Dermatone/Referred pain in ankle...I need HELP

[Bubbly]

I have a patient that I have been seeing for over 2 years, date of injury March 1, 2001 which is work related. With doctor prescription I have been working under icd codes lumbar disc displacement, lumb/lumbosac disc degen, lumbosacral neuritis nos and postlaminect synd-lumbar. He has had lumbar fusion 4/5 and sacral. About a year ago the patient had a long car trip about 7 to 8 hours one way for family funeral. which really caused a flare up, since then he has had surgery to remove scar tissue around the fusion, this made the situation worse. He then had trial on neuro-stimulator, which did not help. Find SOAP notes below

SUBJECTIVE COMPLAINT:
“I feel better, I haven’t been doing anything though.”, remarks the patient. Z notes pain in the following areas: the right calf both front and back and the top of right foot and ankle, he does not mention any discomfort in the right hip. Z places his pain at a level 7 on the pain scale, pain drawing supports the above comments.

OBJECTIVE EXAMINATION:
Visual Examination; Z's gait is much improved over prior observation, he remains guarded. Sitting does not appear to be the problem that it was last session. The patient remains mindful of his movements and is restricted and guarded in the lower back.
Range of Motion Testing; No change, Z is guarded in his movement and his range of motion is limited for flexion and extension of the lumbar area and the area to which the pain is referred, lower right leg.
Palpatory Examination; Trigger/tender points are absent both sides for the piriformis. Hamstrings remain tight both legs.


ASSESSMENT:
The physician states the patient is suffering from (LUMBAR DISC DISPLACEMENT 722.10), (LUMB/LUMBOSAC DISC DEGEN 722.52), LUMBOSACRAL NEURITIS NOS 724.4) AND (POSTLAMINECT SYND-LUMBAR 722.83)
Action Taken: Prone, supine and seated position used in treatment massage session, areas warmed by friction and effleurage. Compression strokes, acupressure, percussion, myofacial release and tapotement used on areas identified above. Z was able to tolerate massage to the right leg.
Functional Outcome: “Feels better, it’s a 5”, notes Z. Walking appears easier in his stride, not as tight. Massage as a complementary component of treatment appears to assist the patient in the relief and management of pain as indicated by the patient


PLAN:
The goal is to assist in the relief and management of pain which the patient feels. The treatment plan for the patient as directed by the physician is massage therapy, which will increase flexibility and circulation, which should reduce hypertonicity and increase the range of motion to the affected areas. The patient will be seen one time per week for 8 weeks. The length of sessions is approved for 45 minutes. Treatments are to begin June 25, 2007 and end August 25, 2007.

ANY SUGESSTIONS

 

[slicedbread1991]

I don't know if those are your SOAP notes and for which visit (visit one or visit this past week), but it seems like you are achieving the goal you mentioned. You want to "assist in the relief and management of pain which the patient feels."

SUBJECTIVE COMPLAINT:
“I feel better, I haven’t been doing anything though.”, remarks the patient.

He's got a fusion, and since the doc didn't suggest any sort of traction that I see, nor Williams Exercises or any other sort of Flexion/Extension exercises, you may have to make peace with yourself that you may not be able to make this client completely well in 8 weeks. It is a long standing issue which has been complicated, as noted by "About a year ago the patient had a long car trip about 7 to 8 hours one way for family funeral. which really caused a flare up, since then he has had surgery to remove scar tissue around the fusion, this made the situation worse."

He/she may have some RSD issues going on - since you say they tried a "neuro-stimulator".

Of course, that's just my thoughts. Maybe a hard core MFR therapist can tell you something to raise your hopes.

Good luck.

PS: I just quoted a lot to show exactly what thoughts I was bouncing off of, not to make you think I was being snotty or soemthing.

 

[grabdriver]

Peuppi,
What are Williams exercises and what does RSD stand for? The SOAP notes are from the end of July 2007
Thanks, George

 

[Mr Grinch]

There are Williams Flexion Exercises and McKenzie Exercises. I had forgotten the named portion of "McKenzie" (I had a brain-fart ). To be honest, I don't do much rehab, so, my in depth knowledge of the exercises is minimal at best, though at some point I did have to learn it. Ah, well. We do all focus on what we enjoy. I lean towards the hands on, and therefore the whole rehab concept never really set foot in my brain. I like to refer people to rehab when necessary. Let someone else do that!

So, there are pics on this link of what the typical excercises look like, and I hope it helps. It sure refreshed my memory.

Here's a comparison of the two:

Williams' Flexion Versus McKenzie Extension Exercises For Low Back Pain

In general, extension exercises may cause further damage in people with spondylolysis, spondylolisthesis and facet joint dysfunction (Harvey 1991), not to mention the possibility of crushing the interspinous ligament (McGill 1998). While flexion exercises should be avoided in persons with acute disc herniation (Harvey 1991).

Brief History of Williams' Flexion Exercises
Dr. Paul Williams first published his exercise program in 1937 for patients with chronic low back pain in response to his clinical observation that the majority of patients who experienced low back pain had degenerative vertebrae secondary to degenerative disk disease (Williams 1937). These exercises were developed for men under 50 and women under 40 years of age who had exaggerated lumbar lordosis, whose x-ray films showed decreased disc space between lumbar spine segments (L1-S1), and whose symptoms were chronic but low grade. The goals of performing these exercises were to reduce pain and provide lower trunk stability by actively developing the "abdominal, gluteus maximus, and hamstring muscles as well as..." passively stretching the hip flexors and lower back (sacrospinalis) muscles. Williams said: "The exercises outlined will accomplish a proper balance between the flexor and the extensor groups of postural muscles..." (Williams 1965, Williams 1937, Blackburn 1981, Ponte et al.).

Williams’ flexion exercises have been a cornerstone in the management of lower back pain for many years for treating a wide variety of back problems, regardless of diagnosis or chief complaint. In many cases they are used when the disorder’s cause or characteristics were not fully understood by the physician or physical therapist. Also, physical therapists often teach these exercises with their own modifications. Williams suggested that a posterior pelvic-tilt position was necessary to obtain best results (Williams 1937).

Examples of Williams' Flexion Exercises
1. Pelvic tilt. Lie on your back with knees bent, feet flat on floor. Flatten the small of your back against the floor, without pushing down with the legs. Hold for 5 to 10 seconds.

2. Single Knee to chest. Lie on your back with knees bent and feet flat on the floor. Slowly pull your right knee toward your shoulder and hold 5 to 10 seconds. Lower the knee and repeat with the other knee.

3. Double knee to chest. Begin as in the previous exercise. After pulling right knee to chest, pull left knee to chest and hold both knees for 5 to 10 seconds. Slowly lower one leg at a time.

4. Partial sit-up. Do the pelvic tilt (exercise 1) and, while holding this position, slowly curl your head and shoulders off the floor. Hold briefly. Return slowly to the starting position.

5. Hamstring stretch. Start in long sitting with toes directed toward the ceiling and knees fully extended. Slowly lower the trunk forward over the legs, keeping knees extended, arms outstretched over the legs, and eyes focus ahead.

6. Hip Flexor stretch. Place one foot in front of the other with the left (front) knee flexed and the right (back) knee held rigidly straight. Flex forward through the trunk until the left knee contacts the axillary fold (arm pit region). Repeat with right leg forward and left leg back.

7. Squat. Stand with both feet parallel, about shoulder’s width apart. Attempting to maintain the trunk as perpendicular as possible to the floor, eyes focused ahead, and feet flat on the floor, the subject slowly lowers his body by flexing his knees.



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Brief History of McKenzie Back Exercises
The McKenzie back extension exercises have been order by physicians and prescribed by physical therapists for at least two decades (McKenzie 1981). Robin McKenzie noted that some of his patients reviewed lower back pain relief while in an extended position. This went against the predominant thinking of Williams Flexion biased exercises at this period of time.

Physical therapists can become "McKenzie certified", but the vast majority of physical therapists who treat low back pain are not. McKenzie has developed diagnostic categories that assign patient to specific treatments. Patients evaluated by McKenzie certified therapists are most likely to be placed into an extension biased exercise program. This is probably why most people think of extension when talking about McKenzie exercises, or because the original exercises were in opposition to Williams' flexion exercises.

The goal of McKenzie exercises is to centralized pain. If a patient has pain in the lower back, right buttock, right posterior thigh, and right calf, then the goal would be to "centralize" the pain to the lower back, buttock, and posterior thigh. Then, "centralize" the pain to the lower back and buttock, and finally just the lower back.

Click here to order this book by the guru himself!

by Robin McKenzie

Typical McKenzie Back Extension Exercises
1. Prone lying. Lie on your stomach with arms along your sides and head turned to one side. Maintain this position for 5 to 10 minutes.

2. Prone lying on elbows. Lie on your stomach with your weight on your elbows and forearms and your hips touching the floor or mat. Relax your lower back. Remain in this position 5 to 10 minutes. If this causes pain, repeat exercise 1, then try again.

3. Prone press-ups. Lie on your stomach with palms near your shoulders, as if to do a standard push-up. Slowly push your shoulders up, keeping your hips on the surface and letting your back and stomach sag. Slowly lower your shoulders. Repeat 10 times.

4. Progressive extension with pillows. Lie on your stomach and place a pillow under your chest. After several minutes, add a second pillow. If this does not hurt, add a third pillow after a few more minutes. Stay in this position up to 10 minutes. Remove pillows one at a time over several minutes.

5. Standing extension. While standing, place your hands in the small of your back and lean backward. Hold for 20 seconds and repeat. Use this exercise after normal activities during the day that place your back in a flexed position: lifting, forward bending, sitting, etc.

What Does Recent Research Suggest About William Flexion or McKenzie Back Exercises?
A. Adams, et al. found that "extension can reduce stresses in the posterior annulus of those discs that are most protected by the neural arch. This protection may be related to disc height loss, to the morphology of the neural arch, or both....

Discogenic pain is associated with stress concentrations in the posterior annulus. That backward bending can reduce such stress peaks in some discs could explain pain relief in some back pain patients undergoing extension exercises... Pain relief would be anticipated only in those patients whose painful discs can be stress shielded by the neural arch in extension, and this may depend on factors such as disc height, and the precise shape of the neural arch....

Backward bending may also correct any posteriorly displaced intradiscal mass, which is presumably an embryonic seforum.xxxe of disc herniation. This dynamic internal disc model may provide an explanation for the commonly noted phenomenon of "centralization", in which distal pain is abolished and symptoms move proximally, often in response to extension exercises (Adams 2000).

B. When rehabilitating patients with back dysfunction, extension exercises that are presumably "passive" for the erector spinae muscles are frequently used. The results of a study demonstrated that "passive" extension exercises were not truly passive for lumbar back extensor muscles. From a clinical perspective, if the performance of passive back extension is important, extension in lying prone may not be the exercise of choice and having patients lying prone may be the most beneficial (Fiebert 1994 ).

C. In one of the more carefully conducted randomized trials of nonsurgical back pain treatments undertaken in recent years, researchers conclude that McKenzie back exercises provide slightly greater pain relief than a placebo--the control group received a patient education booklet on low back pain. Neither chiropractic manipulation nor McKenzie back exercises provided a significant functional benefit.

One of the most important tests of a therapy's efficacy is how it affects back problems over the long term. McKenzie proponents have argued that their protocol reduces recurrences of back pain and decreases utilization of services. This study showed evidence that McKenzie back exercises do not reduce low back pain recurrence.

"This casts doubt on the ability of the self-care-oriented McKenzie (back exercises) to reduce the utilization of services," suggest the researchers. "There was no evidence that the higher initial costs of the physical treatments were offset by later savings," they add (Cherkin 1998).

D. Nachemson arguably discredited Williams flexion back exercises when his study showed that these exercises may significantly increased the pressure within intervertebral discs of the lumbar spine (Nachemson 1963).

E. Two studies have shown that lower back stiffness may only be a symptom of lower back pain and not the cause of it. (Johannsen 1995, Mellin 1985) Johannsen, et al. conclude that "...increased spinal mobility does not necessarily lead to LBP (low back pain) improvement, and mobilizing exercises alone cannot be recommended to LBP patients (Johannsen 1995).

F. Is there another explanation for symptom relief resulting from McKenzie? What about tight iliopsoas muscles? Isn't it more likely that the effectiveness of McKenzie extension exercises is associated with the elongation of the iliopsoas muscles secondary to the stretch positions. The truth is that there is no reproducible data that shows that the exercise effect has anything to do with the nucleus pulposis "moving"... (Jorgensson 1993, Ingber 1989).

RSD = Reflex Sympathetic Dystrophy (And apparantly they have a new name for it too. = CRPS = Learn something new everyday.)
There are a lot of people who will disagree with me, but I do believe that RSD can oftentimes be helped with TCM (Traditional Chinese Medicine). I worked in a Pain Management Clinic for a time and we did find that Tai Chi and acupuncture helped these people. Many went with the nerve block's just because their MD was not TCM oriented, and also because the patient did not want to work for the outcome (there are a lot of psychological issues surrounding that kind of pain). I saw nerve blocks ruin many lives, that, had the patient been able to become emotionally avaliable and try TCM, they may have been able to experience a better quality of life. I am not saying it is for everyone, but I do think it's worth a shot prior to more drastic measures.

Reflex Sympathetic Dystrophy (RSD/CRPS)

Overview

Reflex sympathetic dystrophy (RSD) or complex regional pain syndrome (CRPS), is a chronic, painful, and progressive neurological condition that affects skin, muscles, joints, and bones. The syndrome usually develops in an injured limb, such as a broken leg, or following surgery. However, many cases of RSD involve only a minor injury, such as a sprain. And in some cases, no precipitating event can be identified.

Pain may begin in one area or limb and then spread to other limbs. RSD/CRPS is characterized by various degrees of burning pain, excessive sweating, swelling, and sensitivity to touch. Symptoms of RSD/CRPS may recede for years and then reappear with a new injury.

Types

Two types of RSD/CRPS have been defined:

Type 1 - without nerve injury
Type 2 (formerly called causalgia) - with nerve injury

Both types share the same signs and symptoms.

Incidence and Prevalence

Millions of people in the United States may suffer from this chronic pain syndrome. RSD/CRPS affects both men and women, and also occurs in children. It can occur at any age, but usually affects people between the ages of 40 and 60 years.

The National Institute of Neurological Disorders and Strokes (NINDS) reviews that 2% to 5% of peripheral nerve injury patients and 12% to 21% of patients with paralysis on one side of the body (hemiplegia) develop reflex sympathetic dystrophy as a complication. The Reflex Sympathetic Dystrophy Syndrome Association of America (RSDSA) reviews that the condition appears after 1% to 2% of bone fractures.

Causes and Risk Factors

RSD/CRPS appears to involve the complex interaction of the sensory, motor, and autonomic nervous systems, and the immune system. It is thought that brain and spinal cord (central nervous system) control over these various processes is somehow changed as a result of an injury.

Causes associated with the onset of RSD/CRPS include the following:

• Cerebral lesions
• Heart disease, heart attack
• Infection
• Paralysis on one side of the body (hemiplegia)
• Radiation therapy
• Repetitive motion disorder (e.g., carpal tunnel syndrome)
• Spinal cord disorders
• Surgery
• Trauma (e.g., bone fracture, gunshot and shrapnel wounds)

In 10% to 20% of cases, no direct cause can be found. Injury that precedes the onset of RSD/CRPS may or may not be significant.

Treatment

The goals of treatment are to control pain and to maintain as much mobilization of the affected limb as possible. An individualized treatment plan is designed, which often combines physical therapy, medications, nerve blocks, and psychosocial support.

Medication

Medications are prescribed to control pain. The type of pain experienced by the patient determines the type of medication prescribed.

Constant pain caused by inflammation is treated with nonsteroidal anti-inflammatory drugs (e.g., aspirin, ibuprofen, naproxen, indomethacin). Due to potenially severe gastrointestinal and cardiovascular side effects, NSAIDs should only be used as instructed.

Constant pain not caused by inflammation is treated with central acting agents such as tramadol (Ultram®).

Sharp pain and pain that disrupts sleep may be treated with antidepressants (e.g., amitriptyline, doxepin, nortriptyline, trazodone) or anticonvulsants (e.g., carbamazapine, pregabalin).

In select patients, generalized, severe pain that does not respond to other medications may be treated with opioids (e.g., propoxyphine, codeine, morphine).

Muscle cramps (spasms and dystonia) can be treated with clonazepam and baclofen.

Localized pain related to nerve injury may be treated with Capsaicin® cream, but its effectiveness has not been proven.

Medications that affect the sympathetic nervous system such as clonidine (Catapres®) can be useful in some cases.

Muscle stiffness may be treated with muscle relaxants such as

• Tizanidine (Zanaflex®)
• Baclofen
• Clonazepam (Klonopin®)

Physical Therapy

Physical therapy should include daily range of motion exercises. Patients should be advised to avoid activities that could accelerate osteoporosis or joint injury.

Nerve Block

Sympathetic nerve block interrupts the transmission of pain signals from a group of nerve cell bodies (called a ganglion). When treating an upper extremity, it is called a stellate ganglion block. A small needle is used to inject an alpha adrenergic aneforum.xxxonist alongside the windpipe. When treating a lower extremity the nerve block is performed in the lower (lumbar) spine.

The procedure, which is usually performed by a physician familiar with the technique, involves the insertion of a needle into the appropriate location and the injection of anesthesia into the ganglion. The effect is monitored over time.

Sympathectomy

Patients who have a good but temporary response to nerve block may be candidates for a surgical procedure called sympathectomy. The goal of this procedure, which involves cutting and sealing (cauterizing) a portion of the sympathetic nerve chain that runs down the spine, is suppression of sympathetic nervous system activity in the affected area. Performing sympathectomy for RSD is controversial and in some cases, the procedure worsens symptoms.

TENS Unit

A transcutaneous electrical nerve stimulation (TENS) unit may be used to treat the affected area. In some cases, spinal cord stimulators are implanted permanently to supply a low intensity impulse to a location in the spinal cord in an attempt to interrupt the pain signals that are being transmitted to the brain.

Psychosocial Support

RSD/CRPS patients often become depressed and anxious because of chronic pain and loss of physical ability. Counseling, support groups, and chronic pain center programs help patients learn coping strategies and provide emotional and psychological support.

Hope this helps.