increased pain in lumbar spine

[Gajba]

Hello,

my patient with chronic back pain (50 years old female) and history of sciatica came to me at Friday.

Symptoms:

local lumbar pain when she stands up from chair, pain in sitting position

Tests:
EIS no pain

FIS pain (L4 - L5) in the middle of the way

My treatment:

McKenzie extension mobilizations in lying
McKenzie EIL - no effect
In standing position SNAGS (pain free) L4-L5 in flexion
I did that 5 times, I forgot 3 x rules :-(
After that I told her to do FIS again, 2-3 times, it was pain free
she went home (happy)

Big Problem:
- Same evening her pain increased
- Tomorrow (Saturday) worse
- Today (Sunday) she came to me, again

Symptoms:
More pain in sitting, more pain when she stands from chair

Tests:

EIS with reduced ROM but no pain
FIS pain (L4-L5 and sacrum?!) pain in the beginning of the way
Hips extension - Ok
SI joints - low discomfort on pressure

Treatment:

McKenzie extension mobilizations in lying, painful in the beginning, and after a couple of pressings better
McKenzie EIL - first pain, after 2-3 times, better
McKenzie extension mobilizations in lying, always painful in the beginning, and after a couple of pressings better
I have tried in standing position SNAGS but I couldn't find pain free movement; In one point it was ok at L4/5 segment, but pain in sacrum appear
After that pain in standing appear
Again, McKenzie extension mobilizations in lying, painful in the beginning, and after a couple of pressings better
EIL - no pain
EIL with overpressure with belt (I have put it on the sacrum)
I put her in standing position and she felt no pain (but pain in sitting and standing up process)
It seems to me good reason (green light) to proceed with EIL with overpressure with belt over sacrum
After all that, she stands up with decreased pain, but with no pain during standing.

I told her to avoid flexion to do every two hour EIL (with some overpressure), not to sit and etc.

It seems I did SNAGS ok but two times more.

More important, perhaps I must do EIL after FIS with patients who have history of derangement???

I think I make worse her disk problem, but why sacrum pain appears?

What do you think?
What should I do tomorrow if she become worse?

Thank you for reading all of this, and of course thank you on your advice...

Best regards

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[sanagupta]

Hello!
Have u taken in account her posture ,and what about the the status of Hip musculature.,Check for piriformis,hams and iliopsos tightness.
Regards

[Gajba]

Thanks, hip muscles were ok.
But her doctor recomanded her injections. So, she is not my patient anymore... I think she was sitting in front of her computer for a few hours after the treatment. It made her deragmenet worse, probably.