back pain- Help!

[eggs and ham]

hi guys, im a student physio just on placement,

ive got a patient who was c/o back pain that radiated down into her calf, her ankle reflex was dull and had a slight lateral shift

gave her mckenzie type ext exs and shift correction things, but she came back worse!

tried repeated ext exs- this Peripheralised her pain and flxn centralised it, and shes now getting better :eek

as this is the first case ive seen of this happen ive been asked to do a case study on her, however struggling to clinically reason it! any ideas?!

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[alophysio]

Hi.

I understand your confusion. More information would be nice about the assessment.

However, in giving McKenzie exercises, it sounds like you think the disc is pinching the nerve. It usually is the problem.

2 things...

1. the disc is not always at fault. If extension increases the pain but flexion relieves the pain, then it is a "compression" pattern of the posterior structures of the motion segment unit. (the axis of rotation F/E is usually the dividing line as to what is posterior or anterior). It is also a "stretch" pattern of pain for anterior structures. Therefore, a meniscoid in the facet joint with swelling could also be causing the apparent compression.

2. If it is the disc, then a study by Edmonston et al (2000) MRI evaluation of lumbar spine Flexion and extension in asymptomatic individuals - Manual Therapy 5(3):158-164, showed that 30% of subjects had a small posterior migration of the disc during extension and this could be causing your patient's pain. Interestingly, they concluded that the clinical signs are what you should be the basis on how you treat your patient, not biomechanical theory!

Lastly, if the disc did leak, it can sensitise the nerve to mechanical stimulation even if there is no bulge, etc. Then only a slight mechanical touch from any structure can also cause the symptoms described.

Better go back to work now! Let us know how she goes...

[Physiophil]

This presnets as classic Anterior Derangement - or the Derangement 7 of the original McKenzie System.

Approx 3% of patients have this. The hypothesis is that the bulge is slightly anterior and clearly lateral. The flexion aspcet of exercises provide teh reductio an centalisation.
The suggestions on anthony are logical but it seems that anterior dernage has not been considered. Check the history of the injury - good chance it is an extension based injury. References include McKenzies book PArt 1 and also try {Busanich, 2006 ; Long, 2004; Clare, 2004; Laslett, 2005}

[zaofer2000]

you could read delitto back pain classification by apta and learn more about you problem

[alophysio]

Hi Physiophil,

I am not McKenzie trained - does an anterior derangement result in posterior aspect pain?

Next question is how does the McKenzie Method explain how the anterior derangement leads to a decreased reflex if the spinal nerves are not compromised?

I would like to learn more about how anterior derangement works - I still think a posterior element problem/pain - more likely than the 3% chance of anterior derangement quoted...

By the way, I could only find the busanich 2006 and clare 2004 references. Could you be more specific with your references please? They seem to be reviews that just say that McKenzie helps compared to other treatments but don't say how...

Also, an extension injury is more likely to injure the posterior elements because extension is limited by the facet joints and lamina. It would have to be severe force to cause an anterior derangement with extension. If there was any degeneration in the disc and subsequent loss of disc height, extension and the resultant torque on the anterior disc would also be even less and so less likely to be the reason for pain...

What do you think?

[marj]

Could it be an anterolateral disc protrusion? Marj