lower back pain

Had this patient..can u help

33 yr old...runner..c/o LBP muscular L5 level from 3 months...tender on palpation
-On assessment...pain on flexion, mobil spin process..full rom, no pain...no neuro signes...
-Grade 4 lumb extensors...grade 5 abd...otherwise 5 throughout...
-ALso has flat feet..using no orthotics currently

Rx
Advised on flexion to prevent etc..lifting etc
hamstring stretches, knee to chest, rotational stretches in supine lying with knees bent
Strengthening lumbar extensors in prone with 10 sec hold at end of rom.
To continue wearing orthotics for flat feet on running etc.
Heat application 2 times per day..15 mins

What do u think on this treatment, anything else I should test, and anything u would add in Rx.
;)
Thanks guys...much appreciated.

How is his gluteal stability on his stance leg and does he get enough hip extension during prior to toe off?

If he is over compensating due to poor extension he may have:
1. Overactive quads and increased lordosis
2. Tight or overactive psoas, therefore ineffective abs generally
3. Reduced or an imbalance in internal femoral rotation
4. Increased lumbar extension and shearing forces on L4-S1 when running, as a result of 1,2 and 3.
5. If his gluteus medius is not stabilizing on landing or just prior to heal strike on the opposite leg, then he may also be collapsing as he lands. This would decrease the effectiveness of his soleus and eccentric ankle dorsiflexion as it tries to absorb some of the weight bearing forces during heal strike (if in fact he has a heal strike).

I could go on but basically you need to watch this person run. The back pain is likely to be a symptom. The cause is likely to be anywhere from the thoracic spine to the toes and will probably be a combination of a few things.

Take a more in depth look, video him and tell us more

thanks for the chance to assist

:smokin

Add to all of that he might have spina bifida check his X-Ray if so avoid manipulating lumbar spine just add power to extensors of lower back.

What about assessing the presence of active trigger points? Lots of patients with back pain have TP in quadratus lumbar, psoas or gluteus, responsible for pain, although you must consider the cause, but its treatment can be helpful to alleviate the pain

Hi

So..continued to treat the above patient. Saw Xrays and confirmed that problem was Muscular.

Also went to check patient running, no major problems were evident.

The patient said that once he started wearing orthosis back pain diminished drastically. Furthermore,Mobes Grades 1 and 2 (AP) on L4 and L5 leverls helped alot. Heat therapy was continued daily. Massage was given after a number of sessions.

The patient stated that he is feeling much better, and only c/o pain on prolonged standing.Due to his work constarints, he will be stopping physio treatment, but I have advised on a month of hydrotherapy.

Any comments? thanks guys:hat

The commonly undiagnosed aspect of those presenting with low back pain , where pronation is a factor , is the function , or lack thereof of the sacro-iliac joints. As you have seen by your commonsense treatment with mobilisation to relevant lumbar joints , this fellow improved as one would expect. What will remain and cause a return of his problem however is the bio-mechanical consequence of poor or nil function to the pair of SIJ's.
Compressive forces exerted over his mature orthopaedic lifetime have included a vector through the pelvis brought about by pronated foot postures that have quietly seen reduced movements and now probably stiffness to his pelvis.
A test is usefull to confirm. I recommend viewer sitting , patient standing , viewed from behind, attach thumbs to the psis on either side while patient flexes hip and knee to 90 degrees, watch for and feel for movements rearwards of each os innominate as flexion takes place . An immobile joint will have each thumb remain in the same horizontal plane as the pelvis hitches slightly , while a fully mobile SIJ will see the ipsilateral thumb roll downwards and rearwards with innominate movement.
There are three worthwile approaches to restoring sij function . I will mention the best and most valuable last. A manipulation where patient is supine, relaxed and largely unaware of what will follow, therapist holds ankle foot of side to be manipulated and while lulling patient to relax further , suddenly exerts a severe yank to the limb into hip and knee extension. Not recommended for children or the elderly, normal exclusions for hip knee pathology apply. Works well but usually only for the one side as the patient will automatically tense if the other side is approached. ( watch for aggression at this point).
Method 2. Patient side lying , uppermost hip knee flexed to 120 degrees, approach from anterior with one hand on the asis , the other around the ischium , , attempt a strong rearward rotation of os innominate of the upper half of pelvis , good luck , hard work and usually only works on the lighter female and smaller males.
Method 3. Stand on the sacrum with patient in prone , a pillow under the pelvis. Jump up and down holding the wall or suitably stable feature of your treatment couch area. Don't fall off. two thirty second periods should do it. Take your shoes off.
Once normal Sij movements are restored the person needs to understand that orthotic use is not a running thing, they must be worn full time to be effective. Further attention to possible dural tightness and restore full mobility to lumbar facet jonts and this guy will be laughing.
Have fun.

Nick, you're barking mad. Everything is caused by the back, nothing is a peripheral problem and now, to cap it all, we are advised to jump on peoples' SIJ.

How's the repeat business? My guess is that 1-3 sessions of physio with you is enough for most peopleto be looking elsewhere - which you interpret as a full recovery. Hmm.

The methods I outlined earlier do indeed work , with the most effective being the one you have commented on. I ought to amend the word "jump" however. The sacrum and pelvis are remarkably robust structures , easily able to accommodate my 80kgs without injury. The act of mobilising with bodyweight is not for the faint hearted, some guidance from an experienced therapist would be of value. With the foot positioned over the sacrum, repeated emphasis is provided by a downward force , mediated by alternate extension and flexion of therapists knee. The other foot is placed over the dorsum of the foot connected to the sacrum. For the less robust patient, the other two methods will work , but require levels of cooperation and strength that make them a poor second to bodyweight mobs.
If you are having a fit about these treatments , you would go into spasms watching me stretch dura. These are treatments I read about in Maitland's book years ago. Not sure which one now, but is well described by him, having been written at a time when Geoffrey Maitland was thought of as the ultimate authority on joint function and movement therapies. I see no reason to alter my affection for these safe and effective treatments, It works, patient tolerance is good with proper education and follow up. Most importantly the effect of a full restoration of SIJ function cannot be ignored.

At the end of the day, it's whatever works I guess, as long as the patient gets better and is happy. I still can't see myself (100kg) standing on my client's back, too reminiscent of the Thai massage most of my clients will have experienced.

Following approach should be followed while managing the patient with low back pain. First try to rule out all the possible serious causes of low back pain like Benign and malignant primary and neural osseous tumors, Infection (e.g., epidural, subdural, intradural abscesses, discitis, peritonitis, and osteomyelitis), metastatic neoplasms, myeloma, trauma like lumbar fractures, metabolic disorders like osteomalacia, parathyroid disease, vitamin B-12 or folic acid deficiency, developmental and congenital disorders like scoliosis, psychogenic like conversion disorder, malingering, extra spinal causes like renal infection and stones, ovarian cyst, pancreatitis, ulcer, aortic aneurysm, etc. Having assumed serious causes have been ruled out, the treatment should be followed as under:

1-Control of pain and inflammatory process

Treatment for the control of pain can be started early and efficiently. Ice, Superficial and deep heating methods like Infrared rays, electrical heating pads, hot packs, moist heat packs, ultrasound therapy, Shortwave Diathermy, microwave diathermy, LASER, transcutaneous electrical nerve stimulation (TENS), Interferential current, Iontophoresis and relative rest may help with controlling the pain and the inflammatory process. Relative rest, which restricts all occupational and avocational activities, for up to the first 2 days following an acute episode, may be indicated to help calm initial pain symptoms. Rest for longer periods of time has not been shown to be beneficial and can cause deconditioning, loss of bone density, decreased intradiscal nutrition, loss of muscle strength and flexibility, and increased segmental stiffness. Passive modalities are valuable during the initial 48 hours of relative rest to aid in pain relief

2-Restoration of joint range of motion and soft tissue extensibility

Extension exercises may reduce the neural tension. An extension bias commonly is employed to help reduce intradiscal pressure. Flexion exercises reduce articular weight-bearing stress to the facet joints and stretch the dorsolumbar fascia.

If sponylolisthesis and/or spondylolysis are present, then improving abdominal strength and flexibility, stretching of tightened hamstring to reduce lumbar lordosis and pelvic tilt exercises are of value. Exercise for improving the strength and endurance of pelvic floor muscle are valuable if there is there is reported weakness of these muscles.

In case of spinal stenosis flexion exercises for the lumbar spine should be emphasized, as they reduce lumbar lordosis and decrease stress on the spine. Spinal flexion exercises increase the spinal canal dimension, thus reducing neural canal. Williams' flexion-biased exercises target increased lumbar lordosis, paraspinal and hamstring inflexibility, and abdominal muscle weakness. These exercises incorporate knee-to-chest maneuvers, pelvic tilts, wall-standing lumbar flexion, and avoidance of lumbar extension. Furthermore, strengthening exercises for abdominal, weak glutei, Quadriceps femoris are helpful. In addition stretching exercise for tightened hip flexors and hamstrings should not be ignored. Longer walking times on an inclined treadmill, stationery cycling, promotes spinal flexion.

3-Improvement of Muscle strength and endurance

Once the adequate control of pain has been achieved the emphasis should be towards gaining the adequate control of musculoligamentous lumbar spine forces to minimize the risk of repetitive injury to intervertebral discs, facet joints, and surrounding structures. Start with the isometrics, then progress to isotonics with effort directed at concentric strengthening.

The spine should be stabilized using strengthening of segmental muscles followed by the prime movers of the spine (latissimus dorsi, abdominals, and erector spinae). Muscle groups should be strengthened in a neutral position to decrease tension on ligaments and joints; this position allows balanced segmental forces between the discs and the zygapophyseal joints and maximizes functional stability with axial loading. The main goal of physical therapy in acute back pain is not to increase strength, but to achieve adequate pain control. No benefit has been demonstrated for strengthening exercises in acute back pain. Exercise should begin with extension exercises in prone position. Flexion exercises can be performed only if no acute dural tension exists.

4- Coordination training
Assess the gait of the patient and try to improve the coordination of the patient. Dynamic exercise in a structured training program maximizes coordinated muscle group activities that lead to postural control and the fusion of muscle control with spine stability.

5-Improvement of general cardiovascular conditioning
Try to improve the conditioning of the cardiovascular system. Aerobic exercises serve best in this regard. Activities like bicycling, stair stepping, brisk walking, aquatics, rowing should be encouraged. These activities raise the endorphin level, create a sense of well being and attain high level function of the patient, thereby maintaining the fitness of the patient.

6-Maintain the exercise programme
Maintenance of the exercise programme is very important for the patient to do at home. This is developed according to patient own tolerance and ability.

7-Correction of the perpetuating factors
An analysis should be made to find all the possible predisposing factors and a resolution plan should be made to correct these discrepancies. Abnormal posture, bad lifting habits, abnormal working position should be analyzed and corrected.

Quote
"A manipulation where patient is supine, relaxed and largely unaware of what will follow, therapist holds ankle foot of side to be manipulated and while lulling patient to relax further , suddenly exerts a severe yank to the limb into hip and knee extension."
Question: Does this qualify as informed consent to treatment?

Quote:
"These are treatments I read about in Maitland's book years ago. Not sure which one now, but is well described by him, having been written at a time when Geoffrey Maitland was thought of as the ultimate authority on joint function and movement therapies."

I trained in Adelaide in Maitland techniques. I cannot recall technique 3 in any of his texts "Practical Orthopedic Medicine", or "Vertebral Manipulation," (which I still have) nor in any of his journal articles. Are you aware of anything else?

Dear Ozben, Hi!

It's really good to have a discussion on the subject of manipulation. Let me add further. How can you compare the techniques described by James Cyriax and G.P.Grieve in their popular books.

Any way keep it up dear colleagues.

I am curious to know how a disc problem can be excluded through viewing X-rays?

The disc problems are usually diagnosed by a skilled and routine subjective and objective clinical examination.

The changes seen on X-rays are usually non specific. These are usually straigthening of the curve of spine in the suspected region. Some times but not usually there is reduced disc height in between the affected vertebral segment indicating severe disc lesion.

I think that it will be of help to you.

Let me add further here.

X-Ray changes are non specific regarding the disc lesions. However, X-rays are usually required to rule out the other pathologies like fractures, mechanical derangements like spondylolisthesis, spodylosis, spondlolysis, diffuse idiopathic skeletal hyperostosis (DISH), inflamatory arthropathies like Ankylosing spondylitis showing fusion of SIJ, congenital anomalies like hemivertebra, spina bifida, measuring the degree of scoliosis or kyphosis, watch the osteolytic or osteosclerotic lesion indicating bone tumours, vertebral collapse due to osteomyelitis, potts disease ( to assess the psoas abscess), etc.

Spinal X-Rays in a patient with back pain are required if the pain:

a- Start before the age of 20 and after 50 years
b- is persistent and a serious cause is suspected.
c- is worse in the night and in the morning, when an inflammatory arthritis(e.g. Ankylosing sponylitis), infection or a spinal tumour may be the cause.
d- is associated with a systemic illness, fever or weight loss
e- is associated with neurological symptoms and signs.

Spinal myelography, CT Scan both contrast or plain, MRI of spinal provide better and detailed interpretation of soft tissue and bony tissue.

I think that it is sufficient to make the discussion more clear. Any more ideas are welcomed.

Regarding the suggested mobilization to the SI via standing on the sacrum. Mobility restriction of the sacrum can be evaluated and treated in flexion, extension and neutral and treated in same position, based on passive motion testing. Common restrictions are: pure left and right rotation about a pure vertical axix, side bending R/L, combined rotation and side bending about an oblique R/L axis, pure anterior glide, pure posterior glide (this will lock all accessory SIJ motions), forward and backward bending, and in cases of significant trauma/significant hypermobility can have obliqu glides or lateral tilt (medial glide applied to S4-5 which is distinctly different from side bending). I have never found pure R/L side glide motion /motion restriction. In the presence of one direction of blocked mobility, the opposite direction is often hypermobile. These are the typical day to day presentations and there are exceptions in which hypermobility or hypomobility aremore global. Treating the hypo is quite rewarding as the hypo also reduces, bringing both directions towards the norm. The sacrum and the ilium/illia and symphysis pubis, sacrococcygeeal and L-S joints and hip are inextricably linked and must be evaluated and treated as a unified whole. Furthermore, I never treat an SI or pelvis without seeking out the compensatory pattern that is often found at the Occipitoatlantal region. The talo-crural and subtalar joints are often also involved and if restrictions are present (such as supinatory fixation) can be addressed with sequential mobilization as the pattern permutates with approriate follow up (to mobilization) exercise.The point I am making is that general mobs to the sacrum without a clear and concise evaluative rationale will provide limited results. The viscoelastic nature of the SI of course must be addressed appropriately.
Jerry Hesch, MHS PT
www.heschmethod.com

hi....iwas recenly diagnosed with spina bifida...i. have very severe backache n m havin problems in my knee joint while walking...i want to know wat specifically i should n should not do...while excersizing as m a bit overweight...can i go for walking or jogging or swimming

I think the fact that he still gets pain in his lower back after a prolonged standing is still cause for concern, this is not normal for most people. fatigue could be an issue with him so as sdkashif said endurance and also core work might work well with this chap. get some TA activation and pelvic stability into the mix as well as mobilising through the region. doing fascial work though a hypertonic psoas can often give great results when treating chronic LBP. Squish, stork, active extension whilst prone and trendelenberg should give you a general idia of his hip stability and any restrictions or imbalances within the lumbopelvic region. put him back in the oven, this guys not done yet!!!