Toe-standing strength as a prognostic parameter in the intervertebral disc syndrome: An observation and report of a case. Michael R. Wiles, BSc, DC, FCCS(C).
Toe-standing strength as a prognostic parameter in the intervertebral disc syndrome: An observation and report of a case Michael R. Wiles, BSc, DC, FCCS(C) 1900 Bayview Ave., Toronto, Ontario, M4G 2E6
The assessment of improvement in patients suffering from intervertebral disc (IVD) syndromes is a clinical judgement usually based on a combination of factors. For instance, the more common prognostic parameters include subjective improvement, increase in the results of the straight leg raising test and decrease in the sensory and motor deficits, if these were initially present. In some cases of low back pain associated with IVD syndrome, particularly long-lasting cases, subjective change (or lack of it) is unreliable due to the likelihood of psychogenic magnification or depression (the "low back loser" syndrome). This problem has led to concern regarding useful prognostic parameters in prospective disc surgery'. Also, the validity and usefulness of the straight leg raising test has been questioned, due to the occurrence of a positive test in cases of gluteal muscle spasm, and hamstring spasm'. Therefore, objective change regarding sensory and motor deficits in IVD syndromes may be useful parameters of prognosis. When manipulative therapy is used as the primary means of treating such a syndrome, an adequate assessment of improvement is necessary in order to prevent iatrogenic hypermotoricity of the involved segment(s). This paper describes an observation
of the usefulness of using toe-standing strength as a prognostic parameter in an acute presentation of an IVD syndrome.
Case Report A 36-year-old female of Chinese origin presented with pain in the left foot of 10 months duration, and previously diagnosed as a "pinched nerve and slipped disc". The pain had originally begun following sleeping in an unfamiliar bed. Chiropractic treatment resulted in only slight improvement and she consulted an orthopedic surgeon. She was diagnosed as having a "slipped disc" and she was urged to agree to discectomy and fusion. Following this consultation, she again consulted her chiropractor. After about thirty-five treatments she was not improved and consulted the CMCC clinic. The foot pain was in the dorsum of the left foot and was aggravated by walking and lifting objects. Rest relieved the pain. Low back stiffness and left fifth toe numbness were associated with the pain. Examination revealed restricted lumbar forward flexion (about 300), with pain in the left gluteal region and left concave scoliosis. Although overt signs of foot drop were not present, the patient was unable to stand on the left toes (even for a brief moment).
TOE STANDING
(SEC.)
(0
20
tt
ItH NI
N5
30
I NIO
40
ft
so
ttIttt
60
70
t N
80
90
TREATMENTS
100
f10
120
140
130
t
(DAYS FROM INITIAL PRESENTATION)
I50
170
(50
t
1(0
190
2(X}
t N25
N28
Figure 1: Toe-standing strength as a function of days from the initial treatment. The Journal of the CCA/Volume 24 No. 3/September 19801
ill
Toe-standing strength
90 *Left SLR* 80-
*0
* 09
*
70- -
60 0
/
50_ SLR (degrees) 40^
304 20_
10- _
10
ttt tttNSt 81
I120
30
40
S0
70
60
t 80fttt t tN15 ttt t
N20
80
90
t t t TREATMENTS
100
11(
t
120
130
t
140
ISO
t
170
160
t
180
190
N20
(DAYS FROM INITIAL PRESENTATION)
200
t
N28
Figure 2: Left SLR test results as a function of days from initial treatment. * Right SLR
90
/
70-|
60-
SLRV
(degrces) 800-
40-
30 t
201
10
20
30
40
50
60
ittt 85tit ti 810tt tt tititti #20 81S #1
70
80
90
100
t
110
t
120
130
TREATMENTS (DAYS FROM INITIAL PRESENTATION)
140
150
ISO
170
I#25 t
180
190
200
t
82f
Figure 3: Right SLR test results as a function of days from initial treatment. The Journal of the CCA /Volume 24 No. 3/September 1980
Toe-standing strength
Right straight leg raising reproduced the left foot pain at 450, and left straight leg raising reproduced this symptom at 300. The left Achilles reflex was absent and there was hypesthesia over the left Si dermatome. Motion palpation of the lumbar spine revealed L5 left rotation to produce pain in the left inner thigh and LS right rotation to produce pain in the left inner thigh and left foot. Fixation in rotation at this level as well as sacroiliac fixation was palpated. Both psoas muscles and the left gluteal muscles were weak. Lumbar radiographs revealed L5-S1 disc thinning with wedging on the left side. A diagnosis of left postero-lateral protrusion of the L5-S1 disc involving the L5 and Si nerves was made. (This explained the hypesthesia, loss of Achilles reflex, and weakness of the left gluteal muscles, and posterior calf muscles.) Therapy was initiated, consisting of specific manipulative treatment to the affected lower lumbar segments, and sacrum. Supportive physiotherapy was also included. Over a period of two hundred days, the straight leg raising test and the maximum length of time for left toe standing was recorded (see Figures 1, 2 and 3). Progress was assessed by both of these methods, and subjective comments by the patient. The therapy was considered complete when no further increases in calf strength were evident.
Discussion The use of the straight leg raising test as an indicator of therapeutic success was limited in this case due to the slow yet progressive increase over a long period (200 days). After 200 days of treatment, the leg raising was still increasing (possibly due to muscular flexibility secondary to a supportive exercise program), whereas the toe standing had not increased since about 120 days. Pain was relieved very early in therapy, but the toe hypesthesia diminished concomitant with the increase in toe standing. Toe-standing time appeared to be a useful parameter of prognosis in this case, and resulted in a clear sigmoid curve as opposed to a more vague improvement indicated by the leg-raising curve (Figures 2 and 3).
References 1. Pheasant HC, Gilbert D, Goldfarb J, Herron L. The MMPI as a predictor of outcome in low-back surgery. Spine 1979; 4:78-84. 2. Kraus H. Clinical treatment of back and neck pain. New York; McGraw-Hill, 1970.
Residencies in Chiropractic Clinical Science Applications are invited for residency appointments in Chiropractic Clinical Science at the Canadian Memorial Chiropractic College. This is a two year full-time programme commencing August, 1, 1981, leading to certification as a Chiropractic Clinical Specialist by CMCC and eligibility for candidacy toward Fellowship in the College of Chiropractic Sciences (Canada). It is a comprehensive programme consisting of clinical, research and teaching responsibilities, as well as mandatory participation in clinical rounds and seminars. Salary and number of available positions are presently under review. Completed applications must be submitted by February 27, 1981. Reply to: Dr. M. Wiles, Co-ordinator, Clinical Residency Programme, CMCC, 1900 Bayview Avenue, Toronto, Ontario. M4G 3E6.
The Journal of the CCA/Volume 24 No. 3/September 1980
113
