Clinical Consult

Healthy and active 45 year old male, attorney, recreational volleyball player injured back while lifting with a bent and twisted trunk posture.  Past history of LBP is present with his last exacerbation 3 years ago (resolved in 6 weeks).  Current (R) buttock pain, intermittent aching in the upper leg, and numbness/tingling in the lower leg anteriorly and at times into the foot.

Currently:  diminished pain since starting medicines from 9/10 to 6-7/10; sleep is achieved best in a recliner, unable to lie in bed even with knees elevated for longer than 1 hour.  A forward bending position leaning against the wall with hand support also help reduce LE pain.

Diagnostic Tests:  MRI findings:  (R) L4/5 and (R) L5/S1 disc herniation.  L 4/5 foraminal stenosis; the actual picture showed dramatic narrowing on the (R) at L45 versus the (L).

Medicines:  currently winding up a metrol dose pack, takes muscle relaxers prn, pain killer hydrocodone up to 2 tabs per day and neurontin.  The Othop spine specialist may perform a steroid injection in 2 weeks dependent on progress.

Initial exam:
L trunk shift, (+) SLR on Right @ 30 degrees, cross SLR is positive for increasing (R)  buttock pain/ache.

Posture:  shift as stated, kyphotic flexed posture, decreased weight bearing (R) leg.

Negative palpatory tenderness about the LS spine and sciatic notch; positive recreation of pain with L4 PA spring.

AROM:  Flexion to 40 degrees then increase of LE symptoms, extension is to minus 5-10 degrees from neutral stand posture, side flexion to the right beginning at 20 degrees increases (R) LE symptoms.

LE strength:  WNL except (R) anterior tib(4/5); weight bearing plantar flexion is WNL for strength however pain increases with weight bearing on the leg.

DTR:  S1 equal bilaterally, diminished (R) L4.

Sensation:  diminished to light touch proximal anterior shin (R).

Unable to lie prone; with several pillows under his stomach he can tolerate this but there is no centralization of symptoms (he is not shifted in this posture).

Current Treatment:  counseled in several postures for sleep and sit, using trans. abdominals to assist in position changes, pt is not working currently, active ankle df/pf, scapular retractions and cervical AROM, light trunk rotations in supine (knee rocks) other attempts to correct the shift and
the kyphotic posture in the standing position have increased his pain.

Ideas, EBP, questions, thoughts are greatly appreciated.

David Parker, MS, PT, OCS

Comments

[Charles Sheets PT OCS Dip MDT]

David -

Which pain is increased with a shift correction - proximal or distal? It is likely that this is going to need to be corrected in weightbearing. Inability to tolerate prone, much less extension, is not a very good sign for this person. (Kopp 1986) Crossed straight leg raise isn't good either. (Deyo 1992)
Best bet is probably to try correcting the shift (add trunk flexion/upper extremity support as needed), as long as pain is centralizing; if it doesn't, work with the patient to find a comfortable position (some variation of sidelying/rotation?) for a few days, then see if those days of taking stress off of the tissue will allow a further mechanical assessment.

Charlie

[britt smith]

Agreed with the above: cross SLR has high Sp for HNP. He most likely would benefit from an epidural or two at this point. Neurotin seems inappropriate (Acute pain vs. chronic pain). Note: Neurotin (gabapentin) has not been approved by the FDA for pain control (only post-herpetic infection pain)...it's an anticonvulsant which hasn't been scrutinized for this application (i.e. effectiveness RCTs). See the Aug. 16th issue of Annals of Internal Medicine for a fantastic examination of industry internal documents related to the 'off label' use of the drug.(Steinman MA, Bero LA, Chren MM, Landefeld CS. Narrative review: the promotion of gabapentin: an analysis of internal industry documents.Ann Intern Med. 2006 Aug 15;145(4):284-93.)

Encourage activity and work with the posture/shift correction etc. Traction.

Give the patient this article: Weinstein JN. A 45-year-old man with low back pain and a numb left foot.JAMA. 1998 Aug 26;280(8):730-6.
Great read...disturbing and reassuring. The article is free on the JAMA website (jama.ama-assn.org)
Good luck.
Britt

[Erica Meloe]

Hi David-
Sounds like a guy I just started to treat recently. I would continue with the positioning effects and see what position eases his sx's. Tough to treat if the person sleeps 1 hr a nite. I know I may get slammed for this-but have you tried some sort of lumbo-sacral support short term? (just to see if it eases him up a bit)
Erica

[Dan Pinto]

Regarding positioning, have you tried placing the patient in prone with multiple pillows under this abdomen/pelvis? What about quadruped with pelvic tilts? He may be able to relax more in these position versus the supine with hip/knees flexed position. In the McKenzie progression the maneuvers used to centralize end with a manipulation - seemingly in a "if all else fails" type of situation. I would check to see if the patient is appropriate for a manipulation. It may open a "window for movement" as Flynn and Britt like to say. What you have going against you is the peripheral symptoms. Regarding impairments, I have noticed local extension/closing restrictions in the segments of the lower lumbar spine in patients who present as your patient is presenting.

[Britt]

If you go the way manipulation, then I would start 'away' from the LS...perhaps the lumbothoracic junction. Robert Maigne advocates manipulating patients with leg pain with the painful side down.

How long has the patient suffered from this episode?

Was the MRI early?
Jarvik et al, 2003 showed that rapid MRI vs. radiographs had the same outcomes...but more surgeries (3x more) in the rapid MRI group.
Jarvik JG, Hollingworth W, Martin B, Emerson SS, Gray DT, Overman S, Robinson D, Staiger T, Wessbecher F, Sullivan SD, Kreuter W, Deyo RA.Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA. 2003 Jun 4;289(21):2810-8.)

...just interested in a little more history.
Britt

[Sean Hayes]

I noticed one poster mentioned the McKenzie progression, but didn't start at the beginning. I would have him begin with sideglides in standing to the right (SGISR)repeatedly. I would avoid all the comfort positions you mentioned because they are not going to reduce his bulge size, quite the opposite. If it isn't too late or irreduceable, you should notice an increase in back pain and centralization of leg pain with possible residual foot and lower leg symptoms due to prolonged n. root compression. It may take up to 200 SGISR to get 5-10 minutes of relief.
If he follows this protocol and it gives him temp. relief, send him home with 10+ SGISR every hour and as needed; sleep/lie on L side and avoid all flexion and sidebending L (toward the shift).
Expect 1.5 to 2 months of treatment progression. Once the symptoms get centralized to his back on a regular basis, you may notice that the SGIS do not fully reduce his symptoms. If so you may need to switch to pressups, or pressups while sidebent to the R.
Hope this helps.

[james smith]

if side glides do not help, remember mckenzie still would have you try flexion rotation (most likely knees moving to pts right)- this does fit a bit with the reports of the pt finding partial flexion somewhat relieving.. if that does not centralize i would then be tempted to try unloading in water or with apparatus to bridge between lying and standing positions. be aware that sometimes this has a "rebound" effect of worsening upon full wt bearing afterward, but if nothing else is helping i think it is worth a try.

[Peter Schrey]

Have you tried standing traction with a pull down bar or with a towel over the door for home use? You can vary the flexion or extension based on where his feet are.

[Robin Saunders Ryan]

There is no published evidence for this approach, but it has worked well in some cases: Use prone lumbar traction, at least 50% of the bodyweight, in a position of comfort (i.e., with pillows under belly and accommodating the lateral shift initially). During the treatment, monitor peripheral sx vs. centralization. If sx centralize, change patient's position during traction to more neutral, or even extension if possible. After traction, follow McKenzie's principles for centralization. This progression may need to take place over a few treatments (i.e., often can't go with 50% of bodyweight and correct the flexion/shift all in one treatment, you need to use caution to avoid irritability). This is a very brief overview, I can elaborate or send more info if you'd like.

I know that traction is currently out of favor in the literature, but there is a current study underway that hopes to clarify the role of traction in LBP/radiculopathy situations where positions alone are not helpful to centralize the symptoms. Initial results seem to show that traction can make a difference to help McKenzie "non-responders".

Disclaimer: My company, The Saunders Group, manufactures traction devices, including a table that is designed specifically to accommodate flexed/shifted positions initially, to treat these difficult patients.

I can elaborate more if anyone wants... I'm aware that my input may be met with some skepticism because of the potential conflict of interest:)

Robin Saunders Ryan, MS PT
The Saunders Group, Inc.

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