clinical case JUNE 2006

CLINICAL CASE JUNE 2006

Male patient, 32 years old, worker in a factory, on an assembly line for cars parts, he came to us in March 2003. The past anamnesis did not reveal any important disease, apart from the common exanthematic diseases in childhood. No surgical operations or important traumas. He wears accident prevention's shoes since five years. Since many years, about ten, he is suffering from low back pains. At the beginning these symptoms were only occasional, they occurred about twice a year, only at seasonal change, whithout joints blockage.
The patient describes these painful events, whose symptoms are not very relevant, but an increasing of the muscular contracture in the low back area was also noticeable. Six years ago, in 1997, when he was 27 years old, he experienced the first joints blockage occurred after an effort. The patient had to lie in the bed for one week more or less, he was treated with usual medicaments, and within 15 days he was able to work again as usual. According to the suggestions of a specialist orthopaedist he follows a set of therapies for the motor reeducation, because he already had a verticalization of the low back area. For about one year he did not suffer from acute low back pains, even if in the morning he experiences always some rigidity of the low back area. The year after, in 1999, he describes three events of joints blockage of the low back area, one caused by an effort, and the other two without any clear cause. These three events disappear completely after a period of rest and a pharmacological therapy. After the last event, lasting more than the previous ones, the patient undergoes a set of vertebral manipulation "to restore the elasticity of the spine". Meanwhile he begins to suffer from an annoying pain affecting the right heel that increases when he stands or when the feet touch rigid surfaces. These symptoms are treated first of all by means systemic medicaments such as antinflammatory medicaments and analgesics, and then by means of mesotherapy, achieving a complete solution of the problems after 15 treatments. He was suggested to wear soft heel cushion made of silicon within the accident prevention's shoes, the patient followed the suggestion. About the midyear 2000, the patient begins to suffer from disorientation, above all during quick movements of the head. Hematochemical and cardiovascular examinations and a specialistic otorhynolaringological check-up did not reveal any alterations. The symptoms of the patient are labelled as "Meniere-like syndrome" and treated with medicaments. In July 2001, when he was on holidays by the sea, the patient experienced an acute low back blockage, with clear signs of radicular involvement. He had to lie in the bed for three months, as consequence he had an annoying and acute sciatica affecting the left limb.

On the 2 November 2001 he undergoes a CAT that reveals: “normal volume of the vertebral canal, normal conjunction foramina, a right postero-lateral herniated disc at the L4-L5 level, a left bulky postero-lateral herniated disc at the L4-L5 level ”. (Pic.1) On the 30 Novembre 2001 he undergoes a rediograph of the spine that reveals: " inversion of the physiological cervical lordosis, width of intersomatic spaces of the dorsal segment of the spine were preserved, no morphostructural alterations of the bones also in the low back sacral segment" (Pic. 2) As the low back pains did not disappear, even if weakened, and above all because of the sciatica, the patient begins a treatment of acupuncture and undergoes a neurosurgical examination. The neurosurgeon prescribes a magnetic resonance performed on the 7 December 2001 that reveals : “a little disc hernia developing backward towards the right paramedian area causing a slightly compression of the anterior dural profile at the L3-L4 level. Near the intervertebral space L4-L5 the resonance revealed a disc hernia expelled backward towards the left median and paramedian ipsi lateral root L5, with an alteration of the signal of the corresponding intersomatic disc related to initial degenerative phenomena.
	Pic. 1	Pic. 2
At this level it is also possible to notice a light reduction of the antero-posterior diameter of the vertebral canal. There are not pathological images of the L5-S1 space. Verticalization of the low back lordosis”. (Pic. 3 with medical report)


Pic. 3`with medical report`	`Lasegue strongly positive on the left side at 30°`

According to this medical report, he was suggested to undergo a surgical operation to quickly resolve the clear compression of the root of the L5 avoiding in this way peripheral degenerative complications.
The patient agreed upon the suggestion to undergo a surgical operation, but Christmas was approaching, so he decided to be hospitalized after the 20 January 2002. Meanwhile he continued acupuncture treatments, and at the midJanuary 2002 the symptoms disappeared almost completely. So he decided to delay the surgical operation to a not specified date.
The recovered wellbeing lasts until the 5 September 2002, during this day the left acute low back sciatica appears again. The patient had to rest and was treated with medicaments including also cortisone-based medicaments. He lies in the bed for three weeks. In January 2003 he experiences again a contracture of the paravertebral muscles and a decreased motility of the low back area even when he lies on the bed, he has some movement difficulties.

He undergoes a new magnetic resonance of the low back area that reveals the same condition of the examination performed on the 7 December 2001. So he is treated with oxygen-ozone therapy. After 6 treatments, he only felt a light improvement of the symptoms. Meanwhile the state of confusion worsened.
He came for the first time to us on the 4 March 2003.
It was suddenly clear he was suffering a lot, he moved slowly and he looked to be very worry, he lamented a left low back sciatalgia with a paresthesia of the left leg.
He had flat feet of 2^nd degree (pic. 4) more marked on right side and an hyperloading of the heel on the left side; oral breathing and atypical swallowing.

VAS = 8.
Mc Gill = pain is described
1) throbbing and severe
4) Sharping as a razor blade and severe
8) aching
14) fearful.
Roland and Morris = 18
Articular ROM = limited and painful in all movements
Lasegue's test strongly positive on the left side at 30 degree.

Pic. 4

The formetric evaluation revealed a pelvis tilt of 6,9 mm. with the left side located higher than the right one, 3,6 degree leftward torsion of the sacrum, anterior rotation of the shoulder girdle and great reduction of the low back lordosis 20,9 degree .(Pic. 5)

He accepts with pleasure to be treated with the "Attivo ks Medical" orthotics, with all pockets activated, and he decides to try this kind of therapy before undergoing the surgical operation. As he did not feel acute pains while walking, he promises to follow our suggestion to go for a walk every two hours for 20-30 minutes each day, even if at home. We inform him he has to correct the oral breathing and the atypical swallowing.
At the first control on the 1 April 2003, he reports a light improvement of the symptoms;
VAS = 4
Mc Gill = moderate pains, but with the same characteristics;
Roland and Morris = 10
Articular ROM = limited but less painful;
Lasegue's test positive on the left side but at 70 degree.
The formetric evaluation reveals a pelvis asymmetry of 2,8 mm with the left located side higher than the right one, 1, 4 degree leftward torsion of the sacrum, average low back lordosis angle of 22,9 degree (Pic. 6)


Pic. `5`	Pic. 6

The states of confusion decreased both in frequency and in intensity. The patient appears to be more relaxed and quiet, he says he trusts he can recover his normal life's standard.
The podogram's result did not change.
We activated the orthotics again, the new thickness of the pockets was of 8 mm, we invited the patient to intensify the use of the orthotichs suggesting him to go for a walk for at least one hour twice a day.
At the second control, on the 18 June 2003, three months and an half after the beginning of the treatment by means of the stimulation of the sole of the feet, the patient says the pains had disappeared already since one month. Low back pains decreased and as consequence also the rigidity of the spine, the sciatica and the paresthesia affecting the left leg disappeared.
VAS = 1
Mc Gill = 0
Roland and Morris = 0
Articular ROM slightly limited, above all while bending, but not painful
Lasegue's test negative
The formetric evaluation reveals no pelvis asymmetry and the reduction of the forward rotation of the shoulder girdle; average low back lordosis angle of 23 degree. (Pic. 7)

The states of confusion belonged to the past and the patient begins to organize his wedding.
The podogram reveals a decrease of the flat foot.
The patient comes back to be visited in May 2004, when he undergoes a new magnetic resonance of the low back area (Pic. 8 with medical ), that reveals a little discal protrusion at the space L3-L4 and a little paramedian hernia at the space L4-L5. Patient did not feel any symptom all the period long, he continued to wear the orthotics all the day long, also within the accident prevention's shoes, continuing to go for a walk for two hours a day. The clinical examination was completely negative, the articular rom was normal, the formetric examination showed an average low back lordosis angle of 27 degree. We replace the orthotics, that by that time are worn out, and we make a date with him for the next year. The patient comes back on the 5 April 2006, he did not feel any symptom all the period long so he remembered about the date only because the orthotics were worn out again. Before visiting us, he spontaneously decided to undergo a new magnetic resonance of the low back are on the 14 March 2006. (Pic. 9)


Pic. 7	Pic. 8 `with medical report`

Pic. 9

This last resonance shows both a remarkable reduction of the volume of the hernia located in position L4-L5, that at the beginning exerted a compression on the medullary sheath, and a greater lordosization of the low back - sacrum area.
Obviously the clinical examination was completely negative, and the formetric evaluation showed a prefect symmetry of the rachis, of the shoulder and pelvis girdle, and the average low back lordosis angle was of 32 degree. (Pic. 10)

Pic. 10

CONCLUSIONS
I whished to explain in detail this clinical case, even if it is one of the several cases we evaluate every day, for the following reasons:
+ the age of the patient, quiet young, who lived his health problems with great emotivity, he had lost any hope to live a normal life;
+ the frequency of the symptoms and the described clinical picture, that sometimes induce patients to follow several therapies that often do not produce any results or at least any long lasting results; I wished to highlight that symptoms, that sometimes appear to be not related, can be analysed from a global point of view and with a global approach and treated by means of a global therapy; I wished to supply my colleagues with an innovative therapeutical treatment, which is still considered to be not conventional, by evaluating the patient according to the standards of the international society of physiatry ot orthopeadics, and by assessing the achieved therapeutical results by means of these standards.

THERAPEUTIC RESULTS BY THE NEURO-BIO-MECHANIC ACTING ORTHOTICS "ATTIVO KS MEDICAL"