How would you treat this chronic low back pain case?

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Subjective History: 35 y/o female presents with hip and back pain.  She had no injury or accident but has been dealing with back pain for 5-6 years.  She sought care from surgeon who ordered MRI (5-6 yrs ago) that showed DDD but that she was too young for surgery and has to deal with the pain.  In Feb 2014, her right hip “gave out” on you on her way to work one morning.  The sensation was a pinching in the groin that hurt on every step.  It hurt so bad that she went to ER who then referred her to Dr. *&$^(.  She has had multiple x-rays, bone scan and then MRI of hip showing a torn labrum in April 2014.  She wound up losing her job after 14 yrs due to not being released to go to work.  She had another consult in Sept 2014 with a surgeon for hip, but was told to lose weight and she was not a candidate for surgery.  She started another job (that involved 8 hrs of standing) shortly thereafter but after one week, she could hardly stand due to right hip pain arising again and numbness in right leg.  She then sought care from her PCP, Dr. *^%*, who referred her for CT scan (for back) and then to Dr. *$&^.  She had a consultation and then referred to PT.  She was told she would have injections.

Onset

Date of Onset: Back pain and numbness in right leg for past 5-6 years. Right hip pain started Feb 2014. In 2010, she had to have ambulance get her from her house due to her back giving out and right leg “stuck” resulting in her having to be put asleep to get the right leg extended again. Onset Due To: Unknown. Recent Symptom Trend: Condition worsening.
Symptoms
Primary Symptoms: She c/o numbness down right leg from hip posteriorly to 5th digit. Provokes symptoms: Any movements. Hurts with standing/walking/sitting and doesn’t matter what type of chair. Relieves symptoms: trying to stretch (nothing specifically) and sometimes medication.

Pain Rating:

Currently: 6.5/10, Best: 3.5/10 (between stretching and medication), Worse: 10/10 (see above but also occurs weekly).

Sleep Disturbance: She barely sleeps. She tosses and turns all night only getting 4-5 hours. This has been going on for years.

Vocational
Current Status: Not working. Has lost 2 jobs in last few years due to functional limitations.

Objective
FABQ (work): 19, FABQ (physical activity): 22.

Oswestry: 56%

Observation: Unable to stand without dysfunctional pattern and using B UE for support.

Observation: Single leg stance 5″ on left limb, 1″ on right limb.

Palpation

Hypersensitivity along entire lumbar spine from L1-S4 mostly centrally > laterally ~3 fingerbreadths from SP

Lumbar Spine Flexion: 
Very restricted to patella bil and pain low back (all AROM equally painful in same location in LB)
Lumbar Extension:
Very restricted
Only ~5 degrees. (all AROM equally painful in same location in LB)
Lumbar L Side Bending: 
Very restricted
Only ~10 degrees. (all AROM equally painful in same location in LB)
Lumbar R Side Bending:
Very restricted
Only ~10 degrees ((all AROM equally painful in same location in LB))

Reflex Tests
Achilles Tendon Reflex (S1)
Absent (0) on right, 1+ on Left
Patellar Tendon Reflex (L4)
Diminished (1+) bilaterally

Neurodynamic Tests
SLR
Positive
~40 deg SLR for LB but not leg symptoms on LEFT, and ~20 deg SLR for LB but not leg symptoms on RIGHT (+ crossover)

Lower Extremity Dermatomes (to sharp prick):
L1: Inguinal Region: Intact

L2: Upper Thigh: Intact

L3: Mid Thigh: Intact

L4: Patella, medial leg, medial malleolus: Intact

L5: Dorsum of foot, 3rd metatarsophalangeal joint: Intact

S1: Lateral aspect of calcaneus, lateral aspect of posterior leg: Diminished
Absent to lateral aspect of foot from calcaneus to MCP of 5th digit.

S2:Medial aspect of posterior leg: Intact

Lower Extremity Myotome Strength

L2: hip flexion: 4/5
Generally weaker on right side
L3:Knee extension: 4/5
Generally weaker on right side
L4: Ankle Dorsiflexion: 4/5
Generally weaker on right side
L5: Great Toe Extension: 4/5
Generally weaker on right side
S1: Ankle Plantarflexion: 3-/5
Unable to perform single calf raise on RIGHT, 18 reps on LEFT
S2: Knee Flexion: 4/5
Generally weaker on right side

With the information provided, how would you proceed? What other objective/subjective information do you need?  Is this individual appropriate for PT services?

Filed under: Differential Diagnosis, Imaging, Lumbar Spine/SIJ, Spine http://intouchpt.wordpress.com/