Dear Dr.Sood,
Your young patient with a central lumbar pain. The McKenzie approach would
try to exclude via repetitive movements if
1) the constant nature of symptoms can be effected, e.g. the pain is
referred from the upper lumbar region. Thus indicating local mobilisations
or manipulations to the lower thoracolumbar area. Adequate assessment to
exclude changes in his behaviour, if only subjective and/or objective, This
might not be the case for example as you mention pain on deep palpation
one small component in the use of Waddells testing).
2) the symptoms can be peripheralised further e.g. to groin/buttocks or
anterior thigh
3) the deformity of the kyphosis can be reversed. A large posterior
protrusion may mechanical inhibit a curve reversal. The compression fracture
may have increased facet pressure but you indicate no changes otherwise on
the xry.
He is unable to sit, typically I would expect the stenotic problem to be
easier if the protrusion or secondary type stenosis was the cause (dependent
on the size of the mass involved). This might be the case if the development
of the kyphosis was relatively slow. It is possible that the protrusion is
vascular in nature involving a haematomia under or of the anterior
longitudinal ligament but again it would probably be at the segmental level
rather than L4-5, L5-S1. Perhaps try to use a slump test to try and
differentiate? If he cannot sit this may have to be adapted for side lying
for example.
The length of time. Any protrusion if present at the start of your
management is probably fribrosed thus unlikely to move further and will
shrink as some of the material is reabsorbed (if relatively recent). Any
stenosis is unlikely to change (in the short term) if bony. In lieu of
neurological signs perhaps the most conservative treatment may be general
aerobic/ conditioning. Perhaps if (really) necessary with epidural/T.E.N.S
in situ whilst undertaking this exercise programme with appropriate
cognitive / behavioural retraining.
I hope these comments are helpful in reaching a satisfactory outcome.
Kevin Wright,
Member of the Chartered Society of Phsiotherapy
p.s. why not complain to your government about the absence of qualified
manual-therapists. Our Government bodies advising on such problems advocate
early intervention can be helpful but the longer the problem exists then
many other factors appear to complicate the situation. It is also of benefit
to allow the therapist to assess and treat as appropriate in particular
where it can take days or weeks before the docter can refer the patient.
Some countries are still prescriptive and this undermines the high
professional standards accorded to those therapists e.g. France
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