45 y/o male w/ chronic L5/S1 L Radic

[JSPT]

I'd love some feedback on a guy I've been working with for several months.

45 y/o mail originally injured in 2005 while shoveling dirt at work. This lead to a diskectomy, then a fusion a few years later. He was functioning well and able to work but always had pain. He slipped on the ice in January 2011 and has had persistent pain in an L5/S1 radicular pattern on the L.

He has had extensive workups on the back; myelogram and CT scans are negative, all surgical hardware is where it should be, and the only positive finding is a slight decrease in activity of the L5/S1 nerve root on EMG.

Presently, he has to lean to the R a great deal to relieve L buttock pain. He reports burning that runs down the back of his leg and ends in the ball of the L foot. When this is exacerbated, he cannot put much weight on the R. His strength is 5/5 and he mostly has normal ROM. He was taken off work in November and has since lost his job. He is fighting comp, but in the meantime wants to get his life back. Let's assume that psychologic factors and other yellow flags are not at work with this case, as I believe they are not.

I'm sure there are some heavy neurologic factors at play, but I don't know where to start, other than with basic nerve tension testing. I just downloaded Diane's power point slides and I'm wading through the Chasm thread.

Any tips on where to begin with this patient?

Addendum: Diane suggested I look at/check the cluneals and other glute nerves. I guess I need more basic info. How does one implicate one of these nerves? In other words, how do I manipulate the nerves and what response am I looking for?

Addendum #2: I promise, I'm making my way through the suggested "getting started" threads and Diane's power point presentation, but in the meantime, I really want to make some progress with this gentleman, as he is in a particularly bad flair. Please forgive the rudimentary nature of my needs.

[Bas Asselbergs]

JSPT, are you the same JSPT we see at RehabEdge? Welcome either way!!

Interesting case. Injury, surgery, surgery again (with hardware), injury.
That makes quite a list.

What Diane says. That would also help YOU feel like you are "doing" something.

Also starting with where the patient wants to move (to) is usually a good idea; combined with extensive (my hobby horse) education about sensitization, nature of persistent pain, need for oxygenation of nerves, gentle motion, etc.
"Edgework" (search here on Soma) by Cory seems really appropriate for this patient as well.

[advantage1]

I agree with Bas and strongly encourage you to educate this gentleman about how nerves can become sensitive. I also find its important to ask the patient what they think is causing their pain. We often forget to ask this important question. Sometimes you will find that the patient has a false belief that something is torn or a disc is out of place. If this is the case review his imaging with him and explain that the findings are normal.

I know you would like to exclude the amber flags such as a fight with his worker's compensation. You can't ignore this. In my experience when a patient is injured at work and there are delays in them returning to work you will find that the patient does not like their job. This is can be an elephant in the room.

Have you had this gentleman score the FABQ? It's a good idea to see if their are any fear avoidance behaviors related to work or physical activity. If so, a graded exercise/exposure program combined with education can go a long way.

[Diane]

Cluneal nerves, posterior cutaneous nerve of thigh, most of the other cutaneous nerves. I don't think I have a thread for the deeper glut nerves, but I have a manual here, which if you are keen to see I can send you. You'll be able to download it anyway eventually, but if you want to read how I treat these, I can send you the pages - you can PM me with your email address. Meanwhile it would be good if you looked them up in an anatomy book; find pages that layer back the glut muscles, so you can see how the nerves plug in to them from underneath.

[JSPT]

Bas- Yep, that would be me. I've been lurking here for a long time, I just don't post much. Honestly, I'm trying to get up to speed on the subject matter discussed before I jump in.

advantage1- Thanks for the reply. I asked to leave out the amber flags because I don't believe they are contributing too much to this guy's pain. I know him as well as anyone can know a patient they've seen for many months over the past 3 years. He loved his job and would walk on lava to get it back. All I can say is that he is highly motivated to return to work, is close to losing his house, and is 100% consistent with his symptoms. I was able to talk him into working with a psychologist who specializes in pain, which has been very helpful.

Diane-I'd love the manual and will send my address. I'll review it and get back to you soon.

Thank you all very much!

[ste5e]

Treating a flared, scared patient can be like getting a riled wasp out of an ajar window with a file. A lot of flapping, the risk of a sting and an iterative, drunken walk to success.
Listen, believe and communicate your belief in his experience but undo the story that he has assembled and re-assemble it into one which explains his pain in light of real neuroscience. Revisit this every time you see him to re-inforce it. Get him to explain it to nearest and dearest and get him to ask you their questions as well as his own. Answer them and then get into whatever technique crosses the chasm for you. I still like graded 'core stability' stuff even though I tell them it is nothing special and not to get hung up on any of the voodoo and progress to functional stuff if they need their hand holding.
It is so exciting taking a scared person on that journey, guiding them as they flip and slide, getting them back into their life with less fear and less pain related disability as a consequence.
Just finished a session with a high five from a guy with a ten year Hx with discectomy, foramenectomy and laminectomy and then another discectomy and who has continuing 'sciatica' - over the last three months he has gone from scared to move to what I would see as end of beginners level Pilates. The rescue dog metaphor - hat tip Diane - has served him well. And he is a cat person!
Kind thoughts,
Steve

[Jason Silvernail]

He's leaning away from his painful side, his body knows what it needs. Manual therapy and exercise treatment that promotes right side bending and flexion might be very useful if they relieve his leg pain. Some side lying work often does wonders for these cases as does perhaps manual traction.
What to do exactly depends on what your clinical process is, and I don't think we know enough about that to advise you further.

[Diane]

Originally Posted by JSPT

Diane-I'd love the manual and will send my address. I'll review it and get back to you soon.

Thank you all very much!

It has been sent.
Not from any fancy smart mobile uberconnected phone but from my big unportable iMac.

[proud]

Hello JSPT,

Few things I might like to know:

1) Is the left buttocks pain the only peripheral symptom this man gets?

2) Is the buttocks pain present all the time...unless he leans to the right?

3) If not...how long before the right buttocks pain is produced if placed into a say....left side glide? In other words..can he perform left side glides at all painfree?

I'll start there.

Edit: Whoops...I missed that he does get more peripheral symptoms. Okay then, this adds another question:

4) Have you ever had the opportunity to see this man when he has the lower leg/foot pain? If so...what impact does left side gliding have on this?

[JSPT]

Proud-

Few things I might like to know:

1) Is the left buttocks pain the only peripheral symptom this man gets? He reports pain in the central left buttock, down the posterior-central thigh, the central calf, and the arch of the L foot.

2) Is the buttocks pain present all the time...unless he leans to the right? During his current flare, which has been the past 3 weeks, it is constantly present. Leaning to the R decreases the L buttock pain about 25%; it does not reduce the rest of the L LE pain.

3) If not...how long before the right buttocks pain is produced if placed into a say....left side glide? In other words..can he perform left side glides at all painfree? Repeated L side-glides do not change symptoms.

4) Have you ever had the opportunity to see this man when he has the lower leg/foot pain? If so...what impact does left side gliding have on this? As above. I've done some nerve flossing in supine. Normally I would rest his calf on my shoulder and passively flex/extend the knee and hip, but he currently cannot tolerate having his calf rest on anything due to severe pain w/ contact. I can do that glide with a pillow, but it has not changed symptoms at all with the 2 times I have done the glides.

Steve- I've had him watch the "Pain explained in 5 minutes video" and given him Jason's handouts on pain. He is a very mechanically-minded guy ("if there is pain, there has to be something being compressed or pinched, like a bad car part"), so I've been working on the education component for the past few weeks, a little at a time.

Until this flare, we have been doing general mobility exercises to reduce guarding and facilitate pain-free movement, as well as some functional lifts (trying to increase his PDL ability level to light duty). I've tried a few manual techniques, including skin rolling and my feeble attempts at Simple Contact, but I'm a novice at these, so its a slow process.

Thanks again for the advice. I see the guy again on Friday, so I continue to be grateful for any suggestions.

[proud]

How about flexion-rotation either painful side down or up?

[JSPT]

Proud- Not sure what you mean; do you mind clarifying?

[proud]

Originally Posted by JSPT

Proud- Not sure what you mean; do you mind clarifying?

Sure. It's a directional movement in the McKenzie classifiaction.

1) Patient is supine
2) Hips and knees passively flexed (hips at 90 degrees to start....this can be changed depending on centralization or reduction of symptoms. Theoretically lower hips angles will target highr segments etc...theortically or conceptually if you like)
3) The hips are then rotated first towrads the side of the peripheral symptoms (in this case to the left.hold or ossicilate on/off for 30 seconds or so) Check for centralization or reduction.
4) If this doesn't work go the other way (more a gapping technique if you like). This would fit more with what Jason Silvernails suggested (that the patient knows what's best and is offloading).

Send the patient home for 24 hours with which ever one seems to do the trick....

Is that clear?

[proud]

Here is a recent article that talks about this form of directional preference:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3172947/

It has some pictures of some different ways to gao about it. As you can see, another thing to have a look at for positioning is the "road kill position". There are images in there that might help.

I do not see any images of the actual flexio-rotation maneuver but I think It's pretty self explanatory.

[advantage1]

Did you assess Slump and PSLR?

Did you perform a McKenzie evaluation to determine if there is a direction of preference that will cause centrailization?

[proud]

Bump:

Any updates JSPT?

[JSPT]

Slump was positive, as was PSLR. I'm going to try the directional preference assessment during his visit today. He was unable to come on Wednesday, but I called him at home and told him to experiment with the side-gliding and R sidelying and to report back to me next time we get together.

Diane- I'm about 1/2 way through the manual you sent and it has been extremely helpful. I think the most difficult part about being new to the ectoderm method is transitioning from the theory and education to actually implementing it in the clinic, at least in my experience. I'm committed to mastering it, no matter how long it takes :-)

Proud- Thanks for the link and the explanation; will try with him next visit.

I try to give every patient by best effort, but that is especially the case with this guy. I really feel his frustration with his situation, and I can't say that I've ever been more motivated to get a patient better.

[JSPT]

Patient came in today w/ severe pain the L buttock (between SI and pirifomris), L posterior calf, arch of L foot, and the L 1st toe throbbing.

The following increased pain: end-range trunk flexion, seated slump test, standing w/ rotation of the lower trunk to the R (chest was stationary and all segments below thoracic spine rotated), seated trunk rotation to the R, seated flexion and R rotation, seated lumbar extension w/ arms crossed. During the slump test on the L, with the knee straight out, changing the amount of cervical flexion/extension did not change symptoms.

The following relieved pain (about 25-50% for all): side-glide of hips to L (a R side-bend), seated flexion and rotation L, lying on the R side w/ 2 pillows between the femur w/ the R knee flexed 90 degrees and the L knee flexed 10 degrees. In the sidelying position, gentle traction on the L LE further reduced symptoms.

I gave him the pain-relieving positions as a home program. Thoughts?

[JSPT]

Any suggestions based on the provoking/alleviating movements noted above?

[proud]

This reminded me a bit of a presenation I have come across a few times. While going through the Mckenzie system year ago, I had an opportunity to speak with Mark Laslett who directed me to his "take" on the Mckenzie classification which takes some of the directional preference stuff and adds a bit. Here is a case study that this scenrio kind of reminds me of:

http://www.oocities.org/h_murray_miller/phil.html

Click on the "figures 2 and 3" to get a visual of manual contact. Sounds to me that lot's of downregulation, education and movement is required here. I actually think Diane's DNM fits in nicely in this case ( Figue 2 is really a skin stretch I think...right Diane?). I have used this rationale and positioning however I sustain the "taking up the slack" (as he calls it) for 3-5 minutes rather than the 4 seconds described here (thanks to Diane...this seemed to help more patients and I can understand why now).

[Diane]

Originally Posted by proud

Click on the "figures 2 and 3" to get a visual of manual contact. Sounds to me that lot's of downregulation, education and movement is required here. I actually think Diane's DNM fits in nicely in this case ( Figue 2 is really a skin stretch I think...right Diane?). I have used this rationale and positioning however I sustain the "taking up the slack" (as he calls it) for 3-5 minutes rather than the 4 seconds described here (thanks to Diane...this seemed to help more patients and I can understand why now).

Yup. He's doing DNM.
Not in 3, but for sure in 2.

[smith]

Whenever I work out, fast walk uphill, my R ankle deep in around the talar dome swells. By now, all of you correctly guess this will give me "catching". Feelings of instability with the catching. If I use pressure, I think I can push the swelling out of the nerve. Decrease intra nerve presssure. Pushing toward the superior. Like in figure 3 of Proud's post. The ankle does seem to work better with this type of stuff. Could this be happening?

Not a good idea to do this with pain of course.