low back pain, scoliosis and core stability

[physiogeneve]

I have a patient (age 30) who has a structural scoliosis with the convex aspect at 25 degrees evident at the th/lumbar junction. She was managed conservatively as a child with "gymnastic exercises" and never suffered from any pain.
8 months ago following a relocation she injured her back whilst unpacking and shifting furniture (classic rptd fl and rotation injury pattern).

She complains of a pain at the lumbosacral junction slightly left sided versus central. There are no neuro signs, no radiating symptoms. Her pain is worse on getting up in the morning but there is no consistant pattern. She now is rather wary of her back.

Main Problems found on examination are:
1. painful arc on lumbar spine flexion at 25% of her range of movement there is a catching pain that continues until half range and then she is pain free. same provocation of pain on return to upright but also very complex series of rotation in the lumbar region.
2. posture: flat lsp and ant rot of pelvis (no other biomech factors in lower limb chain)
3.SIJ normal land mark positions but initially had the L psis higher than R which I treated with METs and traction to left leg. LLD no longer present.
4.TrAb/multif - activation very difficult and very quick to fatigue
5.overactive ER spinae during flexion of lsp
6. poor stability through the pelvic girdle with transfer of wt , poor gluts ++,tight hamstrings.
7. palp of L5/S1 facet L positive of her symptoms at end of range , and stiff Lsp generally.
8. unable to disassociate lsp and pelvis through flexion of Lsp in standing.

How have I treated.
Lots of stabilising exercises (Lsp/pelvis/LL), stretching.
Tried mobilising LS junction L and even soft tissue release/trigger point but if I give her more movement which she looks as if she needs
the pain gets worse. (ruled out Spondylolisthesis)
McKenzie extensions and postural advice

My hypothoses of her problems were
1.LumboSacral compromise due to mm imbalance
2.global muscle system failure due to central stabilising insufficiency.
3.facet joint (L5/S1 left compromise)
4. possible disc compromise -reduced disc space L5/S1 and L4/5.
5. Scoliosis creating biomechanical changes through out the spine.


Any suggestions as to what may be causing the "catching" pain and suggestions for effective treatments.

The problem is not severe and infact on the first assessment I thought it would be pretty straight forward to deal with but No I have not done what I had hoped to do in the length of time that i had hoped.


Thank you for your help.

[alophysio]

Hi,

I missed this post somehow...

Sounds pretty comprehensive (your assessment and treatment that is!)

I would say a lot of the imbalances etc are long standing. Finding out what is new is the challenge in these patients. Esp since she has been pain free until now. I have given up trying to improve these long standing things. I once had a patient who was in her 80s with a first time back pain and she had terrible scoliosis that never troubled her until then - it was an acute injury that settled within 2 weeks of rx.

Can you explain the anterior pelvic tilt yet flat L/S? How does that happen? There has to be extension happening somewhere...

I would try a manipulation. Childs in 2004 wrote a paper about using a clinical prediction rule for people with LBP who will benefit from a manipulation. Find it under pubmed. Goot go. Sorry!

[charlize29]

Hi physiogeneve,

I would try Pilates PROVIDED you GET MEDICAL CLEARANCE. You have already mentioned that her "gymnastic exercise" resulted to pain relief. Try to strengthen also the gluteal muscles and stretching of the hams would definitely help.

Regards,
charlize29

[sdkashif]

It seems that your patient is suffering from mechanical low back pain as morning pain and stiffness is short lived ( less than one hour) in mechanical low back pain as compared to inflammatory back pain. Your patient has movement related pain along with scoliosis. So have a look over some of the suggestions.

Movement related pain

Patients with movement related pain are most comfortable at rest; pain is precipitated only by activity and jarring. Heavy manual work, repeated twisting, fast walking and running (especially on hard surfaces) and traveling in car on rough grounds all precipitate pain. Movement related pain occurs in traumatic fracture dislocations, in symptomatic spondylolysis or spondylolisthesis and as a result of chronic degenerative segmental instability. Diagnosis may be confirmed by lateral flexion and extension roentengenograms of the lumbar spine and noting abnormal translational movement. A basic scheme of progressive stabilization by strengthening regional and segmental musculature isometrically should be considered. According to Grieve mature patients and those in most pain may need to start abdominal exercises with knee bent and progress more slowly. Side lying stabilization techniques and dynamic abdominal bracing may also be used. Home exercises should be efficiently monitored and the patient taught avoidance of posture and activities known to constitute his specific additional stimuli.

Mechanical pain without posture and movement exacerbation ( Static Sensitive)

Patient with static sensitive low back pain have the have an inability to maintain any one position ( other than lying) for a normal length of time and obtain relief by changing position and moving. Many of these patients appear to have a discrete structural disease, such as scoliosis.

Altered pattern of muscle recruitment have been clearly delineated. One of the most common of those is overuse and early recruitment of low back muscles. Another pattern associated with low back pain is over use of hip flexor (iliopsoas) and weakness of abdominals. It is frequently important to retrain the gluteal muscles and inhibit overuses of lumbar extension, a maladaptive pattern.

Dynamic trunk stabilizers, aside from gluteal maximus which originates or inserts into the lumbodorsal fascia, are the latissimus dorsi, transversus abdominis and internal obliques muscles. The main purpose of strengthening these muscles is to produce a forceful couple that is designed to stabilize the trunk and effectively controls the antigravity weight line or the way in which this area bears weight.

There are many types of isometrics exercises and Grieve provides some good examples to improve power of gluteal and abdominal muscles in the treatment of chronic low back pain, including abdominal wall and abdominal bracing exercises. These exercises avoid the higher intradiscal pressure and emphasize the eccentric control, free breathing and maintenance of functional position of spine. When performing exercises for upper abdominals, the feet should be plantar flexed to inhibit action of psoas.

Isotonic exercises can be helpful for some patients and may be used in all patients as progression of exercise programme, with or without manual or mechanical resistance.


References:

1-Management of Common musculoskeletal disorders, Physical therapy Principles and methods, 2nd edition, By Darlene Hertling and Randolph M. Kessler

2-Mobilisation of Spine, A primary handbook of clinical methods, By Gregory P. Grieve, Fifth Edition

[physiogeneve]

Thank you for the reply. This is in fact what I have been doing with this patient using the Performance Stability work and the the principles of Pilates (reformer, chair, cadillac exercises).
We are making good progress now but I guess it is only going to prove successful with the full compliance of the patient outside the Treatment Studio!!

I have both books you referenced and have been using them also- thank you.

Thanks, it is nice to know that my clinical reasoning was on the right track.