History and Presenting Symptoms
A 41-year-old male presents with a history of recurring episodes of mild to moderate pain in his lower back. He states that his back pain just seems to come and go, with no specific triggering activities. He does not participate in any competitive or recreational sports, and recalls no injury or trauma to his back. He has recently been diagnosed as a borderline non-insulin dependent diabetic, and is trying to improve his diet to manage his blood sugar levels.
Exam Findings
Vitals. This heavy-set man in his early forties weighs 218 lbs, which at 5’10’’ results in a BMI of 32—he is not just overweight; he is obese. Since he reports no regular exercise, his additional weight is very likely due to excess fat mass. Although he is a non-smoker, his blood pressure and pulse rate are both elevated—144/96 mmHg and 88 bpm. His waist circumference measures 48 inches, indicating that he is carrying much of his weight around his mid-section.
Posture and gait. Standing postural evaluation finds generally good alignment throughout his pelvis and spine, but a flattened lumbar lordosis with a large abdominal load. He has bilateral knee valgus and calcaneal eversion, with pes planus and hyperpronation bilaterally. During gait, both feet demonstrate an obvious toe-out. Inspection of his shoes finds scuffing and wearing at the lateral aspect of both heels.
Chiropractic evaluation. Motion palpation identifies limitations in segmental motion at L4/L5 and L5/S1, with local tenderness. Both of these segmental dysfunctions demonstrate loss of endrange mobility in all directions. Additional fixations are noted at T12/L1, T9/T10, C5/6, and C1/2. Lumbar ranges of motion are somewhat limited in all directions by his excess weight, and extension is limited to 10° by localized back pain. Neurologic testing is negative, although his deep tendon reflexes are generally sluggish. Examination of the knees and ankles finds no ligament instability, and all knee and ankle ranges of motion are full and pain-free.
Imaging
Upright, weight-bearing X-rays of the lumbar spine demonstrate loss of intervertebral disc height at L4/L5 and L5/S1, with moderate osteophyte formation at those levels. There is no discrepancy in femur head or iliac crest heights, and no lateral listing or lateral curvature is noted.
Clinical Impression
Moderate lumbosacral osteoarthrosis and disc degeneration, with mechanical dysfunction. There is also poor biomechanical support from the lower extremities, and his condition is exacerbated by the excess weight his skeletal structures must carry.
Treatment Plan
Adjustments. Specific chiropractic adjustments for the lumbosacral, lower thoracic, and cervical spinal regions were provided as needed.
Support. Custom-made, flexible stabilizing orthotics were provided to support the arches and decrease stress on the knees and back.
Rehabilitation. This patient was shown elastic tubing exercises to begin strengthening his spinal stabilizers and core musculature. He was also instructed to gradually initiate a daily brisk walking program to increase his metabolic rate.
Response to Care
He responded well to his spinal adjustments, and to the reasonable changes in diet that were suggested. He also adapted quickly to his orthotics, which allowed him to begin his program of brisk walking without exacerbation of back or leg pain. He was very dedicated to his home spinal stabilization program, and enjoyed showing the progress in his exercise log. After six weeks of adjustments (10 visits) and daily home exercises, he was symptom-free and had lost 17 pounds. At that point, he was released to a wellness program to oversee his continued exercise and weight loss program.
Discussion
This patient was obese, based on his BMI, and he had three of the signs of Metabolic Syndrome—waist circumference over 40″, blood pressure over 130/85 mmHg, and elevated blood glucose (by report). In addition to experiencing chronic stress on his musculoskeletal system, he was also at risk of developing diabetes, cardiovascular disease, and an early death. His chiropractic care included orthotics to support his strained lower extremities, and specific exercises to improve his core stability, along with dietary recommendations. As is true with most patients, he was aware of the necessary lifestyle changes for health, but needed guidance and professional support through the initial stages.
Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.