thigh.
His only complaint was pain that would wake him up at 2 AM, which was very intense. He would take a Norco and walk for 30-45 minutes to reduce his pain. He could sleep until 6 or 7 AM, which is when the excruciating pain would return. Again, he would take a Norco and walk. The pain would go away and not return the rest of the day until 2AM. He was very active with Tai Chi and Kung Fu over 10 hrs per week.
His only complaint was pain in the middle of the night.
I couldn’t provoke his pain during the evaluation.
He had already been through 6 weeks of PT without change, so I was only trying to figure out his sleep issue.
I had a working hypothesis
1. Overnight, the disc imbibes fluid and increases in size.
2. It was possible that the change in fluid content was increasing his pain since the pain went away when he was up walking during the night
3. If I could prevent the disc from taking on fluid, his pain might shut off
That was my only thought pattern that made sense for his symptoms.
I had him sleep in a recliner and to call me in 2 days with the result.
He was painfree in the recliner and did not wake at all.
Because he already had 6 weeks with an MDT trained clinician, I didn’t feel that bringing him into the clinic was going to be productive, so I followed by phone.
After two weeks, which is how long it is expected to see results if given the right direction and load, he was able to return to bed without waking.
This patient returned to therapy for a different issue a year later and we had a conversation about his back (he was seeing a different therapist). His strength recovered and he didn’t require surgery.
Moral of the story:
1. Sometimes you have to think outside of the box
2. Don’t let the image dictate treatment
3. Only treat the patient if we can improve their lot in life
4. Always develop a relationship with the patient you are treating.