Advice on RX prolapsed disc with radiation into L Foot

[physio48]

Hi

I am look for some advice on treating a patient with a suspected prolapsed disc at L5/S1, L4 (awaiting scan to confirm) with radiation of pain into her left foot. I don’t get many patients with this condition so I am a little unsure of the best line of treatment.

The patient has a past history of LBP with some radiation of pain (sciatica) into her left buttocks which has resolved with rest, pain meds and physiotherapy in the past.

The patient is 38, female, slightly overweight and was fairly fit before the accident as has quite an active job.

This current episode resulted post falling over during being assaulted. She was taken to A & E had an x-ray which was clear and advised to take pain meds for the pain. LBP developed over the next couple of days but the patient kept working f/t. A week later the pain started to move down her left leg and she started having trouble sleeping and walking. She visited her GP, prescribed more pain meds and referred for physio. Pt still continued working although on -

On presentation she had had an antalgic gate, was unable stand upright fully, sit without moving positions constantly and unable to lie supine without knees bent. All movements of LX were decreased by half, THX also, myotomes left hip flexion weak, dematome L5 decreased to touch, reflexes hard to find in both lower limbs, SLR left 30 degrees with pain in LX, Slump Pain in LX on knee extension left and central tenderness of L5/S1, L4. SIJ stiffness on palpation, no increase in pain on compression/decompression, bilateral muscle spasm of QL's were also present.

Initially I used acupuncture to help with pain/decrease muscle spasms and increasing ROM with some basic stretching exercises which helped improve ROM and reduce pain.

I would really appreciate some advice on treatments/exercised which ones to use and why (I have researched a fair bit into this and some recommend flexion type exercise to stretch the nerve increase blood flow into the area/removed waste products/and some extension type a little confused which to use) – I would also appreciate any recommendations for courses in the UK for treating prolapsed disc problems.

Many thanks

(Sorry to have babbled on to much)

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[physiofixme]

Hi

Do you have McKenzie courses in the UK??? If so I think you'd really benefit from doing a McKenzie course. Basically it's a whole philosophy of treating disc problems. Very very effective. For this patient I would focus on lumbar extension. Get her in prone (pillow under belly) and do some manual therapy techniques to mobilise her lumbar spine in to extension....stick to gd 3 mobilisations for now. I would then get the patient doing self extension exercises - lying prone, and pushing up with arms (hips stay in contact with floor) Like a cobra in yoga. She should just keep repeating this in sets of 10...ie. 2-3 repititions of 10 EVERY HOUR. This should help reduce pain. What is likely to happen is that the pain will start to move up her leg...this is a good thing. The further down the leg the pain is, the more irriated the disc and nerve are. I'd STOP doing any flexion or stretches until she has no leg pain. Also educate her on sitting posture...to avoid sitting when possible and opt for lying prone on the floor if relaxing at home. Also she needs to avoid lifing and avoid bending too much ie: making beds, vacuuming, cleaning bath etc until she has no leg pain. See if you can find a copy of "Treat your own back" by Robin McKenzie at your local bookstore and have a read and lend it to your patient. Also look around your libraries or other physio resources and look for " The lumbar spine - mechanical diagnosis and therapy" by R.A McKenzie. Hope this all helps.

[physio.smith]

I have often found McKenzie principle useful with these type of patients. The techniques are very useful to manage and help the patient self manage the problem. The book mentioned is a definitely worth a read.

There are courses available in the UK, see your Frontline magazine or The McKenzie Institute (UK) Trust Website for courses.

[physio48]

Many thanks for your advice have both books on order and trying to find a place on a local course.

Pt now doing better following the Mckenzie extension exercise as recommend, pain has now moved from foot to upper shin. Pt is mobilising better and in less pain.

Hopefully books will arrive soon

Many thanks

[hari priya]

Hi

I am look for some advice on treating a patient with a suspected prolapsed disc at L5/S1, L4 (awaiting scan to confirm) with radiation of pain into her left foot. I don’t get many patients with this condition so I am a little unsure of the best line of treatment.

The patient has a past history of LBP with some radiation of pain (sciatica) into her left buttocks which has resolved with rest, pain meds and physiotherapy in the past.

The patient is 38, female, slightly overweight and was fairly fit before the accident as has quite an active job.

This current episode resulted post falling over during being assaulted. She was taken to A & E had an x-ray which was clear and advised to take pain meds for the pain. LBP developed over the next couple of days but the patient kept working f/t. A week later the pain started to move down her left leg and she started having trouble sleeping and walking. She visited her GP, prescribed more pain meds and referred for physio. Pt still continued working although on -

On presentation she had had an antalgic gate, was unable stand upright fully, sit without moving positions constantly and unable to lie supine without knees bent. All movements of LX were decreased by half, THX also, myotomes left hip flexion weak, dematome L5 decreased to touch, reflexes hard to find in both lower limbs, SLR left 30 degrees with pain in LX, Slump Pain in LX on knee extension left and central tenderness of L5/S1, L4. SIJ stiffness on palpation, no increase in pain on compression/decompression, bilateral muscle spasm of QL's were also present.

Initially I used acupuncture to help with pain/decrease muscle spasms and increasing ROM with some basic stretching exercises which helped improve ROM and reduce pain.

I would really appreciate some advice on treatments/exercised which ones to use and why (I have researched a fair bit into this and some recommend flexion type exercise to stretch the nerve increase blood flow into the area/removed waste products/and some extension type a little confused which to use) – I would also appreciate any recommendations for courses in the UK for treating prolapsed disc problems.

Many thanks

(Sorry to have babbled on to much)

hi,its nice to see that your patient improved with extension exercises.i agree that these exercises will be helpful for posterolateral disc protrusion.
you mentioned that the patient is getting relief when lying supine with knee flexed.in this position the lumbar spine goes into flexion. why is it not aggravating pain. i just want your opinion on this

[physio.smith]

In supine would not necessarily aggrevate the problem as discs unloaded.

Flexing allows more room for the disc to protrude posteriorly, which again unloaded may not aggrevate symptoms....key though is what happens when they stand after this...tend to get 'nut cracker' type effect and protrusion squeezed and causes pain when standing.

Patients with posteriorly prutruding discs often sit slumped, flexed, to one side etc..and get relief....it is often hard to pursuade them that this is not necessarily the best thing for them!

[Lachlan]

My understanding of the reason why extension may also increase the patients pain with disk problems in the acute phase is that you can get a "pinch" effect where the area which is protruding posterior gets pinched with extension- even though the movement is unloading the disk.

Therefore its often more comfortable for patients to have a pillow under their stomach in prone or with knees bent in supine. Starting out with gentle extension exercises so as not to flare up the condition.

It really is important to note whether the pain is centralising- this represents a good prognosis. If the pain is not centralising but i suspect disk is the issue i will still get patients to perform gentle extension exercises until next session where hopefully i can get a better assessment in as they are not so irritable.