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A 37-year-old professional soldier presented to a chiropractic clinic complaining of severe pain in the lower back (pain radiating down the anterior and the lateral aspects of the upper left leg). The pain was bilateral and quite sharp on the left side. The patient briefed about an accident that he had met the previous year. He had to remain in the hospital for almost a week and suffered traumatic injuries and symptoms. The patient was experiencing severe neck and back pain since then. Post-traumatic radiological examinations revealed an abnormality in chronic L4-L5 facet and left sacroiliac joint. However, there were no signs of fractures or any nerve injury. Physical therapies, including proper posture habits and moderate exercise, improved the pain.
The most likely diagnosis of this presentation is:
Low back pain (LBP) is a widespread ailment affecting almost 80% of the population at least once in a lifetime. It is often accompanied by other symptoms, including radiating pain towards the lower limb muscles, decreased movement and strength of muscles and has also been reported to trigger a sensory decline. Low back pain majorly affects L4-L5 and 1st sacral vertebra, which is a passage of peripheral nerves of the lower limbs. In almost 10% of patients, the primary origin of the pain is not found in the spine or surrounding region. When muscles are shortened for an extended period, they trigger muscle atrophy and cause stiffness of the joints, thereby leading to a reduced range of motion.
Exercise remains a mainstay approach in chronic low back pain (CLBP) management with its ability to reduce the risk of future back injuries, improve joint flexibility and movement and muscle strength. Evidence also supports the benefits of Craniosacral therapy in CLBP patients.
The L4-L5 facet dysfunction instigated due to trauma and left SI dysfunction was confirmed in this patient. The patient resumed his routine activities as his symptoms were improved after spinal manipulation therapy. Physiotherapeutic training under guidance was also recommended to improve the stability of his lower back.
There was nothing extraordinary about the medical history than the patient’s extraction of teeth in 1997 comprising removable partial dentures and a bridge.
The initial examination included a physical exam to look for stiffness, posture abnormalities and range of motion, which revealed a lower right rim of the ilium compared to the left side, lower right shoulder and bilateral pes planus. Range of motion was notably decreased. Kemp’s test displayed positive on the left. The reflexes of S1, L5 and L4 were asymmetrical. The pinprick technique was used to examine dermatomes in the legs, which was found to be normal. Palpation of the spine showed a restricted movement at T3-T8 on both sides, at L4-5-S1 on the right and L5-S1 on the left in the right rotation.
Further, the Yeoman’s test revealed dysfunction in the sacroiliac (SI) joint. Results from neurological and orthopaedic examinations were normal. Therefore, L4-L5 facet dysfunction caused due to trauma and left SI dysfunction was confirmed.
Based on the detailed exam, an addition of cranial therapy along with the chiropractic treatment plan was considered. A technique of a Cox flexion-distraction with lateral flexion was undertaken which involved a flexion movement of the lumbar spine while holding the spinous process of L5. In addition, other high velocity-low amplitude techniques were applied to treat the abnormalities in the pelvis and the lumbar spine region. The left gluteal musculature was given trigger point therapy. Symptoms were significantly improved with this treatment approach, and he was able to resume most of his daily activities. To avoid recurrence, physiotherapeutic training on practising different types of recommended exercises was given. Bone scintigraphy was performed after 11 months of trauma, showing a lesion on the right sphenoid region, which was then, treated using the Sacro-Occipital Technique (SOT) sphenoid lifting technique.
Conventional treatments for LBP have limited benefit in improving the overall quality of life. Thus, complementary and alternative medicine (CAM) therapies have emerged as an important choice in the treatment of the low back. The most prevalent CAM therapies for back pain include spinal manipulation, acupuncture, and massage. Spinal manipulation therapy uses a high-velocity, low-amplitude manual thrusts which are believed to displace and deform the tissues and adjust the anatomical orientation. Evidence has proven the impact of spinal manipulation on primary afferent neurons from paraspinal tissues, the motor control system, and pain processing.
According to Cecchi F et al., spinal manipulation provided better short and long-term functional improvement and more pain relief than physical therapy. In this case, low back pain was significantly improved after the cranial techniques. Fischer and colleagues represented a strong association of craniomandibular dysfunction with complex regional pain syndrome with decreased range of motion in the hip joint. According to the authors, the central nervous system acts as a bridge to pass on information between the temporomandibular joint and the rest of the body.
The outcomes of this case suggest that adding craniosacral therapy to spinal manipulation may be helpful to treat the symptoms of LBP.
J Chiropr Med. 2015 Mar; 14(1): 57–61.
Cranial Treatment and Spinal Manipulation for a Patient With Low Back Pain: A Case Study
Wayne Powell et al.
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