We report the results of an intervention using an altered weaning technique and treatment effect modifiers for a person with LBP who had difficulty weaning due to severe pain.
The man was 72 years old, and unemployed. After waking up unable to move due to lumbar pain, he called for emergency medical assistance. He was admitted to the hospital with a diagnosis of lumbar deformity with no evidence of fracture and began physical therapy the next day.
The first assessment was positive for Straight Leg Raising (SLR) and positive for Crossed SLR (CSLR). In addition, pain was induced due to compression of the sciatic nerve. Pain was present in the left thigh, in the left buttock and in the lumbar region, the Numeric Rating Scale (NRS) was 8. Abnormal sensation and numbness were present in the left lateral lower extremity and throughout the toes. The STart Back Screening Tool (SBST) was 6 points (medium risk) and the Roland-Morris Disability Questionnaire (RDQ) was 19 points.
He was in so much pain that he could not turn over. After lumbar extension mobilization, the site of pain shifted from the posterior left thigh to the buttock, presenting a centralization-like phenomenon. This phenomenon was an indication that Directional Preference (DP) was an extension. On day 7 of admission, both SLR and CSLR were negative and he tried to use a wheelchair. However, the pain worsened after using the wheelchair and both SLR and CSLR were positive. This suggested that neurological symptoms occurred in the sitting position. Additionally, because the pain was worse in the morning, we thought it might be caused by the intervertebral disk. With these considerations in mind, we decided to start the weaning process in the standing rather than the sitting position. In addition, to promote movement in the direction of lumbar extension, joint mobilization of the thoracic spine and scapulothoracic joint was performed.
The final evaluation was as follows; SLR and CSLR were negative, pain induced by peripheral nerve compression resolved, NRS 1-2 left big toe pain and mild numbness from big toe to outer lower leg remained, RDQ score was 9 points. On day 23 of admission, the man was discharged home with independent walking.
The man was able to increase his ADL using an altered weaning method based on initial physical therapy findings and pain characteristics. In addition, we believe that treatment selection based on treatment effect modifiers, centralization and DP, resulted in better outcomes.
Based on the physical findings, various methods of weaning can be used to assess and intervene. This case illustrates one of these methods. It is hoped that it will assist decision making in future clinical practice.
Treatment effect modifier
Weaning method
