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Case Study: Comprehensive Physical Therapy Approach for Kevin, a 47-Year-Old with Lumbar Spine Issues

Kevin, a 47-year-old self-employed professional, came to our physical therapy clinic with a complex medical history, including multiple herniated discs at the L4 and L5 levels and a pars fracture in one of the lumbar vertebrae. Kevin had tried various therapies, including physiotherapy, hands-on treatment, and needling, but his consultant suggested surgery as the next step. However, with an estimated recovery time of 11 months, Kevin sought our help as he couldn’t afford to take that much time off work.


Initial Assessment


During our initial selective functional movement assessment (SFMA), Kevin’s primary discomfort and functional limitations were identified:


• Lumbar Flexion: Kevin exhibited significant difficulty in bending forward, indicating dysfunction in the lumbar region.

• Hip Flexors: Both his right and left hip flexors were extremely tight, with more severe restriction in the left hip’s abduction.

• Primary Pain: Kevin’s primary pain was localized on the left side, correlating with his tighter left hip.

• Big Toe Restriction: He also had a restriction in his right big toe due to a previous joint fusion surgery.

• Sensitivity to Compression: His neck, thoracic spine, and lumbar spine were all sensitive to compression, indicating possible inflammation or nerve impingement.

• Single Leg Stance: Kevin’s balance was notably off, revealing a vestibular issue affecting his overall stability.


Detailed Findings


Further neurokinetic testing and functional assessments provided more insights:


• Hip Stability and Motor Control Dysfunction: In a bird dog position (a functional test where the patient extends one arm and the opposite leg while on all fours), Kevin showed poor stability and motor control in both hips.

• Neurokinetic Imbalances: We discovered a neurologically overactive left sacroiliac joint and an underactive left iliolumbar ligament. Similarly, the interspinous ligament at L4 was overactive, while the interspinous ligament at C4 was underactive.

• Vestibular Issue: Kevin’s off-balance single leg stance pointed to a vestibular issue, which was confirmed by specific balance tests.

• Impact of Scar Tissue: One of the most remarkable findings was a scar on the back of Kevin’s head, which he had sustained in his youth. This scar was disrupting his entire motor control system.


Understanding Scar Tissue and Motor Control


Scars, particularly those on the head, can significantly impact the body’s motor control system. The nervous system can become overactive around the scar tissue, causing compensatory patterns and disruptions in normal muscle function. In Kevin’s case, the scar on the back of his head was likely interfering with neural pathways, leading to poor coordination and control throughout his body.


What is a Pars Fracture?


A pars fracture, or spondylolysis, is a stress fracture in one of the bones (vertebrae) that make up the spinal column. The pars interarticularis is a small segment of bone that joins the facet joints in the back of the spine. When this area becomes fractured, it can cause significant pain and instability in the lower back.


Pars fractures are commonly seen in athletes who participate in sports that involve repetitive spinal extension and rotation, such as gymnastics, weightlifting, and, in Kevin’s case, Gaelic football (GAA). The physical demands of these sports can place a significant amount of stress on the lumbar spine, leading to the development of stress fractures over time.


Neurologically Overactive Ligaments


When we say that a ligament is neurologically overactive, we are referring to the small sensory receptors within the ligament that are sending too many signals to the brain. These receptors, called mechanoreceptors, provide the brain with information about the position and movement of the joints. When they become overactive, they can cause the muscles around the joint to become overly tight or spasm, leading to pain and dysfunction.


In Kevin’s case, the overactive left sacroiliac joint and interspinous ligament at L4 were causing significant muscle tightness and pain in the lumbar region. This overactivity was also contributing to his poor movement patterns and lack of stability.


Treatment Plan


Our treatment plan focused on addressing Kevin’s immediate pain, improving his movement patterns, and restoring balance and motor control:


1. Core Stabilization: We developed a regimen to stabilize Kevin’s core. Despite his strength, Kevin lacked the necessary control and coordination in key muscle groups like the transverse abdominis and the multifidi. Exercises such as planks, dead bugs, and bird dogs were tailored to improve his core control.

2. Hip Flexor and Abductor Stretching: Targeted stretching exercises were introduced to improve flexibility in his hip flexors and abductors. These included dynamic stretches and static holds to gradually increase range of motion.

3. Balance Training: To address the vestibular issue and improve Kevin’s single leg stance, balance exercises were incorporated. These included standing on unstable surfaces, single-leg exercises, and incorporating head movements to challenge his vestibular system.

4. Soft Tissue Mobilization: Hands-on techniques, including massage and myofascial release, were used to address muscle tightness and improve tissue mobility, particularly around the hips and lumbar spine.

5. Scar Tissue Management: We applied specific techniques to the scar tissue on Kevin’s head to reduce its neurological impact. These included gentle massage and neural mobilization techniques to decrease sensitivity and improve neural function.

6. Functional Movement Re-Education: Kevin’s treatment included re-educating his body to perform basic movements correctly. This involved practicing movements like squatting, bending, and lifting with proper form to prevent further injury and improve functional capacity.


The Role of Selective Functional Movement Assessment (SFMA)


The Selective Functional Movement Assessment (SFMA) acts as a road map to discover what someone like Kevin really needs. The SFMA is a systematic approach to identifying movement pattern dysfunctions. By breaking down complex movements into their component parts, we can pinpoint the specific areas that are contributing to pain and dysfunction.


For Kevin, the SFMA provided a step-by-step plan to ensure that each aspect of his movement and stability was addressed. This comprehensive assessment allowed us to create a tailored treatment plan that focused on his unique needs. The SFMA helps in:


• Identifying dysfunctional movement patterns.

• Isolating the root causes of pain and dysfunction.

• Providing a clear path for rehabilitation.

• Ensuring a step-by-step approach to recovery.


Understanding Kevin’s Physical Demands


Kevin is an avid participant in Gaelic football (GAA), a sport that places high demands on the body, particularly the lower back. The sport involves a lot of running, jumping, and sudden changes in direction, which can exacerbate existing back problems. Kevin’s involvement in such a physically demanding sport likely contributed to the development of his pars fracture and the overall stress on his lumbar spine.


Conclusion


Kevin’s case illustrates the complexity and interconnectivity of the human body. By addressing not only the symptoms but also the underlying dysfunctions, our holistic approach aims to help Kevin manage his condition and improve his quality of life. This case underscores the importance of a comprehensive assessment and personalized treatment plan in physical therapy, particularly for individuals with multifaceted issues like Kevin.


The initial session with Kevin has set a foundation for his rehabilitation journey. Through targeted therapeutic interventions and a clear plan based on the SFMA, we are hopeful that Kevin will make significant progress in managing his back issues and achieving a better quality of life.

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