Chuck, a 45-year-old farmhand, was seen in the clinic with the chief complaint of chronic back pain for 3 years. This discomfort, present on his right side, was described as deep, nagging, and constant, with periods of acute exacerbation into the right hip, groin, and down the back of the leg to just above the knee. Full symptoms would occur with prolonged walking or standing and would persist for several weeks. The patient was unable to lift more than 25 pounds (11 kg) without aggravating his symptoms. His back took several hours to fully relax after lying down, even on “good” days.
Pain onset had first occurred while the patient carried a small bale of hay in front of his body. He had stepped in an unseen pothole, stumbled, and fell. The next day, he noticed full symptoms, which persisted as recurring episodes for several months. Between and during episodes, he achieved only partial relief with ibuprofen (800 mg/d). Physical therapy reportedly aggravated his pain.
During the next 3 years, the patient visited several physicians, visits that were prompted by three to four substantial recurrences of pain radiation per year. Negative results from electromyographic, magnetic resonance imaging, and radiographic studies—coupled with negative results from tests of reflex changes and nonspecific, nonradicular patterns of muscle weakness—during these 3 years left the patient with no specific diagnosis beyond “low back pain with recurrent lumbosacral sprain.”
Chuck was unable to work on the farm and said that he had the impression that physicians believed he was “malingering,” or “lazy.” He was depressed because he thought his family also shared these beliefs, and he became concerned about his marriage.
Osteopathic manipulative treatment given to the patient consisted of applying the springing technique to the right sacral shear, counterstrain to the iliacus and piriformis tender points, and indirect balanced ligamentous tension to the thoracolumbar and sacral regions. Fascial patterns were treated with high velocity low amplitude (HVLA) techniques aimed toward symmetry, and abdominal and pelvic diaphragms were treated with indirect and direct myofascial release, respectively. Post-OMT iliac crest heights and flexion measurements were normal. The patient left with instructions to drink lots of fluid, switch to acetaminophen as needed, avoid jumping or lifting until his next visit, and return in 1 week for follow-up examination.
At 1-week follow-up, the patient noted that both his acute and nagging pains had been relieved for nearly 4 days, but mild nagging pain had since recurred. A recurrence of sacral shear (approximately 40% of original) and piriformis muscle dysfunction were also noted and re-treated with OMT. Two weeks later, the patient returned with no symptoms and no recurrence of pain. He was instructed to make an appointment for 1 month later, but to cancel the appointment if he remained symptom-free. He phoned 1 month later, reporting that he was without pain and able to function normally at home.