The patient is a 68 yo male, morbidly obese (say ~ 300lbs and 5'5"). Initial eval presented with R buttock and lateral R thigh pain to the knee. Observation revealed Lateral shift to L. Pt had decreased weight bearing through R LE. Lumbar Flex ~ 50% PDM , Ext 0-25% PDM, L slide glide ~50% and R sd glide 0% with increased R buttock and lateral leg pain. R limited in IR but equal to L, but limited in Extension with ~ -5 degree of extension increasing buttock and leg symptoms.
From my Mckenzie Training I know to try to correct the lateral shift first. Self correction on wall increased R buttock and R lateral pain and stayed mildly worse. I tried correction myself with the same results.
I questioned myself, as through history flexion seemed a direction of preference and RFIL with OP is the only thing that mildly reduced his symptoms but after a couple visits no major changes.
Still seeing his lateral shift I thought that maybe I just didn't push hard enough into the lat shift correction. So I tried lat shift correction for 5-10 minutes which gave me a work out - given how stuck he was and his girth being difficult to get my arms around. Response was similar to the first day increased R Buttock and Lateral leg pain but not truly worse after - no peripheralization. Pt was still shifted.
So I am having a difficult time with my decision making with seeing his evident lateral shift, but taking into account his age and body type - can shifts present if they are truly not far lat derangement? Am I just not pushing hard enough into shift correction?
I did also try some Flexion in Rot with trunk to L to close R side. But pt could not tolerate motion?
I have seen some lat shifts in the past in fact an ipsi shift but did see some centralization with shift correction so things did progress well. So just wondering if you pass along any advice.
If it looks like a shift, smells like a shift, chances are.... Lumbar lateral shifts can be tough! A coworker of mine had a similar case where he and an intern wrapped two gait belts around him just to get leverage and shift corrected him for 45 minutes prior to derangement reduction!
Here are tips I've learned over the years and from some DipMDTs I've seen in action at my clinic
- shifts are notoriously difficult to correct, and McKenzie himself said in the first edition of his text, The Lumbar Spine, that after 6 weeks, they may be irreducible (at least with MDT)
- end range is key!
- if pain increases, and peripheralization occurs, but he does not remain worse, keep pushing
- remember, however, that you may need to ease into end range over the course of 20-30 minutes
- if you need a break, get him to do sets against the wall while you take a break or just push him into overpressure as he is actively doing the shift correction
- try adding slight trunk flexion for gapping during the shift correction to see if this makes it more tolerable and get him to end range
- if reps do not work, try duration
- try having him lie in hips offset of modified hips offset or "roadkill" position
|modified hips offset for right posterolateral or far lateral derangement|
Hello wife! Thanks to Dr. Nicole Religioso!
- start him with heat to relax lumbar spine in this position prone 5 minutes, then 5 minutes prone on elbows, then try pressups
- you can also try progressive extension in this position with moist heat if you have a table that extends
- duration often helps reduce stubborn derangements and helps them obtain end range reduction
- I know this will be tough on a bigger patient, but try QL release on the ipsilateral side
- Lastly, you may need to open before closing just to get him moving better, so try rotation in flexion either prolonged or pressure on/off to the right (LEs to left) to gap the involved side
- then try shift correction, roadkill or some other closing to see if you can get closer to end range
- remember in MDT, end range is key for derangement reduction and stretching dysfunction, so either way, you have not tried everything unless you reach end range!
Please keep us updated on his progress in the comments section or email me!