49 y.o female

Symptoms: severe pain in the low back and right lower extremity; numbness of right toes

Onset: gradual worsening since return to work as a teacher in September

Past History: two previous episodes of low back and right leg pain in the last four years; each episode resolved within six weeks with treatment focussing on neural mobilization, SI joint mobilization, and motor control exercises; CT scan during second episode revealed herniated disc at L5/S1, but symptoms had already resolved; painfree and full function following symptom resolution

Medical History: otherwise unremarkable

Activities: generally very active - walking,running, yoga, etc. Very limited since recurrence of pain.

Objective Assessment:
Neuro. scan - decreased right S1 reflex, weakness of the right L5 key muscle, slight decrease in sensation of the right L5 and S1 distribution
Function - limited sitting tolerance (about 30 minutes)
Pain - 8/10 on Numeric Pain Rating Scale; moderate to high sensitivity in the right lower quadrant
Movement - lumbar flexion 50% with pain
positive slump test
straight leg raise positive at 25 degrees on the right
no segemental tenderness in the lumbar spine

Treatment: Education re: pain mechanisms
neural mobilizations
ATM for lumbar flexion
3 sessions in the last two weeks

Results: ATM immediately reduced pain in the back and leg; after only one session, pain report decreased by 50%, straight leg raise increased to 50 degrees, and lumbar flexion increased about 25% with less pain. Pain returned between the second and third sessions, but was much less severe. Improvements in mobility were sustained. There also seemed to be some improvement in neurological signs; however, this was inconclusive. This result was much quicker and longer-lasting than previous interventions with this patient.

Plan: Continue using ATM to reduce pain and improve mobility. Progress to strengthening for back extensor muscles. Monitor neurological signs.