Clinical Notes in Physiotherapy

One special case of dysfunction is the adherent nerve root (ANR) syndrome. This syndrome may mimic a posterior derangement and, therefore, be confusing to the examiner. Differentiation may be accomplished through identifying the patient's symtomatic response to end-range flexion in standing compared with flexion in lying. In the case of a derangement, alteration of pressure gradients within the intervertebral disk through movement leads to compression of the nerve root regardless of the weight-bearing status. Therefore, in the case of a derangement, peripheralization will occur in both the flexion in standing and flexion in lying positions. The flexion in standing movement (Fig. 9-5a), which invloves the combined motions of trunk flexion, hip flexion, knee extension, and ankle dorsiflexion, is expected to be symptomatic in the presence of an ANR, whereas flexion in lying with hips and knees flexed (Fig. 9-5) reduces tension through the sciatic nerve and is asymptomatic in the presence of an ANR.

Centralization is possible only in the case of a competent disk in which the annular wall remains intact. In such cases, the derangement is considered to be reducible and lasting changes are often achieved. In the presence of an incompetent disk, or disk in which the annular wall is compromised, symptoms may appear to be centralized in non-weight bearing but do not remain centralized in standing. In such cases, a derangement is deemed as irreducible.

MDT is a comprehensive approach to the conservative management of most activity-related spinal disorders. It is a system of patient examination, classification, and intervention that is based on an individual's symptomatic and mechanical response to movement and position. At the conclusion of the examination the individual is classified as having a derangement syndrome, dysfunction syndrome, postural syndrome, or "other". Individuals classified within one of these mechanical syndromes are considered to be ideal candidates for MDT, whereas those falling into the "other" category require additional examination or refferal. The hallmark features for each of the mechanical syndromes are summarized in Table 9-1.

✅ The McKenzie Method of Mechanical Diagnosis and Therapy

Quadratus Lumborum Side-lying MET - The practitioner stands behind the side-lying patient, at waist level. - The patient has the uppermost arm extended over the head to firmly grasp the top end of the table and, on inhalation, abducts the uppermost leg until the practitioner palpates quadratus activity (elevation of around 30° usually). - The patient holds the leg (and, if appropriate, the breath) isometrically in this manner, allowing gravity to provide resistance. - After the 10-second (or so) contraction, the patient allows the leg to fall towards the floor, slightly behind him over the back of the table. - The practitioner staddles this leg (to stabilize its position) and, cradling the pelvis with both hands (fingers interlocked over the crest of the pelvis), leans back to take out all slack of the soft tissues, including quadratus, easing the pelvis away from the lower ribs, during an exhalation. - This stretch should be held for between 10 and 30 seconds. - This method will be more successful if the patient is grasping the top edge of the table, so providing a fixed point from which the practitioner can induce stretch (see Fig. 5.25). - Contraction followed by stretch is repeated once or twice more with the leg raised in front of the trunk, and once or twice with raised leg behind the trunk in order to activate, and subsequently stretch different quadratus fibres. This calls for the practitioner changing from the back to the front of the table for the best results. - When the leg hangs to the back of the trunk the long fibres of the muscle are mainly affected; and when the leg hangs forward of the body the diagonal fibres are mainly involved. - The direction of stretch should be varied so that it is always in the same direction as the long axis of the abducted leg.

Quadratus Lumborum Test B - The patient stands, back towards crouching practitioner. - Any leg length disparity (based on pelvic crest height) is equalized by using a book or pad under the short-leg-side heel. - With the patient's feet shoulder-width apart, a pure side-bending is requested, so that the patient runs a hand down the lateral thigh/calf. (Normal level of side-bending excursion allows the fingertips to reach to just below the knee.) - The side to which the fingertips travel furthest is assessed. - If side-bending to one side is limited, then quadratus on the opposite side is probably short. - Combined evidence from palpation (test A) and this side-bending test indicate whether or not it is necessary to treat quadratus.

Quadratus Lumborum Test A - The patient is side-lying and is asked to take the upper arm over the head to grasp the top edge of the table, 'opening out' the lumbar area. - The practitioner stands facing the back of the patient, and has easy access for palpation of quadratus lumborum's lateral border - a major trigger point site (Travell & Simons 1992) - with the cauded hand. - Activity of quadratus is tested (palpated for) with the cephalad hand as the leg is abducted, while also palpating gluteus medius (and TFL) with the cauded hand. - If the muscles act simultaneously, or if quadratus fires first, then it is stressed, probably short, and will benefit from stretching. - When the leg of the side-lying patient is abducted, and the practitioner's palpating hand senses that quadratus becomes actively involved in this process before the leg has reached at least 25° of elevation, then quadratus is probably overactive. - If quadratus has been overactive for any length of time then it is almost certainly hypertonic and short, and need for MET can be assumed.

✅ Assessment and Treatment of Quadratus Lumborum

MET Treatment of Piriformis (Method B. Supine) This method is based on the test position (see Fig. 5.19). - With the patient supine, the treated leg is placed into flexion at the hip and knee, so that the foot rests on the table lateral to the contralateral knee (the leg on the side to be treated is crossed over the other, straight, leg). - The angle of hip flexion should not exceed 60°. - The practitioner places one hand on the contralateral ASIS to prevent pelvic motion, while the other hand is placed against the lateral flexed knee as this is pushed into resisted abduction to contract piriformis for 7-10 seconds. - Following the contraction the practitioner eases the treated-side leg into adduction until a sense of resistance is noted; this is held for 10-30 seconds.

MET Treatment of Piriformis (Method A. Side-lying) - The patient should be side-lying, close to the edge of the table, affected side uppermost, both legs flexed at hip and knee. - The practitioner stands facing the patient at hip level. - The practitioner places his cephalad elbow tip gently over the point behind trochanter, where piriformis inserts. - The patient should be close enough to the edge of the table for the practitioner to stabilize the pelvis against his trunk (see Fig. 5.22). - At the same time, the practitioner's cauded hand grasps the patient's ankle and uses this to bring the upper leg/hip into internal rotation, taking out all the slack in piriformis. - A degree of inhibitory pressure (sufficient to cause discomfort but not pain) is applied via the elbow for 5-7 seconds while the muscle is kept at a reasonable but not excessive degree of stretch. - The practitioner maintains contact on the point, but eases pressure, and asks the patient to introduce an isometric contraction (25% of strength for 5-7 seconds) to piriformis, by bringing the lower leg towards the table against resistance. - After the isometric contraction ceases, and the patient relaxes, the lower limb is taken to its new resistance barrier and elbow pressure is reapplied. - This process is repeated until no further gain is achieved.

Mitchell et al (1979) suggest that if there is relative shortness (as evidenced by the lower leg not being able to travel as far from the mid-line as its pair in this position), and if that same side also tests strong, then MET is called for. However, if there is shortness as well as relative weakness, then the reasons for the weakness (trigger points for example) need to be dealt with prior to stretching using MET.

Piriformis Strength Test - The patient lies prone, both knees flexed to 90°, with the practitioner at the foot of the table grasping the lower legs at the limit of their separation. - This internally rotates the hip and therefore allows comparison of the range of movement permitted by shortened external rotators such as the piriformis. - The patient attempts to bring the ankles together as the practitioner assesses the relative strength of the two legs.

Piriformis Stretch Test - When it is short, piriformis will usually cause the affected side leg of the supine patient to appear short and externally rotated. - The supine patient's tested leg should be placed into flexion at the hip and knee so that the foot rests on the table lateral to the contralateral knee (the tested leg is crossed over the straight non-tested leg, as shown in fig 5.19). - The angle of hip flexion should not exceed 60°. - The non-tested side ASIS is stabilized to prevent pelvic motion during the test and the knee of the tested side is pushed into adduction, to place a stretch on piriformis. - If piriformis is shortened the degree of adduction will be limited and the patient will report discomfort posterior to the trochanter.