Management of Post-Traumatic Piriformis Syndrome: Case Study

Management of Post-Traumatic Piriformis Syndrome: Case Study Diagnosis and Chiropractic Management of Post-Traumatic Piriformis Syndrome: A Case Study Chief complaint A 37-year-old male patient presented himself at a local chiropractic clinic with a chief complaint of persistent low back pain that was radiating into his left buttock, all along the posterolateral aspect of his left thigh and calf, and to the lateral aspect of the foot. History of the patient illness The pain initiated 2 years ago. The patient reported a blunt trauma of his left buttock in a motorcycle accident 8 months before his symptoms were first noticed. The patient was presented with low back pain, radiating from sacrum and gluteal region to the lateral aspect of the foot, all along the posterolateral aspect of his left thigh and calf. The pain was occasionally accompanied by paresthaesia and burning sensation. When asked to rate his pain with a numeric rating scale (NRS), he noted his low back pain to be 3/10 at best and 7/10 at worst. Prolonged sitting and car driving aggravated his symptoms. And standing up and walking a few steps for a moment would make the pain partially relieved. The patient also noted that prolonged external rotation of the affected hip (sitting posture) made the symptoms more intense. He avoided sitting in a cross-leg posture due to the pain. The patient had a transient relief of his pain after treatment of physiotherapy. However, the pain came back after a few days. Other than the traumatic fall on his left hip in a motorcycle accident, the patient’s medical history was not remarkable. Relative family history, social and environment history Both of the patient’s parents were diagnosed with disc herniation of the lumbar spine in their 50s. The patient went to gym 4 times per week, doing cardiovascular and weight bearing training. And he used to play soccer once a week. However he had to stop playing since his low back pain and leg pain started to bother him. The patient was an attorney and his job required him to sit in front of his desk for more than 6 hours per day. He reported that he had to stand up and walk a few steps in the office every 30 minutes due to the pain. Relevant medications The patient’s symptoms were partially relieved by taking Panadols. He was not taking any other prescribed or non-prescribed medications. List of possible diagnoses from the patient history Lumbar disc herniation The patient was presented with symptoms and signs of radiculopathy including sensation disturbance of the lower limb, pain shooting to the foot, and pain worsened by sitting and relieved by walking. According to the dermatome, the nerve roots of L5, S1 or S2 were possibly affected. Considering that both of the patient’s parents are diagnosed with lumbar disc herniation, it should be on top of the differential diagnosis list, for recent studies have suggested that lumbar disc herniation may be attributed more to genetic factors than to environmental and constitutional risk factors. The patient’s occupation which kept him sitting for a prolonged time increases the chance of lumbar disc herniation. The history of blunt trauma could also be a factor of developing lumbar disc herniation. Sciatic nerve irritation of other origins The patient’s altered sensation on the lower extremity is in the distribution of sciatic nerve. Sciatica should be taken into consideration. However, the underlying cause of compression or irritation of sciatic nerve should be revealed with further examination and investigation. Piriformis syndrome Piriformis syndrome is an uncommon form of sciatica in which the sciatic nerve is compressed and irritated by piriformis muscle. It usually occurs in people who are middle-aged (mean age 38 years old). Robinson described 5 significant manifestations of piriformis syndrome in 1947, including: (1) history of trauma in the gluteal region; (2) pain in the sciatic nerve distribution; (3) symptoms relieved by traction and aggravated by sitting or stooping; (4) palpable tenderness or mass over piriformis muscle; (5) positive straight leg raise test. This patient was presented with the first 3 features of piriformis syndrome, whereas the 4th and 5th need further examination. Sacroiliac joint syndrome Sacroiliac joint syndrome is the dysfunction of sacroiliac joint that is attributed to either hypermobility or hypomobility, causing low back pain, buttock pain and sciatic lower limb pain. Lower abdomen, groin and medial thigh are occasionally affected as well. The symptoms of sacroiliac joint syndrome and sciatica are often similar. Hamstring syndrome Another possible differential diagnosis is hamstring syndrome. Hamstring syndrome is caused by entrapment of the proximal sciatic nerve by the hamstring tendons (1). It usually occurs associated with trauma such as hamstring tears or strain (2). However, in many cases, not significant history of trauma is noted (1, 2). Patients with hamstring syndrome present with lower gluteal pain and radiate down to posterior thigh and knee (2). The symptoms are similar to sciatica of other origins. Results of the neurological exams Observation, static palpation and range of motion Observation and static palpation are performed to look for any degree of antalgic posturing, any deviation from a normal spinal curve, pelvic position, and muscle spasm or bulks. Characteristic findings of each differential diagnosis are listed below. Lumbar disc herniation Possible hyper-lordosis of lumbar spine in an antalgic posture; Significant decrease in lumbar active and passive range of motion, especially in lumbar flexion and unilateral lateral flexion; Possible limited hip range of active motion due to muscle weakness; Possible palpable restricted lumbar vertebral segments; Hypertonic or tender lumbar muscles on static palpation, especially erector spinae (ES) muscles; Piriformis syndrome Possible limping or walking with the assistance with crutches due to pain and lower extremity muscle weakness; Possible hip external rotation on the affected side due to excessive piriformis muscle contraction, which is also known as â€Å"piriformis sign† (3); Significant decrease in hip active and passive range of motion, especially in hip internal rotation and adduction; Ipsilateral short leg (3); Tenderness at the sciatic notch on palpation; Possible hypertonic gluteal muscles (3); Sciatica Findings depend on the causes of sciatica such as lumbar disc herniation, piriformis syndrome and hamstring syndrome. Sacroiliac syndrome The posterior superior iliac spines (PSIS) on both sides are not at the same horizontal level; Possible redness and swelling at the affected sacroiliac joint; Possible leg length discrepancy; Significant decrease in sacroiliac joint mobility; Possible local tenderness on static palpation; Hamstring syndrome The pain is more localized, but possibly radiating; Tenderness of hamstring tendons or over ischial tuberosity on static in palpation; Significant decrease in hip active range of motion, especially in hip extension; On observation, static palpation and range of motion assessment, the patient was noticed for: Positive piriformis sign (hip external rotation) on the ipsilateral (left) side; A relatively shorter left leg compared with the right leg; Tenderness over contralateral (right) sacroiliac joint; A palpable â€Å"sausage-shaped† mass in the ipsilateral (left) gluteal region (3); Hypertonic left hamstrings; Tenderness over left sciatic notch on static palpation; Limited hip active and passive range of motion, especially internal rotation; Decrease in sacroiliac joint mobility; Other findings were not remarkable. The results of the assessment suggested that piriformis syndrome and sacroiliac syndrome were most possible diagnoses. Coordination and gait analysis Coordination and gait should be examined before other assessments are done, for this test provides us a big picture of the patient’s lower extremity function including motor function, joint integrity and coordination. Any gait dysfunction or antalgic gait should be recognized and further tests should be performed to look for the causes. No abnormal movement or disturbance of the patient’s gait was observed. He also reported a partial relief of symptoms when he was walking. The insignificant findings made lumbar disc herniation less likely, however, there was still a possibility. Sensory exam Sensory exams of peripheral nerves were performed to look for any sensation change on the symptomatic lower limb, which would lead to localization of the lesion. Assessments included fine touch, pain, temperature, and proprioception. Decrease in two-point discrimination and light touch was noticed over the lateral aspect of the left leg and foot. Motor exam Lower extremity muscle strength was tested to identify which nerve roots were affected according to myotomes. On examination, no significant findings were noticed. deep tendon Reflex Abnormal deep tendon reflex may be seen in lesions of muscles, sensory neurons, lower/upper motor neurons, neuromuscular junction and mechanical factors such as joint disease. On examination, the patient’s Achilles reflexes were normal (+2) on both sides. An abnormal Achilles reflex suggests a tibial nerve lesion (S1-2). Neurodynamic assessment Straight leg raise The test is designed to look for any impingement of the dura and spinal cord or nerve roots of the lower lumbar spine, especially in sciatic nerve (L4, L5, S1). The patient’s result was negative (70 °), suggesting less possible lumbar disc herniation. Bonnet’s test Bonnet’s test is a variant of straight leg raise and used to test for entrapment of sciatic nerve by piriformis muscle. The patient’s result was positive, indicating possible piriformis syndrome. Bowstring test Bowstring test is another variant of straight leg raise and used to test for entrapment of sciatic nerve by hamstrings. The patient’s result was negative, suggesting less possible hamstring syndrome. Orthopaedic examinations Valsalva maneuver Valsalva maneuver was done to look for any disc herniation causing radiculopathy. This would increase intrathecal pressure which may reproduce the patient’s symptoms. The patient’s result was negative, indicating less possible lumbar disc herniation. Lumbar compression-distraction test This test is also designed to look for disc herniation. When the compressive force is applied, it increases the intrathecal pressure and replicates symptoms if the patient has disc herniation. And the symptoms are relieved by distraction. The patient’s result was negative, suggesting it was less likely to be disc herniation. Gaenslen’s test Gaenslen’s test is to assess sacroiliac joint involvement. The patient’s result is negative. Yeoman’s test Yeoman’s test is designed to assess the integrity of the sacroiliac joint. The patient’s result is negative. Squat test Squat test is designed for quick screening of lower limb pathologies including joint disease, motor and sensory neuron lesions. The patient’s result was positive. Supported belt test Supported belt test helps to determine whether the pain is of lumbar origin or pelvic origin. The patient was noticed for having pain only without supported belt, suggesting his symptoms were caused by pelvic dysfunction. List of possible diagnoses from the neurological exam Piriformis syndrome Sacroiliac syndrome Further blood and radiological tests At this stage, no further imaging or other tests are needed, for the diagnosis can be made based on the patient’s history and results of neurological and orthopaedic examinations. It is recommended that the patient should be treated for piriformis syndrome at the start. A conservative treatment plan should be designed to reduce pain intensity, stretch hypertonic muscles and increase lumbar and sacroiliac joint mobility. However, if the patient does not respond to the treatment or the symptoms are worsened after the treatment, further investigations should be done. Considering a large extent of soft tissue and nerve involvement, magnetic resonance imaging (MRI) would be the most effective imaging method. A lumbopelvic view should be taken. This does not only demonstrate possible hypertrophied piriformis muscle and sciatic nerve entrapment, but also helps to rule out other differential diagnoses such as lumbar disc herniation. Nevertheless, many studies failed to show consistence of radiographic abnormalities in piriformis syndrome. Therefore, no significant findings on MRI do not necessarily exclude piriformis syndrome. CT and ultrasound are also used to look for abnormality of piriformis muscle, but they are not as sensitive as MRI. EMG is an investigation to assess abnormal spontaneous activity of muscles which are innervated by sciatic nerve, thus differentiating sciatica and lumbosacral radiculopathy; however, EMG findings are often normal in piriformis syndrome. Local injection of anaesthetics or steroid can be applied for both diagnostic and therapeutic purposes (4). This technique is widely used after initial evaluation. However, the specificity and efficacy is not well determined by clinical trials (4). A certain portion of patients with piriformis syndrome do not respond to piriformis muscle injection (5). Final diagnosis Based on the patient’s history, the results of neurologic and orthopaedic examinations, and likely radiographic findings, piriformis syndrome is the most likely diagnosis. Chiropractic management Conservative treatment is recommended at this stage, for 79% of patients with piriformis syndrome showed a significant improvement with use of non-steroid anti-inflammatory drugs (NSAIDs), muscle relaxants, thermo-therapy and rest (fishman, osteopathic approach). The aim of the chiropractic treatment is to reduce the intensity of pain, relax piriformis muscle, increase the range of motion of the hip joint, and increase mobility of lumbar and sacroiliac joint. The tone and length of the left piriformis muscle and other affected muscles (hamstrings, other lateral rotators, gluteus muscles) should be assessed with chiropractic muscle test and static palpation. Any trigger point, tenderness, hypertonia are noted. Stretching exercise and muscle release are introduced first to help the patient relax the hypertonic piriformis muscle. The patient needs to receive the muscle release training daily for 2 weeks until the muscle tone is assessed again and any improvement of his symptoms is seen. Stretching of other affected hypertonic muscles is also required. The mobility of the patient’s lumbar spine and sacroiliac joint should be assessed with orthopaedic examinations and chiropractic motion palpation. Any restricted segment is adjusted with high-velocity low-amplitude (HVLA) spinal manipulation. Chiropractic adjustments help to relieve pain, increase joint mobility and re-establish biomechanical stability of the body. References 1.Saikku K. Entrapment of the proximal sciatic nerve by the hamstring tendons. Acta orthopaedica belgica. 2010 06;76(3):321-4. 2.Puranen J. The hamstring syndrome. A new diagnosis of gluteal sciatic pain. The American journal of sports medicine. 1988;16(5):517-21. 3.Boyajian-ONeill LA. Diagnosis and management of piriformis syndrome: an osteopathic approach. The Journal of the American Osteopathic Association. 2008 11;108(11):657-64. 4.Jankovic D. Brief review: Piriformis syndrome: etiology, diagnosis, and management Article de synthà ¨se court: Le syndrome du muscle piriforme – à ©tiologie, diagnostic et prise en charge. Canadian journal of anesthesia. 2013 10;60(10):1003-12. 5.Martin HD, Martin H. Diagnostic accuracy of clinical tests for sciatic nerve entrapment in the gluteal region. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2014 04;22(4):882-8.

Real Estate Agent Essay -- miscellaneous

Real Estate Agent Buying or selling a house or an apartment is one of the biggest decisions of a person’s life. And when selling or establishing a price for real estate, people seek out real estate agents to do the dirty work. A real estate agent has to convince a prospective homeowner that he or she is trustworthy and knowledgeable. In many ways, the agent acts as a counselor to individuals and families about to embark on a huge commitment. Real estate agents have a thorough knowledge or real estate market in their community. They know which neighborhoods will best fit their client’s needs and budgets. Real estate agents are generally independent sales employees who provide their services to licensed brokers on a contract basis. In return, the broker pays the agent a portion of the commission earned from property sold through the firm, by the agents. They are familiar with local zoning and tax laws, and know where to obtain financing. A good real estate agent is informed about things like schools, tax rates, public transportation systems, and should be aware of going mortgage rates. To be eligible to become a real estate agent, he or she must first be a high school graduate, be at least 18 years of age, and pass a written test. In every state real estate agents must obtain a state license to sell and rent properties. Over 1,000 universities, colleges, and junior colleges offer courses in real estate. Many local real estate associations sponsor courses covering...

Outsider Essay

The Stranger by Albert Camus is one of his best works. This novel tells the story of a man, Meursault, who is a moralist. Nothing seems to matter to him and his or anybody else’s actions makes no difference. Camus’s use of language allows readers to discover the mood and meaning being conveyed through diction and word choice. His use of fgurative language can be seen throughout. Such an example of figurative language is imagery. From reading The Stranger, one can clearly picture whats happening as Camus beautifully describes every action f Meursault. In the first chapter, Meursault hears that his mother has died and says â€Å"Maman died today. Or yesterday maybe, I don’t know. â€Å". Him saying this shows his emotional indifference and establishes his character traits. It doesn’t show that he didn’t really care about his mother, but that he really doesn’t give great thought to much of anything. The death of his mother shows Just how emotionless Meursault is for the fact of not grieving over his mothers death. But while at the funeral, Camus oes in great depth to explain the heat of the day and all of Meursault’s surroundings. Continuing with Camus’s use of imagery, at Maman’s funeral Meursault states â€Å"She was right. There was no way out. † as he talks to the nurse who had said â€Å"If you go slowly, you risk getting sunstroke. But if you go too fast, you work up a sweat and then catch a chill inside the church. â€Å". Meursault says this only to his understanding that a person is born into a life that will only result in the death of that person. Death, like the harsh effects of the sun, is unavoidable. This idea is central to Camus’s philosophy in The Stranger, which posits death as the one central, inescapable fact of life. In prison, where Meursault has much time to reflect on his past, does he discover all the over-looked, finer aspects of his former free life. The author conveys this sense of discovery through the detailed flashbacks in the second part of the novel during his arrest. For example, Just moments before Meursault’s execution, he vividly recalls is mother’s funeral. Whereas he was empty of feeling at the funeral, now he too faces eminent death and thus savors the moments as to when he was the mourner. Through Camus’s use of diction and language, he has expressed the mood and meaning to this story of a man who has been wrongly accused. And by doing so the author has grasped his readers and has given them a different perspective on life and how things are fine one moment and can go terribly wrong the next moment. Outsider By lalalalalalal

Raising The Minimum Wage - 870 Words

The topic of raising the minimum wage has many different viewpoints. It is thought to be affected negatively and positively. Some believe it increases unemployment and poverty. Others believe it creates jobs, helps the economy and low-income families by giving them more money to give back to the economy. Doug Hall, director of the Economic Analysis and Research Network and David Cooper, Economic Analyst at the Economic Policy Institute, expressed how the increase in minimum wage affects certain genders, families, education backgrounds, ages, and the economy (Hall Cooper, 2014). It is said that the increase mainly affects women with a compromising percentage of 54.5 (Hall Cooper, 2014). It affects at least 20 year olds and mostly white workers. The increase in minimum wage also affects workers with a college degree or higher more than those with a high school diploma. It also affects low to moderate-income families and those who work full time. Hall and Cooper believe that the rise in minimum wage will not cause job losses, but create jobs. They also believe that the workers will spend their extra earnings and those who make close to but higher than the minimum wage will, â€Å"receive boost in earnings due to â€Å"spillover† effect, giving them more to spend on necessitie s† (Hall Cooper, 2014). They believe this will help with economic growth. Holly Skylar, Director of Let Justice Roll Living Wage Campaign, which is an organization that seeks to raise minimum wage, believesShow MoreRelatedRaising The Minimum Wage? Essay1217 Words   |  5 PagesThe minimum wage is one of the most discussed issues around the country. Everyone has a different opinion if raising the minimum wage would help families across the country to have a better lifestyle or if would cause an unbalance in the economy. Democrats and Republicans have a different view on this issue, while Democrats supports raising the minimum wage by $15 an hour, Republicans have stated that they refuse increasing the wage because it would leave different factions of Americans outside ofRead MoreRaising Minimum Wage912 Words   |  4 PagesMinimum wage has long been a topic that has brought on many heated debates. It has been said over and over again that minimum wage should be raised. These people say that raising minimum wage only does good for people. However, I, alon g with many other people, believe this is wrong, and we should instead be making moves to keep minimum wage where it is. Raising minimum wage may provide some positive effects, but those positives only go on to be overwhelmed by the negative effects caused by it. WagesRead MoreRaising The Minimum Wage?1575 Words   |  7 PagesThe issue of raising the minimum wage from $7.25 to $15 an hour is a heavily debated topic. Both sources against or in favor of the minimum wage refer to a â€Å"growing gap† between low-income workers and high-income earners. Sources against the minimum wage believe raising it will increase this gap, whereas those in favor of the minimum wage believe it will decrease this gap. The arguments in favor of the minimum wage rely mostly on ethical beliefs, such as â€Å"pay should reflect hard work,† to advanceRead MoreRaising The Minimum Wage888 Words   |  4 Pages Raising the Minimum Wage The employment effect of the minimum wage is one of the most studied topics in all economics. Today, the debate over raising the minimum wage has been a hot topic after President Obama explained in his 2014 State of the Union address that he intends to raise the minimum wage from $7.25 to $10.10 per hour, an increase of over 40 percent. While the President and his supporters claim that this increase would greatly benefit the economy and result in growing the businessesRead MoreRaising The Minimum Wage?1122 Words   |  5 Pagesâ€Å"Raise the wage!† reads many protestors’ signs across America. Many people believe this to be the answer to the financial inequality that plagues our country. The federal minimum wage was established to keep workers from settling on a poor living standard (Leonard A.11). Since this was passed, multiple debates and issues have risen. One begins to ask the question, is this truly the best way to resolve the unequal distribution of wealth? Aft er research, it has been found that there are many drawbacksRead MoreRaising The Minimum Wage1979 Words   |  8 PagesResearch Raising the minimum wage can result in job losses due to lower profits for businesses. It can also potentially decrease employee hours by changing them from full time to part time. Additionally, it may reduce the full time benefits that they receive. If this were to happen, then the employees affected will actually be earning less than they did before the increase. For example, from the Article Maximum Divide on Minimum Wage (Mejeur, 2014), they state, â€Å"Labor costs are the largest shareRead MoreRaising The Minimum Wage1037 Words   |  5 PagesRaising the minimum wage from $7.25 to $10.10 is not a good idea. The unintended consequences that would come about as a result is reason enough to shy away from such a proposal. Those who support an increase contend that it will alleviate poverty. Suppose these advocates are right and a spike in the minimum wage does reduce poverty for some fortunate workers. This positive development will be offset because an increase in the minimum wa ge will further price out inexperienced workers from the jobRead MoreRaising The Minimum Wage?2447 Words   |  10 PagesThe minimum wage is defined as the lowest compensation, by law, which an employer may pay his or her employees. In the United States, this monetary value is set by a collection of laws on the federal, state, and local levels. While state and local governments may choose to observe a higher minimum wage than the national minimum wage, the federal government ultimately controls the income of the nation’s lowest-earning employees. At the federal level, the minimum wage was last raised in 2009, fromRead MoreRaising The Minimum Wage1864 Words   |  8 Pagespersevere, and really believe in yourself, good things will come. Drastically raising the minimum wage goes against all of those principles, rewarding lethargic actions and poor life choices. Raising the minimum wage to $15 will do more harm than good for middle class americans by decreasing the value of th e money in their pockets, driving out big companies, and generally increasing unemployment. Increasing the minimum wage causes middle class Americans have less money in their pockets to spend. RepresentativesRead MoreEffect Of Raising Minimum Wage1215 Words   |  5 PagesEffects of Raising Minimum Wage The minimum wage in this country has been a controversial issue. Many people believe it will help reduce poverty and boost the economy. However, they are not looking at the downfalls this will bring to our country. This could make the unemployment population rise, it will raise prices of other things, and would have little effect on reducing poverty. Raising the minimum wage would have a negative influence on our country. This movement throughout our country