How would you treat this chronic low back pain case? Follow-up

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I wrote a post several weeks ago giving readers history and objective findings of a difficult chronic low back pain case.  Revert back to it before reading on.

Patient was treated in physical therapy for 3 weeks with no expression of improvement per SANE scale, no change per GROC, only short term centralization phenomenon but no carry-over beyond 3 hours, and no changes in pain rating scale (still 6/10 currently, 6/10 at best and 6/10 at worse).  However, Oswestry score did decrease from 56% to 42%, a drop from 28 to 21 points, or 7 point difference.

Therefore, even though high construct of central sensitization, “ramped up CNS”…she was referred out as I wasn’t doing anything for her.

She returned to our office s/p 1 week ESI (epidural steroid injection) for further therapy with following results:

1. Her pain is significantly improved and highest pain has been in a week has been 2/10.

2. No leg symptoms (centralized)

3. Only has taken 1 pain pill in a week (initially took pain pills everyday).

Some insight/questions:

1. She did have a positive crossed SLR on initial evaluation (highly specific for IDH)…maybe she did need ESI based on this finding itself…or as my assumption…she was so ramped up that this gave a false positive finding.

2. Even though functionally improved, patient did not express changes at all with a multi-modal physical therapy treatment so don’t rely on functional scales.

3. It has been only a week s/p ESI, but was this the intervention needed for success?

What are your impressions for referring out for ESI? What signs/symptoms indicate success for this procedure, or is it just failure of PT intervention?

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