Low back pain, Sciatica, 1
This is a continuation of the previous low back pain case report of a patient with low back pain and sciatica with pain radiating down the leg to very briefly explain my view on the implication of the clinical findings and the rationale for the treatment approach.
Central low back pain suggested an injury to a central structure of the back, most likely to be the disc as indicated in the patient's history and confirmed by the CT scan. Radiating leg pain indicated more severe injury, a peripheralization phenomenon as well as the possibility of a nerve root irritation. Recent evidence as provided by the 'Australian Physiotherapy Association Low Back Pain Position Statement' supports the effectiveness of spinal manipulative therapy and specially designed exercises on the treatment of acute and chronic low back pain. In contrast, rest-in-bed, traction, electrotherapy and generalized back exercises give no evidence of promoting better recovery. The patient therefore responded well to chiropractic treatment instead of traditional physiotherapy. As an allied health profession, musculoskeletal physiotherapists certainly do not endorse chiropractic theory and approach. Nevertheless, their willingness of applying hands-on treatment, if used appropriately, could certainly help spinal injuries of mechanical origin. As a general rule, quick thrust manipulations are not indicated for disc conditions. Many other more gentle and multi-directional mobilizations/manipulations can be used instead.
Despite settling from acute symptoms, the patient's back and leg pain persisted. The acute disc protrusion could have settled but the effect of such protrusion on the surrounding soft tissues could have persisted. It is hypothesized that the surrounding soft tissues were irritated and inflamed as a result of the disc protrusion. Scar tissues/adhesions/thickenings gradually developed despite healing of the disc itself. Muscle spasms could also develop into muscle tension/tightness. Such complicated soft tissue pathology gradually stiffened up the spine, hence restricting spinal movements. Lumbar lordosis (low back S-curve) and extension (backward bending) are often reduced in such disc pathology. As scar tissues could have developed at close vicinity to or adhered to the nerve root, neural (nerve) mobility was also restricted and leg symptoms persisted. Immediate aim of treatment should be minimizing such soft tissue and muscular tension and restoring neural and joint mobility. Manipulative/mobilization technique should therefore be more specific. Centralization phenomenon when peripheral (limb) symptoms recede more centrally often indicates good prognosis or recovery. The long-term goal should be preventing recurrence of the problem.
Luck LI
Musculoskeletal Physiotherapist
Central low back pain suggested an injury to a central structure of the back, most likely to be the disc as indicated in the patient's history and confirmed by the CT scan. Radiating leg pain indicated more severe injury, a peripheralization phenomenon as well as the possibility of a nerve root irritation. Recent evidence as provided by the 'Australian Physiotherapy Association Low Back Pain Position Statement' supports the effectiveness of spinal manipulative therapy and specially designed exercises on the treatment of acute and chronic low back pain. In contrast, rest-in-bed, traction, electrotherapy and generalized back exercises give no evidence of promoting better recovery. The patient therefore responded well to chiropractic treatment instead of traditional physiotherapy. As an allied health profession, musculoskeletal physiotherapists certainly do not endorse chiropractic theory and approach. Nevertheless, their willingness of applying hands-on treatment, if used appropriately, could certainly help spinal injuries of mechanical origin. As a general rule, quick thrust manipulations are not indicated for disc conditions. Many other more gentle and multi-directional mobilizations/manipulations can be used instead.
Despite settling from acute symptoms, the patient's back and leg pain persisted. The acute disc protrusion could have settled but the effect of such protrusion on the surrounding soft tissues could have persisted. It is hypothesized that the surrounding soft tissues were irritated and inflamed as a result of the disc protrusion. Scar tissues/adhesions/thickenings gradually developed despite healing of the disc itself. Muscle spasms could also develop into muscle tension/tightness. Such complicated soft tissue pathology gradually stiffened up the spine, hence restricting spinal movements. Lumbar lordosis (low back S-curve) and extension (backward bending) are often reduced in such disc pathology. As scar tissues could have developed at close vicinity to or adhered to the nerve root, neural (nerve) mobility was also restricted and leg symptoms persisted. Immediate aim of treatment should be minimizing such soft tissue and muscular tension and restoring neural and joint mobility. Manipulative/mobilization technique should therefore be more specific. Centralization phenomenon when peripheral (limb) symptoms recede more centrally often indicates good prognosis or recovery. The long-term goal should be preventing recurrence of the problem.
Luck LI
Musculoskeletal Physiotherapist