Question about patient with low back pain
Hi Folks,
I have only been practicing for a few months. I am having trouble sorting out one of my patients with low back pain.
History: 1.5 years of low back pain. Insidious onset. Reports that pain worsens with prolonged standing and is the worst in sidelying at night (supine is fine).
Observations: 25 year old male of medium build. Decreased lumbar and thoracic curves. Increased cervical lordosis with head forward posture. Decreased bulk in glute max R and L.
O/E:
ROM: lumbar is basically full but patient has increased pain with
extension and rotation/side flexion to both sides.
Neuroscan: is unremarkable.
Palpation: is very tender from L2 to S1 bilaterally along facets. Also
very tender over quadratus lumborum on both sides. No
increase in resting tone of hip external rotators.
Special testing: Much increase in pain with general lumbar torsion
test to both sides.
Diagnostic Imaging: None.
We have been working on core abdominal strengthening. He doesn't tolderate manual therapy well because of the tenderness. Manual traction has been helpful.
Any other treatment ideas?
What is the root problem?
Despite the lack of hard neuro signs, could this be disc involvement?
What are other possible pathologies?
Thanks!
neurological signs and disc involvement
Slump sitting (as your patient prefers to sit) would probable increase his backpain if there is a disc prolapse or herniation as this position increase the amount of pressure on the disc.
However it is possible to have a disc prolapse or herniation without any positive neurological signs, it just depends on whether the injured disc is causing narrowing of the intervertebral foramen (pressing on the nerve root) or spinal canal (causing spinal stenosis) or none of the above. If there is no pressure on the spinal cord or nerve root then all neurological test will be negative.
Re: neurological signs and disc involvement
Hi.
All the above posts are interesting and relevant questions.
However, this patient case is screaming out to me as a classic active extension pattern. I will write quite strongly in this post only because i am almost 100% certain that i am right because i have seen this very same pattern many times before...
I do not think he has disc pain. I do not think AS.
From the sounds of it, i would be willing to bet he has overactive back extensors. He will tell you he is trying very hard to keep a "good posture". He will tell you that when he slouches, he feels better but it is "bad" for him to do so because you shouldn't slouch.
When he does his core exercises, i bet he is overactive in his posterior pelvic floor and finds it hard to do.
Active SLR with compression of his 
SIJ will make his legs feel very heavy - while supine, get him to lift one straight leg up at a time and get him to note the "heaviness". Then use your fingers/hands via his PSIS and compress them medially and repeat. He will report significant heaviness in his legs.
The treatment solution is firstly to get through to him that he needs a lordosis and kyphosis in his body. He may be trying too hard to matintain good posture. He is probably overactivating his posterior pelvic floor and utilising his IO instead of TrA. He needs to learn to relax. You will probably find flexion-type exercises help, especially since it is the only movement that doesn't hurt.
He probably has a lot of fear of flexion due to his medical training and everyone worrying about discs etc but everything you have posted so far says that extension is painful - why put him into more extension when he stands with his hips hyper extended and flat backed?
Once his muscle overactivity comes down, you will see his extension pain decrease. Co-ordination and progression of his core stability work without IO/EO or RA activation will be important as well as relaxation of the posterior pelvic floor.
I am probably not making sense as it is midnight here but i will summarise.
1. He is probably suffering from excessive compression of the L/S. Utilise flexion-based exercises and stretches.
2. Tenderness in the facets, poor response to manual therapy (Maitland and mackenzie mobes) is classic for this condition.
3. The patient needs to get his head around the fact that he himself is making things worse by trying to maintain extension.
4. Restore normal spinal curves
5. Co-ordinate core-stability properly and specifically without the posterior pelvic floor.
6. Read Peter O'Sullivan's chapter in Grieve's Modern Manual Therapy or his Nov 2005 Masterclass article in Manual Therapy.
Link=www.sciencedirect.com/sci...e89ed9d8ae
I apologise for being so strong on this matter but I am almost 100% sure i am right...
Thanks for reading this far! I hope i didn't offend anyone.
Re: neurological signs and disc involvement
try out with gr-2 central PA 4 restricted extn & pain,gr-2 lateral PA for side flxn.make sure 2 reproduce the same pain during the session of manual therapy.
for pain relief try out-ultra reiz current or tens-neuralgia mode followed by traction in extn-prone posn.
Re: neurological signs and disc involvement
Hi.
Why do people keep suggestion extension for this patient when clearly extension makes the patient worse (ext, SF and Rot in standing all occur in extension at the lumbar spine).
Why do we want to keep putting him into pain provoking positions? He is already not tolerating manual therapy using PAs.
Re: neurological signs and disc involvement
i suspect a discal bulge compressing the iv foramen bcz traction is relieving the pain.
in old cases of discal bulge with fibrosis, extn may be painful bcz it further compresses the already compressed postr structures.due 2 this the lordosis could be decreased.
i dont think the spinal extensors can be tight bcz the lordosis is decreased.
prolonged flxn exs can further harm it ,whereas extn may not improve it but will certainly not harm it,
so i suggest u 2 continue tracn and go 4 an MRI to be sure.
Re: neurological signs and disc involvement
Hi.
A number of things.
Firstly, I don't think it is a nerve root problem because slump testing is negative. Neuro testing is negative. Flexion *relieves* the pain. Extension and LF and Rot make the pain worse. Also, the facet joints along the whole L/S are sore. This is not what you would expect from a disc bulge onto a nerve root.
Secondly, he is 25y.o. He would not have a fibrosed disc yet, especially without any history of trauma.
Thirdly, I did not say the spinal extensors are tight. I said they were overactive. A very important distinction should be made there. They can still be overactive with his decreased lordosis because he is probably co-contracting with his abodominals - probably external obliques. He is already overactive in his QL. His decreased bulk in the gluts is probably because he is hamstring dominant in his extension strategy.
Fourth, Extension can harm this patient. His spine is already in a compressed state. Further compression of these structures can cause sclerosis, spondyloslithesis, facet joint arthritis, disc problems, etc. Again i ask, why subject him to painful positions when his body is telling him flexion is the best place for relief.
Traction helps to decompress and relax the overactive muscles and joints. If you told him to hang from a bar, it would do the same thing.
I would still recommend that teaching how to have a relaxed posture with restoration of his spinal curves and activating his core muscles without global muscle activiation is the way to go. What i have written in this post is from learning this material from Peter O'Sullivan, Diane Lee, LJ Lee, Barbara Hungerford, Trish Wisbey-Roth, etc. Peter O'Sullivan's work on this exact type of problem has been sensational and the results in my clinic tell the story...
Lastly, electro is not going to solve his problem...
What do others think? Am I way off beam?
patient with low back pain
Hi guys,
I am a sports training and physiotherapist from India. I agree with what alophysio is saying. We need get into the root of the problem. Using electrotherapy would only relieve you of the symptoms, but the problem would come back. Core training for this individual is very important, with attention to be focused on TA(transverse abdominus) and gluts tightening, as it will prevent instability while doing exercise and prevent further damage to the back. Flexion exercises can be done, but with care. Maybe we can check for gluts and hamstrings tighening also ans stretch it if needed. I hope i made some sense, as it is my first post.
Cheers.
:D
