Present history
A 21 year-old female undergraduate student presented with a 2 year history of spinal, pelvic and distal thigh pains with an insidious onset. There were no reports of neurogenic-type pain or sensory changes. See Fig. 1 for the body chart.
The patient reported a slight weakness negotiating a flight of stairs but she was unsure if she felt weakness in her lower extremities or her trunk. Aggravating factors included walking up more than down stairs, sit to stand transfers and stepping up curbs. In sitting, no symptoms were evident.
There was no history of weight change, night sweats or recent infections/systemic illness. Early morning stiffness was described as minimal but lasted 40 min. There was no family history of any significance. The patient recalled always being last at running races as a child but no missed milestones or paediatric input was highlighted. Medication included naproxen and paracetamol as required, taken a few times per week with mild relief. No other medical, drug or mental health history was noted. Attendance at University had not been interrupted. No change to social activities or family relationships were reported due to the symptoms.
Past treatment included recent private physiotherapy and the patient’s interpretation was that “core exercises” had been initiated. These had been performed twice a day for 2 weeks. Subjectively, pain severity and the sense of strength when negotiating stairs had improved by 10% since starting the exercises. Care was transferred to the authors NHS service as is typical in the UK to enable free provision of assessment and treatment.
Questionnaire responses
A 9-question tool called The Subgroups for Targeted Treatment (STarT) back screening tool questions patients on matters such as catastrophising, fear, anxiety and depression [1]. The tool has been advised to identify back pain patients who may have modifiable aspects to their presentation that may benefit from cognitive-behavioural approaches [1].
The initial STarT back score was 7 with a subscore of 4 (see Additional file 1) indicating a high risk factor for spinal pain-related disability [1]. The score indicates significant psychosocial risk factors for a poor prognosis [1] and stratification to physiotherapy services to deal with psychosocial elements would be advised [1,2,3]. The EuroQol 5D (EQ. 5D) questionnaire gives health related quality of life and psychometric analysis that has demonstrable construct validity and reliability [4]. The patients EQ. 5D responses demonstrated severe pain, functional impact and anxiety/depression scores (see Additional file 2).
Examination
Subtle spinal rotation and thoracic scoliosis concave to the right was noted on standing. The gait pattern was entirely normal including rope walking tasks. The sit to stand movement pattern was abnormal. A wide base of support was achieved by abducting the hips. The lower limbs were internally rotated and the upper limbs were used to assist rising from the chair.
Dermatomes, reflexes and tone were deemed normal. There were no Babinski or Hoffmann’s reflexes. There was no clonus at the feet. The Romberg’s test was also negative and there was no dysdiadochokinesis. Myotomal examination revealed no focal weakness when examined in isolation, but weakness was apparent during sit to stand and bridging tasks. Single leg stance demonstrated a good ability to maintain pelvic and trunk posture with no Trendelenburg. There was no visible muscle atrophy but a mildly raised BMI may have limited the ability to detect a loss of muscle bulk.
Lumbar spine movements into extension and side flexion were normal and pain free. Flexion was relatively reduced (fingers to mid-tibia) and some spinal pain was reported at the end of range. Rising from flexion involved bracing of the lumbar spine and movement generation from the thoracic region and hips. Neurodynamic tests were unremarkable. Spinal palpation was pain free. The thoracic spine moved well and gave no pain responses. The hips moved well and quadrant testing was normal. Distal joint screening revealed no evidence of inflammation or synovitis.
Impression & Treatment
Atypical movement patterns were evident but no focal neural concerns on testing in clinic, pointing to either central cord or nerve root pathology, were detected. The initial plan was to monitor and continue exercise-based physiotherapy input especially in light of recent gains from exercise.
Physiotherapy focused on functional movement quality with a trunk and lower limb strengthening programme. No formal myotome weakness was detected but the functional challenge when standing and the effortful nature of bridging was enough to warrant a programme to strengthen these tasks. Bridging was the main focus of the physiotherapy programme that involved review and progression of an exercise programme. Sit to stand exercises from a raised position were also encouraged. Reassurance was provided regarding the negative examination findings in clinic as evident fear and anxiety had been displayed in clinic and on the questionnaire responses. A review with the initial Extended Scope Practitioner (ESP) was advised if no further gains were made or any regressions materialised.
Some subjective gains were reported but objectively there were no gains after four sessions of treatment over a 2 month period. The ESP reviewed again. Isolated trunk and limb strength was re-assessed using myotome testing as well as isometric hip strength testing into abduction and extension. This again proved negative. Bridging remained effortful but the sit to stand movement was the main evident limitation.
An MRI of the entire spine was ordered by the ESP to assess the cord/neural health. If this test proved negative the next suggestion was to explore a neurology referral. The MRI hoped to differentiate or rule out the following possible origins to the bilateral lower limb weakness: spinal cord pathology such as compression from intervertebral discs, inflammation or intrinsic tumour, or more rarely a parasaggital brain lesion. The lack of upper motor neuron signs suggested a lower probability of any brain lesions though. Anterior horn cell disease could be ruled out and was low on the hypothesis list as the patient was young and did not have any fasciculations. Spinal canal stenosis and cauda equina change could also be examined but there was no bladder/sphincter symptoms or saddle changes so again the level of concern was low. A primary muscle disorder was another possible origin to be considered.
Blood tests ordered by the general practitioner had shown no significant change to inflammatory markers, urea, electrolytes or liver function. Repeat tests were scheduled by the general practitioner but did not include creatine kinase.