Clinical Reasoning Process ?

[emad]

Hi friends :

I am going to mention a case study i have those days .

Base
Here i can not endorse CT scan ,MRI ,X-ray reports , because the reports are not written by competent ,skillful professionals , here the orthopedist refer the case for x-ray ,MRI . they report for him a report which satisfy his demands/intentions to perform a surgery :!: :!:
Society
Here where i live there is a university with all medical schools , with surrounding 11 towns and about 150 village ,
This case was assessed by the head of the orthopedic departement in the university , who teach all doctors surround me !!

The Patient
Female 54 years , her weight is good , she work in her house daily activities as all her past years .
Past history
She report since 3 months i had up and down stairs very fast , after that i feel back pain ,all that what i remember , i had no trauma ,or i gone up fast then feel that back pain .
After that day there was very bad back pain , cough ,sneeze increase my back pain , i can not walk , go out of bed , or even stand .
Present History
I have performed examintion , now the all complaints and pain were since 3 months .
I find
lumbar palpation and all back :arrow: no pain
active trunk flextion :arrow: no pain
active trunk ext :arrow: no pain
active trunk rotation :arrow: no pain
SLRT :arrow: no pain until 70-80 flex
muscle test :
knee flex&exten :arrow: normal
hip flex&exten :arrow: normal
ankle dorsi :arrow: 1 grade
ankle planter :arrow: 4 grade
gait of course :arrow: high steppage gait

The doctor
performed MRI, then concluded there is a disc protrusion , which needs surgical interevernce
My Hypothesis
no disc
i feel it is neuritis , nerve root inflammation leads to the drop foot


I hope your views :idea:

cheers
emad :lol:

[rolf]

Hi emad!
where do she experience the pain during SLR?Same area as the chronick pain?Was the SLR done in sitting or supine position?
Was the SLR crossed positive(for some ortopeds op.indication)
What about her reflxes,sensibility,vibration sens.?
Ankel dorsal flex grad 1 "smells like" nervroot L5 "irritation".
A protrusion on this level can "mecanicly" give a nerveroot inflammation.
The disc can also be "leeking" and give riise to a nerve root infammation!
In one way or another we have to,reduse the inflammation and mob. the n.ischiadicus !If the motor problem is increasing an op. might be the right thing to do!But before an op. conservative treatment has to be tried!
RIN

[enea]

Hi :D ,
did you think a big neurological problem, as lesion at the second motor neuron?

[emad]

hello all:
Welcome Ena to the forum;
First
To be fair , i think all those examinations and tests which i concluded negative now , surely i feel t may be postive since 2 months , when she visited the surgeons.
The limb affected is the left

Rin :
SLRT , which i have performed was from supine , there was at all no pain until 85 flexion , but i have NOt addeded DF to the SLRT .
The right lower limb SLRT was negative until 90 flexion from supine .

then all trunk examinations i performed from standing posture , i have not tested slump.
I have not tested reflexes , i am not accustomed to perform , even have no hammer in my office :wink:

muscle test
dorsi flexion :arrow: no more than grade 1
eversion :arrow: 0
toes adduc&abd :arrow: 0
toes exteni :arrow: 0

i performed tinel sign just over the head of the fibula was negative , i will try it again

then since 3 months she was completely bed ridden , now she can walk very easly, climb stairs with no pain , cough and sneeze now , do not referr pain .
just numbness below the knee level

Bernard :
What is awareness technique?

cheers
emad :lol:

[bernard]

Emad,

try this => Low back
http://www.somasimple.com/forums/showthread.php?t=60

If patient feels no pain during exercice => no root problem, in contrary => possible?

[emad]

Hi Bernard:

The issue is copletely away of what are you thinking , you think it may be just sciatica , pain to any reason the patient afraid of moving the foot , no

it is type of lower motor neuron lesion , but the main problem if the probelm is the compression by the disc , or the root after it gone out away from the disc ,
exactly like cases of compression of drop wrist .

cheers
emad :lol:

[bernard]

Emad,

Every day I see human beings who have sciatica and numbness since sciatic nerve is their problem?
Disc bulging is a possible consequence of dys-functioning of the human being => changing the function =reestablishing it is often the better way of repairing?
Numbness is often a sign of severe nerve insult but if you relax the areas around the injury, you let a chance of better recovery?

Clear?

[emad]

Thanks
i will tr to be online after 7 hours
bye

[rolf]

Hi emad!
As you say it seems like a lower motor neuron lession caused by agreat lumbar protusion.
How can this women walk very easily with more or less a drop fot?
Have the muscle tests aways been that weak?Is her strenght de.or increasing?
A big lumbar protrusion with just great motor weakness and no pain might be quite serious.
The hip abductor ,glutmed and min is also inervated by the L5nerve.
How is her hip stability?Positive trendelenburg? :roll:
RIN

[emad]

Hi Bernard & Rin

Rin :

I believe it is lower motor neuron lesion but NOT caused by disc protrusion .
it is a lower motor neuron lesion below the level of anterior horn cells .

You are right i am going to assess the fallowing :
reflexes
sensations
prone knee flexion test
slump test
trendlenberg sign
spring test

Rin you wrote :
A big lumbar protrusion with just great motor weakness and no pain might be quite serious.

Is this practically /scientifically existe disc protrusion with motor affection , and NO pain

some of signs i can remeber
she has very good bladder &bowel control
numbness along lateral leg compartement
no pain in morning ,or with activity and walking :roll: :?

Bernard
I think i can feel very well weakness , from just sciatica or pain , do you think Bernard ,sciatica /pain could lead to weakness of flaccid type :?: :idea:

cheers
emad

[emad]

Hi Bernard:

Seems you insist the case no more than sciatica :!: :idea: :lol:


i hope so , it will be new,great experince for me :idea: :idea: :idea:


cheers
emad :lol:

[bernard]

Emad,

If the roots were injured as you thought, it might be very painful. It seems that all roots lesions near the spinal cord are very, very painful (for the sensitive side). The motor side is in front of the sensitive one, so a "physical" conclusion is to think that you have a partial numbness and a partial weakness => the two roots were stressed => hope it is only a stretch without rupture?

Look at any sign of nerve regeneration as pain, warm, electrical signs and vanishing of weakness.

[emad]

Ok , Bernard

Do you think there is a disc protrusion causing that lesion :?: :!:

cheers
emad :lol:

[emad]

Hi Bernard :

Thank you :D

all what i believe in this is a case of peripherial nerve lesion , at all the disc is cause, i will try breathing ex,and relaxation .

i will try to use neural glides of the sctiatica


cheers
emad :lol:

[emad]

Hi all :

Seems you are right Bernard :!: :shock: :shock: :shock: :shock:

i assessed today that patient again ::

1) When i tried to assess the knee flexors from prone , :arrow: pain behind knee
2)+ terndlenberg sign
3)i asked her to stand on toes this i can give scale 7/10
4)i asked her to stand on heels ,i can give scale 3/10
5)There are signs of toes flicker contraction which could be grade 2
6)I tried to test well adduction , i found the activity between big toe and
the second is good , the most weak is between 5&4 toes
7)Breathing 10 times :arrow: NO pain at all


My Treatment
sciatic neural glides
nerural mobilistion in the form of DF&hip flex the the vice
active abduction,dorsi,ever,inver

cheers
emad :lol:

[nari]

emad

Well done - the world of neurodynamics is exciting, isn't it!


Nari :P

[emad]

Hi Nari:

seems so , but i think through this patient i have learned a lot first of all , the meaning , i have spoken with this patient a lot a lot to change her understanding that there is a disc , however there signs of good progress , but she still so afraid so so afraid that , the orthopedist surgon told her if she does not the operation there will be atrophy of her lower limbs ..

Have you any suggesation for my treatment

cheers
emad :lol:

[rolf]

Hi emad!

I f this women have increased her muscular strenght ,even if its just a little bit,since you started treatment ,you have to convince her about her possibilities,not the limits."fearavoidens"Be possitive but realistic.
Belive it or not but manuell traction have been used in similar conditions with good result(+neve mob,of course)Training in wather with wetwest,,swiming.Get this womenon the the move,in one way or another.
Motion is lotion for the possitive emotions!!!!!!!!!!!! :lol: :lol: :lol: :lol:
rin

[emad]

Hi Rin:
You are right , i encourged this patient to return as possible to her daily activities within the limit of pain, you mean manual traction of the whole lower limb along the limb axis , with some degrees flexion ,exter rotat, abduction .

Rin you can go the topic Neurodynamics to check how i perform glides, sharing us your views .

cheers
emad :wink:

[enea]

hi somasimplers,
years ago I found a woman whit LBP and drop foots. Every doctors told her was sciatica. After 3 treatment, the patient was worsened, and I thinked a central problem of nervous sistem. Infact, the patient was afflicted of SLA (sclerosis lateral amiotrophic). Now is dead.
Emad patient's remember me that case. But today I'm learning a different way of see a treatment and cause.
I'm from Verona, juliette e Romeo's city.
thank you everybody and excuse my english :oops:
Cheers Enea :P

[emad]

Hi Enea:
welcome to the forum

Just , now i have assessed that women ,there is no regression at all , on the opposite she is more better , even the ankle dorsi flexion begin , but very slow and weak, today she reports the numbness decreased significantly,limping improved.

cheers
emad :lol:

[Diane]

Hi Enea,
Ditto what Emad said. (Emad, glad your patient is doing better.)

(As one of the English speakers here, I am supremely grateful that Bernard decided to have the forum be in English, because altho I speak quite a bit of Spanish, my French is very limited. I admire the multilinguality of everyone else.)
Welcome,
Diane

[nari]

Enea, welcome to the forum.

I am interested in the philosophy and practice of physiotherapy in Italy, so I hope you keep posting.

I have done in the past 6 years of Latin and 5 years of French - both quite rusty ( ie, almost forgotten) but my Italian is non-existent..

We always have to watch out for signs that tell us there is something much more going on than it appears. We call them "red flags' and the doctor sometimes misses the bad signs in his or her busy day.

Nari