Reply To: Neurodynamics of Lumbar Radiculopathy

[Laura Thornton]

Wow, thank you all for responding!

I think it’s only fair to start with updating from our last visit with the patient:

No change in sensation or single heel raise. Can perform them in the pool, but not on land. Reports less uncomfortable sensation, but is getting restless and wants to do more exercise since it’s been several weeks since the onset.

Patient had a EMG with the neurologist he is also seeing: [from patient’s own words, is getting us a copy for next session] “There is definitely something compressing on the nerve, but the nerve is still working somewhat.” Patient has MRI and cortisone injection scheduled (date unknown).

>> Myra, the patient, and I started with a discussion on the research supporting injection + PT has great results compared to each treatment alone. He expressed frustration of the time it was taking to see results, and wondering if surgery is the best option to cut his recovery time down. Myra made some excellent points saying that 1) changing your anatomy forever by laminectomy, etc. to just cut down recovery time isn’t a smart way to look at recovery 2) if the nerve needs time to regenerate and heal (1 mm/day), surgery isn’t going to change that piece. We reassured him on the fact that he is not having any progressive neurological deficits, we will review and start safe and appropriate resistance training at the end of today’s session, and the positive results we are seeing this this type of injury that get better on its own without surgical involvement, it again just takes time.

Lumbar flexion ROM: Fingertips to FLOOR (improved)

Dermatome: Diminished to light touch in the following areas: dorsal and plantar surface of 5th digit, plantar surface of 4th digit, lateral border of foot and lateral 1/3 dorsal and plantar surface of foot, lateral > medial heel, posterior/lateral lower leg up to halfway up lower leg. Posterior/lateral gluteal crease and posterior/lateral thigh. (We wanted to map out entire area to keep close monitoring of sensation)

No change in DTR, no change in strength.

SLR: 90 degrees with posterior/lateral calf “stretch”, worse with dorsiflexion, no change with cervical flexion.

>> Addition of supine sciatic nerve glides with foot in plantarflexion

SLR Reassess: 90 degrees + hip ADD first feeling of “stretch” (worse with dorsiflexion, no change with cervical flexion. Sensation Reassess: no change.

Progress to seated slump sliders with slight thoracic and cervical flexion with full knee flexion >> thoracic and cervical extension and knee extension

SLR Reassess: 90 degrees + hip ADD/IR + dorsiflexion (slight feeling of “stretch”), no change with cervical flexion. Sensation Reassess: no change. Lumbar Flexion AROM: Can reach entire lengths of fingers to floor with slight stretch in posterior/lateral thigh.

Thoracic UPA mobilizations reassessed >> could not reproduce leg pain today, although hypomobility still present in mid-thoracic region. Thoracic mobilizations still performed (with ensuring no reproduction of symptoms during treatment, low grade) as well as lumbar gapping mobilizations to L4-L5.

SLR Reassess: same as previously (no gain or loss, although considering this a full SLR at this point and equal to the other side). Lumbar Flexion Reassess: Can now place entire palm onto floor with slight stretch in posterior/lateral calf.

HEP: Thoracic extensions over ball on wall in standing. Cable column upper extremity resistance including rows, lat pull downs, tricep extensions, bicep curls with ensuring that the anchor stays above shoulder height (to avoid any spinal compression). Addition of front and side planks (this guy can hold 2 ½ minute planks, we were reassessing along entire way for any change in pain, sensation, etc.)

Comments:
It’s definitely a blessing and a curse to treat this patient. He’s young, motivated, fit, and compliant with everything we tell him, but he tends to push the envelope and he wants to get better as fast as possible (can you blame him?) I think it will be essential for us to continue to make sure we are monitoring his neuro status, supporting appropriate exercises he can do, be supportive of the changes he sees, and continue to discuss at each session prognosis.

I can’t tell what the prognosis will be in terms of motor function and sensation, or as Myra says there’s no “crystal ball” here. He’s improving with other components (SLR, lumbar flexion, “uncomfortable” sensation in his right leg), which I think is a great sign. I am a huge proponent of reassess and I am on him like a hawk with everything new we add (I’m probably annoying at this point).

There is definitely nerve tension going on within his system with his previous thoracic injuries and Myra sent me to review David Butler’s work on mobilization of the nervous system to review anatomy, pathophysiology, as well as the existence of tension points within our system, one including the mid-thoracic region. I think it’s going to be important to address this component, however I’ve been hesitant until the last session to add any slump neural tension components, because like Nick mentioned, how would you take neurological deficits in mind as you add neurodynamic treatment? Sounds like you all agree to be as slow and gradual as possible, with constant reassess and modifying if he shows increase in irritability or change in neuro status.

Should I take that he can perform a single heel raise in the pool as a good sign? I feel like I’m on the fence, since he wasn’t performing them before. Still cannot perform single heel raise, although can perform double heel raise and has great strength in supine position MMT.

P.S. Unfortunately, I did not consider T4 syndrome in my differential diagnosis list, however it did cross my mind briefly upon reflecting after the session and I did think of you all fondly ha!