Far-lateral disk herniation: case report, review of the literature, and a description of nonsurgical management.

OBJECTIVE: To review the history and examination of a far-lateral lumbar intervertebral disk herniation (FLLIDH), as well as the treatment and outcomes of a nonsurgical approach. CLINICAL FEATURES: A 60-year-old healthy male subject had a 3-week history of right buttock and calf pain. He initially had a left lateral list and asymmetrical pelvic landmarks. Range of motion (ROM) of the lumbar spine revealed full and pain-free lumbar flexion, right-sided pain with lumbar extension and left side bending, and painful and restricted left side bending. Neurologic examination was unremarkable. INTERVENTION AND OUTCOME: The patient was treated with a lumbar epidural and nerve root injection, as well as manipulation. Physical therapy consisted of deweighting treadmill, autotraction, and strengthening exercises. Outcomes were measured by using the Modified Oswestry Questionnaire, as well as a numerical pain rating scale. His initial Oswestry was 73%, pain 9/10 at presentation. Upon discharge, the Oswestry was 0% and pain was rated as 0/10. CONCLUSION: A significant decrease was noted in both the Oswestry Questionnaire, as well as the pain rate. The patient returned to running on alternate days for a minimum of 30 minutes, which was his primary goal. This case demonstrated a positive outcome using a multidisciplinary approach in a patient diagnosed with a FLLIDH. He obtained his goals and his function was fully restored.

Interrater reliability of judgments of the centralization phenomenon and status change during movement testing in patients with low back pain.

OBJECTIVE: To determine the interrater reliability of judgments of status change, including the centralization phenomenon during examination of the lumbar spine, and to determine the effects of training and experience on reliability. DESIGN: A videotape study of judgments by physical therapists and physical therapy students of the results of movement testing during the examination of patients with low back pain. SETTING: Outpatient physical therapy clinic. PATIENTS: Patients receiving physical therapy treatment for low back pain. INTERVENTION: Patients with low back pain were videotaped while performing a variety of movement tests including single, repeated, and sustained movements. Forty licensed physical therapists and 40 physical therapy students were provided with operational definitions of the three potential judgments of status change with movement testing; centralization, peripheralization, status quo. All therapists and students viewed the videotape and made a judgment regarding the patient's status change in response to the test. MAIN OUTCOME MEASURE: Percentage agreement and kappa coefficient values for agreement. RESULTS: Interrater reliability was excellent for the total sample of examiners (kappa = .793), for the licensed physical therapists (kappa = .823), and for the students (kappa = .763). CONCLUSIONS: Judgments of status change are reliable when operational definitions are provided. Clinical experience does not appear to substantially improve reliability.

A nonsurgical treatment approach for patients with lumbar spinal stenosis.

The purpose of this case report is to describe a physical therapy approach to the evaluation, treatment, and outcome assessment of two patients diagnosed with lumbar spinal stenosis. Evaluation consisted of assessment of neurological status, spinal range of motion, and lower-extremity muscle force production and flexibility; administration of the Modified Oswestry Low Back Pain Questionnaire and the Roland-Morris Disability Questionnaire; assessment of pain using a visual analog scale; and performance of a two-stage treadmill test. The treatment program was designed to treat the impairments, and harness-supported treadmill ambulation (unloading) was used to address the limitation in ambulation identified by the treadmill test. Outcome assessment included measuring changes in the status of the impairments and assessing responses to the disability questionnaires and performance of the two-stage treadmill test. Improvements were noted on all outcome measures for both patients after 6 weeks of physical therapy and at the 4-week follow-up examination. Larger case series and randomized trials with long-term follow-ups are recommended.