Mr. COP was first referred for a physiotherapy assessment at Diane Lee & Associates – Consultants in Physiotherapy by his massage therapist. He was initially assessed on August 26, 2014.
Mr. COP is a 29-year-old RCMP officer who presented to the initial assessment with complaints of chronic low back pain and newer onset right hip pain. He reported that the low back pain initially started 6 years prior during his Basic Training for the RCMP. He had an incident during defensive training where his back was hyper-extended while he was lying in a prone position. He reported feeling a “crack” in the back with immediate pain that persisted for several days. He did not receive any sort of formal treatment at that time. Ever since that initial incident, Mr. COP describes frequent flare-ups of his low back pain with the symptoms worsening over the past 2.5 years. He was also concerned with a new and insidious onset of right hip pain approximately 6 months prior to the initial physiotherapy assessment. He felt this hip pain was also related to a recent onset of paraesthesia (pins and needles) in the anterior aspect of the right thigh. Mr. COP has not taken any time off of work for these injuries.
Mr. COP has had past treatment, which has included massage therapy and chiropractic, both which seemed to only provide temporary benefit. He had also tried training with kinesiologists (Innovative Fitness) but found that the training only worsened the right hip pain so he had stopped with all training at the time of the initial assessment. He had never tried physiotherapy. At the time of the initial assessment he was still routinely receiving treatment from his chiropractor and massage therapist. His goals for physiotherapy treatment were to decrease his pain symptoms and to rehabilitate his low back and hip to eventually return to working out with a trainer.
Past medical history was unremarkable for any previous injuries or health concerns/issues. He was occasionally taking Robax for his pain. X-ray of his lumbar spine done prior to the initial assessment was negative. At initial intake, Mr. COP completed a Patient Specific Functional Scale (PSFS) questionnaire where he was asked to identify activities and then rate them (0 equals unable to perform the stated task, 10 equals able to perform stated task at pre-injury levels). He identified the following: sitting – 5, static standing – 6, walking up stairs/inclines 4. During the course of physiotherapy treatment, Mr. COP also had a MRI of the lumbar spine and MR arthrogram of the right hip (as prescribed by his family physician), both of which were normal.
At the initial assessment, Mr. COP complained of 2 areas of pain:
- Localized low back pain; aggravated with driving and sitting
- Right buttock pain which radiated to the lateral and anterior aspects of the right hip; aggravated with stairs, steep inclines, and lunges (left foot forward)
He also reported “tingling” in the right anterior thigh. He was unsure what aggravated the tingling but he could especially notice it when he lightly brushed his thigh with his hand. His pain was the least intense in the mornings and worsened throughout his day, most notable on his workdays.
Mr. COP has been working as an active duty RCMP officer since the onset of his low back pain. He strongly believed that the gear he is required to wear when on duty (vest and duty belt which he estimated weighed approximately 20 lbs combined) aggravated his symptoms as he was more sore during work shifts and at the end of his typical 4 consecutive (12 hour shifts) workdays.
Based on the activities identified in the PSFS and Mr. COP’s subjective story, the meaningful tasks identified at the initial assessment included:
- Working out with a trainer (running, lunges)
The screening tasks that were chosen to further assess were derived from the requirements to perform the above meaningful tasks. They included: standing postural screen, squat, right one leg stand (OLS), and seated trunk rotation.
Standing Postural Screen
The standing postural screen is an important screening task as it provides useful information on how a person habitually stands. Rarely will you find an individual without any habitual asymmetries or torsions in standing. The key to proper movement (in whatever screening task is chosen) is that the individual can move out of these asymmetries/torsions in order to move with good alignment, biomechanics, and control for that specific task. We can only know if a finding during a screening task is relevant if we know the starting position for that task. In other words, is the finding just an unwinding of a torsion to an aligned position or is it an actual site that is failing to transfer load transfer with an optimal strategy?
There were no reported symptoms during evaluation of the static standing postural screen. Mr. COP stood with his pelvis rotated to the left in the transverse plane (TPR) with a congruent left intrapelvic torsion (IPT). The right hip appeared slightly anterior relative to the right acetabulum, a finding that was congruent to the positional finding of his pelvis (left TPR). The mid thorax appeared rotated to the right. Specific segmental thoracic ring shifts were noted with the 6th and 7th thoracic rings in a left translated/right rotated position in standing. These mid thoracic ring shifts were incongruent to the positional finding of the pelvis (left TPR) and right hip.
A squat is a useful screening task to assess a patient’s habitual movement patterns when moving through a squat to sit. If a patient has a non-optimal squat then they are likely to sit with poor alignment (e.g. an increase in right pelvis transverse plane rotation during a squat will likely result in a patient sitting in a non-optimal right TPR of the pelvis); therefore, a squat is an important screening task when sitting is a meaningful task for a patient.
In an optimal squat, there should be no loss of control of either sacroiliac joints (SIJ). Both innominates should remain posteriorly rotated relative to the sacrum throughout the movement. There should be no transverse plane rotation of the pelvis; the pelvis should just anteriorly tilt as a unit. In the optimal squat, the hips should remain centered in the acetabulum (seated) of the pelvis, the lumbar vertebrae should remain in neutral, there should be no thoracic rings shifts, and the hips/knees/ankles should symmetrically flex during the squat movement. Any deviation from the above would constitute a site that is failing to transfer load with an optimal strategy.
During Mr. COP’s squat, the following relevant findings were observed:
- Further left translation/right rotation of the 6th and 7th thoracic rings
- Loss of control of the right SIJ during the mid range phase of the squat
- Anterior translation of the right hip (relative to the acetabulum) in the earlier stages of the squat
- L5 rotated left during mid to later stages of the squat
Manual correction of the 6th and 7th thoracic ring resulted in restoration of control of the right SIJ and L5 and an improvement (but not full correction) in the alignment/biomechanics of the right hip. When the thoracic rings and the right hip were concurrently corrected, Mr. COP noticed an improvement in his squat in that he did not feel “twisted” and there was a greater ease to the movement. Based on these findings, it was determined that the 6th and 7th thoracic rings were the primary driver and the right hip was the secondary driver for the squat screening task.
Right One Leg Stand
The ability to transfer load during a right one leg stand (OLS) is an important screening task for any meaningful task that requires single leg loading, such as walking, running, and hiking. It can be used to assess motion control of the weight bearing side as well as intrapelvic mobility on the side of hip flexion. Optimally, during a right OLS (weight-bearing side), the ipsilateral SIJ should remain controlled (innominate posteriorly rotated relative to the sacrum), the right head of femur should remain centered (no anterior translation or rotations) relative to the acetabulum, there should be good alignment/biomechanics/control through the right lower extremity/ankle/foot, and the thorax.
Mr. COP had greater difficulty with single leg loading on the right. During a right OLS, the following relevant findings were noted:
- 6th and 7th thoracic rings remained in left translation/right rotation throughout the task
- Poor control of the right SIJ occurred during mid range of the task
- The right femoral head translated anterior relative to the acetabulum early on in the task
- L5 rotated left during mid range of the task (at approximately 20 degrees of left hip flexion and therefore was not related to the left IPT created by this task)
Manual correction of the thoracic rings 6 & 7 resulted in full control of L5 and the right SIJ. Correction of thoracic rings 6 & 7 only improved the alignment/biomechanics of the right hip in that it continued to translate anteriorly during the task, but much later during the task. Full correction of the right hip did not occur with correction of the thoracic rings 6 & 7. Manual correction of both the 6th and 7th thoracic rings and the right hip simultaneously resulted in the best change, with no sites of failed load transfer noted. Mr. COP also felt the most “stable” in this task with both the 6th & 7th thoracic rings and right hip corrected concurrently. Based on the findings, it was determined that the 6th and 7th thoracic rings were the primary driver and the right hip was the secondary driver for the screening task of a right OLS.
Seated Trunk Rotation
For the purpose of this case, seated trunk rotation serves two purposes. First, it is a valuable screening tool for any thoracic dysfunction in that a more detailed examination of the biomechanics and control of the individual thoracic rings can be assessed. Second, trunk rotation is important for Mr. COP as it is essential for running (for the meaningful task of returning to gym workouts with a trainer).
During a seated trunk rotation screen, Mr. COP reported greater effort to turn to the left, as compared to the right. He was also unable to rotate to the left to the same degree as he could to the right. During left seated trunk rotation there was failed load transfer of the 6th and 7th thoracic rings in that they remained in a left translated/right rotated position throughout the trunk rotation task. Optimal left seated trunk rotation requires right translation/left rotation of the segmental thoracic rings (ipsilateral rotation, contralateral translation). Manual correction of the 6th and 7th thoracic rings (create space between rings, posteriorly rotate the left 6th and 7th ribs and wait for them to auto-correct to neutral) resulted in a reported improvement in ease of left trunk rotation and an increase in the amount of left seated rotation. Based on these findings, it was determined that the 6th and 7th thoracic rings were the primary driver for the screening task of left seated trunk rotation.
Screening Tasks Summary
In summary, findings from the above screening tasks helped guide further assessment and treatment. The primary driver is the body area, that when corrected, results in the best total body response. In some instances, there can be a situation with a primary driver/secondary driver for a screening task. In other words, the primary driver, when corrected, will improve (> 50%) the alignment/biomechanics/control (ABC’s) of the suspected joint/body region. There will be an improvement, but not full correction of the other area(s) demonstrating non-optimal strategies for function. This scenario suggests a primary (> 50%) and secondary driver (< 50%) situation. This knowledge then helps improve efficiency in that it allows one to prioritize what body area needs to be addressed in subsequent treatment.
The following is a quick summary of Mr. COP’s findings:
- Squat: primary driver – 6th and 7th thoracic rings; secondary driver – right hip
- Right OLS: primary driver – 6th and 7th thoracic rings; secondary driver – right hip
- Seated trunk rotation: primary driver – 6th and 7th thoracic rings
In both the squat and right OLS screening tasks, there was non-optimal alignment, biomechanics, and control of L5 during the mid to later stages of the task. In both cases, correction of the 6th and 7th thoracic rings (primary driver) resulted in full correction in control of L5 during these tasks. Because full control of L5 was restored with the thoracic ring correction, a more detailed assessment of the motor control system (deep core muscle recruitment, strategy, capacity) was not assessed during the early stages of Mr. COP’s rehabilitation.
As his function improved through the course of treatment, higher load/more challenging screening tasks were used as part of his ongoing assessment (e.g. left lunge). It was during these higher load screening tasks that a motor control issue (neural system impairment) was noted. At this point, correction of the primary driver (thoracic rings 6 & 7) did not fully restore control at L5. As a result, further analysis of the motor system was done and atrophy was then noted on palpation of the segmental fibers of deep multifidus. It was likely that there was not enough capacity in these muscles at these higher load screening tasks to fully control L5.
Vector analysis is a technique used to further analyze the driver in order to determine the underlying system impairment (articular, neural, visceral, myofascial) for the driver. A “listening” approach to vector analysis was used to determine system impairments for Mr. COP. This specific skill involves correcting the primary driver to the point of first resistance (R1) and then letting go and feeling (passive listening) for the location, direction, and length of the first vector that pulls the driver back into non-optimal alignment.
There was an underlying neural system impairment that was causing the non-optimal alignment and biomechanics of the 6th and 7th thoracic rings. During the vector analysis, it was evident that both these rings were correctable, suggesting that the joints of these thoracic rings were neither stiff nor fixated; the articular system was not impaired. Upon release of the correction, the “feel” (passive listening) of the vector was on the right posterior aspect of the ring and the resultant pull on the right side was inferior and long. Over-activation was palpable in the fibers of the right longissimus muscle that attach to the transverse processes and adjacent ribs of the 6th and 7th thoracic rings.
Vector analysis helps determine the most dominant vector that needs to be addressed. As is common in more persistent pain situations, release of the dominant vector of over active muscle will reveal other vectors. It is like peeling back all the layers of an onion. Once the right longissimus (to 6th and 7th rings) was released with a dry needling technique, over-activation (neural system impairment) was noted in the left latissimus dorsi and left serratus anterior muscles.
As for the right hip, there was non-optimal anterior translation of the head of the right femur in the screenings tasks of right OLS and squat (secondary driver). Vector analysis of the right hip again showed a neural system impairment in that there were over-active fascicles in right rectus femoris and right vastus lateralis muscles (dominant vectors).
Once these muscles were released through a dry needling technique, over-active fascicles (neural system impairment) was noted in the deep external rotators of the right hip (piriformis, gluteus medius).
Mr. COP’s story began 6 years ago during Basic Training with the hyper-extension injury to his low back. At that time, there was a probable localized joint/ligament sprain with subsequent disuse/pain limited inhibition/atrophy of the deep fibers of multifidus, most notable at L5/S1. At the time of the initial assessment, there remained marked atrophy of these muscles. Given that he had no formal treatment and our understanding that there is no spontaneous recovery of core muscles post-injury, it is unlikely he ever regained proper motor control of these deep fibers of multifidus, resulting in control issues at L5/S1.
As a result of this loss of segmental L5/S1 control during higher load tasks (e.g. lunge, gym workouts), Mr. COP likely learned to brace with the more superficial extensor muscles in his back (right longissimus). This resulted in an over-active fascicle of the right longissimus (fibers to 6th and 7th thoracic rings), which created the left translated/right rotated position of the 6th and 7th rings.
The right longissimus muscle attaches from the heads of the ribs and transverse processes and runs caudally with fibers attaching to the sacrum. Over-activation of this muscle can create the incongruent torsion between the left translated/right rotated mid thorax (rings 6 and 7 specifically) and left rotated pelvis, as was the case with Mr. COP.
Loading in this non-optimal pattern likely created altered biomechanics in the lumbar spine during the functional tasks of sitting and driving, which is a likely source for the persistent low back pain symptoms. Over time, the right anterior femoral head position (congruent to the positional finding of the left rotated pelvis) likely compressed the right lateral femoral cutaneous nerve as it passes under the right inguinal ligament in the groin. The compression of this sensory nerve can create the paraesthesia in the right anterior thigh, consistent with a diagnosis of Meralgia Paraesthetica.
Mr. COP’s duty belt could have also contributed to some compression of the lateral femoral cutaneous nerve. During the course of the physiotherapy treatment, Mr. COP had a consultation with a neurologist, who confirmed the diagnosis of Meralgia Paraesthetica; he felt the nerve compression was directly from wearing the duty belt.
The principles of Integrated Systems Model (ISM) treatment are first to release and align the drivers and then teach a new strategy for connect or control, and move according to the patient’s goal(s) and their cognitive belief. The outline of the treatment early on was as follows:
R: Primary driver – 6th & 7th thoracic rings: right longissimus fascicle, left latissimus dorsi, left serratus anterior; Secondary Driver – right hip: right rectus femoris, right vastus lateralis
A: Align thoracic rings 6 & 7 – best cue was to “create space in between the middle ribs in the mid axillary line, like a fish hook pulling to the ceiling”; seat the right hip with the cue “create space for the back of the hip by relaxing the buttock muscles and allowing the sitz bones to widen away from each other”
C: Given that correction of the 6th & 7th thoracic rings resulted in full control of L5 and the SIJ, no specific “connect” cue was needed during the earlier stages of rehabilitation (focus was placed on the “align” and “move” pieces)
M: Incorporate the above align cues into the following movement training exercises: start with standing with weight shift to the right, progress to right OLS, progress to squat (10 x 3 each, daily)
Mr. COP responded very well to this initial treatment and was able to learn the proper “align” cues and incorporate them in the lower load movements of weight shift to the right, right OLS, and squat. As his symptoms became less intense and irritable, the movement exercises were progressed to the higher load movements of left lunge (moving from a high to low lunge) and eventually to a left lunge position with added thoracic rotation. It was at these higher load tasks/movements that a motor control deficit (neural system impairment) was noted. Correction of the primary driver at these higher load tasks (6th & 7th thoracic rings) was no longer sufficient to fully control L5; a “connect” cue (“gently draw PSIS’s together”) was needed at this time in order to build up the capacity of deep fibers of multifidus in order to allow full control of L5/S1 during these more challenging tasks/movements.
Treatment, which began as once per week, was slowly decreased to once every 2 weeks as Mr. COP improved. He was eventually able to start training again with the kinesiologists (Innovative Fitness) with concurrent physiotherapy treatment. Subjectively, he noticed a slow but gradual improvement in the right anterior thigh paraesthesia (less intense, less irritable). He was able to return to workout out with the kinesiologists with no pain or aggravation of his symptoms. He continued to have some symptoms, primarily right hip/buttock pain, during his work days especially towards the end of a 4 day block of shifts.
Mr. COP continued to work full time/duties throughout the course of the treatment. This complicated treatment given that his job required him to wear a heavy vest (that compressed through the thorax) and duty belt at all times and he regularly sat/drove for extended periods of time. As a result, Mr. COP continued to require occasional dry needling/release of the above over-active muscles in order to move with more optimal alignment, biomechanics, and control. As he continues to improve with regards to his symptoms and activity tolerance, the frequency of physiotherapy treatments will decrease as new and healthier movement patterns are established and the align/connect cues become automatic.