Crohn's Disease Case Study


Author's

Patrick Allen, Ethan Brown, Jared Johnson, Kasie Lessley from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Patient Characteristics

● Demographic information
- Age: 27 
- Sex: male
- Race: Caucasian
- Occupation: DPT student
● Medical Diagnosis: Spondylolisthesis secondary to chronic Crohn’s disease (CD)
● Previous care or treatment: Pt was diagnosed with Crohn’s disease as a teenager. Pt experiences periods of abdominal cramps and pain along with bouts of diarrhea and loss of appetite. Pt also reports occasional severe muscle cramping and twitching after prolonged exercise. Pt has no other significant medical history. Pt is adherent to medical management of Crohn’s disease through primary care physician.[1][2]

Examination

  • Subjective: Patient was referred to our clinic with instructions to assess and treat functional impairments secondary to spondylolisthesis. Pt presents to physical therapy with chief complaints of insidious onset low back pain which worsens with prolonged sitting or standing. Pain has been increasing over the past couple months with occasional radiation to the buttocks and thigh. Pt also complains of weakness and fatigue in both legs that presents when his back is painful. He reports difficulty sleeping uninterrupted due to lower back pain most nights, and is unable to sleep on his stomach. Pt is an avid recreational kayaker. Pt’s primary goal is return to kayaking without pain. Additionally, pt wants to improve strength in both legs and return to his normal exercise program without limitations from pain or lack of stability in his spine. Pt inquired about the possible effects of his Crohn’s Disease in correlation with his spinal fracture and impairments. Pt denies changes in bowel or bladder function since LBP onset.
  • Self Report Outcome Measures:

 - Visual Analog Scale (VAS)
            ▪ Worst: 7
            ▪ Best: 2
            ▪ Current: 4

- Oswestry Disability Index (ODI): 25% - moderate disability

- Fear Avoidance Beliefs Questionnaire Physical Activity (FABQpa): 12

  •  Objective
    - Posture: In standing patient displays increased thoracic kyphosis, forward head, protracted shoulders, increased lumbar lordosis as well as anterior pelvic tilt. 
    - Lumbar AROM:
    ▪ FB: 75% no pain, but has to use hands to assist return to neutral with significant juddering of paraspinals
    ▪ BB: 50% with sharp pain
    ▪ RSB: 50% with pain
    ▪ LSB: 50% with pain
    ▪ Rrot: 50% with pain
    ▪ Lrot: 50% with pain
  •  Neuro Screen
    ▪ Sensation: decreased light touch sensation at lateral calf bilaterally
    ▪ Reflexes:
    ● L4: 2R, 2L
    ● L5: 1R, 1L
    ● S1: 2R, 2L
    ▪ Motor:
    ● Hip Flexion: 5/5 bil
    ● Hip Abd: 4/5 bil
    ● Hip Add: 5/5 bil
    ● Knee Ext: 5/5 bil
    ● Knee Flex: 5/5 bil
    ● Ankle DF: 4/5 bil
    ● Ankle PF: 5/5 bil
    ● Gr Toe Ext: 4/5
  • PIVM
    ▪ Hypomobility of mid thoracic-spine
    ▪ Hypomobility at L1/2, and L2/3
    ▪ Hypermobility at L4/5 (5/6)
  • Hip ROM
    ▪ +Thomas Test bileral
    ▪ Hip Extension: PROM 5 degrees Right, 10 degrees Left
    ▪ Hip ER PROM: 20 deg bilaterally  
  • Palpation
    ▪ Tenderness over L4/L5 vertebra with hyper-tonicity of paraspinals
    ▪ Step deformity noted at L5
    ▪ Pain in abdominal right lower quadrant with palpation
  •  Special test:
    ▪ Active Straight Leg Raise (ASLR): R: 2, L: 1[3]
    ▪ Prone Instability Test (PIT): positive
    ▪ Quadrant Test: positive bilaterally with extension
    ▪ Aberrant Movement Pattern During Active Trunk Flexion: Positive; with juddering and use of hands to return from 75% forward bending. 
  • ICF Findings
    - Body Structures/ Function (Impairments)
    ▪ Decreased strength primarily in LE
    ▪ Decreased ROM in trunk
    ▪ Decreased postural control
    - Activity limitations
    ▪ Recreational Kayaking
    ▪ Unable to perform all ADL’s unrestricted/ pain free (shoe tying)
    ▪ Unable to engage in normal exercise routine without restrictions
    - Participation restrictions
    ▪ Has been unable to be recreationally involved with friends and social networks due to his activity limitations.
    ▪ Pt has pain when sitting at school for long periods of time
    ▪ Difficulty transferring patients due to back pain
    - Environmental Factors
    ▪ Pt has little family support at home currently (his apartment) as he has moved away from his hometown for school.

Clinical Impression

  • Patient demonstrates classic signs of instability in the lumbar region. Treatment will be directed toward improving pts core stabilization and motor control of deep spinal stabilizers. Improvement of posture and education on lifestyle modification including the reintegration of functional activities.

Intervention

Week 1:
Motor Learning Phase: Pt was seen for 3 visits per week to ensure proper activation of deep spinal stabilizers and increase their endurance.

  • Spinal Stabilization Program: Train transversus abdominis and multifidus contraction in supported positions. *Goal: Progress contraction to 10 x 10 seconds while maintaining diaphragmatic breathing.
-Prone and supine w/biofeedback (inflate to 70 degrees, correct contraction = decrease of 10mm Hg)
-Sidelying multifidus contraction with PT providing manual rotary resistance at L4/L5 level -Transversus abdominis contraction in sitting with diaphragmatic breathing
I Ab brace supine HEP2go.JPG
  • Joint Mobilization: Grade 3 and 4 thoracic facet joint traction in supine *Stretching: Hip flexors, hip external rotation stretch, pectoralis major stretch
  • Patient education:
-Home Exercise Program: perform transversus abdominis (TrA) contraction 3 times a day for 10 repetitions of 10 seconds in supine.
-Postural Education: Therapist emphasized importance of avoiding sustained positions and importance of proper posture to minimize stresses on spine. PT instructed patient on maintaining proper thoracic posture (minimal kyphosis, decrease forward shoulders and forward head posture) in sitting. Patient was also instructed in proper standing posture (decrease excessive lumbar lordosis, maintain erect posture in thoracic and cervical spine).
-Counseled patient on avoiding activities promoting end range lumbar extension, rotation. Therapist and patient planned on PT for 12 weeks for return to advanced activities - sports, and lifting activities.
-Patient instructed to hold off on kayaking, weight training, running until adequate lumbopelvic control is established. Therapist encouraged use of a bicycle for moderate aerobic exercise and walking in the meantime.
-Therapist contacted pt’s MD to establish a collaborative relationship should the patient have any changes in bowel function or unexplained changes in back pain throughout treatment. Also establish safety for treatment based on pt’s most recent blood work and medical status.

Week 2 and 3:

Motor Learning Phase II: Scaled back to 2 visits per week once pt was able to consistently perform an independent contraction of TrA. Continued to address postural deficits. By end of phase patient saw significant reduction in pain with static postures of 60 minutes or less.

  • Spinal Stabilization Program: Maintained TrA contraction in supported positions while in neutral spine. Added perturbations through extremity movement to load the trunk muscle complex in a static capacity. Low load tasks were chosen to prevent substitution by trunk prime movers. Unilateral exercises were used to add a transverse plane stabilization demand to the exercise program. Pt progressed through exercises in each supported position as tolerated.
-Prone - hip extension, shoulder elevation, contralateral hip ext and shoulder elevation
-Supine hook lying- bridge, hip external rotation + abduction, hip flexion march
-Side lying - clam shell, hip abduction
2 brace with abd and er Hep2go.JPG2 bridge.JPG
2 clam hep2go.JPG2 hip abduction hep2go.JPG
  • Joint Mobilization: Grade 4 thoracic facet joint traction and supine thoracic rotation mobilization
-Thrust mobilization was avoided due to the high prevalence of osteoporosis in patients with Crohn’s disease.
  • Stretching: Hip flexors, hip external rotation stretch, hamstring stretch, quadruped lumbar flexion “prayer” stretch, pectoralis major stretch performed while maintaining neutral spine. Manual stretching performed for the hip flexors using a Kaltenborn ventral glide technique.
  • Patient education:
-Home Exercise Program: Perform new TrA activation exercises in fifteen minute sessions twice a day, perform dorsiflexion with Theraband (Tband) once a day. Perform TrA contraction throughout day during sitting and standing while maintaining neutral spine. Above stretches added to home program to be done intermittently throughout day. Continue with aerobic exercise program.

Week 4 - 7: Unsupported Trunk Stabilization Phase: 2 visits per week. Continued to train the trunk musculature with the spine in a neutral but unsupported position. Patient was challenged by progressing to more demanding positions, and adding in functional movements in neutral spine. Exercises that strengthen the scapular stabilizers to assist with postural changes were also added. The patient had a Crohn’s flare up requiring cancelling PT due to GI pain in week 5. Pt saw his MD and was prescribed a dose of ciprofloxacin, and was able to resume PT at full intensity in week 6. Week 6 re-evaluation revealed all lower extremity MMT reached 5/5. Patient no longer required verbal cueing for posture in week 6, but reported fatigue in upper back muscles when maintaining proper posture for the entire day.

  • Spinal Stabilization: Patient taught to maintain a neutral spine and abdominal brace technique during exercise as practiced at the beginning of the program.
-Supine: Single leg bridging, straight leg raise with contralateral leg in 90/90 position
-Quadruped: Single arm and leg raises, contralateral arm and leg raise, walk out to plank, hip abduction + external rotation
-Tall and Half Kneeling: lifts and chops in all planes, Tband bilateral and unilateral shoulder abduction, extension
-Standing: monster walks multiple planes
-Long sitting: bilateral and unilateral scap stability exercises with Tband
-Chosen because this is the position of the patient’s sport
-Manual perturbations provided in quadruped, tall kneeling, long sitting positions
3 hiphinge.JPG3 kneel antirotationpress.JPG
3 kneeling chop.JPG3 lateral lunge.JPG
3 monster walk.JPG3 quad arm and leg extension hep2go.JPG
3 quad hip abd hep2go.JPG3 single leg bridge hep2go.JPG
  • Functional Movement:
-Hip Hinge in neutral spine
-Squat without loss of neutral spine, maintaining half squat position and taking steps forward, backward, and side to side
-Lunge while maintaining neutral - sagittal, frontal, transverse planes.
  • Joint Mobilization: None necessary, as pt demonstrated improved lumbar and thoracic PIVM as well as decreased muscle guarding. *Pt education:
  • Patient Education:
-Home Exercise Program: Stretch throughout day as before. Continue moderate aerobic exercise program, increasing the intensity during weeks 6 and 7 to include bicycle sprints at 1 minute sprint time to 3 minutes recovery time. Discontinue low level TrA exercises. Add functional movement practice and current trunk stabilization exercises to home program and perform daily for one 30 minute session.

Week 8 - 11: Unsupported Trunk Stabilization Phase II: Patient seen for 2 visits per week. Exercises involved controlled movement of lumbar spine. Amplitude of movements slowly increased as patient demonstrated proficiency. Increased loading of functional movements in neutral. Program also focused on building endurance of trunk stabilizers while maintaining proper breathing patterns.

  • Spinal Stabilization: Allow controlled spinal movement in a pain free range in multiple positions.
-Active Flexion: Crunches, crunches w/rotation at controlled pace
-Active Extension: Supine plank for back extension while avoiding end range
-Lateral Flexion: side plank for time, push up to straight arm side plank
-Quadruped: Plank on elbows, plank with arm or leg lift
-Half Kneeling, Long sitting: diagonal chop with spinal rotation in half kneeling, ball toss/catch in long sitting, unilateral Row in long sitting, unilateral scap stability exercises, battle ropes in tall kneeling
4 crunch.JPG4 extensionplank.JPG
4 GobletSquat.JPG4 lunge with reach.JPG
4 plank.JPG4 pullthrough menshealth.JPG
4 sideplank.JPG4 splitstance cablerow.JPG
4 T-Pushup.JPG
  • Functional Movement:
-Hip Hinge in neutral spine with cable column loading
-Squat without loss of neutral spine with kettlebell held anteriorly in varied stances
-Lunges -multiple planes while maintaining lumbopelvic stability, adding arm drivers, then adding a dumbbell to the reaching arm
-Began transfer training week 10
  • Patient education:
-Home Exercise Program: Continue stretching throughout day. Begin adding back weight training 3-4 days a week in week 8. Perform spinal stabilization exercises for 30 minutes daily. Combine stationary bicycle exercise in 2 minute sprint efforts with a circuit of 3-4 trunk exercises in neutral spine to challenge patient’s ability to simultaneously brace his abdominals and perform diaphragmatic breathing. Allow return to kayaking for short duration at easy pace.
-Counseled pt on gradually increasing loading with resistance training and resumption of sport due to potential for osteoporosis and arthralgia associated with Crohn’s Disease.

Week 12-14: Return To Activity: 1 visit every 2 weeks: Patient continued returned to sport and full exercise program. Added ballistic movements in standing, both in the form of weighted ball toss and catch activities and hops, bounds, and jumps. Pt discharged from therapy with negative active straight leg raise test, ODI of 6%, and max pain of 3/10 with heavy lifting and sustained postures for over 3 hours. Patient able to perform full pain free AROM in all directions without aberrant movements except extension, which was painful but full range.[4]

Outcomes

Pt discharged from therapy with negative active straight leg raise test, ODI of 6%, and max pain of 3/10 with maximal lifting and sustained postures for over 3 hours. Patient able to perform full pain free AROM in all directions without aberrant movements except extension, which was painful but full range. 

Discussion

It is not uncommon for patients with CD to complain of low back pain. The source of the pain back be referred pain from the involvement of the ileum, spondylolisthesis (as with our patient), or other musculoskeletal issues that arise secondary to CD. Additionally, CD may be associated with osteoporotic joint problems. It is important for a physical therapist to be aware of the comorbidities associated with CD as certain treatments may be contraindicated, such high velocity thrusts and other joint manipulations. Additionally, it is important to note that CD patients may suffer from dehydration, so it is critical to note any signs of dehydration.[5]

Related Pages

Crohn's Disease

Spondyloisthesis

References


  1. Nelson, B. et al. Case 39-2014: A 9-Year-Old Girl with Crohn's Disease and Pulmonary Nodules. N Engl J Med. 2014; 371(25) 2418-2427. doi:10.1056/NEJMcpc1410938
  2. Lichenstein, G. Hanauer, S. Sandborn, W. Management of Crohn's Disease in Adults. Am J Gastroenterol. 2009; 104: 465-483. doi:10.1038/ajg.208.168
  3. Ferrari, S. Vanti, C. O'Reilly, C. Clinical presentation and physiotherapy treatment of 4 patients with low back pain and ischemic spondylolisthesis. J Chiropr Med. 2012; 11(2): 94-103. doi:10.1016/j.jcm2011.11.001
  4. Olson K. Manual Therapy of the Spine (2nd edition). St. Louis, MO. Saunders; 2009.
  5. Goodman CC, Snyder TEK. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th ed. St. Louis, MO: Saunders-Elsevier; 2007