THE PATIENTS
Inclusion Criteria
Patients were included in this series if they:
- presented with acute asymmetrical or unilateral low back pain with or
without radiation into the lower limb
- suffered severe acute low back pain sufficient to prevent a normal dynamic evaluation
- had onset of acute symptoms less than seven days history
- had normal bladder and bowel function
- were good general health
Exclusion Criteria
Patients were excluded from this series if they:
- exhibited evidence of radiculopathy indicating nerve root irritation or
compression
- exhibited sciatic scoliosis or lateral shift (McKenzie 1972, McLean et al 1996, Gillan et al 1998)
Diagnosis:
These patients may be classified by the Quebec Task Force system as type two or three (acute) (Spitzer 1987), derangements three or five (McKenzie 1981), or acute simple back pain (Waddell 1998).
The nine patients comprised a diverse group, ranging in age from 23 years to 69 years, three females and six males. Occupations varied from heavy manual work to clerical work. All were in acute pain of such intensity that ambulation was extremely difficult. Duration of symptoms prior to consultation ranged from one day to four days. All complained of disturbed sleep because of pain. The majority complained of acute pain and stiffness on attempting to rise from bed in the morning. Analgesics had been ineffective in giving adequate pain relief. Verbal consent was obtained prior to all procedures.
Table 1 presents a profile for each patient in the series. Three patients are presented in detail in order to provide an insight into the use of the procedure. Patient F and H responded most successfully, and Patient I did not.
PATIENT F - Ian
Ian was a fit 35-year-old male civil engineer. Over a period of 14 years he had suffered episodes of low back pain and sciatica which had been treated successfully with physiotherapy, acupuncture and osteopathy. Chiropractic had been ineffective. Three days prior to presentation he had an acute onset of bilateral low back and left posterior thigh pain, extending to the ankle and toes of the left foot at times. Pain was intermittent, exacerbated by standing or by lumbar extension and relieved by sitting. There were no paraesthesiae and there was no exacerbation of symptoms with coughing or sneezing. Sleep was disturbed when turning over in bed. Pain and stiffness were most acute on rising from bed in the morning.
Observation:
The acute back pain affected the patient’s weight bearing in walking and standing such that he constantly sought the support of available furniture.
ACTIVE MOVEMENT EXAMINATION (STANDING)
Flexion - loss of flexion and radiation of pain into the left buttock and
posterior thigh beyond about 50% of normal range.
Extension - extension was limited to about 50% of normal range, with
enhancement of left buttock pain and abolition of thigh pain.
Left Rotation - normal.
Right Rotation - normal.
Left Side Flexion - normal.
Right Side Flexion - normal.
Repeated movements were unable to be assessed because of the severity of
symptoms.
The goals of treatment were to reduce pain, restore mobility, restore normal function and facilitate return to work.
INTERVENTION
Day One, Treatment One:
Ian was comfortable in prone lying. A hot pack was applied in this position for 15 minutes. Then he was placed in left side lying and a series of eight side lying tractions were given. There was no pain during this procedure. Six side lying mobilisations were performed with no exacerbation of symptoms. A repeat set of eight side lying tractions was given, again with no pain. He was taped in lumbar extension with 5cm rigid sports tape, given posture advice, and instructed in the use of a lumbar roll when sitting.
Day Three, Treatment Two:
Ian reported he had slept normally with no night pain, had some stiffness on rising from bed but was able to sit with no discomfort. The pain had centralised (McKenzie 1981, Donelson et al 1990, Donelson et al 1997, Sufka et al 1998) to the left hip only.
Treatment was the same as for the previous treatment but with the addition of prone active extension in lying, with seat belt fixation (McKenzie 1981). Following treatment, on examination he had restriction of flexion and mild pain at 90% of normal range, with full pain-free mobility in all other directions.
Ian was satisfied that the symptoms were sufficiently resolved for him to return to his normal daily work activities. He was discharged from treatment.
PATIENT H - David
David was a 26-year old male clerical worker, who had slipped over four days previously hurting his low back. The pain had started in the left low back but was now situated in the right buttock, posterior and medial thigh extending to the knee. There was tingling experienced in the medial right thigh only when sitting. Sleep was disturbed by pain. His symptoms were exacerbated by coughing, sneezing, lumbar flexion, sitting and rising from a sitting position. Rising from bed was extremely painful and difficult. He had been prescribed non-steroidal anti-inflammatory tablets. A similar episode of acute right back pain without no radiation had been treated by the author 12 months previously.
OBSERVATION
David was comfortable in standing but weight transfer in walking caused him obvious discomfort.
ACTIVE MOVEMENT EXAMINATION (STANDING)
Flexion - loss of flexion and severe pain beyond about 20% of normal.
Extension - loss of flexion and severe pain beyond about 20% of normal.
Left Rotation – normal.
Right Rotation – loss of rotation and severe pain beyond about 10% of
normal.
Left Side Flexion - normal.
Right Side Flexion – slight loss of side flexion and no pain beyond about 80%
of normal range.
Repeated movements were not able to be assessed because of the severity
of symptoms.
The goals of treatment were to reduce pain, restore mobility, restore normal function and facilitate return to normal employment.
INTERVENTION
Day One, Treatment One:
David was comfortable in right side lying with his hips at 45 degrees flexion. A hot pack was applied in this position for 15 minutes. After that, a series of eight side lying tractions were given and there was no pain during this procedure. Six side lying mobilisations were performed with no exacerbation of symptoms. A repeat set of eight side lying tractions was given, again with no pain. David stated that he felt a decrease in pain following these procedures. He was sent home with posture advice and instructed in the use of a lumbar roll when sitting.
Day Two, Treatment Two:
David reported he had slept better and his back was not as stiff on rising from bed in the morning as it had been. Pain had centralised (McKenzie 1981, Donelson et al 1990, Donelson et al 1997, Sufka et al 1998) to the right hip/upper buttock. Treatment was the same as for the previous day. On examination following treatment, his flexion range had improved to about 60% of normal and all other movements were pain-free and normal range, other than a minor loss of left rotation past about 80% of normal.
Day Three:
David did not require further treatment as all symptoms had resolved other than a slight sensation of stiffness at the very end range of flexion. He was discharged from treatment.
PATIENT I - Patricia
Patricia was a 69 year-old widow in good health. Two days previously she had a fall, landing centrally on her buttocks in a sitting position. She took little notice and carried on gardening. Consequently, she developed acute low back pain, which she attributed to ‘gardener’s back’. The pain then intensified, peripheralising over the next 12 hours and extending into the right buttock and posterior thigh to the knee. Patricia had been given no pain relief by her doctor as she had a history of gastrointestinal problems. Pain was constant and badly disrupted her sleep. She had experienced what she described as ‘sacroiliac’ back pain many years before.
OBSERVATION
The severe, acute back pain affected her gait, to the extent that she could not bear weight on the right leg without exacerbating the pain. She was pale, sweaty and severely distressed by the pain. Patricia was tense and guardedly held herself in a degree of lumbar flexion.
ACTIVE MOVEMENT EXAMINATION :
Not able to be assessed because of the severity of symptoms.
The goals of treatment were to reduce pain, restore mobility, restore normal function and facilitate return to normal activities of daily living.
INTERVENTION
Day One, Treatment One: Patricia was uncomfortable in all lying positions, however left side lying was the least painful. A hot pack was applied in this position for 15 minutes. After that, a series of eight gentle side lying tractions were given and she reported a decrease in pain during this procedure. After that, a series of six side lying mobilisations were given and there was no exacerbation pain during this procedure. A repeat set of eight side lying tractions was given, again with some pain relief. Patricia was sent home with instructions to lie in the pain-relieving position (left side lying) and to avoid sitting or flexing the lumbar spine.
Day Two, Treatment Two:
Patricia reported an over all decrease in pain. She was able to tolerate sitting for brief periods, although rising from standing from sitting increased her pain. The distribution of radiating pain remained unchanged however, still radiating posteriorly from the buttock to the knee. Treatment was as for the previous day.
Day Three, Treatment Three: The level of pain had intensified and there was still no change in the distribution of radiating pain. All lying positions were uncomfortable other than supine in lumbar flexion with two stacked pillows under the knees.
At this point, Patricia was referred to a musculo-skeletal specialist for assessment and consequently an L3 disc lesion causing pressure on the L4 nerve root was confirmed by magnetic resonance image scanning.
Interestingly, I saw her three months later, where she was significantly improved. She had been offered surgery to the spine as an option but had declined it. Her pain was now intermittent, mild in nature and only occasionally felt in the posterior thigh. Over the next six weeks, her symptoms totally resolved with palliative physical therapy modalities.
DESCRIPTION OF SIDE LYING TRACTION AND MOBILISATION PROCEDURE:
This is a gentle procedure, which should cause the patient no discomfort. The patient is asked to report any increase in pain or peripheralisation of symptoms, in which case the procedure is discontinued.
1. The patient is asked to lie with the knees together, painful side down and the hips flexed to about 45 degrees. The head is supported with a pillow to keep the spine in as straight a line as feasible. The pelvis and thorax are not rotated relative to each other.
In this procedure the therapist is positioned behind the patient, facing the patient’s feet. Using a soft foam square for comfort and improved adhesion, the heel of the hand is placed on the lumbar spine centrally at the level of the intervertebral disc between the fourth and fifth lumbar vertebrae (L4/5). The supraspinous ligament is nestled between the therapist’s pisiform and trapezium. The therapist’s elbow is braced against the anterior superior iliac spine. For a left side-lying patient, the therapist is pushing with the right hand/right hip. For a right side-lying patient, the therapist is pushing with the left hand/left hip.
The therapist then adjusts the height of the couch or changes position so that the force of traction is coming from the hips, horizontally via the forearm, using his or her body weight. This is illustrated in figure one with foam removed for clarity of hand position. A series of eight firm but not forceful sustained tractions of four seconds duration are performed. There is not a great deal of movement. Ideally there should be a sensation of taking up the slack in the tissues, then releasing after four seconds. After each procedure, the therapist asks the patients if there has been any increased discomfort or peripheralisation of symptoms.
2. After traction, the patient’s pelvis is stabilised with the other hand, and extension mobilisations performed. The foam square may also be used for patient comfort. This is illustrated in figure two. These mobilisations are in a postero-anterior plane, the force coming from the therapist’s free hand, which is clenched, into a fist and a V formed between the thumb and the flexed index finger. The lumbar spinous process fits into the V and the force is transmitted to the articular pillars via the therapist’s horizontal forearm. If needed, the therapist can brace the elbow against the hip as described above, to increase stability and force. The extension mobilisations are performed at the level of L4/5 with the patient still in side lying. Five to six mobilisations will suffice. While it is wise to start with a gentle mobilisation, often there will be a surprising degree of pain free mobility of the segment and a stronger mobilisation will cause no discomfort. Occasionally, these mobilisations are painful. If this happens, the traction is repeated and the pain should diminish.
After the extension mobilisation, a repeat set of eight tractions is given. The patient can then be re-assessed for range of motion and pain before being sent home with instructions regarding posture and maintaining the lumbar lordosis.
IMPLICATIONS FOR PRACTICE
The author has observed that a significant number of acute lumbar pain patients treated with this procedure have responded favourably regardless of age, state of health or fitness. The majority of these patients were more comfortable lying on the painful side, in a degree of bilateral hip flexion, than in any other posture. Occasionally, the patient was more comfortable lying on the pain-free side, with the painful side up. In this case, treatment was commenced painful side up, then switched to painful side down once it was comfortable to do so.
The patients for whom this new treatment approach appears to have produced the most beneficial response, have been those who had acute unilateral or asymmetrical pain across the fourth and fifth lumbar intervertebral segment, with or without buttock and/or thigh pain, and/or pain extending below the knee.
This procedure is not recommended for patients with central or symmetrical pain as the asymmetrical nature of the technique may cause peripheralisation of symptoms.
Another group of patients which should be excluded from this treatment approach are those who exhibit a relevant sciatic scoliosis or lateral shift (McKenzie 1981, McLean et al 1996, Gillan et al 1998) The author suggests that these patients are better dealt with using other lateral shift correction procedures (McKenzie 1972, Ross 1998). While it appears that this technique can produce a rapid resolution of symptoms, it should be seen essentially as a ‘first aid’ treatment. Once the acute symptoms were settled, lumbar extension should be restored and lordosis maintained. In this way, the patient is still empowered with the responsibility for his or her back care maintenance.
If it is accepted that the contents of the intervertebral disc have the capacity to move in response to specific loading strategies (McKenzie 1981, Fennell 1996), it can be argued that this traction technique may reduce an internal displacement within an intact intervertebral disc, by creating a negative pressure. Further, it is suggested that the side lying mobilisation procedure subsequently aids restoration of the lumbar lordosis and that the combination of these two procedures creates an effect greater than the sum of its parts.
It may very well be that this technique offers no more rapid improvement than the natural history of uncomplicated low back pain, however the significant pain relief and improvement in mobility in eight of these patients may indicate that further clinical evaluation of this technique is warranted.
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Correspondence:
