Lumabr traction aggravates the pain

[sanagupta]

Hello!
I came across a patient who had a disc protrusion with pain radiating to the lateral aspect of right leg(MRI shows at level of L4-L5.He had been to various physio's and all tried traction which worsened his symptoms.Slr on affectedside merely15 degrees.
I started the treatment with contrast fermentation to reduce the spasm at his back,and little exercises as single knee bending and laterals.He could not tolerate the PA 's at any part of his back
After Few sittings he could tolerate PA glides well but wen i tried tracton just for 5 minutes..his pain agreevated.
Though he tolerated unilateral manual traction nad helped reduce his pain at the referring site
Now after almost one month he has only 10% pain that also after stress of 2 km walking...
I m unable to understand his intolerance to traction and why he is still having the pain..he can also not sit in long sitting without considerable pain....please help
Regards
Sana

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[sdkashif]

It is possible that you may be using the wrong technique of traction.
Have a look on the over view upon the spinal traction procedures.
Spinal traction has effects of mechanical elongation of spine, facet joint mobilization, promoting muscle relaxation, reduction of pain. Spinal traction is indicated for spinal nerve root impingement, hypomobility of joints from dysfunction or degenerative changes, joint pain from symptomatic facet joints, muscle spasm or guarding, meniscoid blocking, discogenic pain, post compression fracture.
Continuous or prolonged traction is an effective mode of therapy. In it a static traction force is applied for several hours to several days usually in bed. Only small amount of weight is tolerable.
The effective force is influenced by the body position, weight of the part, friction of the treatment table, method of traction used and the equipment itself. Generally for vertebral separation:
1-In cervical spine, under friction free circumstances a force of approximately 7 percent of the total body weight separates the vertebrae. A minimum force of 11.25 to 13.5KG (25 to 30 lb) is necessary to lift the weight of head when sitting and to counteract the resistance of muscle tension. The greatest amount of separation occurs during the first few minutes of treatment at a given force. To avoid treatment soreness, the first treatment should not exceed 10 to 15 lb. Muscle relaxation can be achieved at levels less than those needed for mechanical separation (4.5 to 6.75KG, or 10 to 15 lb) in the cervical spine. Progression of dosage at succeeding treatment will depend upon the goals and patient reactions.
2-In lumbar spine a minimum friction free force of half the body weight is necessary for mechanical separation. Some authorities suggest that 1/3 of the body weight should be used for lumbar traction. While some suggests that 60 percent of the body weight should be used for lumbar traction. Generally lumbar traction should be applied in range of 18 to 45KG. To avoid treatment soreness, the first treatment should not exceed half the patient weight. Progression of dosage at succeeding treatment will depend upon the goals and patient’s reaction.

There are controversies that exist between different literatures regarding the dosage applied for the spinal traction. Opinions vary among different authorities.
Have a look over a very useful article on Lumbar Traction.

www.thesaundersgroup.com/lumbar.pdf

I think that it will be of help to you. Please feel free to discuss more ideas or views in this regard.

[sanagupta]

Hi!
Thanx for the reply and the pdf document provided was quite helpful,but it seems to me that if lumbar traction has to be effective then the half of body weight must be used ...but i used merely 15 kgs that too fora person weighing 70kgs.So,in my view lumbar traction was almost ineffective,my technique mqy be wrong but his pain aggrevated with the traction provided by other therapists also(he went to almost 4 therapist)...so why was his pain aggrevating to the extent that he could not sleep at night.....

Thanx ones again for ur valuable info
Regards
Sana

[sdkashif]

Well! If the patient has the weight of 70 KG, then you should try the 35 Kg of traction instead of 15 KG. 15 KG is too small weight to produce any therapeutic effects. Usually the lumbar traction applied is in range of 18 to 45 KG. AND 15 KG is not in that required range. That is the main problem here. So you should use the right weight to produce the effects. MOREOVER, make sure that foot end is raised while using the continuous traction.

Have a good day there.

[sanagupta]

Hello!
Thanx for ur prompt reply.I was giving traction in 90-90 position.I''ll try giving it in foot end elevated position..can u please tell..how does that help.
Thanx once again.As i can feel that u have done extensive work on traction..i'll like to know if a person has unilateral weakness of abduction,flexion (disc prolapse at C5-C6)will traction help once full range is gained and patient can do 10 rep.both ways....or is it just the muscle weakness...prolapse is 45 days old...when she complained of marked weakness in right arm and pain ,affected movements were flexion and abduction
Regards
Sana

[sdkashif]

Thanks for your enquiry. Well if you want to enquire about the role of traction in cervical disc lesion. The answer is that cervical traction will definitely help in relieving the signs and symptoms of the root compression. For more information see my reply on cerical disc lesion elswhere in this forum.

For detail studies see the best availabe texts on the subject. These are

Therapeutic Exercise Foundations and techniques third edition by Carolyn Kisner & Lynn Allen Colby

Textbook of orthopaedic medicine by Cyriax/Coldham Vol II Treatment by manipulation massage and injection 11th Edition.

Mobilization of the Spine A Primary handbook of clinical methods By Gregory P. Grieve Fifth Edition.

If there is weakness in the upper limb. Perform a manual muscle testing and do the grading the musces. Use the graded active ROM exercises to maintain and increase the strenght in the upper limb muscles. In the mean time treat the main problem there in cervical spine. Use modalities like SWD, Ultrasound therapy and microwave diathermy, etc to relive the pain and inflammation and oedema aroung the affected nerve roots in cervical spine. Avoid Acitive exercises of spine in acute stage. Use Isometric exercises in the beginning.

I think that it will be of help to you.

[sanagupta]

Hello!
Thanx for ur reply..cervical patient does not have any pain in neck or radiating in arm..its just tireness that sets in after 10 or 15 rep...I'll definately go thru the text suggested...Will keep u posted about the patients recovery...Once again thanx for ur prompt reply.
Regards
Sana

[jerryhesch]

Regarding lumbar traction. It sounds like the client is still in the acute phase and is simply not ready for traction, if you have tried the modifications already suggested. A minimum of 6 weeks for early scar formation is required, sometimes much longer. For each phase of healing it is appropriate to ascertain whether he/she tolerates flexion or extesnion and if too symptomatic it may be that neutral is the only posture tolerated at this time without adding additional stress via position or traction. The literature can come across as idealistic and clinical reality can be different. MRI's are not perfect tests, they have false positives and false negatives. I have had several over the course of 11 years and can state the same with regards to radiographs and CT scans-there is some common ground in serial tests and there is also a wide range in the Radiologist's report. With respect to your client, it might be appropriate to slow it down, reduce short term expectations and cotinue with a common-sense gentle approach. If pain is severe and protracted, communication with referring physician is essential. Perhaps an epidural will help, ongoing patient education is essential. These are a few "off the cuff" thoughts. Additional medical testing may be waranted, rare pehnomenon like discitis could be at work, requiring anti-biotics.
Best of luck.
Jerry hesch, MHS, PT

[bhani]

Hi i read about your doubt i think you should try NTT as it helps in radiating pain also you take a look at the SI joint coz even though there is a disc protrusion there maybe a impingment there also look out for piriformis tightness the Sciatic nerve gets caught up there also.

[sdkashif]

Thanks for your valuable reply. Well I can understand your doubts of radiological studies. It is not always happen that clinical signs correlate with the radiological studies. But I think that at present best availbale data is from MRI from which we can assess the pathological improvement in the soft tissue recovery. And in other words what will be the other reliable criteria of assessing the response to treatment as we all know the signs of clinical recovery some times also don't correspond to the radiological data. In general in clinical studies usually there is strict criteria used with great competence of the all medical professionals involved making the chance of error to minimum. Looking forward to hear more useful comments from you.

[wernerspine]

Why do you continue trying traction?>???
Listen to your patient. Previous treatments included traction that agravated the back?
The management of patients conditions are not a recipe approach, from your subjective and objective examination you make a decision of what type of treatment s/he will benefit most.
Of course use an evidence base approach.

[sanagupta]

Hello all,
Hi Bhani...i have ruled out the involvement of SIJ,piriformis tightness.As far as NTT is concerned it reall y aggrevated his pain....
hi wernerspine..I discontinued traction the very first day,tried using traction only after 15 days only wen his symptoms reduced..but as it aggrevated again i never used it again..i was wondering why traction increased his pain...what went wrong,that was strange thing that i came across ????
Lastly read this forward Sdkashif....]



Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain
Maureen C. Jensen, Michael N. Brant-Zawadzki, Nancy Obuchowski, Michael T. Modic, Dennis Malkasian, and Jeffrey S. Ross


ABSTRACT

Background The relation between abnormalities in the lumbar spine and low back pain is controversial. We examined the prevalence of abnormal findings on magnetic resonance imaging (MRI) scans of the lumbar spine in people without back pain.

Methods We performed MRI examinations on 98 asymptomatic people. The scans were read independently by two neuroradiologists who did not know the clinical status of the subjects. To reduce the possibility of bias in interpreting the studies, abnormal MRI scans from 27 people with back pain were mixed randomly with the scans from the asymptomatic people. We used the following standardized terms to classify the five intervertebral disks in the lumbosacral spine: normal, bulge (circumferential symmetric extension of the disk beyond the interspace), protrusion (focal or asymmetric extension of the disk beyond the interspace), and extrusion (more extreme extension of the disk beyond the interspace). Nonintervertebral disk abnormalities, such as facet arthropathy, were also documented.

Results Thirty-six percent of the 98 asymptomatic subjects had normal disks at all levels. With the results of the two readings averaged, 52 percent of the subjects had a bulge at at least one level, 27 percent had a protrusion, and 1 percent had an extrusion. Thirty-eight percent had an abnormality of more than one intervertebral disk. The prevalence of bulges, but not of protrusions, increased with age. The most common nonintervertebral disk abnormalities were Schmorl's nodes (herniation of the disk into the vertebral-body end plate), found in 19 percent of the subjects; annular defects (disruption of the outer fibrous ring of the disk), in 14 percent; and facet arthropathy (degenerative disease of the posterior articular processes of the vertebrae), in 8 percent. The findings were similar in men and women.

Conclusions On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.

The lifetime prevalence of low back pain is approximately 80 percent; 31 million Americans have low back pain at any given time1. In the United States, low back pain is second only to the common cold as the reason patients cite for seeking medical care. The estimated cost of medical care for patients with low back pain exceeds $8 billion annually2. Although there has been no increase in the incidence of this problem, over the past 30 years the rate of disability claims related to low back pain has increased by 14 times the rate of population growth1.

The relation between abnormalities in the lumbar spine and low back pain is controversial. Previous autopsy studies, as well as myelography, computerized tomography (CT), and magnetic resonance imaging (MRI), have shown abnormalities in a substantial number of people without back pain3,4,5,6,7,8. A recent study using MRI reported a high prevalence of disk herniation in people without symptoms and urged caution in relating symptoms to such lesions,6 although the nomenclature was not precise. The term "herniation" can be used to describe a wide spectrum of abnormalities involving disk extension beyond the interspace, from a bulge to a frank extrusion; therefore, the reported data on the prevalence of herniation can be misleading. Well-defined morphologic terms may be more useful in describing this abnormality and may correlate better with symptoms.

Using a well-defined morphologic nomenclature, we examined the prevalence of abnormal disks as well as other findings in MRI examinations of the lumbosacral spine in people without back pain. In addition, we correlated the level of physical activity by the study participants with disk abnormalities.

Methods

We studied 98 people (50 men and 48 women) without symptoms of back pain, from 20 to 80 years old (mean age, 42.3 years). Volunteers were recruited by distributing flyers in the hospital, mailing an announcement to all staff physicians, and advertising in the hospital newspaper. Participants did not need to be affiliated with the hospital. Applicants completed a consent form approved by the Investigational Review Board and were interviewed by one of us. Those with a history of back pain lasting more than 48 hours or any lumbosacral radiculopathy were excluded (about 20 patients). To reduce bias in the interpretation of the MRI scans, abnormal scans from 27 people with back pain were selected and mixed randomly with the scans from the 98 people without symptoms.

The level of physical activity was scored as follows: 0, no exercise; 1, occasional exercise (less than weekly); 2, weekend exercise; 3, workouts three or four times a week; and 4, workouts five or more times a week or regular workouts that included strenuous activity such as weightlifting or horseback riding.

All MRI scans were obtained at Hoag Memorial Hospital with 1.5-T imagers (Signa, General Electric, Milwaukee; and Magnetom SP4000, Siemens Medical Systems, Iselin, N.J.). The studies consisted of four spin-echo sequences: a coronal localizer with a repetition time and echo time (TR/TE) of 400/15 msec, a sagittal view with a TR/TE of 300-600/11-23 msec, an axial view with a TR/TE of 700-900/11-15 msec, and a sagittal view with a TR/TE (dual-echo sequence) of 2500-2600/16-21 and 90-105 msec. Technical specifications included a slice thickness of 3 and 4 mm for sagittal and axial sequences, respectively; a field of view of 26 and 20 cm for the sagittal and axial images, respectively; and a matrix of 192 by 256. The T1-weighted axial sequences were stacked slices extending from the inferior aspect of L3 through the inferior aspect of S1. There were two excitations for the T1-weighted axial and sagittal images, with one excitation for the T2-weighted sagittal images.

All studies were read at the Cleveland Clinic by two experienced neuroradiologists familiar with the MRI imagers used. The readers did not know the clinical status of the subjects. All identifying information and dates were obscured. Readings were carried out in groups of 9 to 11 studies per session, which included 1 to 4 studies from people with symptoms. The readers independently evaluated the status of the 5 intervertebral disks in the lumbosacral spine in all 125 subjects (a total of 625 disks).

The terms used to classify disks were defined as follows: normal, no disk extension beyond the interspace; bulge, circumferential symmetric extension of the disk beyond the interspace (around the end plates); protrusion, focal or asymmetric extension of the disk beyond the interspace, with the base against the disk of origin broader than any other dimension of the protrusion; and extrusion, more extreme extension of the disk beyond the interspace, with the base against the disk of origin narrower than the diameter of the extruding material itself or with no connection between the material and the disk of origin. This terminology was selected on the basis of the findings of a companion study that evaluated interobserver and intraobserver variability when different nomenclatures were used to describe disk abnormalities in the same 125 MRI studies. In that study, all scans were read independently at least twice by the two neuroradiologists (evaluator 1 and evaluator 2), with a minimum of two weeks between the readings. The data in the current study are based on the second reading in the companion study, in which the terms we selected (normal, bulge, protrusion, and extrusion) were used for the first time. With these definitions, an interobserver agreement of 80 percent (for all 125 subjects) was found (kappa = 0.59)9.

Nonintervertebral disk abnormalities were assessed on the basis of a consensus by two other readers at Hoag Memorial Hospital. The following abnormalities were recorded: Schmorl's nodes, facet arthropathy, spondylolysis, spondylolisthesis, annular defects, and stenosis of the central canal or neural foramen. The criteria for stenosis of the central canal and neural foramen were obliteration of the epidural fat with flattening of the thecal sac and obliteration of the perineural fat, respectively10.

For statistical analyses, the prevalence of disk abnormalities observed by the two readers was determined according to the subjects' @#%$, age, and physical-activity score, with the use of a generalized linear model for correlated binary data11. All tests of significance were two-tailed.

Results

Table 1 summarizes the prevalence of disk bulges, protrusions, and extrusions in the MRI studies. With the results of the two readings averaged, 52 percent of people without symptoms had a bulge at at least one intervertebral disk, 27 percent had a protrusion, and 1 percent had an extrusion. Thus, 64 percent of these people without back pain had an intervertebral disk abnormality, and 38 percent had an abnormality at more than one level.

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&nbsp &nbsp &nbsp &nbsp Table 1. Prevalence of Bulges, Protrusions, and Extrusions on MRI Scans in 98 Asymptomatic Subjects and 27 Symptomatic Subjects.


The prevalence of bulges and protrusions according to the age of the subjects and the location of the abnormalities in the intervertebral disk space are presented in Table 2 and Table 3. The prevalence of bulges and protrusions was highest at L4-5 and L5-S1; there were few abnormalities at L1-2. The MRI scan of an asymptomatic subject with a disk protrusion and its schematic representation are shown in Figure 1. No significant relation was found between @#%$ and the prevalence of bulges (data not shown) or between age and the prevalence of protrusions (Table 3). The prevalence of disk bulges increased with age (P<0.001) (Table 2), and this trend was present for each disk level. Figure 2 shows a circumferential disk bulge. Age was also significantly associated with the presence of more than one disk abnormality. Sixty-seven percent of the 27 people who were 50 years of age or older had multiple abnormalities, as compared with 27 percent of the 71 younger participants (evaluator 1, 20 of 27 older subjects vs. 21 of 71 younger subjects; evaluator 2, 16 of 27 vs. 18 of 71; P<0.001).

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&nbsp &nbsp &nbsp &nbsp Table 2. Number of Subjects with Bulges, According to the Age of the Subject and the Location of the Bulge.


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&nbsp &nbsp &nbsp &nbsp Table 3. Number of Subjects with Protrusions, According to the Age of the Subject and the Location of the Protrusion.



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&nbsp &nbsp &nbsp &nbsp Figure 1. A Disk Protrusion in a 24-Year-Old Woman without Back Pain.

The T2-weighted sagittal image (TR/TE, 2500/102 msec) (Panel A) shows an L5-S1 protrusion (black arrow) with a small annular defect, as evidenced by the focus of high signal intensity at the posterior disk margin (white arrow). The T1-weighted axial image (TR/TE, 800/11 msec) (Panel B) shows the left paracentral disk protrusion, with subtle posterior displacement of the left S1 nerve root (arrow). A schematic axial representation (Panel C) depicts the left paracentral disk protrusion.



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&nbsp &nbsp &nbsp &nbsp Figure 2. A Disk Bulge in a 21-Year-Old Man without Back Pain.

The T2-weighted (TR/TE, 2500/102 msec) image shows a midline sagittal section through a circumferential disk bulge at L5-S1 (black arrow). In addition, the small focus of high signal intensity at the posterior margin (white arrow) is compatible with a small annular fissure.


The prevalence of disk abnormalities varied little with the physical-activity score. However, among the 48 people who exercised regularly (a score of 3 or 4), the prevalence of protrusions at L5-S1 was 16 percent, as compared with 4 percent among the 50 people who were more sedentary (evaluator 1, 8 of 48 people who exercised regularly vs. 3 of 50 who were more sedentary; evaluator 2, 7 of 48 vs. 1 of 50; P = 0.05).

The most common nonintervertebral disk abnormalities in people without symptoms were Schmorl's nodes (herniation of the disk into the vertebral-body end plate), in 19 percent of the subjects; annular defects (disruption of the outer fibrous ring of the disk), in 14 percent; and facet arthropathy (degenerative disease of the posterior articular processes of the vertebrae), in 8 percent. Seven percent of the asymptomatic subjects had spondylolysis, 7 percent had spondylolisthesis, 7 percent had stenosis of the central canal, and 7 percent had stenosis of the neural foramen.

Discussion

We found a high prevalence of abnormalities in the lumbar spine on MRI examination of people without back pain. Only 36 percent of those examined had a normal disk at all levels. About half had a bulge at at least one intervertebral disk, and about a quarter had at least one disk protrusion. Given the high prevalence of back pain in the population, the discovery of a bulge or protrusion on an MRI scan in a patient with low back pain may frequently be coincidental. Therefore, the clinical picture should be correlated with the MRI results. Abnormalities of the lumbar spine by MRI examination can be meaningless if considered in isolation.

Only a small number of the asymptomatic people we studied had disk extrusions on MRI examination. Appropriate statistical comparisons of people with symptoms and those without symptoms cannot be made from our data, because the scans for those with symptoms were selected retrospectively. However, our data are consistent with the hypothesis that the prevalence of extrusions in people with symptoms of back pain may be substantially higher than in people without symptoms. Previous studies using CT and MRI5,6 did not distinguish between protrusions and extrusions. The term "herniation" may be too generic for clinical relevance. Classification of protrusions and extrusions may be more helpful in characterizing the findings.

The presence of disk abnormalities in the lumbar spine of asymptomatic people is well known. In a study of 33 people presumed to have been free of back pain, postmortem examination of the entire spine showed a 39 percent prevalence of posterior disk protrusions4. In another study, 24 percent of 300 myelograms in people without symptoms showed abnormalities of the lumbar disk3. Wiesel et al. used CT to examine 52 people without symptoms and found the prevalence of herniated disks to be 19.5 percent in people under the age of 40 years and 26.9 percent in those over the age of 405; however, only the L4-5 and L5-1 intervertebral disks were evaluated6. In our study, one third of the participants had disk extensions beyond the interspace at the L1-2, L2-3, or L3-4 levels. Using MRI in 67 people without symptoms, Boden et al. found herniated disks in 20 percent of the people less than 60 years old and in 36 percent of those 60 years of age or older6. In another study, MRI examination of 41 women without symptoms showed that 54 percent had a disk bulge or herniation at one or more disk spaces,8 although only L3-4, L4-5, and L5-1 levels were examined.

In our study, the prevalence of disk bulges, but not protrusions, increased with age. Since protrusions are less common than bulges, a larger study might have demonstrated a similar association between age and protrusions.

Annular "tears" may be painful, possibly because of leakage of the contents of the nucleus pulposus into the epidural space, with related nerve irritation12. Annular defects have been demonstrated by MRI13. The 14 percent prevalence of annular defects in our study may be an underestimate. The reported prevalence of posterior radial tears at autopsy in asymptomatic people is 40 percent for those between the ages of 50 and 60 years and 75 percent for those between 60 and 7014. Annular tears may lead to disk degeneration15. In our study, all the disks with annular fissures also had a decreased signal on the T2-weighted image, and all but one had an associated bulge or protrusion. These findings support the contentions that annular defects are generally associated with disk degeneration and that such defects are frequently asymptomatic.

Abnormalities other than disk disease, such as facet arthropathy, have been cited as an important and often overlooked source of low back pain and sciatica. Abnormal facets can be injected with corticosteroids. Our study underscores the difficulty of establishing facet disease as the source of pain, since 8 percent of our subjects without back pain had facet arthropathy.

In conclusion, on MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions. Because bulges and protrusions on MRI scans in people with low back pain or even radiculopathy may be coincidental, a patient's clinical situation must be carefully evaluated in conjunction with the results of MRI studies.

Supported by grants from Hoag Memorial Hospital and the Harbor Radiology Research and Education Fund.


Source Information

From Hoag Memorial Hospital, Newport Beach, Calif. (M.C.J., M.N.B.-Z., D.M.); Riverside MRI, Riverside, Calif. (M.C.J.); and the Cleveland Clinic, Cleveland (N.O., M.T.M., J.S.R.).

Address reprint requests to Dr. Brant-Zawadzki at Hoag Memorial Hospital, Department of Radiology, 301 Newport Blvd., Newport Beach, CA 92663.

References

1. Robertson JT. The rape of the spine. Surg Neurol 1993;39:5-12.[Medline]
2. Deyo RA, Tsui-Wu Y-J. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine 1987;12:264-268.[Medline]
3. Hitselberger WE, Witten RM. Abnormal myelograms in asymptomatic patients. J Neurosurg 1968;28:204-206.[Medline]
4. McRae DL. Asymptomatic intervertebral disc protrusions. Acta Radiol 1956;46:9-27.
5. Wiesel SW, Tsourmas N, Feffer HL, Citrin CM, Patronas N. A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine 1984;9:549-551.[Medline]
6. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects: a prospective investigation. J Bone Joint Surg [Am] 1990;72:403-8.
7. Powell MC, Wilson M, Szypryt P, Symonds EM, Worthington BS. Prevalence of lumbar disc degeneration observed by magnetic resonance in symptomless women. Lancet 1986;2:1366-1367.[CrossRef][Medline]
8. Weinreb JC, Wolbarsht LB, Cohen JM, Brown CEL, Maravilla KR. Prevalence of lumbosacral intervertebral disk abnormalities on MR images in pregnant and asymptomatic nonpregnant women. Radiology 1989;170:125-128.[Abstract]
9. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159-174.[Medline]
10. Helms CA. CT of the lumbar spine -- stenosis and arthrosis. Comput Radiol 1982;6:359-369.[Medline]
11. Liang K-Y, Zeger SL, Qaqish B. Multivariate regression analysis for categorical data. J R Stat Soc [b] 1992;54:3-40.
12. McCarron RF, Wimpee MW, Hudkins PG, Laros GS. The inflammatory effect of nucleus pulposus: a possible element in the pathogenesis of low-back pain. Spine 1987;12:760-764.[Medline]
13. Yu SW, Sether LA, Ho PSP, Wagner M, Haughton VM. Tears of the anulus fibrosus: correlation between MR and pathologic findings in cadavers. AJNR Am J Neuroradiol 1988;9:367-370.[Abstract]
14. Hirsch C, Schajowicz F. Studies on structural changes in the lumbar annulus fibrosus. Acta Orthop Scand 1952;22:184-231.
15. Yu S, Haughton VM, Sether LA, Ho K-C, Wagner M. Criteria for classifying normal and degenerated lumbar intervertebral disks. Radiology 1989;170:523-526.[Abstract

[zaofer2000]

maitland recommend rotation movements (not pa) in the EOR short and slowly when you have irradiated pain, pain stress after some activities may be that you need to learn your client neural tissue movements exercises (maitland, buttler...)

[sanagupta]

Hello...
Sorry i could not understand what u want to say..can u please elaborate.
I had checked with neural mobility of my client, with treatment improved to SLR 70 degrees..
EOR?
Regards
Sana

[waleedtawfiq]

Dear Sana
I think you face with chronic pain, in this case you need to change your approach to this patient as it is important to consider the same thing in all patient.Now the pain is accepted as multidimenssional concept,BioPsychoSocial. involve in your team if you work in the hospital Psychologist to assess his Psychology condition, occupational therapist to assess his Social aspect of the pain and Biological aspects you already done.
Regarding to the treatment you applied was fine in my openion the only thing is the pain you have to stop it as soon as possible, because your patient will lose his confidance about your ability to fix his problem.As you mentioned he was treated by PT before but there was no progress and this might affect his believe on the ability.If you can't just send him to pain management programme and they will cover all the aspect of the pain.As rehabilitation I think after hotpack you can do SLR gradually by streching the Hamstrings Muscles with motivation of the patient to relax with deep breath, and try please to know your patient verywell. and see if he still trust on you.Hope this well be helpful otherwise just send him to any pain clinic to assess all the aspects of the apin and its effect.good luck:rollin

[sdkashif]

Dear Sana, Hi

Have a look over this article to get more detail about the cervical traction role in relieving the root compression symptoms due to desic lesion.

www.thesaundersgroup.com/cervical.pdf

[friendlypain]

Hi Sana,

There are three things that come to mind when traction of the lumbar spine produces pain. Quadratus Lumborum, Psoas, and a dural or plexus adhesion/injury. QL and Psoas splinting of the lumbar spine is always a factor when dealing with acute pain. In fact PSOAS IS EVIL and the source of almost all shear injuries in the lumbar spine (IMHO). What I would do in your situation is to simply activate the stretch reflex without lengthening the muscle (as this will cause it to splint the minute the patient attempts to move) in iliacus and psoas. The pain should be decreased after that technique. Now if you would do a traction after that technique is up to you. The less stimulus the lumbar spine receives at this point the better though. If the brain even thinks that there is going to be some kind of unforseen force going through that area, psoas will contract hard and splint the lumbar spine.

QL splinting and dural/plexus injuries and adhesions should be considered only after the psoas release has been attempted because, as I have said before, PSOAS IS EVIL!!!!!!!!!

Adamo

[sanagupta]

Hi!
THanx for ur suggestion ...and i think it really explains the reason for increasing his pain...as QL did increase his pain...neck movements also increased his pain at the referred site sometimes...
any further explanation u'll like to give
Anyways thanx

Regards
sana

[friendlypain]

Hi Sana,

I dont have anything specific for you right now in terms of studies but I will give you my professional understanding of the whole acute, then subacute, lumbar spine pain.....

I do agree that a bulge will not always cause an issue. In fact... I am not sure why X-Rays and MRI's of the lumbar spine are done at all if the disks have been continously compressed and torqued throughout the day. Degenerative disk disease is such a layman diagnosis and shows either the lack of experience or lack of knowledge that the professional employed to make that diagnosis (oooops... rant). Maybe I'll start a different thread on this subject.....:eek

Any insult in the lumbar spine will cause protective splinting to protect it from further insults. One must remember what force is going through the lumbar (and cervical) spine.

This is where things get a little complicated so I will define the major forces. Compression ("squishing" together) which bones resist quite well, Tension (pulling away) which muscles resist fantastically, and Shear (force that is parallel to the surface) which collagen fibers are supposed to be able to resist with some degree of success.

Bones loaded in Bending are subject to compression on one side (which it resists easily) and tension on the other (which it cannot withstand and fractures). Bones loaded in Torsion develop inner shear stress with the maximal stress in the periphery and the least/no stress in the centre.

Muscles are viscoelastic (which means it is extensable and elastic over time) and irritable ( :lol it's a long night) because it can respond to stimulus. Now that stimulus is either electrochemical (ie action potential) or mechanical. If the stimulus is strong enough the muscle responds by developing tension. When a stimulated muscle develops a tension, the amount of tension present is the same throughout the muscle and tendon and at the site of the tendon attachment to bone. So, if a muscle is a kilometer long and develops tension, the tension is the same the ENTIRE kilometer. Even if the cause is limited to a small area.

So... I am sure the pieces are coming together now. When the lumbar spine is under tension (a very unnatural position and potentially very dangerous in terms of resisting force) the brain freaks out and tries to prevent it by developing tension in the muscles with attachments in the area stimulated. This is why there is a brief moment of tension before the patient regains control of the muscles and relaxes. If the brain freaks out and the patient can not reassert control then a painful splint occurs where the muscle prevents further tension.

Why would the brain freak out? Shear is a very scary force that the lumbar spine NEVER wants to experience. If there is compression and shear at the same time, the force is almost to much for the body. Add torsion and we are looking at a surgery date. What does this have to do with putting the lumbar spine in traction. If a joint is unstable due to acute inflammation and it is put into traction, the muscles that are protecting it from further forces are placed into a stretch. Since a muscle is viscoelastic, it will become more stretched and more loose and less protective of the joint if stretched over time and it will not have the necessary tension to contract forcefully and quickly enough to counteract unforseen forces. That's why it freaks out... it knows the joint will be unstable and vulnerable to more serious injury.

When the joint inflammation settles down and enters the subacute phase then the joint becomes slightly more stable but the muscles continue to splint to prevent a relapse. Pain that is felt now by the patient is now mainly coming from the muscles as opposed to the joint and referral pain is more common. As blood flow is restricted by the contracted muscle, it feels cramped and becomes more vulnerable to strain. Trigger points develop because of the lack of oxygen to sustain ATP production and muscle fibers are stuck in contraction. Trigger points shorten muscle fibers which puts them in a position of possible strain injury. A muscle will shorten in order to keep itself comfortable and not put a strain on the trigger points. So, again, when the lumbar spine is put into traction, the muscle will then contract to protect itself from strain which will put added forces on the spine.

This is just forces acting on the spine... god forbid if there is a pain/spasm cycle going on... But since I am sure your eyes are tired and carpal tunnel is settling into my wrists, I'll save it for later. 8o

Hope I did not bore ya
Adamo

[sanagupta]

Hello!
Good piece of information...it really helped me to analyse and put together the knowledge i had.......
I fully agreee with this pain-spasm cycle at work in most of the problems, speacially the spine.....i have seen in most of the patients breaking this cycle is tough ..and once acheived it works wonders...
Regards
Sana

[Johnnyegypt]

I am trying to access this PDF, but unfortunately it seems to have been taken offline. Do you happen to have a copy that you can attach ?
thanks