Transcript Lateral shift correction traditional

Case Study
Lateral shift correction alternative
Clinical Decision Making
• History:
• 41 year old female PT
• -onset of left LS pain 5 weeks ago after con-ed
class which involved manipulation
• - increased soreness in the lumbar spine on left in
the area of the PSIS
• - drove one hour home, next morning woke stiff
and sore
• - difficulty sitting or lying on the couch and
sleeping
• - Turing in bed especially difficult
History
•
•
•
•
•
•
•
•
•
•
- 3 days later worsening
-significant restrictions in flexion
- assistance to dress and put on shoes and socks
- better if up and moving
- tried shift correction ( actually laterally flexing)
as well as the extension progression
- no resolution, extension felt good , no worse.
- 10th day symptoms decreased and less guarded
-One week ago exacerbation left LS pain
- deterioration of sitting tolerance
- returns to the course today and would like to be
evaluated. Pain level: 5/10.
History
SQ:
-denies pain in the lower extremities, numbness and
tingling, disturbance of gait or changes in bowel or
bladder function, pain with cough and sneeze
-no significant weight loss and describes her general
health as good.
Previous History
-recurrent bouts of left lumbosacral pain past two
years: insidious
- She suspected the SIJ as the source of the problem
and self treated with muscle energy techniques
-always improved within 1-2 days
-episode is different in quality, intensity of symptoms
and duration.
Functional restrictions
• Sitting: left low back 1 hour, pain eases upon
standing
• Standing prolonged: Time to prepare dinner: left
low back pain, eases walking
• Fwd Bending: immediate increase in left low back
pain, eases on return to the erect position
• Position of comfort for the night: Best in right side
lying
Physical Examination
• Observation: Slender fit female, no acute distress
• Posture: right contra lateral shift, accentuated
lumbosacral angle and a loss of the low lumbar
lordosis
• left iliac crest high resulting in pelvic obliquity
• appears related to mild right thoracic left lumbar
scoliosis
Physical Examination
• Flexion: Finger tips to mid tibia: pain and poor
unrolling in the first 30 degrees of flexion
deviation to the right and complaints of tightness
on the left.
• Extension: 20 degrees, stiff below L2, with
immediate deviation to the right
• Lateral flexion left: 15 degrees with stiffness
reported on the right
• Lateral flexion right: 5 degrees with comparable
left lumbosacral pain. **
Trial Rx
• -initial attempts at shift correction with repeated
side gliding right: vasovagal syncope, after 3-4
pulls and needed to rest in a recumbent position
for 15 minutes
• - stood she stated that her back pain was slightly
better 3/10 and active range of motion was slightly
improved.
Assessment
• -sub acute mechanical low back pain, with a right
contra lateral shift with no referral to LE
• -directional preference for side gliding to the left
• -progressing to directional preference for
extension after shift correction is achieved
Assessment
• S &I -presentation not severe, not irritable
• N -nature of the condition warrants caution
• S -sub acute
• S-improving overall and is not yet stable
• - recent evidence of exacerbation potential for
progression
• -initial response to shift correction is of some
concern.
Treatment
• vasovagal response, recent exacerbation and
nature decided to evaluate the effect of
• Unloading from high bar - eases the left low back
pain
• Side gliding in the unloaded position: less painful
than standard shift correction, no recurrence of
the vasovagal response
• Repeated side gliding: over correction is achieved
& LBP improved.
•
• In the traditional McKenzie protocol shift correction should be
followed by extension in standing.
Lateral shift correction
traditional
Shift correction unloaded
passive---------active
Treatment
• sacral lumbar extension: hand on sacrum to apply
traction during unloading simultaneous manual
resistance to facilitate sacral lumbar extension
• - perceived resistance through range to the
movement greater on the left than the right easing
with repetition
• Reassess: RSB, posterior pelvic tilt in standing
(lumbosacral flexion), flexion, all demonstrated
improved range with less pain at end of range
– o N.B. It can sometimes be problematic reassessing flexion
following reduction of a derangement, as it can reverse the gains.
Treatment
• Instruction in self correction on the wall.
• Prone progression: prone to prone on elbows to
REIL
• At approximately 50% range of extension there is pain
centrally.
:R
• *pain with central and unilateral PA’s and the unilateral was
most comparable at L5
Treatment
• Potential treatment options at this point:
• DP progress: continue REIL with expectation that pain will
diminish with repetition
• Mobilize L5 and continue REIL
• Given previous positive responses to unloading, elected to
apply lumbosacral traction in the prone position (hand cups the
sacrum and applies force caudally IV sustained)
Treatment
• R: central and unilateral PA’s are improved
• complete EIL to full range painfree
•
•
•
•
•
•
standing
Extension: full range without pain
-Sacral lumbar extension full range without pain
-SBR full range and painless.
-Flexion: without pain.
-Pain level: 0/10
HEP Treatment
• Patient instructions:
•o
•o
•o
Minimize sitting, interrupt frequently to extend
Sit on wedge to maintain low lumbar lordosis.
Home exercise
Unloading and shift correction as needed
Followed by prone progression.
Discussion Clinical Decision
Making
• Multiple decision-making and clinical reasoning
paradigms At the core of the processes was:
• Comparable sign, asterisk signs for symptoms and signs
• Assess-Treat-Retest-Assess-Treat to evaluate the examiner’s
thought process as well as the value of each technique used in
the treatment progression.
Discussion Clinical Decision Making
• a number of treatment approaches may be
effective in the treatment of this patient.
• quality of the clinical reasoning and selection of
technique would be validated by the continuous
assessment and changes in symptoms and signs.
Treatment based classification
– Directional preference: shift correction progressing to extension,
– She is 4/5 for CPR for manipulation
»o
Pain less than 16 days (most recent exacerbation)
»o
No pain below the knee
»o
Hypomobility at on segment
»o
Hip ROM
»o
FABQ was not administered
Discussion Clinical Decision Making
Maitland:
Most likely: rotation IV in RSL, sustained.
-position of comfort is RSL
-Rotation is highly effective in the low lumbar spine.
Signs and symptoms are asymmetrical, so an asymmetrical
technique should be more effective
Initial choice of rotation is with painful side up
Sustained technique is most likely to be effective when sustained
positions or activities provoke the symptoms.
– Additional potential techniques based on area of symptoms and
comparable signs:
» Central PA
» Unilateral PA on left
» Traction
Discussion Clinical Decision Making
McKenzie: MDT/DP
-derangement with the potential for some pre-existing
dysfunction given the previous history of recurrent episodes
Shift correction in standing followed by prone progression
-If patient had been unable to continue to progress with prone
progression with their own movement therapist intervenes:
-First with rotation in extension a unilateral PA prone
May progress to manipulation, painful side down.
Then continue with prone progression
Discussion Clinical Decision Making
• Visit 2 (Next day)
• Subjective:
•o
Drive home much better than expected using the wedge.
•o
Went immediately to the swing set to unload and was
surprised that the first repetition was painful (this is not
unusual after sitting.). Shifted and did sacral lumbar extension
in unloaded position. Pain decrease with each repetition
•o
Able to stand in the kitchen to prepare dinner without
pain (improved)
•o
Still had difficulty sitting on couch (expected, as she
will drop into flexion)
•o
Slept better and woke with less pain and stiffness than
usual (has not yet exercised due to time constraints)
•o
Drive into the clinic this morning much better than
yesterday.
•o
Currently pain 1/10, central and slightly left LBP
Discussion Clinical Decision Making
• Objective:
No lateral shift
Flexion finger tips to mid tibia, without deviation right and
improved unrolling, tight at end of range(improved)
Lateral flexion right 30 degrees with slight pulling on left
Extension 30 degrees, tight in center
Discussion Clinical Decision Making
• Assessment:
Subjectively and objectively better.
Behavior of symptoms, response to intervention and changes in
signs confirm the hypothesis of derangement and election to
treat with directional preference.
Centralization achieved and shift corrected
– Could be confirmed with side gliding
– If not complete could be accomplished in extension or with
mobilization.
– Reassess central and unilateral PA
Discussion Clinical Decision Making
• Treatment:
•o
•o
•o
REIL: Slightly stiff with complaints only stiffness
Central PA L5 stiff, slightly sore
*Unilateral PA L5, most comparable, stiffer
•o
Repeat, unilateral with exploratory movement. As
technique is performed it becomes clear that caudally directed
is more comparable than straight. 4 x IV
• Reassess:

Central PA improved: increase range and less resistance
through range.
– EIL full range with less stiffness
– Lateral flexion right full range without pain.
– Flexion improved : finger tips to distal tibia without pain or
deviation
Discussion Clinical Decision Making
• Assessment: Progress as expected and is
consistent with hypothesis, At this point she is
fully centralized and extended.
• The dysfunction suspected does not appear to be
significant given rapid rate of change and ability
to maintain gains.
• Plan: Progress to trunk strengthening and
stabilization training with extension bias
Progression of shift correction
to extension: unloaded
contract-relax-stretch