lumbar radicular conditions

radicular pain

pain (gain of function) caused by a problem at the nerve root

radiculopathy

weakness, numbness (loss of function) caused by a problem at the nerve root

referred pain

pain from a problem in a muscle, joint that is felt in a place different to where the problem is

radiculopathy overview

- common in male 30-50 y/o

- can caused by either lateral canal stenosis or disc herniation

risk factors for radiculopathy

- driving occupations

- lifting and twisting

- previous hx of LBP

- smoking

- obesity

- multiple pregnancies

directional preference/specific exercise definition

pt reports that flexion consistently makes LE appear and worsen while standing up and going for a walk makes it feel better

loading strategies

passive or active forces applied w/ goal of creating positive change progressing towards end of range w/o flaring sx

what is a 1st appt positive predictor of success w/ PT

centralization

what do nerves need to be healthy?

BF, movement, space

how do disc herniations heal

autoimmune system recognizes LDH protrusions as foreigners which triggers inflammation cascade

common causes of sciatica

- compression, ischemia

- impaired axonal transport, demyelination, axon degeneration

- loss of n. function

- chemical irritation

- inflammation

- gain of nerve function

femoral n. tension test (prone knee bend)

hold Ely position and maintain for 20+ sec to reproduce neurologic sx

- indicative of L2-L4 n. root lesion

- can add slump

is piriformis a common cause of n. tension?

fairly rare

discussion if pt should have surgery or not

- radiculopathy w/ clear myotomal deficits

- unresponsive to quality, multimodal conservative care

- discuss risks and benefits w/ surgeon

- diagnostic confirmation of involved level

EMG/NCS as assessment tools

can help decide if it's a motor or sensory issue

- needle EMG: can measure muscle activity at rest or contracting

- NCS: e stimulus to n. generating AP that is recorded; can evaluate # of functioning and speed of n. fibers

NCS for lumbar radiculopathy

sensory n. APs are typically normal in radiculopathy since lesion is proximal to corresponding dorsal root ganglion

- if it's abnormal most likely other lesions

needle EMG for lumbar radiculopathy

sharp waves and fibrillations can show spontaneous activity

- recommend 2 extremity muscles and one paraspinal muscle reading

most effective at ruling IN lumbar radiculopathy

negative NCS and positive EMG

MDT background

repeated end-range movements and postures

- emphasizes pt empowerment and self-treat

primary syndrome classifications of MDT

- derangement

- dysfunction

- posture

- other

MDT derangement syndrome

MOST common

- inconsistency and change of sx is major characteristic

- directional preference is hallmark (specific repeated movement or sustained position causes improvement)

MDT dysfunction syndrome

pain from mechanical deformation of structurally impaired tissues (adhesions, scar)

- sx must be present 6-8 weeks

- pain is always intermittent and arises at end range of a restricted movement***

- adhered n. roots fit under category

treatment of MDT dysfunction

repeated movements in direction of dysfunction or in direction that reproduces pain

- aim to remodel tissue that limits movement

MDT posture syndrome

refers to pain due to mechanical deformation of normal soft tissue from prolonged end range loading or periarticular structures

- pain arises during static positioning

- pain disappears when pt is moved out of static position

- no pain w/ performing movement or activity

treatment of MDT posture syndome

correction of posture by improving posture by restoring l/s lordosis avoiding provocative postures and avoid prolonged tensile stress on normal structure

extension subgroup key exam findings

- sx distal to knee

- sx centralize w/ extension

- sx peripheralize w/ flexion

- (+) n. root compression signs

- (+) SLR

extension subgroup intervention

- extension exercises

- mobilization to promote ext

- temporarily avoid flexion activities

- address neurodynamic and other deficits as needed

flexion subgroup key exam findings

- sx peripheralize w/ ext

- n. mobility deficits possible

- 65+ w/ possible sings of LSS

- sx distal to knee

- (+) n. root compression signs

- (+) SLR

flexion subgroup interventions

- flexion exercises

- mobilization to promote flexion

- unweighted/modified ambulation and aerobic exercise

- temporarily avoid ext

- address neurodynamic and other deficits as needed

lateral shift subgroup key findings

- sx peripheralize w/ ext

- sx centralize w/ flexion or directional preference for flexion

- visible frontal plane deviation of shoulders

- asymmetric side-bending AROM

- (+) n. root signs and SLR possible

- limited SB ROM opposite the lateral shift

lateral shift subgroup interventions

- lateral shift correction in standing

- NWB shift correction: ext. in prone off center

- address neurodynamic and other deficits as needed

derangement syndrome managgement

- find position/direction that makes them better and progressively load it while monitoring sx changes

- may have observable deformity

derangement w/ lateral shift intervention

shift is named for direction shoulders are going

- sideglide towards affected side and block shoulders as PT

- might take many reps to improve

- self sideglide should go past neutral

derangement w/o shift deformity force progression

static: midrange -> end range

dynamic: midrange -> end range -> self-overpressure

clinician generated: pt end range -> overpressure -> mobilization

derangement w/o shift deformity green yellow and red light

green: centralizing, increase ROM through set and/or reduction in pain

yellow: produce sx during but no worse afterwards

red: worsening ROM, pain and peripheralization

MDT extension progression

prone lying -> prone lying in extension -> extension in lying -> extension in lying w/ OP -> extension mobilization -> extension in standing

MDT flexion progression

flexion in lying -> flexion in sitting -> flexion in standing -> flexion in lying w/ OP

MDT exercise parameters

- static 2-3 min if reps aren't tolerated

- 8-15 reps, slow pace

- relaxed LE and spinal muscles

- get to end range

- 10 reps every couple hrs for HEP

who needs neural mobilizations

- pt reported neural-type sx

- (+) neural tension test at baseline

- alr addressed non-neural factors and still have (+) neural tension

referred pain from spine findings and interventions

findings:

- back pain w/ (+) spine exam findings and (-) neural tension tests

interventions:

- treat w/ mobz and/or stabilization and reassess LE ex

- may need neuromobz after

radicular pain from spine findings and interventions

findings:

- derangement classification

- acute or chronic

- centralize w/ one direction and peripheralize w/ another

interventions:

- MDT repeated or sustained exercises and postures that centralize

- may need neuromobz

adhered nerve root dysfunction finding and intervention

findings:

- scar tissue around nerve

- chronic

- end range directionally specific movements produce sx but no worse afterwards

interventions:

- neural mobz w/ or w/o spinal mob

- may need neuromobz