The following is a case report of a patient commencing treatment for lower back pain at the Lumbex Spine Clinic in Fort Worth, Texas on October 11, 2004. This clinic is a dedicated non-surgical lumbar spine decompression and strengthening facility.

A 68 year old male minister entered the clinic on crutches with complaint of lower back pain and left anterior thigh pain. He stated that the pain appeared suddenly with no apparent cause, although he had a long history of recurrent bouts of lower back pain. Before this latest episode, he could walk normally without a cane or crutches and could handle the everyday duties of a minister. The pain was aggravated by walking but relieved by sitting. He had been treated for the previous episodes with chiropractic manipulative therapy with typically fast resolution of symptoms.

Exam showed a six foot two male of 220 lbs. He had a left anterior list. Minor's sign was present. Valsalva was negative. Kemp's test would evoke pain at the left L5 facet area. There was abnormal tenderness over the facet joints of L5-S1 on the left. Dermatomal testing and reflexes were normal. Lumbar range of motion was painful and restricted in extension. Initial diagnosis was lumbar facet syndrome. He was placed on a treatment plan of daily treatment for three weeks and then decreased frequency until maximum improvement. Initial treatment consisted of three sets of lumbar extension exercises on the ATM2 upright treatment table followed by 25 minutes of lumbar decompression therapy and then four sets of 15 reps on a lumbar-specific exercise machine. After three treatment sessions the patient was seeing some improvement in low back symptoms and could stand straighter. He was asked to walk for a gait examination and exam showed that the left knee would give way without warning. Further examination showed normal range of motion and ligamentous integrity of the left knee joint. The left hip joint had slight decrease of passive external rotation with abnormal tenderness at end range. Active range of the hip was evaluated on the ATM2 with the hip rotation unit. Muscular incoordination and weakness was noted on internal and external rotation.

The treatment plan was altered to include internal and external rotation strengthening exercises on the ATM2 hip treatment apparatus. The hip exercise protocol was to have the patient exercise against maximum concentric resistance until muscle failure in both ranges of motion. The knee buckling phenomenon improved with the first treatment. On the fourth visit the patient had given up the crutches in favor of a walking cane. On the sixth treatment the patient presented with no cane and normal gait.

The patient received a total of eight treatments of active therapeutic movements to the left hip and twenty four treatments of lumbar decompression, stabilization, and neuromuscular reeducation. He was dismissed with full recovery from signs and symptoms.

This case points out the need to address the contributing and perpetuating factors of low back pain. One can only speculate how the low back condition would have responded without the hip treatment intervention. What is certain, however is that the clinician has a responsibility to identify and treat contributing and perpetuating factors to the chief complaint, wherever they may be.