Case of the Week: Sept 6, 2011: The Dreaded Lumbar Lateral Shift | Modern Manual Therapy Blog

Case of the Week: Sept 6, 2011: The Dreaded Lumbar Lateral Shift

While I do see my fair share of lumbar patients, I don't see too many lateral shifts. I always tell my students that sometimes a colleague and myself would take turns doing shift corrections as the patient swore and pounded on the wall for over 45 minutes (after a brief history). I had just finished telling one of my students this story when a former fellow in training of mine called me and said a friend of his had a lateral shift of between 2-3 weeks in duration.

History: Four weeks prior to evaluation, he helped a friend move for several hours. This resulted in acute LBP which resolved in a few days. Two weeks later, while golfing, had onset of severe left LBP, and was unable to stand upright and found himself shifted to the left. He had been seeing a chiropractor who was using an activator on him in prone and gave him no home exercises. He was no better. He rated his complaints as 7/10 and constant with intermittent pain radiating to his right thigh, but not below the knee. MRI was positive according to patient, but I didn't end up looking at it, trusting the MDT classification and my hunches.

Objective: moderate lumbar lateral shirt to the left in standing, severe loss of sidegliding in standing to the right. Lumbar forward bending and backward bending not tested.
As McKenzie states you have approximately six weeks to correct a true lumbar lateral shift before various changes like adaptive shortening make it very difficult to treat; you are supposed to take a brief history then start shift correction immediately.

Assessment: Signs and Sx consistent with subacute lumbar lateral derangement with lateral shift to the right

Plan: Correct the shift, hope it stays!

Treatment: Started with shift correction in standing, performed this from mid to end range slowly, but progressively. Both he and I were surprised it wasn't extremely painful. I kept this up for about 10-15 minutes, taking a break as needed. He was sweating and my arms were getting quite a workout! He was about 75% corrected, but could not maintain the shift correction upon walking more than 10 feet. I performed  another series of corrections for about another 10 minutes and ended with some slight extensions. This peripheralized and worsened his LE complaints, so I discontinued the extension. I held the next set of shift corrections at end range sideglide, took him to the table in overcorrected position and got him in supine eventually. He had very little pain at this point, going from a 7/10 to 2/10. I proceeded with flexion in rotation closing (LEs to right, trunk relatively to left) and took him to end range. He was again surprised that it didn't hurt more. I really worked on progressing his end range and adding some sidebending to take him further.

He ended up maintaining at least 75% shift correction. He returned the next day, with only some shift correction intact, but his pain was reduced to 5/10. LE pain was abolished. My colleague followed up, as I was off in the morning. He performed more shift correction and did some STM on his lumbar spine. The patient then had a long weekend and had to be part of a wedding party. We were worried about his long drive. We reviewed his HEP from the first day, which consisted of use of a lumbar roll and shift corrections hourly against the wall.

Patient returned for the third visit and he was happy to report feeling better. He was slightly shifted. Lumbar sidegliding in standing still moderately blocked to the right. We started him in prone with hips offset. I released his right quadratus lumborum and performed some TASTM to his erectors which were moderately restricted right greater than left.  I Followed this with some lumbar rotation in flexion in closing. He was pain free, and only minimally shifted, but could walk and maintain the correction. HEP was unchanged.

On the fourth visit, the patient reported only having "stiffness" in the morning, but was Sx free the entire day for the past two days. He was very compliant. Treatment remained the same as last visit. The next follow up, was completely pain free and tested recovery of function. He had full sidegliding to the right, lumbar extension also pain free and WNL repeatedly. Repeated flexion was WNL and pain free. Repeated extension was not blocked by extension, indicating stable lumbar derangement. He left with repeated extension for prophylaxis, but was worried about bowling the next night. I told him to be careful and to extend before and after every turn and to avoid prolonged sitting. He was still just minimally shifted. We concluded that he always had a slight shift as all his repeated motions were free and painless.

Fifth visit, the patient was sore, rated 5/10, but not shifted. His lumbar sidegliding was WNL, but extension was moderately blocked. Sx were intermittent. If you see my previous post, I feel liberal interpretation of the CPR is warranted. He was acute again after having an abolished derangement. After some TASTM to his lumbar paraspinals right > left, I performed one lumbar thrust manipulation to each side. He was immediately pain free and repeated extension was now full and pain free. He left with repeated extension in standing against a table to isolate his hips for more isolated end range loading.

Discussion/Summary: Subacute lumbar lateral derangement with deformity of lateral shift. Responded well to end range loading to reduce the derangement. STM and functional release to right lumbar paraspinals and QL helped free up his movement and helped unblock his sidegliding in standing. After reducing and maintaining reduction of the derangement, the patient rederanged


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