Figure 3 - uploaded by Seth Peterson
Content may be subject to copyright.
Change in the patient's lumbar lateral shift posture. (A) Patient posture at the initial physical therapy evaluation with a right lumbar lateral shift. (B) Patient posture at discharge
Source publication
Background:Lumbar lateral shift (LLS) is a common clinical observation but has rarely been described in a patient with a history of lumbar surgery. The purpose of the current case report was to describe the use of the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) in the multi-modal treatment of a patient with an LLS and a history of mul...
Contexts in source publication
Context 1
... discharge, she had not experienced leg pain in 3 weeks. Her posture was notably improved compared with her initial visit (Figure(3), and lumbar AROM was no longer painful. Hip abduction had improved to four of five on the right side and 4z of 5 on the left side. ...
Citations
... Another disagreement was resolved after obtaining an article describing the SMT technique used by the authors. Only three disagreements were adjudicated by a third investigator, all of which related to the number of motion segments in each patient [84,92,101]. ...
Background
This review aimed to identify variables influencing clinicians’ application of spinal manipulative therapy (SMT) for persistent spine pain after lumbar surgery (PSPS-2). We hypothesized markers of reduced clinical/surgical complexity would be associated with greater odds of applying SMT to the lumbar region, use of manual-thrust lumbar SMT, and SMT within 1-year post-surgery as primary outcomes; and chiropractors would have increased odds of using lumbar manual-thrust-SMT compared to other practitioners.
Methods
Per our published protocol, observational studies describing adults receiving SMT for PSPS-2 were included. PubMed, Web of Science, Scopus, OVID, PEDro, and Index to Chiropractic Literature were searched from inception to January 6, 2022. Individual patient data (IPD) were requested from contact authors when needed for selection criteria. Data extraction and a customized risk-of-bias rubric were completed in duplicate. Odds ratios (ORs) for primary outcomes were calculated using binary logistic regressions, with covariates including age, sex, symptom distribution, provider, motion segments, spinal implant, and surgery-to-SMT interval.
Results
71 articles were included describing 103 patients (mean age 52 ± 15, 55% male). The most common surgeries were laminectomy (40%), fusion (34%), and discectomy (29%). Lumbar SMT was used in 85% of patients; and of these patients was non-manual-thrust in 59%, manual-thrust in 33%, and unclear in 8%. Clinicians were most often chiropractors (68%). SMT was used > 1-year post-surgery in 66% of cases. While no primary outcomes reached significance, non-reduced motion segments approached significance for predicting use of lumbar-manual-thrust SMT (OR 9.07 [0.97–84.64], P = 0.053). Chiropractors were significantly more likely to use lumbar-manual-thrust SMT (OR 32.26 [3.17–327.98], P = 0.003). A sensitivity analysis omitting high risk-of-bias cases (missing ≥ 25% IPD) revealed similar results.
Conclusions
Clinicians using SMT for PSPS-2 most often apply non-manual-thrust SMT to the lumbar spine, while chiropractors are more likely to use lumbar-manual-thrust SMT relative to other providers. As non-manual-thrust SMT may be gentler, the proclivity towards this technique suggests providers are cautious when applying SMT after lumbar surgery. Unmeasured variables such as patient or clinician preferences, or limited sample size may have influenced our findings. Large observational studies and/or international surveys are needed for an improved understanding of SMT use for PSPS-2.
... If the patient has a lateral lumbar shift, a shift correction could be used to determine if the patient's primary complaint centralizes or peripheralizes. 43,44 In the absence of a lumbar shift, the patient's reports of their symptomatic response (increase and/or decrease) to posture, position (flexion or extension), repetitive motion (flexion or extension), mid-range motion, load, and tension may provide valuable clues to generate hypotheses related to the most likely source of the radicular symptoms at any given time. These hypotheses should be tested to determine if these variables peripheralize or centralize the patient's radicular symptoms. ...
Background
There is considerable overlap between pain referral patterns from the lumbar disc, lumbar facets, the sacroiliac joint (SIJ), and the hip. Additionally, sciatic like symptoms may originate from the lumbar spine or secondary to extra-spinal sources such as deep gluteal syndrome (GPS). Given that there are several overlapping potential anatomic sources of symptoms that may be synchronous in patients that have low back pain (LBP), it may not be realistic that a linear deductive approach can be used to establish a diagnosis and direct treatment in this group of patients.
Objective
The objective of this theoretical clinical reasoning model is to provide a framework to help clinicians integrate linear and non-linear clinical reasoning approaches to minimize clinical reasoning errors related to logically fallacious thinking and cognitive biases.
Methods
This masterclass proposes a hypothesis-driven and probabilistic approach that uses clinical reasoning for managing LBP that seeks to eliminate the challenges related to using any single diagnostic paradigm.
Conclusions
This model integrates the why (mechanism of primary symptoms), where (location of the primary driver of symptoms), and how (impact of mechanical input and how it may or may not modulate the patient's primary complaint). The integration of these components individually, in serial, or simultaneously may help to develop clinical reasoning through reflection on and in action. A better understanding of what these concepts are and how they are related through the proposed model may help to improve the clinical conversation, academic application of clinical reasoning, and clinical outcomes.
... We identified 17 case reports or series describing 144 patients after lumbar laminectomy. Two reports from the medical profession [52,64], 1 from physical therapy [71], 1 from an athletic trainer [40] and the rest were chiropractic specific. Favorable responses were described with spinal manipulation [41,52,54,56,58,60,63,72,76], spinal manipulation under anesthesia [42], spinal mobilization with or without McKenzie method [71], FD manipulation [49,51,61,69,76], and massage [40]. ...
... Two reports from the medical profession [52,64], 1 from physical therapy [71], 1 from an athletic trainer [40] and the rest were chiropractic specific. Favorable responses were described with spinal manipulation [41,52,54,56,58,60,63,72,76], spinal manipulation under anesthesia [42], spinal mobilization with or without McKenzie method [71], FD manipulation [49,51,61,69,76], and massage [40]. ...
Background and Purpose
Pain and disability may persist following lumbar spine surgery and patients may subsequently seek providers trained in manipulative and manual therapy (MMT). This systematic review investigates the effectiveness of MMT after lumbar surgery through identifying, summarizing, assessing quality, and grading the strength of available evidence. Secondarily, we synthesized the impact on medication utilization, and reports on adverse events.
Methods
Databases and grey literature were searched from inception through August 2020. Article extraction consisted of principal findings, pain and function/disability, medication consumption, and adverse events.
Results
Literature search yielded 2025 articles,117 full-text articles were screened and 51 citations met inclusion criteria.
Conclusion
There is moderate evidence to recommend neural mobilization and myofascial release after lumbar fusion, but inconclusive evidence to recommend for or against most manual therapies after most surgical interventions. The literature is primarily limited to low-level studies. More high-quality studies are needed to make recommendations.
... However, a manual correction and exercise approach developed by McKenzie may have positive benefits, particularly with shifts less than 3 months' duration [1,10]. Evidence suggests an LLS can be treated with surgery [9] or with McKenzie's manual correction and self-treatment protocol [6,11,12]. ...
Background
A lumbar lateral shift (LLS) is a common clinical observation in patients with low back pain (LBP), and a shift contralateral to the side of pain is the most common presentation. An LLS that can rapidly alternate sides presents several treatment difficulties and has rarely been described. The purpose of the current case report was to describe the presentation and management of a patient with an alternating LLS.
Case Description
A 39-year-old male with a 7-week history of LBP and previous lower extremity radicular pain was referred to physical therapy. An alternating LLS was present.
Outcomes
The patient was treated for six visits over 37 days. Treatment included modified self-correction of the LLS, motor control and trunk muscle endurance training, and development of an activity management program. The patient’s LLS resolved, his worst pain improved from 3/10 to 0/10, and the Oswestry Disability Index improved from 26% to 4% disability. The patient reported maintenance of improvement at 6-month follow-up.
Discussion
The current approach produced a positive outcome in a patient with an alternating LLS. The current understanding of mechanisms and optimal treatment of an alternating LLS is limited.
Level of Evidence
4
... We identified 16 case reports or series describing 143 patients after lumbar laminectomy. Two reports from the medical profession[42,63], 1 from physical therapy[60], 1 from an athletic trainer[45] and the rest were chiropractic specific. Favorable responses were described ...
Background
The purpose was to identify, summarize, and rate scholarly literature that describes manipulative and manual therapy following lumbar surgery.
Methods
The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and was registered with PROSPERO. PubMed, Cochrane Database of Systematic Reviews, ICL, CINAHL, and PEDro were searched through July 2019. Articles were screened independently by at least two reviewers for inclusion. Articles included described the practice, utilization, and/or clinical decision making to post surgical intervention with manipulative and/or manual therapies. Data extraction consisted of principal findings, pain and function/disability, patient satisfaction, opioid/medication consumption, and adverse events. Scottish Intercollegiate Guidelines Network critical appraisal checklists were utilized to assess study quality.
Results
Literature search yielded 1916 articles, 348 duplicates were removed, 109 full-text articles were screened and 50 citations met inclusion criteria. There were 37 case reports/case series, 3 randomized controlled trials, 3 pilot studies, 5 systematic/scoping/narrative reviews, and 2 commentaries.
Conclusion
The findings of this review may help inform practitioners who utilize manipulative and/or manual therapies regarding levels of evidence for patients with prior lumbar surgery. Following lumbar surgery, the evidence indicated inpatient neural mobilization does not improve outcomes. There is inconclusive evidence to recommend for or against most manual therapies after most surgical interventions.
Trial registration
Prospectively registered with PROSPERO (#CRD42020137314). Registered 24 January 2020.
... MDT allows for the treatment to adapt as patient presentation changes. MDT also follows referral patterns and symptomatic and mechanical responses to repeated movements to confirm findings in a safe and more reliable manner [10][11][12][13][32][33][34]. Without an initial MDT evaluation prior to surgery, it is difficult to say if the appropriate level received the surgical intervention with only MRI results dictating treatment. ...
