Written by: Pat Stanziano, MPT, Dip Sport Physio, Cert MDT, CSCS
Late in the day on Saturday, I noticed that I was having some left-sided lower back pain. I figured that if I could make it to bed that night, without making it worse, then I would be fine by the next morning. Does any of this sound familiar so far??
Well I don’t know what happened during the night, but in the morning, my pain was not only in my back, but in my left butt cheek, my left hamstring, and halfway down my left calf. Not only that, but when I got out of bed, I passed by the mirror and saw that the top half of my body was slightly shifted to the right and my hips sticking out to the left. My first reaction, believe it or not, was “hey, this is a good opportunity to educate some people out there” and hence the idea for this blog.
Now being a physiotherapist, and especially a McKenzie practitioner, I quickly realized that I had awaken with a left posterior-lateral lumbar derangement with radiculopathy below the knee and a relevant right lateral shift. ?!*WHAT*!? Let’s break that down: Left posterior-lateral lumbar derangement simply meaning pain in the left lower quadrant of the back; radiculopathy below the knee implies that I was having pain in my leg right down to my calf that wasn’t attributed to any type of injury to this area, but rather was originating from my back; relevant right lateral shift describes how the upper half of my body was shifted to the right and when I tried to straighten myself up, I wasn’t able to maintain that position.
Now to confirm this. First I checked my lumbar range of motion (ROM): (1) Flexion, or forward bending, was painful and significantly restricted as I was unable to get my fingers to pass my knees; (2) extension , or backward bending wasn’t as bad as I expected – just minimally restricted, and painful; (3) side gliding right was not restricted, but increased the pain in my calf; (4) left side gliding was significantly restricted and painful as I was unable to get myself past the neutral position. I was unable to check for any neural signs except for the positive left slump test I had (A slump test is when you sit on the edge of a bed, table, or chair, slouched down as far as you can, and producing pain with either leg extended forward).
Now normally with someone, who presents with back, and maybe leg pain, I would move on to see how various repeated movements will affect the signs and symptoms. However, the problem of this laterally shifted position needed to be addressed first. So I tool myself to the closest wall leaned against it with my right side, and started pushing my hips over to the wall. This absolutely was killing my back; but as I continued for 15,20, 30 reps, I noticed my the pain in my leg was going away . . . first in my calf, then behind my knee, then my hamstring. As I was getting physically exhausted, and my back and left butt cheek still in pretty significant pain, I decided to take a break.
I went back to bed for an hour or so and laid on my left side with a pillow placed under my hips in efforts to keep my hips at a neutral -to-slight-right-offset position (i.e. the opposite to what I was stuck in). When I woke up again, I was laterally shifted . . . again, and pain only down to the hamstring. But this time, it took fewer reps to get rid of this leg pain and correct my posture. Throughout the course of the day, my task was to repeat the sideglide in standing exercise against the wall, 10-20 reps every hour. In addition, I tried to avoid extreme movements, like bending forward to tie my laces, sitting for long periods of times, or any twisting movements.
By the end of the day, I was able to maintain a fairly upright position in standing and my pain was located to the lower left side and the upper portion of my left butt-cheek. This was certainly a good effort on my part to get that pain centralized. A staple of the McKenzie method, the centralization phenomenon, or sequential abolishment of symptoms from a most distal-to-proximal direction, is often an indication for a good prognosis.
We shall see where I am tomorrow . . .
I opened my eyes this morning, laying on my left side with the pillow under my hips (as in my picture from yesterday). I had NO pain . . . Could it be that after the my relentless pursuit to centralize my symptoms and maintain a neutral spine during the night, that everything had resolved?? I knew better. My first few steps away from my bed were very stiff, but that is normal because the discs in our back rehydrate during the night (analogy: picture squishing a balloon that is half-filled with water, versus squishing one completely filled with water: which one is easier/harder to move?). But by the time I reached the bathroom, that lower left-sided pain was creeping back. On a good note, my posture was fairly straight; no right lateral shift like I had yesterday . . . woohoo!!
After taking some time to do my usual morning routine and being cautious to avoid extreme end-range movements, like sitting upright on the toilet or at the table (as opposed to sitting slouched), bending my knees at the sink to brush my teeth (as opposed to bending at my back), and resting my foot on the opposite knee to put my socks on (as opposed to bending toward the floor), I finally did my first set of sidegliding in standing against the wall (15 reps). My pain, which was sitting just above my butt cheek responded by moving to just left of center spine. The task during my return to work would be to, at least, maintain this current state. I said to myself that I would try to do at least 5-10 reps of my exercise between clients scheduled on the half hour between 9am-12pm.
Once 12pm came and I hadn’t the chance to do any of my exercises, my pain had returned to just above the left butt cheek. I immediately did 20-30 reps and centralized my symptoms. After an extended break (lunch with my wife, baby and some fellow newbie parents), the next opportunity to do the same exercises came just before my 3pm client. This time the pain was already just left of centre and really didn’t change much after my set. I was better at doing the exercises regularly during my afternoon block, but there no longer seemed to be any progression. It seemed that it was time to make a change in movement strategy. The question became whether I would be a responder to repeated lumbar flexion, or repeated lumbar extension. Having seen hundreds of people who presented similarly to me, I was inclined towards one and not the other. But I decided to attempt both because some times there does turn out to be a surprise or two.
So when I returned home, I had dinner and then proceeded to evaluate the effect of these repeated movements. I laid on my back and started bringing my knees toward my chest; repeated lumbar flexion. In a matter of moments, the pain shot out to my left butt cheek like a bolt of lightning. I got up and tried to walk it off. But no luck, the pain had peripheralized, a big no-no (it’s the opposite of centralization).
After performing my corrective sidegliding in standing exercises to re-centralize my symptoms, I laid on my stomach, put my hands in push-up position, and started pressing my upper body away from the ground; repeated extension in lying. Like daggers going through my back, I needed to stop before I could complete the full set. Again, I got up and walked around. Unlike the flexion, the pain increased during movement, but did not peripheralize. In addition, it settled to its previous without having to do the sidegliding.
Despite the McKenzie model telling me that this last scenario (i.e. increased pain during movement, but not really any worse after) was a yellow “proceed with caution” light, I certainly did not want to feel that stabbing pain again! It was time for some analysis: (1) left sidegliding in standing centralized my pain, but was not getting rid of it – green light; (2) flexion in lying was peripheralizing my pain again – red light; and (3) extension in lying increased the pain, but it did not last – yellow light. What if I combined (1) and (3)?? I laid on my stomach again, and shifted my hips to the right; opposite to the side of pain, similar to what I had done as my corrective sidegliding exercise in standing. With my hips in this position, I proceeded to do the press-ups. The first couple reps increased my pain, but not knife-like as before. However, I was able to press on and the pain slowly started to reduce. I rested my back (and arms) after 10 reps. By rep 7 of my next set, the pain was completely gone! I laid there for a second without pain, remembering that’s how I woke up in the morning. I wondered whether or not the pain would trickle back once I stood up. Well, it did, just left of centre. Since I was able to find a repeated movement that completely got rid of my pain, even though it was in lying, I decided that was going to be my new corrective exercise, provided that I was starting it with my pain at this new baseline (i.e. just left of centre).
My task for the rest of night was to perform the exercise at least twice more (10-15 reps each time, and to sleep in the same position as I did yesterday (left sidelying with a pillow under my hips).
We shall see where I am tomorrow . . .
Woke up this morning, sans pain . . . CHECK
Got out of bed, sans pain . . . CHECK
Finished my morning routine, sans pain . . . CHECK
Lifted the garage door open, sans pain . . . CHECK
Survived wiping out on the snow-covered ice at the bottom of the driveway, sans pain . . . ummmm, ya . . . not so lucky!
And that was my morning, folks. Trying to undo this mess of a situation that left me with some significant left-sided low back pain. Now because I didn’t necessarily feel it in my left butt cheek, I decided to try the prone press up with my hips offset to the right, as opposed to the sidegliding in standing exercise. After a couple of sets (10 reps), I centralized, then abolished my pain. I would go through my morning performing the same thing at the very hint of pain.
Because it was a low-key type of day with my family, sitting and watching movies, laying on the floor and playing with the baby, I was actually performing different movements and positions that I hadn’t even tried in the previous few days. A few things I made sure of:
1.) When sitting for long period of time (especially in a recliner), I used a lumbar roll to maintain neutral lumbar spine position
2.) Even though I did some forward bending, I tried to avoid doing so repeatedly
3.) I did not bend at the back to lift anything. For example, when I needed to pick up baby from play mat, I made sure to go down to my knees to pick her up and then used my legs to rise to my feet, all while trying to keep my low back straight.
It’s New Year’s Eve, and the night is still young. I’m not feeling that my issue is 100% resolved, but things seem to be headed in the right direction. I wonder how things would be different if I didn’t take that spill this morning . . . oh well, c’est la vie. But I will do my exercises at least once more before the night is over.
We shall see where I am tomorrow . . .
Sorry my Day 4 update is coming on day 5, but thankfully in this case, no news is good news.
I have not had much pain, and the very infrequent episodes that occurred throughout the day became less and less intense. For the most part, my pain was brought on by prolonged sitting. Because it was a day spent with the extended family, there was a lot of sitting going on: at the dinner table, watching the Winter Classic, driving 30-45 minutes back and forth.
Driving was probably the worst, because in the other situations, you can easily get up and break the monotony by doing the exercise or even walking around. But with driving, you are not so inclined, because arriving at your destination superceeds all else. The other fact about driving is that car seats are horrible for sufferers of low back pain. Nobody really knows how to adjust the angle of the seat. If you are like my parents, you think the more vertical, the better. Well that is not the case. Most ergonomics and orthopedics textbooks tell us that the optimum angle to maintain between the upper body and lower body is 100-110 degrees. This angle is not measured from the horizontal, but rather from the tilt of the seat itself.
There are other factors to consider when adjusting a car seat for optimal lumbar position, such as height, leg room, and seat tilt. A feature that most vehicles have now-a-days is the lumbar support adjustments. Now this is just my opinion, and not based on any kind of scientific research, but I think this feature is just garbage. Now let me give you an analogy: mouthguards in sport are said to reduce the incidence of oral-fascial injuries, but also head and brain injuries; how confident would you be in the ability of such a mouthguard to do these things, if it was molded to someone else’s mouth and given to you for use??? I would assume, not very confident. So I think the same could be true for these automatic lumbar supports; if you were not the one the support was modelled for, then is it really going to give you the optimal performance? I’ll let you answer that question. Sorry about the little rant there . . . A simple solution is to get yourself a McKenzie lumbar roll that you can take with you anywhere? (we will talk about use of the lumbar roll in the next blog . . .)
We shall see where I am tomorrow . . .
The resolution of your low back pain should be accompanied by the resolvement of your obstructed range of motion (ROM). So let’s take a look at how I have faired over the past week.
Now it’s important to note that my only exercise was to extend backwards, and yet it has restored (for the most part) my ROM in all directions. I do still feel that my flexion (or forward bending) could be a little bit better, but it’s understandable that the final few degrees would be lacking if it is the movement that I restricted myself from doing over the past week.
That brings us to the next phase of rehab: restoration of function. It’s important to start introducing movements in all directions now, especially flexion. However, the key is not to undo what you have worked so hard to achieve during the time you were resolving your pain. So introduce a few repetitions of flexion first, immediately followed by your regular set of extension in standing or prone pressups. In each subsequent day, if you remain pain-free, then you can start to increase the repetitions of flexion until you are performing the same number of flexion and extension exercises. You generally continue this regimen until you are 100% pain-free and your ROM is 100% resolved. Your McKenzie therapist will help prescribe the correct balance of repetitions and monitor your progression.
The number one predictor for an episode of low back pain, is that there was a previous history. So that means the hardest thing to do is make sure you don’t fall into the same bad habits and patterns that led you to the episode in the first place. Easier said then done, right? Well here are some pointers:1.) good posture and biomechanics – people often wonder where their low back pain came from. Look no further than this point here. As a little test, get into the most horrible posture you can drudge up and time how long it takes for you to feel a little strain. Then relax from that position and walk around until the strain goes away. Next, get back into that same position and time again: it probably doesn’t take as long to feel the strain the next time, right? Now can you imagine doing that for 8 hours a day, 5 days a week, for years and years and years? Now you may or may not get low back pain from a prolonged posture, or repeated movement, but it might predispose you to an episode of low back at any slight or awkward movement or position down the road. The use of lumbar roll can help maintain a neutral spine position when sitting for long periods of time at a desk or in a car. Sit your butt to the back of the seat and slightly lean forward. Slide the lumbar roll down to the space in the back, just above the hip bones. Then lean back into the chair and the roll will help you maintain the natural curve in your lower back.
2.) Take a quick break – if you have a job where you are in the same posture for a prolonged time or performing the same movement, a little respite every so often goes a long way in preserving your strained tissues.
3.) Move in the opposite direction – A little analysis of the movements and positions that you perform most during the day, and then performing movements in the opposite direction not only preserves your strained tissues, but may in fact reverse the damage caused to them.
Finally, a word on “core” exercises. That word is thrown loosely around to mean anything from stomach crunches, to medicine ball twists, to planks. Well, here is my take: Core strength and abdominal strength are incorrectly understood to be synonymous.
The abdominal muscles alone are overrated when it comes to true core strength and conditioning. The abs’, like any other muscle in the trunk you can see or touch (obliques, paraspinals, etc), main function is to produce movement; much like the biceps produces movement at the elbow.
The “core” actually consists of many different muscles that run the entire length of the torso and into the extremities, and comprise of both the muscles you can see and those that you can’t. Confused yet? Don’t be. The “core” is really, how all these muscles act together to prevent movement or to slow down the rate of movement caused by an external force, not only the spine, but the pelvic and shoulder girdles.
Gravity, an external force, applies a downward force on your body, all day, every day, no matter what position you are in. When you are laying down on a flat surface, there’s really no where else for you or your body to go, so there is really no core activation. However, when you are sitting or standing, gravity likes to push your head and shoulders toward the floor; if you are not conditioned, leading to bad posture. So one of the best core exercise you can do is sit or stand up straight. Can you think of exercises that build a solid foundation to fight against external forces, whether it is gravity or something else?
If you have anything to say about this or anything else I have posted on my blog about low back pain, feel free to send me a comment.
Cheers to your health.
Pat Stanziano, MPT, SPC, Cert MDT, CSCS
DISCLAIMER: I am a trained practitioner, Certified in McKenzie’s Mechanical Diagnosis and Therapy. As low back pain may have a wide array of signs and symptoms, the movements described in this post may not be suitable for you. So, I will not be held responsible should your condition worsen if you have attempted such movements. Instead, if you are dealing with a back condition, I encourage you to contact your closest McKenzie practitioner to determine your appropriateness for this type of therapy.