unable to sit

[spandanphysio]

Hello friends I have pt, 28 yr female having lumbar canal stenosis after she fell during pregnancy 3 yrs back. Right leg is involved. Symptoms get worsened progressively. She can't sit or walk even for 5 minutes when she came to me before 3 months. Standing time was 10-15 minutes also had repeated lower back pain. MRI which was taken 8 months back shows L5-s1,L3-L4 posterior disc prolapsed with pressure on thecal sac. I'm giving intermittent traction, lumbar spine flexion exs, neural tissue mobilization and core stabilization. Right now she is having occasional minor back ache and occasional radicular symptoms when she walks for very long distance or stands for prolonged periods of time. Her sitting time is 10-12 minutes only. After that she develops 'stretching in posterior side of right leg. She can sit for some more time if she puts both legs straight on a stool but when she stands she goes into moderate flexion for some time. So please share your opinions regarding this. What should be done to allow her to sit?

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[Gawaine]

this question is probably more appropriate for the ortho kids...... try that forum... but i'm curious why you're doing flexion exercises? my instinct would be to do extension/mckenzie stuff with a posterior disc protrusion...

[spandanphysio]

this question is probably more appropriate for the ortho kids...... try that forum... but i'm curious why you're doing flexion exercises? my instinct would be to do extension/mckenzie stuff with a posterior disc protrusion...

hi gawaine it's a typical case of neurological claudication both from physical examination and M.R.I as i have mentioned.and pt has improved a lot from flexion exercises only.extension exercise will increase her symtoms.

[Gawaine]

actually, you wrote in your first post "M.R.I which was taken 8 months back shows L5-s1,L3-L4 posterion disc prolapse with pressure on thecal sac"........

but i read through some of your other post in the ortho forum... and i'm still confused...

you're using the term "neurologic claudication" to mean a limping due to neurologic complications, right? i see that extension would be bad for a stenosis patient, but i thought we were dealing with a patient with posterior disc prolapse... you should do extension exercises for posterior disc protrusion, correct? but not if there's stensosis involved.........

hmmm.... maybe this is why i'm a stroke junky and not an ortho kid...


patrick

[spandanphysio]

hi gawaine i don't mean only limp by claudication.i used the worls of pt coz instead of tinging and numbness she was filling like that.when she was alright i.e able to walk and stand without any symtoms i started bridging but stipped again coz 2 days earlier she climbed 30-40 steps and again developed acute pivd with tinging this time.right now i have puted her on traction,deep heat and rest.

[alinguyen]

hi,
how are her biomechanics during sitting/standing? observe whether she has abdominal muscle/quads, hamstrings/gluts/erector spinae etc muscle imbalance (yanda). also observe relative strength of the muscles which help maintain posture does she lumbar flex or extend during sitting, does lumbar support or lack of lumbar support help? does changing the tilt of her pelvis assist with sitting? is she rotated during sitting?

the idea is that if she's getting claudication during sitting, find out whether it's due to the position/ relative flex/ext of the spine that is causing the claudication and whether you can perform exercises to help strengthen the relative weaknesses to allow her to maintain a good lumbar position that she can feel comfortable with.

[neurospast]

Lumbar canal stenosis .....I'm not nitpicking but...
You question is if you could prolonge the sitting time. Why can't she sit longer than 10 minutes? Does she sit/stand in a certain position/posture? How about her pelvis levelled? What about a more resent MRI?
I assume because of pain/discomfort. In that case you should palpate the gluteal area and lower back for Triggerpoints in this; All gluts (if they have active triggerpoints sitting & lying on the back may provoke pain), paravertebral high tension of muscles could irritate the nervous system. Quadratus lumborum & Latisimus Dorsi. Irritation of the nervous system could result in irritation of other organs like muscles whci then could effect movement patterns.
An active point you will find without problems follow the charts and ask about referred pain (but don't get fooled if it doesn't correspond with the books) The pain on touch should be extremely sharp, not dull (otherwise you might irritate more organs e.g. muscles) and should start to ease within 10-20 seconds. Do not continue if they don't you might be just aside of 1. Palpate again if necessary. Don.t push to hard, unnecessary to do so. Gentle does the trick.
Best of luck & your friend as well.

[spandanphysio]

hello friends i have cheched again her she isn't having trigger points.but i foung left side of sacral hiatus prominant.all other bony landmark of pelvis r leveled.she is having trobbing in lumbosacral region than she develops claudication like symtoms.she can sit 5-10 minutes extra if she sits on chair with stright legs.i have advised to use sacral tube.but y she repeatedly develop tinging after climbing stairs?does she suffering from sacro iliac dysfunction?what extra examination should i carried out?

[neurospast]

I am not sure where exactly you have this 'buldge'. in case it is at the top of the crest of the pelvis (crista iliaca) it could well be an inflamated ligament like ilio-lumbar ligament which holds L5 into possition (with other ligaments). it would feel like a spongy gel type of substance which is painful from achy to sharp and could cause via via some referred pain. Look into the local anathomy. a good atlas (to my opinion) is sobota because it is more like drawings instead of cadaver pictures. The local anathomy with knowledge of biomechanics could help you on your way.
I am still surprised that you did not find any triggerpoints because gluteal muscles, iliopsoas, quadratus lumborum and other muscles tend to become hyperactive when the back becomes unstable (which puts a strain on core stability)

[morwenna]

Not a spinal expert either,. ..... but after all these months is it not possible/likely that she has some adverse neural tension/tethering of the sciatic nerve?

ANT stretches and mobilising techniques might help?

[kcspt]

Most likely is an SI dysfunction which will give you back pain, and some radicular type symptoms. Her mechanism of injury corresponds well with a rotation of the innominate especially with a predisposition of ligament laxity being pregnant. It will also limit walking and sitting. Ask the patient if it feels like they are sitting on a slope or a ball under one ischial tuberosity. I would try some muscle energy techniques to see if this helps.

[spandanphysio]

hello friends thanx all of u for discussion.u r right kcpct it seems si joint pathology as her left side psis becomes prominent(comes backwards and outwards) as patient assumes squatinig or in side lying on right side.she has signs like radiculopathy in right leg,filling of stretch of sciatic nerve,occanationaaly tinging numbness in sole and side of foot.frequently streaching in right front of thigh.i have tried sitting on sacral tube as well as some exs. that mobilises si joint.but results r poor.
spine surgeon has diagnosed her as coccyxodynia but treatment of it shows no better results.she has developed problem in sitting since 6-7 months not from starting when she fall during pregnancy.
pls friends help me regarding this case as i have tried everything that i can.