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Sacroiliac Dysfunction A Case Study

CPT William Murray

Pain is a widespread issue in the United States. Nine of physical therapist. She was evaluated and her treatment 10 Americans regularly suffer from pain, and nearly every consisted of a transcutaneous electrical nerve stimula- person will experience low at one point in their lives. tion unit while in the PT clinic, aqua therapy, and ice Undertreated or unrelieved pain costs more than and heat application. $60 billion a year from decreased productivity, lost income, After several weeks, Ms. T returned to the primary care and medical expenses. The ability to diagnose and provide ap- provider and informed her that the pain has not decreased and “feels like that it is getting worse.” She also informed propriate medical treatment is imperative. This case study ex- the provider that she was having difficulty sleeping and amines a 23-year-old Active Duty woman who is preparing to constantly feeling tired secondary to pain. Throughout the be involuntarily released from military duty for an easily cor- next several months, the primary care provider tried nu- rectable medical condition. She has complained of chronic low merous medication trials with no relief for the patient. Ms. back pain that radiates into her and down her leg since ex- T gives a history of being prescribed numerous medica- periencing a work-related injury. She has been seen by numer- tions within several drug classifications. She stated vari- ous providers for the previous 11 months before being referred ous side effects that are related to the medications and to the chronic pain clinic. Upon the first appointment to the some complaints that she associates with a medication. chronic pain clinic, she has been diagnosed with sacroiliac See Table 1 for complete medication list and symptoms. joint dysfunction. This case study will demonstrate the impor- In addition, Ms. T had several radiologic studies in- tance of a quality lower back pain assessment. cluding plain x-ray and magnetic resonance imaging (MRI). The MRI on March 5, 2009, found an L5–S1 de- generative disc with a right annular fissure and shallow Chief Complaint and a disc extrusion and mild facet arthropathy; an L4–L5 Comprehensive Assessment shallow central disc extrusion and mild facet arthropa- thy; and an L3–L4 shallow central disc protrusion. In Ms. T is a 23-year-old single woman who is an active duty comparing the L-spine x-rays on April 21, 2009, to a service member. She functions as a medical technician. prior x-ray taken on January 9, 2009, there was worsen- Ms. T presents with complaints of chronic . ing of degeneration at L4–L5. Ms. T was referred to the chronic pain clinic by a nurse Ms. T now describes the character of her pain as a “dull practitioner who requested that she have a Medical constant ache” with “intermittent stabbing, shooting, and Evaluation Board (MEB) for retainability. burning pain” that radiates bilaterally to the lower extrem- ities with the right leg pain greater than left. She also notes MEDICAL HISTORY chronic bilateral metatarsal paresthesia and chronic bilat- Ms. T states that she has a sudden constant low back pain eral posterior lower extremity dysesthesia. Ms. T rates her that started 10–11 months ago when she was moving a pa- pain scores with the visual analog scale, quantifying her tient up in the bed. She states that she “heard an audible pop pain from the last week at best as 3/10 to the worst as and felt a sharp pain.” After the event she was unable to con- 10/10. The current pain level of 5/10 is in her lower back at tinue working and reported to the emergency room that L4. She states that “sitting or standing for prolonged peri- evening. During the emergency room visit, she received a ods of time” increases her pain and “swimming, the heat- lumbosacral radiologic examination, with two views, and ing pad, lying on back, and medications” all help her pain. received ketorolac 30 mg IV, cyclobenzaprine 10 mg by Her Modified Beck Depression Inventory (Rodin, Craven, mouth (PO) with a prescription for one tablet twice a day, & Littlefield, 1991) is 22, which indicates a moderate-se- and a prescription for meloxicam 15 mg PO once a day. vere (19–29) depression; however, she expresses no suici- Ms. T followed up after 1 week with the primary care dal ideation. Her Oswestry Disability Index (ODI) is 26 out clinic and informed the provider that she had no “real of 50. (Note: The number or percentage of the ODI is not relief” with the medications. She was informed that she should wait for three additional weeks and then have a CPT William Murray, MSN, RN, ACNS-BC, RN-BC, US Army, Nurse follow-up appointment. One month after the initial in- Corps, Kailua, HI. jury she had another follow-up with her primary care The author has disclosed that he has no financial interests to any com- provider who recommended (PT). mercial company related to this educational activity. Ms. T waited two and a half weeks to be seen by the DOI:10.1097/NOR.0b013e31820f513e

126 Orthopaedic Nursing • March/April 2011 • Volume 30 • Number 2 Copyright © 2011 National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited. NOR200188.qxd 3/8/11 9:53 PM Page 127

TABLE 1. MEDICATION HISTORY

Classification Medication Effect Opioid Darvocet N-100 Made her sleepy Percocet 5/500 Made her have muscle weakness Tylenol #3 Caused gastrointestinal upset Tramadol Worked with no side effects Nonsteroidal anti-inflammatory drug Mobic Worked somewhat with no side effects Naprosyn Made her “sleepy” Ibuprofen Worked the best for her with no side effects Benzodiazepine Valium Worked somewhat but always made her feel “cloudy and tired” Muscle Relaxant Flexeril Worked somewhat but always made her feel “cloudy and tired” Anti-epileptic Topamax Worked well but also made her feel “tired” Antidepressant Elavil She does not remember any effects she may have had

significant at any one point; however, looking at the trends parallel to the floor without any abnormal positioning; in the score over time will demonstrate the measurement there are no abnormal curvatures of the cervical, tho- of the disabling effects of spinal disorder.) racic, or lumbar spine; and the iliac crests are parallel. Ms. T’s current medication regimen includes tra- Ms. T is able to maneuver onto the examination table madol 50 mg PO one tablet every 6 hr with an average without difficulty and any facial grimacing. daily dose of two to three tablets, ibuprofen 800 mg PO one tablet every 8 hr with an average daily dose of three SPINE AND NERVOUS SYSTEM tablets daily, and acetaminophen 500 mg PO two tablets for the flexion of the spinal column re- every 6–8 hr with an average daily dose of four to six sults in 75Њ of range with minimal persistence of lumbar tablets not exceeding 4 g/day. She denies any food or concavity (lumbar ), suggesting possible muscle drug allergies, tobacco use, or any personal or family spasms. This movement causes some pain but does not history of alcohol/drug abuse. reproduce the exact chief complaint pain. Extension of Ms. T denies any childhood illness and has no surgical the spinal column results in 30Њ of range. This move- history. She is a gravida 0 para 0 and denies any psychiatric ment causes some pain but does not reproduce the exact problems or a past psychiatric diagnosis. She reports a lower back and leg pain. Lateral flexion results in 45Њ of medical history of irritable bowel syndrome with no current range bilaterally and the movement causes some pain. problems or a flare-up at present and denies loss of bowel or Rotation results in varying findings: right-side rotation bladder control. Her current immunizations are up-to-date equals 30Њ whereas left-side rotation equals 45Њ (facet and she is waiting for the H1N1 vaccine to arrive. load) and rotation to the right causes pain into lower Ms. T reports no known family history of illnesses. right paraspinal area at S1; Gillet’s test is undiagnostic Her review of systems is unremarkable with the excep- because of the inability to evaluate S2 and the posterior tion of reports of headaches starting approximately superior iliac spine. 5 months ago occurring after she has been standing or Ms. T has intact sensation to light touch; however, walking for any prolonged periods of time lasting she has a right-sided deficit to pin prick following the greater than 30 min. She reports the headache as a L4 dermatome level. This has not been noted by the sharp stabbing pain at a 7/10 pain rating that starts at patient on previous examination. See Table 2 for more approximately the level C5 and radiates up into the oc- diagnostic data. cipital and temporal region. The patient reports the Upon lying supine, the assessment of the lower extrem- headaches lasting approximately “one or two hours and ities reveals a leg length discrepancy of 2 cm. Gaenslen’s only goes away when I can lie down and take some test is positive for right (SIJ) dysfunction; Tylenol [acetaminophen].” In addition, she notes that Faber/Patrick test is positive for right SIJ dysfunction; occasionally the headaches have caused her to become is positive at 25Њ for irritation. nauseated resulting in a couple of vomiting episodes. With Ms. T in the prone position, the Sacroiliac Shear Test is positive; Yeoman’s Test is positive for right SIJ dys- PHYSICAL EXAMINATION function; posterior superior iliac spine tenderness is Ms. T is of average height and normal weight and is noted bilaterally with the patient demonstrating a jump quick to respond appropriately to questions. Her ap- sign. Trigger points are noted bilaterally in the paraspinal pearance is clean and neat. Her vital signs are unre- muscles approximately at L2–L3 at the Inferior markable: height 66 in., weight 135 lb, and body mass Latissimus Dorsi with the patient demonstrating a jump index 21.8. She demonstrates a smooth gait with contin- sign upon . Trigger points are also noted bilater- uous rhythm as she enters the room. She demonstrates ally paraspinal at the level of C5–T2, affecting the superior the ability to stand erect without difficulty. Her head is trapezius and splenius capitis. See Table 3 for informa- midline and is easily maintained, and her shoulders are tion about these diagnostic tests.

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TABLE 2. PATIENT DIAGNOSTIC DATA

DTR—Patellar DTR—Achilles Strength Pulses R side 2ϩ 2ϩ 4/5 2ϩ Ͼ 3 s L side 3ϩ 2ϩ 5/5 2ϩ Ͼ 3 s Gaenslen’s test ϩ Faber test ϩ Straight leg raise ϩ @ 25Њ Sacroiliac Shear test ϩ Yeoman’s test ϩ Posterior superior iliac spine tenderness demonstrating a jump sign Note. TP noted bilaterally paraspinal at C5–T2 affecting the superior Trapezius and Splenius Capitis and at L2–L3 at the Inferior Latissimus Dorsi both causing jump sign.

GENERAL EXAMINATION nerve root irritation and results when the nucleus pulposus prolapses into the annulus fibro- Other findings for Ms. T include the following: head, sus. Any movement from sitting to sneezing usually ex- ears, eyes, nose & throat (HEENT) within normal lim- acerbates the radiculopathy symptoms and pain. its; negative icterus; is supple; cardiac: regular, Patients who have a diagnosis of lumbar disc hernia- rate, and rhythm; S1 and S2 noted without murmurs, tion have a 95% chance to also have a diagnosis of sci- regurgitation, or gallops; pulmonary: Lung fields are atica. As the condition continues, the extremity pain clear to auscultation bilaterally in all lobes; dermato- from radiculopathy often masks the back pain. The logic: skin is warm, dry, and without rashes. physical examination for disc herniation will be fo- cused on the lower extremities. Signs of disc herniation Differential Diagnoses include weakness of dorsiflexion of 70%, great toe ex- tension of 70%, ankle plantar flexion of 95%, and knee Several of the differential diagnoses may have occurred extension 99% (Lin, 2009). as a secondary condition to the primary diagnosis. Once Rule-in criteria for Ms. T: The impression from the the primary diagnosis is corrected, then the secondary MRI on March 5, 2009, stated L5–S1 degenerative disc may resolve. with a right annular fissure and shallow disc extrusion and mild facet arthropathy; L4–L5 shallow central disc DISC HERNIATION WITH NERVE IMPINGEMENT extrusion and mild facet arthropathy; L3–L4 shallow The average age of patients who have herniated lumbar central disc protrusion. The L-spine series x-rays of discs are 30–50 years. These patients usually have a his- April 21, 2009, compared with the prior x-ray January 9, tory of nonradicular low back pain. In disc herniation, 2009, showed intervertebral worsening of disc degeneration

TABLE 3. DIAGNOSTIC TEST

Test and Patient Position Technique Positive Findings and Comments Faber/Patrick test—left Keeping the patient’s right leg is straight; bend his left Pain over the left SIJ area. In SIJ dysfunction supine leg with the ankle above the right knee. Hold the addition, may have pain in right iliac crest and places firm pressure over the the groin and buttocks. medial aspect of the left knee with the opposite arm. Stresses the SIJ and hip joint Gaenslen’s test —left SIJ Place the patient on the left side of the examination table Pain in the left SIJ. Examination dysfunction supine with the left lower extremity hanging off the table stresses the SIJ counterrotation and placing pressure with the right hand on the thigh. and the hip joint simultaneously Flex the patient’s right knee and hip with firm while also stretching the pressure on the knee with the left hand. femoral nerve. Straight Leg Raise—nerve root Keeping the patient’s right and leg legs straight, secure Pain radiating from the back to irritation supine the ankle of the patient’s affected side with your hand the leg. Differentiate hamstring and passively raise the patient’s leg. Record the degree tightness from reproducible of elevation at which the pain is reproduced. pain. Yeoman’s/extension test— Secures the patient’s left thigh with your left arm. Then Pain over the SIJ. Considered to SIJ dysfunction prone place firm pressure over the with your right hand be the most specific and while elevating the patient’s left leg. reliable test. SI shear test—SIJ dysfunction Place your palm over the patient’s posterior iliac wing. Pain in the SIJ prone Quickly press down and back toward the toes. Gillet’s test—fixed or Places your left thumb over the patient’s second sacral The PSIS moves superior or dysfunctional SIJ standing spinous process while placing your right thumb on the remains fixed at the level S2 right PSIS. Then have the patient flex the right hip. spinous process. Normal finding: the PSIS moves inferiorly to the S2 spinous process. Note. PSIS ϭ posterior superior iliac spine; SIJ ϭ sacroiliac joint.

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at L4–L5. She has a positive straight leg raise at 25Њ for Rule-out criteria for Ms. T: White female, abrupt nerve root irritation and the right-sided deficit to pin onset of pain, no cardiac abnormalities on previous prick following the L4 dermatome level that has not chest x-ray, and heart rate 86 beats per minute regular, been noted by the patient previously. rate, and rhythm; S1 and S2 noted without murmurs, Rule-out criteria for herniated disc: Since Ms. T has regurgitation, or gallops. SIJ dysfunction on physical examination, she will ini- tially be treated for that. She has not seen chiropractic BENIGN TUMORS, MALIGNANT TUMORS, OR medicine for immobilization of her SIJ but has been MISCELLANEOUS LESIONS schedules for a diagnostic/therapeutic SIJ injection. It is The majority of patients with spinal tumors or lesions likely that she will do very well with correct treatment will present typically with deep, dull pain, no matter the plan and will reevaluate for further diagnoses once chi- specific category of lesion. Initially the onset of pain will ropractics has manipulated the SIJ and SIJ injection be intermittent and progressively become constant. has been completed. Palpation on the spine usually elicits mild to moderate pain. L-spine x-ray series should be obtained and, if sus- picious for malignancy, a chest x-ray should be obtained. Facet pain is not a common source of pain because the X-ray films will frequently show multiple punched-out, pain originates from the posterior spinal element. Patients lytic bone lesions. In addition, MRI and computed tomo- often have difficulty localizing the exact source of their graphic scans are useful studies for bone lesion charac- pain; however, movements that stress the joint by hyperex- terization (Srinivasan, Tolhurst, & Vanderhave, 2009). tension are a positive identifying action that can re-create Familia history (98% specificity) of known cancer is a the patients’ pain. Patients will indicate that the pain is ag- risk factor, and signs and symptoms include “unex- gravated by prolonged sitting or standing, and complain of plained weight loss (94% specificity), persistent pain de- low back pain especially in the morning. In addition, pa- spite bed rest (90% specificity), and pain lasting more tients will indicate pain in the hip and buttocks area with than one month (81% specificity)” (Lin, 2009). pain radiating down to the lower extremity but not passing Rule-in criteria for Ms. T: Persistent pain lasting the knee. X-ray films will show a narrowed disc space and 10–11 months. osteophyte formation of the inferior and superior facet. Rule-out criteria for Ms. T: There is no supporting ev- Computed tomographic scan will demonstrate arthritic idence for tumor or malignance with x-rays or MRI, no facet changes (Hu, Tribus, Tay, & Bhatia, 2006). unexplained weight loss, and no known family history. Rule-in criteria for Ms. T. She complains of a “dull constant ache” with “intermittent stabbing, shooting, CAUDA EQUINA SYNDROME and burning pain” that radiates bilaterally to the lower This disorder results from sudden compression of mul- extremities with the right greater than the left. She tiple lumbar and sacral nerve roots. Cauda equina is states that “sitting or standing for prolonged periods of rare and considered a neurosurgical emergency. The time” increases her pain. The impression from the MRI primary cause of Cauda equina syndrome is a large cen- on March 5, 2009, found L5–S1 degenerative disc with a tral disc herniation; however, it may also be caused by a right annular fissure and shallow disc extrusion and hematoma, epidural abscess, trauma, and/or malig- mild facet arthropathy as well as an L4–L5 shallow cen- nancy. Signs and symptoms include “back pain and tral disc extrusion and mild facet arthropathy. multilevel , often involving both legs.” Rule-out criteria for Ms. T: Sacroiliac joint dysfunc- There can also be difficulty with bladder and bowel tion was diagnosed on physical examination. Facet load function (Lin, 2009). Urinary retention is the most con- rotation to the right causes pain into lower right sistent finding during examination. paraspinal area at S1. She will require the same follow- Rule-in criteria for Ms. T: Her pain occurred suddenly up treatment needed as disc herniation and cannot ab- involving the lower extremities. solutely be ruled out until the workup is complete. Rule-out criteria for Ms. T: She denies loss of bowel/bladder control; the MRI does not reveal an area ANKYLOSING that requires decompression. See Table 4 for rule-in often involves white men who and rule-out criteria. are younger than 40 years. It is located within the verte- bral and sacroiliac . Signs and symptoms of anky- losing spondylitis include chronic low back pain, de- Final Diagnosis creased range of motion in the back, and decreased Ms. T has a history of trauma related to repositioning a thoracic expansion. In some instances, this problem has patient. “A common initiating event [of back pain] is a his- affected peripheral joints and extra-articular organs. tory of lifting a heavy object while in a twisted position” Patients have a greater than 90% of being positive for (Benzon, 2005, p. 357). The physical assessment of Ms. T’s the HLA-B27 histocompatibility antigen. In addition, as lower extremities reveals a leg length discrepancy of 2 cm. stated by Roldan (2009), patients will display “aortic re- Gaenslen’s test is positive for right SIJ dysfunction; the gurgitation, aortic root sclerosis and dilation, leaflet Faber Patrick test is positive for right SIJ dysfunction; and thickening, and subaortic bump on echocardiography.” the Straight leg raise was positive at 25Њ for nerve root ir- Rule-in criteria for Ms. T: The L-spine x-rays series ritation. With Ms. T in the prone position, the Sacroiliac from April 21, 2009, indicate intervertebral worsening Shear test is positive; Yeoman’s test is positive for right of disc degeneration L4–L5. SIJ; and posterior superior iliac spine tenderness is noted

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TABLE 4. DIFFERENTIAL DIAGNOSES

Diagnosis Criteria Present to Rule In Criteria Present to Rule Out Disc herniation with MRI impression on March 5, 2009; Comparison L-spine Positive SIJ dysfunction upon examination. nerve impingement x-rays from January 9, 2009, and April 21, 2009; Will need to correct and reevaluate to Positive straight leg raise; and right-sided determine nerve impingement. sensory deficit. Facet syndrome MRI impression on March 5, 2009; Pt. c/o “dull constant Positive SIJ dysfunction upon examination. ache with intermittent stabbing, shooting, and Facet injection scheduled. burning pain.” Ankylosing spondylitis L-spine x-rays from April 21, 2009. White female; abrupt onset of pain; no cardiac abnormalities note on examination or previous chest x-ray. Benign tumors, Persistent pain No evidence from x-rays or MRI; no malignant tumors, unexplained weight loss; and no or miscellaneous family history. lesions Cauda equina Occurred suddenly involving the lower extremities. No loss of bowel/bladder control; MRI syndrome does not reveal an area that requires decompression. Note. MRI ϭ magnetic resonance imaging; SIJϭ sacroiliac joint.

bilaterally with Ms. T demonstrating a positive jump sign. mation of the joint (ankylosing spondylitis), degenera- These tests all indicate that Ms. T has a dysfunctional SIJ. tive disease of the joint (), metabolic dys- “Pain in sacroiliac joint does not originate in the lumbar function affecting the joint (gout), infection, and/or a area as in facet syndrome and rarely radiates below the tumor. As stated by Benzon (2005, p. 357), “The pain [of knee as in a herniated disc” (Benzon, 2005, p. 357). SIJ] can be dull, sharp, or aching in character.” A com- mon theme is that patients identify the preceding event Underlying Pathophysiology as “lifting a heavy object while twisting.” In addition, sit- ting, bending, or riding in a car can agitate the pain. The Chronic pain is defined by Cline (2004) as “a painful pain does not originate from the lumbar region, and pa- condition that lasts longer than 3 months, a pain that tients may have some into the hip and persists beyond the reasonable time for an injury to down the leg but usually not extending past the knee heal, or a pain that persists 1 month beyond the usual (Benzon, 2005). course of an acute disease.” Chronic pain can be divided into four categories: pain lasting longer than expected for an injury or disease, pain due to a degenerative dis- Final Diagnoses and Treatment ease of neurologic condition, pain related to cancer, and Plan for Ms. T pain that exists without an identifiable cause. There is no biologic function of chronic pain. Sensory neurons Ms. T’s final diagnoses in the pain clinic were chronic may become autonomously overactive if chronically pain, chronic low back pain, and SIJ dysfunction. Her bombarded even after the pathways are interrupted. treatment plan for SIJ included the following: Also peripheral nerve lesions have revealed that chronic 1. Continue tramadol 50 mg PO one to two tablets every pain produces chronic derangements of the 4–6 hr with a maximum dose of eight tablets per day (Adams, 2009). The pathophysiology of chronic pain is 2. Continue ibuprofen 800 mg PO one table every 8 hr grouped into three categories: nociceptive, neuropathic, 3. Continue acetaminophen 500 mg PO one to two and psychogenic. “Nociceptive pain is associated with tablets every 6–8 hr with a maximum of eight ongoing tissue damage, neuropathic pain is associated tablets per day with nervous system dysfunction in the absence of on- 4. Continue PT/transcutaneous electrical nerve stim- going tissue damage, and psychogenic pain has no iden- ulation unit tifiable cause” (Cline, 2004). Patients with chronic pain 5. Consult chiropractics for joint manipulation may experience multiple categories simultaneously. 6. Follow-up with clinic for transcutaneous electri- Up to 80% of Americans will experience low back cal nerve stimulation trial. pain and up to 30% of low back pain are caused by SIJ 7. Return to clinic in 3–4 months or earlier if needed for dysfunction. There are numerous pathologic conditions SIJ steroid injection or for possible facet injection that can cause SIJ dysfunction including trauma, tumors, infection, and inflammation. Factors that predispose pa- The MEB will determine whether the soldier will be tients to SIJ dysfunction include trauma, leg length dis- retained for military service, retrained for a new profes- crepancy, spinal deformity, previous surgery, disc sion, or released from active duty service. The note for pathology, lumbar facet syndrome, pregnancy, inflam- the MEB was as follows:

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1. Injury incurred in the line of duty: Yes ACKNOWLEDGEMENTS 2. Is this service member deployable: No A special thanks to Dr. Mary Heye, PhD RN, ACNS-BC, 3. Is this service member retainable: Yes RN-C, Dr. Cheryl Lehman, PhD RN, CNS-BC, RN-BC, 4. Findings: The patient with right greater than left CCRN; and Sarah Murray, MSN RN, ACNS-BC, RN-BC SIJ dysfunction on physical examination. She has for encouraging and motivating me throughout the not yet seen chiropractic medicine for mobilization writing process. I appreciate your time and all of your of her SIJ and has been scheduled for a diagnostic/ feedback that you have given me. therapeutic SIJ injection. It is likely that she will do very well with correct treatment plan and implementation. REFERENCES Adams, R. D. (2009). Section 2—Pain and other disorders of somatic sensation, headache, and backache. In A. H. Treatment Plan Critique Ropper, & M. A. Samuels (Eds.), Adams and victor’s prin- Ms. T stated that she was happy with her current pain ciples’ of neurology (9th ed.). Retrieved November 8, medication regimen because she does not like taking pills 2009, from http://online.statref.com/Document/Document. and she does not want anything that makes her feel aspx?docAddressϭHVcAGWebdyfO8uSEVfwCXA% ϭ ϭ ϭ “sleepy or out of it.” During the history and physical ex- 3d%3d&Scroll 303&Index 6&SessionId 10D4 amination, she stated that she “does not like to take pills.” FFEFSRWYRDXG Later discussion during the plan of care revealed that Benzon, H. T. (2005). Pain originating from the buttock: Sacroiliac joint dysfunction and . In she did not want to start any additional medication (e.g., H. T. Benzon, S. N. Raja, R. E. Molloy, S.S. Liu, & S. M. duloxetine or gabapentin) for medication management. Fishman (Eds.), Essentials of pain medicine and regional The addition of cervicogenic headaches and myofascial anesthesia (2nd ed., pp. 356–365). Philadelphia: Elsevier. pain syndrome secondary to SIJ dysfunction could have Cline, D. M. (2004). Management of patients with chronic been added to the list of diagnosis. Treatment of the primary pain. In J. E. Tintinalli, G. D. Kelen, & J. S. Stapczynski diagnosis, however, will alleviate the secondary diagnoses. (Eds.), Emergency medicine: A comprehensive study guide There was an omission of a consult for the patient to (6th ed.). Retrieved November 2, 2009, from http:// discuss the decrease in function and her altered body online.statref.com/Document/Document.aspx?doc Addressϭ-l61MAiRhfP9L7BbjnS_A%3d%3d&Scrollϭ image with a pain psychiatrist. In addition, Ms. T stated ϭ ϭ that she was happy that she was going through the MEB to 1&Index 2&SessionId 10D31FDOHYINQORL Hu, S. S., Tribus, C. B., Tay, B. K., & Bhatia, N. N. (2006). be separated from military service and to go home. With Chapter 5. Disorders, diseases, & injuries of the spine. In this new diagnosis, the MEB will be held until the patient H. B. Skinner (Ed.), Current diagnosis & treatment in has finished her medical treatment for further evaluation. orthopedics (4th ed.). Retrieved November 8, 2009, from http://online.statref.com/Document/Document.aspx? Outcome Measures docAddressϭAFehZL9UFGuy_8R1Xx_miw%3d%3d& Scrollϭ1&Indexϭ0&SessionIdϭ10C90FACOYTPUPNB An ongoing assessment for Ms. T will be conducted each Lin, M. (2009). Chapter 51—Musculoskeletal back pain. In visit. Ms. T documented that her ODI is 26 out of 50. Marx, et al. (Eds.), Rosen’s emergency medicine concepts Oswestry Disability Index is a measurement of the dis- and clinical practice (7th ed.). Retrieved November 7, abling effects of lumbar spinal disorders. During her 2009, from http://www.mdconsult.com.libproxy.uthscsa. follow-up visit, the ODI will be assessed to discern edu/book/player/book.do?methodϭdisplay&typeϭbook whether the chiropractor is having any therapeutic ef- Page&decoratorϭheader&eidϭ4-u1.0-B978-0-323- ϭ fect. In addition, Ms. T is scheduled for a sacroiliac 05472-0..00051-7–s0045&displayedEid 4-u1.0-B978-0- 323-05472-0..00051-7–s0060&uniqϭ169672147& steroid injection, which will also help to distinguish ϭ ϭ ϭ whether she has a disc herniation with nerve impinge- isbn 978-0-323-05472-0&sid 913652430#lpState open&lpTabϭcontentsTab&contentϭ4-u1.0-B978-0- ment and/or facet syndrome. 323-05472-0..00051-7%3Bfrom%3Dtoc%3Btype% In most patients with chronic pain, a complete recovery is 3DbookPage%3Bisbn%3D978-0-323-05472-0 not a reasonable outcome, but a reduction in pain and increase Rodin, G., Craven, J., Littlefield, C. (1991). Depression in in functional status can be expected (Cline, 2004). The ex- the medically ill: An integrated approach (pp. 5). New pected outcome for Ms. T is a full recovery with the treatment York: Brunner/Mazel. plan of exercise, joint manipulation, and joint injection to re- Roldan, C. A. (2009). Connective tissue diseases & the store the natural motion and function of the overlying muscle. heart. In M. H. Crawford (Ed.), Current diagnosis & treat- If other diagnoses are determined, then the facet steroid injec- ment cardiology (3rd ed.). Retrieved November 7, 2009, from http://online.statref.com/Document/Document.aspx? tions will be employed. Facet steroid injections have been ϭ shown to immediately decrease pain by 50%–80% in patients docAddress Xb5xAFbp7PRQ1_JzZR7P4A%3d%3d& Scrollϭ2&Indexϭ6&SessionIdϭ10C6305QNEVWSQIH. with facet pain and 90% of pain within 12 hr (Benzon, 2005). Srinivasan, R. C., Tolhurst, S., & Vanderhave, K. L. (2009). The frequency of follow-up visits will be determined at every . In G. M. Doherty (Ed.), Current diag- visit; however, as a guideline she will have 3–4 months between nosis & treatment surgery—2010 (13th ed.). Norwalk, CT: visits to allow her time to evaluate the effect of the procedures. McGraw-Hill.

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