Advice on disc protrusion

[MrPhysio+]

Hi all,
Very interesting reading, and good histories. The problem with scanning over the years is that as scan resolutions become better, more 'problems' are discovered. Recent evidence indicates that between 67% & 75% of people aged between 30 - 80 years of age will have degenerative changes evident on scanning. These changes include disc bulges and spinal cord / nerve root compressions. What is even more interesting is that mild to moderate degenerative changes can be completely symptom free, also including spinal stenosis, nerve compressions.
Therefore a person may have had a disc disruption / compression for years without knowing, hurt their back in another way, have a scan, and find out information that is completely useless to the current new problem. This explains why many treatments, including surgery. Therapists are trying to fix something that is not broken.

Forgive the simplicity of this next suggestion, but I believe that the majority of your symptoms can be explained by a tethering of your piriformis muscle to your sciatic nerve. Stretches can sometimes improve this condition, but can also worsen the irritation. Your sciatica is explained by tethering, as are the exercise induced symptoms, as well as the problem caused by sitting.Lumbar muscle spasms are due to the erector spinae muscles spasming or tightening to act as a splint, which then decreases your mobility further, and increases compression forces.

I believe that you need a very deep piriformis friction massage, then gluteal / sciatic exercises over two days. If the treatment is not firm enough, it will fail. Your previous history of severe pain in the gluteals should not preclude this deep type of treatment, but it will hurt!
I carry out such treatments all the time, and they are safe, and usually unmask the nature of symptoms, and often provide information as to whether tethering or the disc is the major contributing factor to the pain.
As other writers have suggested, you are now in the chronic pain category, therefore compensatory changes will have occurred with the failed treatments and time eg further tethering, muscle imbalances.

As you cannot readily access your physio, you could try the following:
1. To find the correct area, place your little finger on the top portion of the gluteal cleft, and your thumb of the same hand onto your greater trochanter
(bump on your upper thigh bone).
2. A third of the way between your little finger and thumb is likely to be a tender point.
3. Find the sharp edge of a cupboard or table top, and back your buttock onto the sore area very firly, to the point of deep pain.
4. Do the same thing 25 mm (1 inch) above and below the first point, on a curve. The areas are probably sore.
5. Do a stretch either in standing or laying down, where you pull the affected side knee towards the opposite shoulder, hold the stretch without bouncing, for 15 seconds. Repeat 10 times, 3 to 4 times daily.
6. Do a hamstring stretch for the affected side with the same directions as for the gluteals.Do not bounce any stretches - have a sustained hold to the point of discomfort, not pain.
7. Morning and night lay on your back, knees bent,with your heel a comfortable distance from your buttocks, knees and ankles pressed together, and rock your knees gently side to side for 5 minutes, not into pain.

Do the above exercises for at least 2 days, even if the buttocks are sore. The pressure against the table top edge can be sufficient to cause bruising, if done correctly. If you do not do the exercises, the treatment is a waste of time, as is a gentle treatment.
Do not increase your daily activity levels within the first two days, no matter how much better you feel.

Note, if any of the exercises cause increased true neural signs such as loss of strength, or numbness beyond what you already experience, decrease the intensity of the hamstring stretches.This is unlikely if you take the exercises gently. The friction massage for the priformis cannot worsen any spinal stenosis, and is therefore safe.

Hope the above helps. It is certainly worth a try, especially as surgery is being viewed as an option.Do not sit for greater than 20 minutes for the first two days, without doing glteal stretches (one for 15 seconds), or better still walk a little (couple of minutes change of position).
Goodluck
MrPhysio+

[Sonj]

Sorry for not replying sooner, I've been out rock climbing nearly every day for the past week, yeeha!!!!

It's 3 weeks since the steroid injection and after the initial horrible reactions in the 1st week I am completely pain free, the difference is astounding!!!

I'm still doing all my stretches and going walking though. The only thing I'm left with is that I'm still waking in the morning a bit tender in my bum and behind me knee and down the lateral side of my thigh. I remember the 1st private physio I went to see massaging into my bum at the painful point as yes it was VERY sore when she did it but effective (if only for a couple of days). I mentioned to the Chiropracter about doing the thing where you use a tennis ball to reach the Piriformis but he reckoned there was too much irritation and inflammation present and this would just irritate it further. I ignored what he said, curious to see if it would help or not but he was right and the deep pressure caused spasms of agony and much nerve pain. But a while back, after being on the Amytriptyline for a couple of months and the pain had subsided enough for me to be able to start doing more stretches without causing too much pain I was able to do several Piriformis stretches which were very soothing to do and he did say that it was then ok to use the tennis ball. I think he thought that Piriformis was going into spasm because of the irritation to the nerve and not the other way around.

Certainly, all the pain was most def coming from the nerve compression as the steroid injection was injected into the right place and has removed all the painful symptoms. Interestingly though, when I do any back extension exercises they still cause my leg to go numb. Probably the disc bulge has not fully retracted and my bending backwards causes it to get squished out more? But all the flexion type exercises are fine. Tho I can seem to do the exercise know as The Cat in yoga fine tho with just not as much flexibility as before. The 2 stretches which still cause problems are lying prone and doing a Cobra type stretch and lying prone and keeping chest and head on floor but lifting leg up. Both of these make my leg go numb and if held in position for too long leg goes a bit sore. But I'm still doing them, but only to the point where they don't cause symptoms.

[Sonj]

PS - the tender point you mention between the gluteal cleft and the trochanter is still a tad tender, certainly even when I press into there with my fingers I can feel a tender spot. How long should I sit on the sharp corner bit of a desk etc?? Cos you are right, it is bloody painful to do that!!! (Excuse my language!)

[alophysio]

Hi,

it is good that you are feeling better.

However, please listen to your body...it is telling you that extension is no good! Numbness is not a 'normal' sign for anything. It would seem to me that you are compressing the nerve root.

Any good Mackenzie therapist worth their salt will tell you that extension is not the only way to treat discs. In fact, there are 7 derangements described by Mackenzie so please don't get caught up on only one of them!

I would still think that the nerve is sensitising the piriformis...but only my opinion! L/S extension, unless you are severely overactivating your hip muscles, doesn't cause leg numbness from an overactive piriformis.

Staying within the symptom range as you are is the smart thing to do! Don't keep reassessing it! Do it once a week only. I had a patient who kept testing his L/S - he was doing it every hour or so - he didn't get better until he stopped testing his L/S!!

Good luck!

[Sonj]

Hi, yeah that's what we were thinking, that it was the nerve irritation annoying Piriformis rather than Piriformis annoying the nerve. Both the Chiro and the Physio said that nerve damage/irritation can take up to 18months to heal properly so it may be that all I'm left with now is just a sort of small residual nerve pain and occasional numbness. And certainly my muscles have lost alot of strength over the past year, so it's gonna take some time to get back to proper strength and fitness. I've been missing out the back extensions now and the prone leg extensions but I did try them again today and it seems not so bad as last week so I guess it's just a case of taking it slowly and cautiously. And I'll do that, just trying it once a week gently to see how it improves as there are other stretches I can do for my back in the meantime.

[alophysio]

THanks for the updates.

Don't forget to try to integrate your rehab exercises into your functional activities. In particular, hill walking and any other aggravating activities.

Of course, don't be in a hurry to do this...just don't lose sight of the big picture - which is to get back to as normal a life as possible.

Thanks again!

[sdkashif]

Have you also tried the neural tension techniques as described by Butler? Have you got any sessions of these from any therapist? These techniques may resolve you residual neural tension.

[Sonj]

Do you have a link to any of these neural tension techniques?

Both the Ortho and Chiro reckon the disc is no longer compressing the nerve and that the nerves down my leg will take around a year to heal properly.

Would you believe it though, I seem to be developing a bit of shoulder impingement, aaaaaaaaaaaaarg!!!!!!!! Just can't win, lol! I think it's due to lying on my front for so long and shoulder being scrunched up, then jumping back to climbing several times a week too quickly. It went stab the other day and I lost ROM for a few hours. ROM back now but it's pretty achy. Chiro said Supraspinatis was very tight. So, that's more exercises for me to do now!! Damn, being a climber is hard work sometimes )

[alophysio]

Hi,

I wouldn't be calling it "neural tension" to a doctor simply because it implies deformation to the nerve (i think).

Neurodynamics (the preferred term of Michael Shacklock) or neural mobility or neural mechanosensitivity are more likely to get a better response from a doctor, especially a neurologist.

The key authors that i know about are:
Bob Elvey
David Butler
Toby Hall
Michael Shacklock (www.clinicalneurodynamics.com.au i think - google it - in fact google all of them! They are physiotherapists)

You can look their work up of www.pubmed.com (it directs you automatically to another site) where you can just type their name into a search strategy and their articles should come up.

Alternatively, you can buy books by Butler and Shacklock (don't know about elvey).

Lastly, how did they suddenly decide that the nerve is no longer compressed? What are your reflexes like? Don't worry about the shoulder - dysfunctions are not limted to just one area - fascia connects the whole thing up in a nice little web!

Good luck!

[sdkashif]

Let me describes the principles of mobilization of the nerves, as described by Butler.

The intensity of the maneuver should be related to the irritability of the tissue, patient response and change in symptom. The greater is the irritability, the more gentle is the response.

If the restriction is primarily tension, the stretch force is applied into the tissue resistance, held for 15 to 20 seconds, released and then repeated several times.

Neurological symptoms of tingling or increased numbness should not last when the stretch is released.

The application of the techniques requires positioning the individual at the point of tension (symptoms just begin), then either passively or having the patient actively move one joint in pattern in such a ways to stretch, then release the tension. Moving different joints in patterns, while maintaining the elongated position on the other joints, changes forces on the nerves.

After several treatments and tissue response is known, the patient is taught self stretching.

Have a look over the techniques for mobilizing the lower quadrant and sciatic nerve.

Straight Leg raising with Ankle Dorsiflexion:

Patient position and procedure.
Supine with lower extremity in straight leg raising position (SLR), add ankle dorsiflexion. Several variations may be done; ankle dorsiflexion, ankle plantar flexion with inversion, hip adduction, hip medial rotation and passive neck flexion. The maneuver may also be performed long sitting (slump sitting position) and side lying. These various positions of lower extremity and neck are used to differentiate tight and strained hamstrings from possible sites of restrictions or nerve mobility in the lumbosacral plexus and sciatic nerve.

Once the position that places tension on the involved neurological tissue is found, maintain the stretch position, and then move one of the joint a few degree in and out of stretch position, such ankle plantar flexion and dorsiflexion, or knee flexion and extension.

Ankle dorsiflexion and eversion places more tension on tibial tract.

Ankle dorsiflexion and inversion places tension on the sural nerve.

Ankle plantar flexion with inversion places tension on the common peroneal tract.

Adduction of one hip while doing the SLR places further tension on the nervous system because sciatic nerve is lateral to the ischial tuberosity; medial rotation of hip while doing SLR also increases tension on sciatic nerve.

Passive neck flexion while doing SLR pulls spinal cord cranially and places the entire nervous system on stretch.

Slump Sitting Stretch:

Patient position and procedure.
Slump sitting with neck, thorax, and low back flexed. Extend the Knee and dorsiflexion the ankle just to the point of tissue resistance and symptoms reproduction. Increase and release the stretch force by moving one joint in the chain a few degrees, such knee flexion and extension, or ankle dorsiflexion and plantar flexion.

Prone Knee Stretch:

Patient Position and procedure.
Prone the spine neutral (not extended) and the hips extended to 0 degree. Flex the knee to the point of resistance and symptom reproduction. Pain in the lower back or the neural signs are considered positive for upper lumber nerve roots and femoral nerve tension. Thigh pain could be rectus femoris tightness. It is important to not hyperextend the spine to avoid confusion with facet or compression pain. Flex and extend knee a few degrees to apply and release the tension.

Alternate position and procedure.
Side lying with the involved hip upper most. Stabilize the pelvis and extend the hip with knee flexed until symptoms are reproduced. Maintain the knee flexion, release, and apply tension across the hip by moving it a few degrees at a time.

Prevention:

These maneuvers especially the SLR with repetitive ankle dorsiflexion and plantar flexion, and the respective upper quadrant maneuvers may be used to prevent restrictive adhesions from developing if done early on in treatment after an acute injury or surgery.

Precautions and contraindications to Nerve tension Testing and Treatment:

Butler Cautions that there is incomplete scientific understanding of pathology and mechanisms occurring when mobilizing the nervous system. The clinician should always use caution.

Precautions:

Know what other tissues are affected by the position and maneuvers.
Recognize of irritability of the tissue involved and do not aggravate the symptoms.
Identify whether or not the condition is worsening and the rate of worsening. A rapid worsening condition requires greater care than a slowly progressing condition.
Use care if there is active disease or pathology affecting the nervous system.
Watch signs of vascular compromise. The vascular system is in close proximity with nervous system and at no time should show signs of compromise when mobilizing the nervous system.

Contraindications:

Acute or unstable neurological signs

Cauda equina symptoms related to spine including changes in bowel and bladder function and perineal sensation.

Spinal cord injury and symptoms.