>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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