Ben ,
Thanks for the update. I would have to agree with John - don't fret over
the reflex. I also do EMG/NCS
studies and have seen, on numerous occasions, the continued absence of the
H-reflex post neurological insult even thought the patient is clinically
asymptomatic. Personally, I will share with you my experience which is
similar to the patient you describe. I was an avid racquetball player.
After one of my matches I developed acute low back pain followed by S1
radiculopathy. Reflex dropper out and even developed calf atrophy. No
mechanical treatment totally eleviated my symptoms. Further diagnostic
tests revealed congenital stenosis, significant disc involvement, and
extensive DJD (probably hereditary). I had to remove myself from that
activity and running as well. Fortunately, with continued conservative care
(combination of McKenzie and other approaches) I avoided "the knife" and
continue to be asymptomatic. However, I am unable to play racquetball
without increasing my symptoms or run. When I don't do those things I am
fine. I now power walk, bike, and cross country ski, and live an active
life. You might have to tell your patient to do the same. Good Luck!
PS: My reflex has never returned
Rege
At 01:19 PM 1/27/2003 -0600, you wrote:
> >Over the weekend there has still been activity limitation by pain, as
> >already mentioned, but I feel confident to progress with this. It is
> >essentially in the lower back, with some radiation through the S1
>distribution on
> >standing & walking (but no p&n or numbness). However I would still very much
> >like to hear any opinion on the relevance of the absent T-A reflex and any
> >implications of this?
>
>
>Ben:
>
>Thanks for the update. It's helpful for all of us to find out how these
>case histories turn out. Please keep us posted on his progress.
>
>In my experience (and I don't have a reference for this) in cases of
>neural encroachment - the reflex is the first to go and the last to
>return (if ever). So, if he is still getting some radiating symptoms -
>and it sounds like he is - there is probably some neural irritation still
>present - so it is not surprising that his reflex has not returned. I
>wouldn't worry if it never returns - I have had patients return to full
>athletic activity without regaining their reflex. I would be more
>concerned that his SLR returns - as that is probably a better indicator
>of neural irritability.
>
>We may never know if some combination of repeated movements / positions
>would have "centralized" his symptoms sooner. Your patient didn't sound
>like a typical posterolateral disc derangement - most of the ones with
>radicular S/S will have decreased flexion and /or an obvious lateral
>shift that is worse in the morning and other signs of disc involvement
>(like +'ve valsalva). Could he have sprained a facet joint during his
>squash game, with resultant swelling on the nerve ? or Could he have done
>a little of both ?
>
>Going back to your original querry about activity and distal symptoms -
>regardless of what caused the compression / inflammation on his nerve -
>the main point is to not encourage activity that worsens neural S/S 's. I
>think nerves are less "forgiving" than any of the other soft tissues we
>treat - hence my motto : "radicular pain - no gain". I think you have a
>lot more leeway with referred pain (although I would still obey the
>centralization principle in most cases).
>
>However, the question of what caused this problem ( in a young active
>individual) may be more important in the context of how to prevent
>reoccurence. He sounds like the type of guy who will return to squash
>playing ASAP. That's a tough sport on your back. What's to keep this from
>happening again ? Is there something tight that needs stretching,
>something weak that needs strengthening ? A habitual posture at work that
>needs correcting ?
>
>PS: Frank, Sam, Henry, etc I enjoyed the McKenzie dialogue. As a
>newcomer to this list, I hope that most (all?) of the discussions can be
>carried out in such a "polite" (i.e. professional) manner.
>
>
>John Jefferson
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