low back ache (urgent recommendations needed)

hi folks,

i have a patient 22/f with LBP since last 2 years
here are the details,
there is no significant H/o lifting weight or fall etc
pain pattern-c/o pain in the lower lumbar area,(constant pain)
- central pain in lower lumbar region,without any
radiation to LE's.
-prone lying & side ly eases the pain 2 some
extent
-supine ly increases the pain,sitting for 30mins
increases pain

ROM- L.flxn-painful & restricted
L.extn- pain at end range
side flxn-painful b/L
rotn-painful b/L
o/e- mildly increased thoracic kyphosis,slightly decreased lumbar lordosis
no neurological deficit found,
central PA over L4,L5 produces same pain
hams tight b/L, pyriformis tight b/L
SLR- produces same pain(central pain over L4,L5)at
70 degrees b/L
slump test-produces same pain b/L
b/L SLR -produces same pain
stretching of pyriformis also produces same pain

investigations- R factor-negative 4 RA
HLA -neg for AS
X ray-appears normal in AP & LAT views,no osteophytes
treatment-
neural mob in slump posn
central PA over L3-L5-(gr2)
b/L lat PA over s1
mckenzies extn exs , stretching of hams,pyriformis & MET for pyriformis

i have treated pt for 2 seatings,there is no relief as of now.
central PA increases pain that subsides aftr 10 mins but patient doesn't get relieved of her original symptoms .
Am i too vigorous with the treatment.

all suggestions are welcome,
waiting 4 postings immediately

thanking you in advance

What are her abdominal muscles like?

Her breathing patterns?

Does she look rigid?

she has good abdominal muscle power
but putting her 4 abdominal MMT produces same pain(central over L4-L5 region)
accessory movts are not stiff but produce pain.
waiting for your reply.
thanks again.

breathing pattern appears normal-abdominothoracic pattern as seen in females.
no usage of accessory muscles of respiration...

Hi
My plan of action for this type of patient is to exclude muscle tightness away from the symptom area in the Lx. As piriformis is tight, try a very deep piriformis friction massage (even to the point of bruising the skin). The patient must be warned, and be careful if they bruise easily or are on blod thinning medication. It is imperative that gluteal and hamstring stretches are given after the treatment, and even if she is in pain the exercises should be done at home 4-6 times daily, 5 repeats, for at least two days. she must not sit around, but keep moving, or tethering can reoccur. Sometimes a prone knee bend test can indicate that this treatment will be of assistance - but not always.
Also, check the ileopsoas length, and stretch if necessary.

If the above is unhelpful, the problem could be central.
Regards
MrPhysio

Don't worry if no change after 2 visits but try ceasing your flexion bias techniques and conc on a McKenzie maitland approach. Add flexion techniques later as these can initially be provocative. sounds like a regulation presentation that should clear in 3 - 6 weeks with appropriate frequency of treatment and adhering to home programme and postural care.
Hope this helps

I agree with some of the advice given so far i.e ensure that hip mobility is adequate to ensure the lumbar spine is not the site of compensatory mobility. Ensure that you also look at combined hip movements and rotations as these are functional movements. How aggressively you decide to mobilize the soft tissue depends on whether you feel the hip restrictions are myofascial or capsular as different techniques would apply (the most effective way to decide how to mobilize myofascial tissue is always up for debate and some may say that bruising implies excessive force while others may not).

Secondly tell us more about HOW the patient flexes and extends not just whether there is pain i.e the lumbo-pelvic-hip rhythm e.g excessive lumbar contribution with late hip movement and also whether there is any hinging/kinking at one level with extension (be sure to rule out segmental instabilities as Mckenzie extensions may aggravate this). If you are using the McKenzie extensions to treat a 'derangement' pattern using centralization procedures than I would agree that mobilizing neural tissue in a flexed/slumped position may be contradictory to this. Although hamstring stretching may be a good idea be sure you are not aggravating the neural tissue as mobilizing/desentizing neural tissue may require a different approach than regular sustained hamstring stretching. Be sure to make sure the thoracic and thoraco-lumbar spine is adequately mobile as this wil also aggravate the lumbar spine and of course make sure as always that there is adequate core stability.

E Huner PT, FCAMT

thanx physio friends for all suggestions,
i have screened out the hips and found it to be normal,
started stretching iliopsoas b/L .it is tight due to slouched posture.
DFM of pyriformis as adviced by Mrphysio is very effective.
accessory movts of thoracic spine are restricted so i'm restoring it.
the pt seems 2 be recovering.

Hi

Sorry, for not getting back to you sooner...

Sounds all good.

One word of caution with piriformis...

I had a patient who went to someone who "bruised" them with deep release of the piriformis. He consequently had a haematoma develop and attach to the sciatic nerve. Subsequent surgery to remove it (it was more than 5cm wide!) resulted in permanent altered sensation along the sciatic nerve distribution.

The lesson is...be careful - do you really need to bruise someone to be effective? Are you able to achieve results using reflex inhibition? Is it really "tight" or is it "overactive"?

Just some thoughts...

Hi
Re piriformis bruising and need for surgery later. I have been undertaking this type of treatment for 16 years, and none of my patients has required surgery for release of haematoma scarring. Obviously, any patient on blood thinners, or high dose medications such as steroid or non steroidal anti inflammatories, requires great thought before treatment.
Alophysio: could the patient you know of already have some serious haematoma type tethering prior to their treatment: or could they have had an underlying venous malformation predisposing serious bruising. Did this patient have a piriformis problem due to an accident involving deep gluteal muscle or impact eg from a fall prior to their treatment?
All the above needs to be checked during assessment before treatment is implemented. Risk versus benefit analysis must always be considered. No treatment is always effective - not even doing nothing!
Regards
MrPhysio

Hi.

The patient did not have a pre-exisiting condition or any other medical reasons why.

I think the release "hit the spot" and he got unlucky.

I freely admit the above post is extremely rare (and probably a bit melodramatic) but worth considering.

I use muscle energy, dry needling and active relaxation with visualisation (ala LJ Lee, Diane Lee - The Pelvic Girdle 3rd Edition) to achieve a release of all the posterior hip muscles and pubococcygeus.

Much nicer, with better patient comfort.

The dry needling is not the painful Chan-Gunn type but more of a cross between Japanese and Chinese acupuncture styles (no muscle twitches elicited).

Personally I have found that painful treatments cause negative reactions so i try to use the ones I stated above. The best thing is that the painful release is always an option if the others don't work! :rollin

hi,
well,i believe that muscle energy tech is most effective for pyriformis.
but as Mrphysio mentioned proper screening is very important prior to treatment.
no idea on accupuncture,so can u(alophysio) suggest me some book on accupuncture?
i thank all for active participation in this topic,looking foreward to this in future as well.
regards
ark:D

Hi!

Sorry, no book reference, just stuff learnt on a course.

But the principle is simple. THink of the needle as an extension of your hands. You can feel lots of things through the end of the needle.

What i feel for first is a good spot to put the needle in. Now you may want to use meridian charts or trigger point charts. I don't care. What I do is feel for "empty points" which kinda feel like "holes" in the tissue. Then there are the obvious "knots" that we all know so well.

For the piriformis musles, i palpate along it's length and find spots that I think would be good to "release" - just like a manual release as described by Mr Physio above. I then stick a needle in until i feel i hit the fascia of the muscle without "piercing" through it. Then i leave it (if i need to see other people) or "bounce" on the fascia (if i have the time).

The result is a much less tender muscle which has hopefully released somewhat. I would also use visualisation to relax the muscles as described above, etc.

If the needling doesn't work, try again but choose your points more carefully!

Hope it helps!

Hi again.
i also use trigger point dry needling techniques for relerase of triggers and tight musculature. I also use it for nerve related pain, whih requires a different approach. In cthe context of this topic and patients that present with a history of pain which is not resolving with the usual therapy, the firm approach tends to gain fastest results. My patients seek out my method as it does provide quick relief, and saves them money. Most people in pain want a fast resolution of symptoms for the least expense, without the therapist having them return frequently for another experiment to slowly ramp up the intensity.
Experience plays a large role in this approach, as inappropriate use of force can be unwise, dangerous, or economically disadvantageous to your clinic. Alophysio is correct in sounding a warning.

Trigger point needling will not alleviate a person who has tethering of gluteal, sciatic tissue. The tethering can cause the secondary muscle tightness, therefore it needs to be addressed in the first instance. The subsequent development of the triggers, if present, can then be sorted out by the needling approach as described by alophysio. If there is no tethering of tissue, there is no need for deep tissue massage or bruising, and the other techniques should suffice. I do not advocate bruising a patient for the sake of it, but patients should be warned that they MAY bruise, as part of informed consent. I do not set out to bruise as part of the treatment. For the same applied force, some bruise and some do not.

As always, use the technique which is the most appropriate given the assessment, your experience level, keeping in mind the safety and timing effectiveness of the treatment to provide the required results for your patient.

Patients are complex, and there are those that have chronic problems that cannot be cured, only maintained at a more tolerable level. Such patients are not to be considered Physio failures - the patient and therapist need to decide where the benefits lie.
Regards
MrPhysio

You may also have a look over these information resources for more information on Back Pain.

EUROPEAN GUIDELINES FOR THE MANAGEMENT OF ACUTE NONSPECIFIC LOW BACK PAIN IN PRIMARY CARE

Acute low back pain-Interdisciplinary clinical guidelines
The guidelines have been developed by The Norwegian Back Pain Network and an interdisciplinary working group

hi sdkashif,
thanx 4 the links,
regards,
ark

It sounds like a pure muscle spasm. What is his occupation , may be we can relate the condition with that . If supine lying increases pain , how the pain will be when the lumbar lordosis is masked. If so i think you have to go for core stabilisation of Transverse abdominus.