Overactive back extensors w/ spondylolisthesis at L5/S1

[spondy_21]

Hi all,
I am not a physio but rather a somewhat informed patient of a physio, make that 5 physios in the past 2 years.

First is my question:

1. How can I relax my back extensors other than being aware? My left lower back is always in extension while standing and walking, and, although I can feel myself tensing my erector spinae and some other muscles, I can not seem to stop doing it.

Here are the factors:

1. Herniated disc at C5/C6 w/ spinal cord compression and intense pain and muscle atrophy in upper left back/shoulder blade muscles. This condition went on for about 15 months before fusion w/ cadaver bone and metal at C5/C6 (one level).
2. Shortly after herniating the disc I fell on my head from a distance of about 6-8 feet. I sustained painful and long-lasting injuries to the right side of my neck and right shoulder. This happened over 2 years ago, and the pain and headaches continue although this is greatly diminished from the onset.
3. A dr. discovered I have I grade I spondylolisthesis at L5/S1, which most likely has been there since I was a teenager.
4. I'm 41.
5. The discs in a lumbar MRI appear fine, and there was no visible neural impingement.
6. A message therapist discovered MUCH adhesion in my abdominal area. I don't know what is technically, but I can say that my abdomen from pelvis to ribs was insanely tight and painful to medium pressure. It is still tight but has decreased with daily periods of lying on top of a massage ball, using it like a foam roller to slowly sink into the fascia/muscle.

History and Current Complaints:

About 2 years ago and a month or so after herniating the disc, my hamstrings tightened up to a painful degree. No amount of stretching seemed to reduce the pain or stretch the hamstrings. To make a long story short, it seemed like my entire body seized up on me; everything was very tight and painful. I stopped all sports, running, and walking for pleasure 1) to give my body a rest and 2) because it made everything hurt more.

After much physical therapy, massage, chiro, surgery and Feldenkrais classes, I am aware enough to feel my left lower back go and stay in extension when I stand and walk. I have been doing core strengthening for about 6 months, and iI think I am fairly strong there. I have been doing glute medius strengthening exercises and other exercises to increase awareness of proper pelvic and spinal movements, esp. on the left side. That is, while lying on my side I can move my hip up and down w transverse abdominis engaged and back NOT going into extension.

The problem is that I can not "relax" my left lower back and even mid back (thoracic section where ribs end) when I stand or walk. A 1/2 mile walk is painful and unpleasant not to mention day to day activities and a return to sports. What's worse is that if I feel like I'm doing it to myself at this point, but I can not stop.

Thanks to whomever is reading this. I apologize if I have written too much or too little, and I would be greatly appreciative of any insight people may be able to provide.

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[SPPAWA]

Hello Spondy,

What are your reflexes like when they test them. Are they very jumpy and accentuated. When they tap your knees with their hammer do they fling out briskly from 90 degrees (if seated) to straight and make your whole body kinda hop as if you were really surprised by being struck by the reflex hammer? Do you have any charts with the numbers they have awarded these reflexes?

Thanks,

SPPAWA

[spondy_21]

Hi SPPAWA,
I don't have any charts with a number ranking for my reflexes.
I have been tested several times in the past couple of years, and no doctor ever noted anything abnormal/extraordinary. That includes a thorough physical exam w/ reflex testing by a neurologist.

[SPPAWA]

Hi SPPAWA,
I don't have any charts with a number ranking for my reflexes.
I have been tested several times in the past couple of years, and no doctor ever noted anything abnormal/extraordinary. That includes a thorough physical exam w/ reflex testing by a neurologist.

Hello Spondy,

Without physically examining you myself I cannot say much. There is a possibility, and it is often missed in such cases, where your lumbar spinal extensors are being activated due to the cord compression in your neck (depending on the degree of compression). With cervical myelopathy (cord compression in the neck) the fibers that are most susceptible to compression from extruded discs or degenerative changes are those which are traveling down to the lower limbs. Another pathway called our reticuospinal projections also travels through this section and can be affected depending on the degree of cord compression which you have.

With cord compression in the absence of any compromise to peripheral nerves one will usually exhibit accentuated reflexes which would occur in reflexes which exist below the level of cord compression. You can think of the role of the above mentioned pathways as "dampeners of reflexes" and thus, when compromised, will lead to the accentuation often seen on examination. This being said, your posture is controlled by reflexes. Spinal posture is controlled in particular by reflexes associated with the vestibulospinal projections which travel through the neck as well to control postural reflexes within the lower back. If the dampening mechanism is compromised due to cord compression it will result in increased tone in posterior (back side) extensor muscles in the lower limb and spine. Increased activation of these muslces, which is commonly seen in individuals who have suffered stroke leads to the odd gait (wallking) pattern where patients hike their hip up and over (circumducitve gait). This occurs as they cannot activate opposing muscles to overpower the extensor tone in the their hip due to and upper motor neuron lesion whether that be located in the brain or spinal cord. It is possible that your neck injury has caused some compromise of the dampening mechanism to these reflexes. Have you also noted stiffness in the legs?

In the event this is the case and other more common treatment avenues have not helped, I would search out a practitioner with experience in vestibular rehabilitation. Increasing the efficiency of the vestibulospinal projections through exercises aimed at them, as has been my experience, leads to improvement in patients I have managed with chronic extensor tone below the level of T6.

I hope this helps.

SPPAWA

[spondy_21]

Thanks, SPPAWA. That's a lot of information. I had to sit with it for a bit, but I understand what you are saying now.

I went through a battery of physical tests with a neurologist who said I was fine - not very helpful. I know the spinal cord is not being compressed now/for the last year because of surgery. Lord knows I have had bizarre feelings and fits all around the muscles of the shoulder blade, rib cage and extensors during the, hopefully, healing process.

Who, that is, what kind of doctor would I go to to verify myelopathy?

[SPPAWA]

Hello Spondy,

I would assume your neurologist would have followed you up with an MRI after your surgery. There is the possibility of some remnant cord damage from previous compression, however, this would be considered only after examination were suggestive of it.

I feel your overactive back musculature is likely firing in an attempt to stabilize your lower back which with a spondy will be inherently unstable. A spondy is a chronic degenerative condition, although often asymptomatic, it will continue to slip as you age. Low impact exercise to keep excess weight off will help keep the stress to the area minimal... NO RUNNING. I would continue with your rehabilitation focused on core activation and ask whomever you found the best therapist who has helped you to date who trained them and see that person. It is possible that you have some micro movement recruitment / firing pattern issues which are promoting your discomfort in gait. I assume they have taken another X-ray of the lumbar spine and assessed your spondy recently for an updated grading?


Cheers,

SPPAWA

[spondy_21]

Hi SPPAWA,
Again, thanks for your time. The neurosurgeon thinks my issues are muscle and not nerve related. The neurologist thinks I "am focusing on the things that are wrong with me and not the things that are right." I kid you not - it was fun to pay that co-pay.

With all due respect, I have read and heard so many contradictory things about the spondy. I also had a PT who has a spondy at L5 and is an avid runner. He advised extension, while every other professional specifically advised against it! Once my back started to hurt less at the facets, I began some extension stretches. They have been great in loosening up my abdominal muscles.

Anyway, I'm not even thinking about running now. I just want to take my dog for a walk and actually enjoy it. I will continue with the core work for sure and am still looking for a good PT that I can work well with.

Thanks again,
SPPAWA