The Effect of Rib Cage Rigidity on Low Back Pain: A Case Study
Author: Susan Lee, PT
Abstract: This case study illustrates the effect of Integrative Manual Therapy on Low Back Pain. In this article, a relationship is found between back pain and respiratory dysfunction. This patient was a 55 year old man with complaints of severe low back pain and left leg pain. The patient reported significant decreased functioning in leisure and activities of daily living. He presented at time of evaluation with limitations in range of motion as well as decreased mobility of the rib cage. The patient received treatment with Integrative Manual Therapy which focused on his biomechanics as well as his respiratory system. After treatment was completed, the patient presented with decreased pain and increased ranges of motion. The patient also reported increased function including being able to sit longer and walk for longer amounts of time and longer distances. He also reported that he was able to return to playing golf.
Key Words: Rib, Low Back Pain, Bone Bruise, Respiratory
History
The patient reported that he loved to play sports. He played football, baseball, and basketball as a teenager. As an adult he played mostly handball. He now plays golf instead. Patient has been in several auto accidents. In the mid 1960s, his car was sideswiped and went nearly 100 yards into a parking lot. Richard did not have a seat belt and was thrown around in the car. In the later 1960s, he was in a car that rolled into a canyon, this time he was wearing a seat belt. In 1982, he was rear ended. He stated that he was not badly hurt each time. However, he experienced mid back pain in the 1980s after working in his attic. While he was still able to lift and exercise, he was beginning to have more low back pain. He played handball, and reported playing harder when he was in pain to deal with the pain.
He was diagnosed (with MRI) with several ruptured disks in 1987. His doctor then, put him in a brace for a time but still wanted to do surgery. Patient declined to have surgery and learned to live with the pain. He exercised, did yoga, and had chiropractic treatments which helped for awhile. Patient has a history of severe asthma going back to childhood along with migraines. Several years ago, patient was using multiple medications to control his asthma. This was not very successful. He began to realize that if the asthma didn’t kill him, the medication might. He was treated by a holistic allergy doctor. The tests showed multiple allergies to food and preservatives which the patient proceeded to eliminate from his diet. He continues to control his allergies that way, being very careful what he eats. He has found that he can occasionally stray off the diet now but rarely does so. His migraines responded to the treatment also though not as well since he still has occasional episodes, possibly from stress. He is medication free for his allergies. He does take some pain medications for his migraines and back pain.
In June, 2000, the patient danced at his daughters wedding for several hours. After that night, he began to experience severe low back and left leg pain. He was severely limited in sitting, standing and walking. He had chiropractic treatment until the chiropractic discharged him, saying there was nothing more he could do for the patient. He still had most of his symptoms. He consulted an orthopedic surgeon in September, 2000, who took an MRI. The MRI report stated that "L2-3 through L4-5 had minimal narrowing and desiccation. There was no herniation or foraminal or central stenosis." At L5-S1, there was "left paracentral disc herniation." The patient was not considered a surgical candidate and was sent to physical therapy.
The patient reports having a very stressful desk job (patient has a history of stressful desk jobs) which requires him to sit through long meetings. It also requires him to drive up to 2 hours at a time. Patient cannot, at this time, exercise.
Richard P. was a 55 year old male at the time of evaluation with complaints of severe low back pain and left leg pain. The patient reported the following goals: to be able to sit for 2 hours without pain during and afterwards; to be able to walk 2 miles without pain (Patient had previously been walking 5 miles); to be able to play golf again.
Evaluation
Upon initial evaluation, the patient was unable to touch his toes in standing (barely reaching to mid thigh) with no flexion in lumbar spine, minimal rotation and sidebending in full spine. The patient presented with total limitation of spinal extension. Cervical range of motion showed a moderate head thrust, severe limitations in rotation, sidebending, flexion, and again, no extension. The patient presented with a flat thoracic and lumbar spine, with compression throughout the spine. He showed very poor rib excursion with restricted diaphragms. The patient had bilateral dorsiflexion of minus 5 degrees.
Initial Treatment
Treatment began with Muscle Energy and ‘Beyond’ Techniques to the sacrum and pelvis from MET1 course, Manual Therapy with Muscle Energy Technique for the Pelvis, Sacrum, Cervical, Thoracic & Lumbar Spine. Corrections were made to:
- left elevated pubic rami
- left anterior innominate
- anterior superior iliac spine (ASIS)
- right posterior innominate
- left inflare, right outflare
- left upslip (this did not fully correct until the sigmoid colon was treated with techniques from VMET, The GI Tract course)
- anterior sacral torsion
- flexion and extension dysfunctions of sacrum
- Type I, II throughout the spine (including the sacrum) were corrected; atlanto-axial joint and occipitoatlantal joint restrictions.
The patient was also treated with the following techniques in order:
- Bone Bruise Techniques (from the MET4 course) were corrected over the pubic rami, sacrum, and full spine
- Visceral Mobilization Techniques, Resistence Therapy to Immune Deficiency Motility and Disruption of Membrane Techniques, were performed as they appeared
- Descended L5 vertebra
- Strain and Counterstrain techniques were applied to anterior and posterior L5 and L4
- Osseous Compression Syndrome to the vertebrae was applied to the full spine through the sacrum
- Compression Syndrome to the disks were applied to the lumbar spine (MET3 course)
- Advanced Strain and Counterstrain disk therapy techniques were applied to the cervical spine
- Disk therapy techniques were applied to the T9 through L5/S1
- Patient’s respiratory, cranial, thoracic and pelvic diaphragms were opened using Advanced Strain and Counterstrain, along with the arteries to the heart, neck, cranial base, and cranium
- The patient’s hips and lower extremities were treated with Compression Syndromes from the Lower Extremity Compression Syndromes course
- Ankles were treated with the "Secret of the Tibiotalar Joint Technique" after the foot and ankle Compressions Syndromes were completed
- Bone Bruise Techniques again were treated as they appeared.
Initial Outcome
Eighty Percent of full range of motion was restored for the patient. He was able to sit for one hour, experiencing only an ache rather than severe pain. He was able to walk one mile easily without pain. He was not yet able to play golf. His very rigid rib cage was seen as a possible reason for the lack of further improvement. The patient was reevaluated at this point to determine what further Integrative Manual Therapy was needed.
Final Treatment
For the next sessions of therapy, the patient’s rib cage was treated with rib cage Compression Syndromes and Torsion Techniques. The patient’s lungs and alveoli were treated with Type I and Type II techniques. Techniques also used were Compression Syndromes for the lungs and other respiratory structures. In addition to these techniques, the patient was also treated with Resistance Therapy to Immune Deficiency Motility and Disruption of Membrane Technique.
Final Outcome
After the final treatment was performed, the patient was able to sit for 2 hours without discomfort. Longer times could occasionally result in some mild low back ache which was easily eliminated with walking. The patient could walk 2 miles easily and was increasing the distance. He could touch his toes in spinal flexion. The patient had returned to playing golf and his game had improved greatly. Because of the increased rotation in his low back, he found that he could hit the ball more gently, yet still hit it farther.
References