Leonard, 38 years old, was diagnosed with L4-L5 lumbar radiculopathy. He was initially injured at work, and repetitive microtrauma was suspected because of his occupation as a warehouse worker at a local distributor. His job duty description included repetitive lifting of 20 lb (9 kg). He completed six weeks of rehabilitation and then rated his pain level as 0/10 at rest and 0-2/10 with work duties (which included a 15 lb [about 7 kg] weight restriction). At that point he had normal active range of motion of the trunk and hamstring flexibility within 10° bilaterally with the supine 90/90 test position (refer to chapter 5). Passive joint mobility of the lumbar spine improved to normal as compared to the restricted mobility noted at L3-L4 and L4-L5 with initial assessment. Although this manual assessment technique has shown poor to fair interexaminer reliability (van Trijffel et al. 2005), an assessment of overall and segmental spinal mobility was necessary. No dysfunction was noted with these tests and measures.
Leonard then was assessed with a Functional Movement Screen (FMS) (Cook et al. 1998). Refer to chapter 6 for specific testing parameters and interpretation of this tool. No pain was noted, and all scores were either a II or a III throughout the screen. Since Leonard consistently scored lower on the deep squat exercise of the screen, hip extension and abduction and trunk flexion movement analyses were performed. The hip abduction movement analysis showed altered muscle firing sequence (see chapter 6 for specifics). Additional motor control and strength and endurance exercises with emphasis on posterior gluteus medius were implemented (specifically clams, standing Thera-Band resistance walks, and side bridging exercises), with careful emphasis on monitoring for common compensations. Common compensations include trunk rotation with the side-lying clam exercise, excessive frontal plane motion with Thera-Band walks, and rotation of the body in the transverse plane with side bridging.
Once Leonard met the goal of normal muscle pattern firing with the same testing, he was given the Rockport Walk Test (see chapter 8 for specific testing procedures and other details). He walked the 1-mile distance in 11 min for a score of “Good.” According to the established FTA for Leonard, this was an acceptable score, and he moved on to the trunk endurance test (see chapter 11 for details of these tests). It would be possible to improve cardiovascular endurance in a client such as Leonard with an aquatic program emphasizing endurance, a controlled walking program on a level surface or treadmill, and possibly use of an elliptical machine. The use of a bicycle is not necessarily prudent for a client with radicular complaints. In the initial trunk endurance assessment, Leonard scored in the normal range of the time frame for trunk flexion for normal individuals (McGill et al. 1999). He did not meet these previously established values for trunk extension endurance in normal individuals (people without pain or dysfunction). It is important to note, though, that these normative values were obtained with college-aged individuals. To our knowledge, no normative values have been established in patients with low back pain. A recent study (Flanagan & Kulig 2007) did reveal that 51.5% of participants after single-level microdiscectomy (from four to six weeks postsurgery) could not attain the fully extended position in a modified version of the trunk extension endurance test (Sorenson test). The authors concluded that the ability to attain the full trunk extension position was closely associated with fear–avoidance beliefs (Fritz et al. 2001), “suggesting this test may be too intense (either real or perceived) for many patients within 4 to 6 weeks following a single-level microdiscectomy.”
Leonard returned to trunk endurance–specific activities including, but not limited to, specific local trunk endurance training with biofeedback and standing gluteal and latissimus muscle strengthening (modified squats, rowing-type activity for latissimus dorsi, etc.). These activities could be integrated into more functional training activities. Trunk abdominal muscle contraction should be performed early in rehabilitation and progressed along with the functional activities used in the later rehabilitation stages.
After passing the trunk extension endurance testing (two weeks later), Leonard successfully completed the Star Excursion Balance Test as outlined in chapter 7 and discussed previously. He was able to reach in all directions with the involved extremity (where he had initially had radicular pain) within 10% to 15% of the distance possible with the uninvolved extremity.
The last assessment in the FTA established for Leonard was the repetitive box-lifting task (chapter 11). He successfully completed the initial attempt (four successful lifts). He was discharged from formal rehabilitation and referred back to his physician with the suggestion of release to full work-related participation. The testing results were faxed to his physician for perusal prior to his return visit.
This FTA was specifically established for Leonard because of his job title (warehouse worker) and his job duty description and requirements.
Specific activities that can be implemented to increase a client’s ability to return to a repetitive lifting job duty could include proper squatting exercises (initially in one plane of movement; progression to all three planes with emphasis on hip mobility and trunk stability; progressive trunk stabilization exercises utilizing trunk abdominal muscle contraction; and actual lifting with emphasis on proper technique, and so on). Lifting tasks should initially emphasize low weight and higher repetitions to establish an endurance base. Specific lifting parameters (weight, distance, positions, etc.) can be integrated into the rehabilitation process on an individual basis when appropriate.