Spinal stenosis and disc protrusion

[Ozy]

Female, age 37 with spinal lumbar stenosis on L4/L5 and disc protrusion on
L5/S1.
She is in constant pain for one year and half, every day on medications.
Restricted movement in lumbar spine in all directions. Pain radiates along the both sciatic nerves down the legs (knee).

Two months ago pain in the neck startes. On RTG degenerative changes. Clinical she has neck protrusion and restriction in movement in all directions.
Neurosurgerist doesn't suggest operation, just spinal brace and physical therapy. But exercises and diadinamics didn't help (off course).

She came to me yesterday - I gave her a postural education, a mobilisation of spine, cervical traction and McKenzie exercise for the neck - retraction and all directions. I gave her a suggestion for night sleeping, beacuse it is very painfull.
She will come today, again.
What sholud I do?
Flexion exercise will worse her protrusion and extension exercise will worse her stenosis - I have tested these movements yesterday.
If I start with izometric and core exercises with lumbar and cervical traction do you think tis would change her condition???

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[jwilso]

if i was treating this patient i would attempt to treat the disc. the stenosis is irreversible but the disc i would hope can be reduced. i would try a mckenzie approach which usually involves extension. this could be in lying or standing but i would go for the position that centralises her pain. i think that you need to treat one thing at a time. treat the back and then the neck once youve sorted the back.

[Ozy]

Thank you very much jwilso,

I was thinkig differently, since her neck problems are (probably) result of her back problems, and they last for a shorter time - that's why I have started with neck.
So, it is important to deal with one problem then the other.
The difficulty is that I haven't found a way to reduce her pain nore centralises in neck and also in lumbar spine.
She feel constant pain even if she is under strong medications - and she is taking them because the doctor told her to do it every 4-6 hours.
She is better only when she change her position (from sitting to standing or standing to lying - prone, supine). While she is longer in same position (a few minutes) the pain is returning...
I am really confused since I haven't found a good response for some mowement in first appointment.
Any other ideas?

[sdkashif]

The problems in the neck as stated by you persists for two months, hence it likely to be subacute onset (6-12 weeks duration onset). Your physiotherapy management plan is suitable approach for treating the neck problems, so continue with that.

For lumbar problems as it indicates that is chronic and spinal stenosis is due to the disc problems, hence it falls into the category of anterior element pain. Here are few suggestions for managment of this type of pain.

Anterior element pain:

Anterior element pain has been defined as pain made worse by sustained flexion of lumbar spine. Anterior element pain is made worse by sitting and is relieved by standing. Patients assume hyperlordotic posture to relieve their pain. Fracture of vertebral bodies and prolapsed intervertebral discs produce anterior element pain. Extension exercises and press ups are more likely to produce remission than flexion exercises. This is because flexion exercises increase the intradiscal pressure whereas extension exercises unload the discs. Therefore, extension exercises advocated by Cyriax and McKenzie are logical for patients with anterior element pain. Lesions resulting in chronic anterior element pain are obscure. Unlike the acute group, the patients with chronic anterior element pain may respond to manipulative techniques.

[Ozy]

sdkashif thanks!
I will check her condition today. If any of movements she was doing at home and work - made her pain disappere or reduce - I will proceed with these neck exercise.
We will repeat postural education.
Only to relax paravertebral muscles I will do mobilisation of whole spine in prone position, in the end of the sesion maybe extension exercise could be posible (she can rise only to elbows), so I could see any changing in condition.

[jwilso]

the other coment i forgot to make earlier was why the spinal brace and physio. surely that is a contadiction. this is obviously a chronic condition. she has had it for 11/2 yrs. dont espect overnight results.

[Ozy]

I agree with you!

[piyushphysio]

If I would be treating this patient I would have concentrated more on active management including functional training as the problem is chronic. If she is taking strong medications for pain relieve and are useless I would see that how much she rates her pain on VAS because most of the chronic pain patient usually becomes hyperalgesic due to smudging in the brain and that can not be treated just by hands on. I think you should start with some core strengthening exercises in functional position, some fitness exercises because being unfit since last 1 yr I'm sure her fitness level could had become low and fitness plays great part in reducing pain.

[Ozy]

Piyushphysio, thank you - core strengthening exercises are the "next level" in my treatment plan, first is decreasing the pain.

I have seen her on the second appointment. She slept well (after long time), because of cervical night roll, no morning pain in her neck, but during day pain appears. She didn't do retraction or other movements of the neck (she was too busy on her job ), also she didn't make correction to her sitting posture...

SdkashifI didn't see any progress of ROM for cervical or lumbar spine, off course. I did mobilization of the spine, some muscle energy techniques for neck, repeat all about postural correction and importance of ROM exercises for the neck.

Jwilso, I explained her reducible and ireducible facts. I will proceed with McKenzie exercise after her return from some distance trip. She will be back in ten days.

Thank you ALL for comments and advices it really helped me a lot to consider different approaches. I can tell you what happened after she returns from the trip, if you want.

Regards!

[jwilso]

what do you mean by mckenzie exercise. are you mckenzie trained? you seem to be trying very hard with this patient. if you are doing spinal mobs, neck traction, postural advice,muscle energy techniques, traction and core stability how do you know what is helping and what is not? where is the clinical reasoning?

[Ozy]

jwilso, yes I am McKenzie trained!
I can't find anything what reducing the pain if the patient is on her first or second appointment after year and a half of constant pain. Her muscles are stiff and painful. It must be "relaxed" first. Moreover, she must be confident in what I am doing (after so much therapies that didn't help her) - to do movements that hurt, even if she will be better because of this movements. I don't know if I was clear enough. However, if you are McKnezie trained you will know what I am trying to tell.
Nevertheless, I proceed with mine clinical reasoning based on assessment, psychological condition of the patient and time of the next appointment (which will be in ten days).
Sometimes you just can't do "by the book". I am sure you had same experience.
Nevertheless, this is just my opinion, and she spends night without pain after first session, so I think I can continue with this "mixed" treatment.

p.s. I did mobilization (also a part of McKenzie approach), traction and one muscle energy technique for the neck. Education off course. That's too much for you? I didn't do core stability!
In addition, yes, I am trying very hard, because I don't think it is normal that someone so young have that kind of problem for such a long period. But I am doing all that I can for all of mine patients

[sdkashif]

I think that McKenzie Method is quite safe both for acute and chronic conditions of the neck disorders. Infact it may improve early recovery in both Neck and Lumbar problems. So you may safely continue with that as McKenzie approach consists of comprehensive assessment and treatment consisting of Cause and effect.

Apart from that you may continue with Cervicothroacic stabilization programme (Flexibility, Postural Training, strengthening) a very good way of improving the neck disorders.

Spinal mobilization and manipulative maneuvers are effective in relieving the pain but does not alter the course of condition in long term; so don't worry about that.

Please see if neural tension test are postive for cervical spine and lumbar spine, you may start with nerve mobilization maneuvers.

Assess the progress of patient by reassessing and pain charts.

[jwilso]

any non-organic signs,yellow flags?

[Ozy]

sdkashif, thank you, I will check neural tension tests in ten days - when she'll be back from her trip

jwilso, yes, there are non-organic signs (or yellow flags).

I will let you know what happened on our next appointment.
Regards!

[asha]

I think you have been a bit confused & in your hurry to bring about pain relief doing a lot of things. On day one you may sometimes not get a movement preference. you have prescribed as home programme all movements, how can you do a clinical analysis.

She came to me yesterday - I gave her a postural education, a mobilisation of spine, cervical traction and McKenzie exercise for the neck - retraction and all directions.

You seem to have got no movement preference & you seem to have gone ahead with progression of forces in the mckenzie approach.

p.s. I did mobilization (also a part of McKenzie approach), traction
and one muscle energy technique for the neck.

during movement testing, of the cervical spine have you isolated the upper c spine & the lower c spine? If you systematically go through with the mckenzie assessment techniques, I think you will find the solution to your problem. If it comes up as an mechanically inconclusive, then go ahead with with other systematic approach. Iam mckenzie trained too & I have seen worse patients that this coming out. Be systamatic & you'll sure find a way out.
In the lumbar spine what is her position or movement preference? If she finds prone better, she may nor be able to try out REIL due to her cervical spine. have you then tried bilateral knee bending in prone ? You may have to wait to reduce the pain in the cervical to start with the lumbar. well it all actually depends on your assessment. Nothing like a good assesment.there's a whole lot of info that you have not mentioned.when the patient comes back to you, be level headed & start on a fresh page. If you are mckenzie trained, this should be an easy job.

[Ozy]

Asha,
I agree with you, I was in a hurry!
She came to me as a patient with lumbar problem, and I was surprised that she has also neck problem.
I didn't have enough time during assessment, and I have spent to much time on the LS, but she told me that the neck pain is something that she can handle right know (she was used to feel lumbar and legs pain)...
Why I gave her "retraction and all directions"?
I never did that before!
But I didn't find the right movement direction, because she was stiff and everything was painful to her (with great deal of yellow flag sign).
So I wanted to "relax" her to move in all directions - to see that nothing will happen if she moves her neck, if you can understand what I am saying?

Another problem, she didn't do any of the instructions that I gave to her (except the cervical role for the night - and then she had better sleep).
I think she will need different approach, because she doesn't want to change herself: the way off seating, and to integrate exercise (retraction or EIL or EIS) in her daily routine.
We just can do much for that kind of patients with McKenzie method...
Off course, everything would be different if I was able to find the right movement at first visit - which is partially impossible for chronic conditions.
On the other hand Asha, you may have different opinion?

[asha]

Well i do agree with you ozy. we can't do anything much if the patient does not do what is being asked as a home programme. Its not always that we get the right direction on day one. Especially if there are too many things happening at the spine, it may take roughly 5-6 sessions. But the patient must adhere to our instructions.

[bilabd]

Female, age 37 with spinal lumbar stenosis on L4/L5 and disc protrusion on
L5/S1.
She is in constant pain for one year and half, every day on medications.
Restricted movement in lumbar spine in all directions. Pain radiates along the both sciatic nerves down the legs (knee).

Two months ago pain in the neck startes. On RTG degenerative changes. Clinical she has neck protrusion and restriction in movement in all directions.
Neurosurgerist doesn't suggest operation, just spinal brace and physical therapy. But exercises and diadinamics didn't help (off course).

She came to me yesterday - I gave her a postural education, a mobilisation of spine, cervical traction and McKenzie exercise for the neck - retraction and all directions. I gave her a suggestion for night sleeping, beacuse it is very painfull.
She will come today, again.
What sholud I do?
Flexion exercise will worse her protrusion and extension exercise will worse her stenosis - I have tested these movements yesterday.
If I start with izometric and core exercises with lumbar and cervical traction do you think tis would change her condition???

try Maitland or Mulligan techniques may be it will be helpfull to refer to Mulligan browse www.mulligan.com

[alasaar]

I have gone though this nice discussion may I say something for you Ozy I have seen such pt but I agree with Asha that you need to be more specific in regards to the assessment details especially localizing the level and the movements mostly effected. I agree with you we tend to look for the faster relive for the pain and we tried different techniques in one time but we need to think is this techniques contradicts with the other one we are using
Thank you all for the information
Regards