Ben:
I think it is sad that we are still so segmentalized when it comes to
management approaches: there is not just one way to treat a condition, and
Mckenzie Physiotherapy is definitely not the only or the best way. From my
clinical experience, McKenzie Physiotherapy works well for lumbar discal
lesions, especially those who present with a list. From what I have read,
the theory for McKenzie Physiotherapy approach is one of many grey areas in
physiotherapy, and evidence for McKenzie Physiotherapy approach is far from
convincing (depending on what you read). But what I do commend the Mckenzie
institute in doing is their committment in continually developing and
modifying their approach based on the evidence.
We will all have our own opinions of which is the best treatment, and until
we actually see the patient, no one can be 100% certain that their method is
the best. I think what is important, especially for a junior
Physiotherapist, is trying to differentially diagnose the problem and
understanding what is going, and through clinical reasoning you can
considering what mode of management. I always say that anyone can mobilize a
joint, but not everyone knows which joint to mobilise.
This is my opinion of what may be occuring and what I would do. From the
information provided by Ben, I would think that there is some form of
compression pattern on the right side, whether it is discal, z-joint,
swelling or other space-occupying lesions, that is compromising the exiting
nerve. From the original post, there is no pain down the leg, so I am
presuming that the nerve is just been compressed and not irritated. Keep in
mind that z-joint pain can also refer, so even if there is pain down the
leg, one must clinically reason where it may be coming from.
If it was post-lat disc, then it would be more likely that one would expect
pain on flexion rather than extension, but it is not a certain sign. It
could be z-joint, which better explains for the pain on extension, and is
not uncommon for z-joint problems to irritate the exiting nerve root (so not
always discal). It also could be a combination of both (why not?). I would
examine the lumbar spine to see which joint may be the problem (my guess
would be right L4/5 or L5/S1 to be hypomobile and reactive to any
compression, ie, PA's).
Using the combined movement approach (Edwards), in the acute stage, I would
try to relieve that side by perhaps positioning the patient in flexion
(position of comfort), and doing rotations or lateral flexion oscillation
movements to open the right side. Theoretically, what I believe I am doing
is providing movement to the exiting nerve root by moving the surrounding
interface (which have mechanical, neurophysiological and biochemical
effects). Once the patient improves, then I would do the same treatment but
in more of a neutral position. When the patient is non-irritable and
non-severe, I may begin to challenge that joint by trying to close it down
(my rationale being that the nerve by then would have settled down and what
we are trying to do is to improve the mechanics of the segment). I may also
do some neural mobilisations, but the treatment should at all times be
comfortable and non-provocative!
Your question of how much this patient can do is a good one, but difficult
to answer. What I usually recommend my patients, especially in the first 1-2
weeks of onset, is to rest and take everything easy. If this means stopping
gym and cycling, then so be it. Or another idea may be to modify his
activities, eg, cycling with lumbar flexion to avoid excessive compression
on the nerve. But once he begins to improve, then you can slowly return him
back to his ADL's. The difficulty is determining how much one can do that is
beneficial, and how much can be damaging. It really does depend very much on
the patient as well.
Good luck and stay inquisitive.
Henry***
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