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L5/S1 disk extrusion

 
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L5/S1 disk extrusion - January 23, 2007 10:06:00 PM   
physioo

 

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I have a 25 yr old and also a 45 yr old who have disk extrusions at the above levels.
They do not want to have surgery...and want to continue twice a week.

They have been seeing a PT who was waiting for surgery and therapy consisted of IFC and heat....with miniaml exercise or manual therapy.

On assessment, there is no decreased dermatmal sensation, tho some myotomal weakness was evident. Severe pain on both flexion and extension.

How would you treat these kind of clients? I was thinking of starting an extension protocol based on the location of the bulge, but this was increasing pain too.

Advice would be greatly appreciated....
Post #: 1
Re: L5/S1 disk extrusion - January 24, 2007 7:09:00 AM   
PTupdate.com


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From: Pittsburgh, PA USA
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Tough to do in a forum like this. But:
1. Is pain constant or intermittent?
2. What positions/movements cause radiculopathy?
3. What positions/movements centralize their symptoms?
4. What level are we talking about?
5. How do you know it's the disc?
6. NSAID's or dose pack used yet?
7. Any neural tension issues?

John Duffy, PT OCS
[URL=http://www.PTUpdate.com]www.PTUpdate.com[/URL]

_____________________________

John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com

(in reply to physioo)
Post #: 2
Re: L5/S1 disk extrusion - January 24, 2007 9:43:00 AM   
physioo

 

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thanks, knew it was hard to post this q
but for what it matters
1. pain intermittent only on specific movts, basically extensions kills her
2. extension
3 flexion
4.l5/s1
5. MRI
7. uses only pain relief meds once in a while
8. SLR positive at 20-30 deg, XSLR sometimes +ve
Slump +ve +++

cheers mate

(in reply to physioo)
Post #: 3
Re: L5/S1 disk extrusion - January 24, 2007 7:54:00 PM   
drbuddy

 

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Suggestions:

1.Have patient use flexion exercises (pelvic tilt, knee to chest, etc) and assume pain relief positions when aggravated, peform neural flossing exercises, and use traction with directional prference (probably flexion in this case).

2. If you can, suggest steroid dosepack to physician.

3. See at least 3-4 times per week (or more) until pain levels are consistently below 5-6/10. I'm not sure if twice a week is gonna cut it.

(in reply to physioo)
Post #: 4
Re: L5/S1 disk extrusion - January 24, 2007 8:21:00 PM   
PTupdate.com


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Agree with Buddy...get her into positions and repeated movements that abolish or centralize symptoms, dose pack or at least a run of NSAIDs, traction (mechanical or manual) and if you can get things relieved somewhat, gradually attempt some neural mobilization.

And remember....the MRI is not always the definitive answer. If you see a huge disc fragment that is smashing the nerve root, that's one thing. Some bulging, found in a very high percentage of the population with no symptoms, should not steer your treatment.

John Duffy, PT OCS
[URL=http://www.PTUpdate.com]www.PTUpdate.com[/URL]

_____________________________

John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com

(in reply to physioo)
Post #: 5
Re: L5/S1 disk extrusion - January 24, 2007 9:03:00 PM   
TC PT

 

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In the case of disc extrusion(complete disruption of the annulus with nuclear material not contained)you have a space occupying lesion that can't really be reduced mechanically...not the same as a bulge. If that is an accurate description of the pt.'s condition then your options are limited. I agree you should work on the neurodynamics, as an adhered nerve root could seriously worsen the symptoms and general prognosis.

You should obviously avoid the motions that peripheralize the pain. The available space is compromised by specific movements that will close it down, creating worsening of neural symptoms.

You can have them strengthen in the affected myotomes and be watchful for worsening of that weakness.

Educate the pt. about what's going on and what to watch for...increasing weakness or radicular pain. General back care guidelines and use of heat or ice for pain management. Maybe a TENS unit.

(in reply to physioo)
Post #: 6
Re: L5/S1 disk extrusion - January 24, 2007 10:10:00 PM   
mcap56

 

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From: New York, NY
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Agree with above. As far as neurological deficit, strength is a more reliable indicator than sensation. Major strength loss gets me more worried than numbness.

Stress repeated motions and symptoms that centralize or reduce the pain. Do NOT force extension. Extension will never reduce an extruded nucleus long term. It goes back to where you started when the extension force comes off. And, in the right circumstance, extension can pinch it off. Do what makes her respond well.

That having been said, an extrusion is by no means a death sentence. Some patients have extrusions and are unaware of it. Read Saul and Saul natural history of non operative disc herniation (something like that). The size of a disc lesion, the degree of annular disruption, etc often have little to do with the clinical picture. I have seen people with massive herniations do well and those with internal disc disruptions do terribly.

One option that hasn't been mentioned - if she was having a really hard time, would be either an epidural or nerve root infiltration under flouro. Remember that it may not be the direct pressure on the nerve root, but rather, swelling in the dorsal root ganglion that is producing radiculopathy. This suggests a role for steriods or anti-inflammatories to see if you can bring that swelling down.

Keep us posted!!!!!!!

Best,
Mar

(in reply to physioo)
Post #: 7
Re: L5/S1 disk extrusion - January 24, 2007 11:36:00 PM   
joelkphysio

 

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I would be trying a traction SLR to see if that increases the SLR (to decrease NR sensitivity)...(or bent knee raise if TxSLR doesnt work)
but watch for the intermittent?? myotomal deficit???
good luck!
Joel

(in reply to physioo)
Post #: 8
Re: L5/S1 disk extrusion - January 25, 2007 8:16:00 AM   
PTupdate.com


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From: Pittsburgh, PA USA
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In line with what Marc indicated, all PT's should be reading the good studies coming from Japan, most published in Spine, regarding the cascade of biochemical events that occur when nuclear material touches a nerve root....endoneural edema, DRG edema, and all kinds of changes down the nerve distribution. Just because something touches, or even deforms a nerve does not mean that is the direct cause of pain and dysfunction.

John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]

_____________________________

John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com

(in reply to physioo)
Post #: 9
Re: L5/S1 disk extrusion - January 25, 2007 6:47:00 PM   
physioo

 

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thanks for the replies guys
appreciate it
client cancelled today, work duties, waitress, 8hrs standing, so not really helping herself...

i did try traction with slr the other day and did that help...fellt good after she said...

when u guys describe neural flossing, what r u actually meaning?

thanks, will keep u posted on next visit...

(in reply to physioo)
Post #: 10
Re: L5/S1 disk extrusion - January 25, 2007 9:14:00 PM   
FLAOrthoPT

 

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basically butler...but for example, let's say you have someone with positive SLR, so you now have them supine hook lying, and you want to floss sciatic....(you can do it sitting which i will descibe too)...you can have them post tilt to flex the spine to open the space around the nerve root so theoretically you free up the kinks there, you can then begin passively taking them with knee bent into full hip flex as long as they are maintaining post tilt of pelvis. Then have them do it actively. Then have them at like 30 degrees hip flex using either a wedge or your knee, and passively take them into knee ext, then actively, then bring up the hip to 45, repeat, to 60 etc and so on until you may be able to get to 90 hip flex, sometimes in one session sometimes in a couple, spread it out teach them this for homework, depending on nerve bias you can have hip rotated ankle plantar flexed etc...you can do it sitting....let's say positive slump...well relieve the tension proximally and using the same concept start to floss..so go into neutral or even ant tilt keep head up..let hip off table so not at 90, start maybe at 30 flex..and passively take ankle into dorsiflexion and slowly bring knee into extension, then actively, repeat as bring hip towards 90, the bring pelvis more neutral etc...so what you are trying to avoid is maxmally tugging at both ends like a slump or SLR test is doing and instead letting the nerve glide through the fascia throughout the range, active is as important if not more than passive...you can apply these concepts to upper extremity too with neck positions shoulder, elbow, wrist, finger, etc...

if you are lost take a butler and a weismantel and a IPA course or two and you'll get it.

good luck, don't overlook peripheral nerve as causes of pain, they are very real! some of your frozen shoulders may be more peripheral nerve related, give it a shot, you may be surprised!

Ben

(in reply to physioo)
Post #: 11
Re: L5/S1 disk extrusion - February 4, 2007 4:23:00 PM   
physioo

 

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From: Canada
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hi all
client is progressing really well..thanks for ur advice....
how would you cont progress...
cheers

(in reply to physioo)
Post #: 12
Re: L5/S1 disk extrusion - February 4, 2007 5:50:00 PM   
jbird007

 

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From: USA
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physio,

You are stealing my bread and butter stuff. GRR!

Touche'

JBird

(in reply to physioo)
Post #: 13
Re: L5/S1 disk extrusion - February 5, 2007 11:07:00 PM   
physioo

 

Posts: 184
Joined: June 27, 2006
From: Canada
Status: offline
but i am in Canada mate!
lol

might be movig to the States...haa...let's ee where the tide goes....

(in reply to physioo)
Post #: 14
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