L LE Symptoms: What do you think? Part 2

A few weeks ago I posted an initial blog entitled, L LE Symptoms: What do you think? Part 1.  I want to first thank Jesse Awenus from jessephysio, Erson Religioso from themanualtherapist, and Kyle Ridgeway from PT Think Tank for their comments and suggestions; as well anyone else who read it and contemplated in their minds what to do.

In short, I did not get the response that I normally would get with this type of case (reason I am posting it).  Here are some of the treatments that I performed.

1. Neurodynamics in supine concentrating on the sciatic nerve, as well as sural and saphenous components with no change in symptoms (even tried femoral nerve in prone but no change either).

2. Manipulation to the thoracic spine (concentrating on T4-10), and the lumbar spine and SIJ (in lateral recumbent positions).  Some relief, but mainly a small dampening of the effect (again, not what you would want to call centralization); just dampening to a small degree.

3. Repeated movements with and without practitioner overpressure.  As I stated in the initial post, this patient did not complain of focal symptoms (and none to palpation over major structures in prone, standing and supine).  The patient also had full-pain, free ROM.  Repeated extension in prone (prone press-ups) in neutral, with the hips shifted to the left (first try and then no change), so tried with hips shifted to the right (no change).  Clinician overpressure locally at L5-S1 and L4-5 hitting end-range (pt could pretty much get to end range on his own though) such as a rotational mobilization with overpressure maybe dampened the symptoms too (pretty much the same effect as manipulation).

4.  General exercise including bent knee rotations, stretching of the hamstrings/piriformis, hip flexors and bridges had no direct effect, possibly psychological that he could move and this did not make symptoms worse or better.

As of now, a dampening effect occurred but no centralization and no real directional preference of certainty.  Symptoms were not necessarily getting worse, but no better (not much improvement over 3 months). I was contemplating referring to medical physician for possible prednisone series to see if it will calm down a chemical mediator, as this was not acting as mechanical as I would want.

Where would you go next?  Have any other ideas?

L LE symptoms: What do you think? Part 1

This case is going to be a 3-post series.  I would like to hear your feedback and comments.

A 29 year old male with main complaint of with L foot and distal shank numbness/heaviness.  It is also described as aggravating but not necessarily painful.  He describes the symptoms as fairly equal throughout and not necessarily in the shank, top of the foot or bottom but all “there”. It started when he got out of the car after a 2 hour trip about 12 weeks ago.  It comes and goes but hasn’t been bothersome enough until now to seek help due to the inconsistent nature.  He has no sleep disturbances due to this. It does get worse sometimes with current commute (1 hour to work) but just seems to be ‘there’ more often than not now.

One thing he really notices is that after he works out (such as running or even swimming), the same location feels more numb.  It would feel like he has cement on his shoe. It doesn’t bother him doing these activities (but has stopped lately due to it recreating the symptoms) and is quite strange that it would only come on afterwards.  It would go away however after a good 10-15 minutes.  It is starting to bother his work now if he is on his feet and walking around for a period of time.  This recently got worse and symptoms would increase from a 1/10 to a 5-6/10, to the point where he would need to sit back down or lie down.  He feels as if the symptoms are starting to arise in the contralateral limb too now.  Both of these factors are why he seeked assistance.

The patient denies low back pain or referral pain all the way down the leg.  It just seems to be “there” at the distal shank/foot (such as a glove/stocking pattern).  From a physical assessment standpoint, he has no pain to provocation to the lumbopelvic region and full ROM that is pain-free in all lumbar spine movements.  DTRs and light touch to palpation is intact but considering it feels ‘heavy’, the sensation may be less. Not really much of an improvement with repeated extension instanding and prone, even with overpressure laterall to the L5-S1 junction.  No pain in the hips and strength is strong and symmetrical bilaterally.

What do you think is going on? How would you approach examining this patient further and more importantly, treating this patient?

Easier Approach to a more Complicated Problem

Desensitization.  Honestly, not a very fun approach to an orthopedic manual physical therapist!  I do sort of gripe to myself when I know I need to do this. Results usually are not quick (which we all like!) and the underlying “problem” is quite complicated and not well understood.  

We typically use desensitization to specific areas of the body, particularly the distal limbs, in order to create a more normal response from a sympathetic nervous system principle to different grades of touch.  This helps in decreasing the hypersensitivity, or more specifically allodynia, of pain when a light pressure/touch or brushing of the skin occurs.  I know many of you know more about the molecular and cellular level of allodynia, but I am going to explain a more pragmatic approach to clinical practice.

A Case Example:

I recently had an older lady who had her radial artery harvested for coronary artery revascularization.  Not to get into awful detail, she came to me many months later basically for strengthening of the wrist/hand and desensitization.  As a fairly common side effect of this procedure, the patient presented with distal/lateral radial antebrachium and dorsal thenar parasthesias from an insult to the superficial radial nerve.  It was bad enough that the patient could not sleep, could not wear sleeves/gloves and literally jumped if lightly touched, aka allodynia.  Very disrupting to quality of life as you can expect and was even going to go get the nerve ‘burned’ until she asked surgeon to come to therapy.

Desensitization obviously came to mind but even the most soft material, such as silk, was a painful stimulus. I wanted more as I was not satisfied.  I tend to treat by the approach of,

“if you can satisfy yourself, you can satisfy your patients”

I opted to perform a more reflex inhibition approach through muscle energy techniques to the antagonist aspect of her thumb.  Meaning, I performed thumb MCP and thumb IP flexion low level contractions with a hold (see below).

Thumb IP Flexion MET (note no hand contact on dorsal thenar eminence)

Thumb Flexion/Adduction MET (note no hand contact on dorsal thenar eminence)

and BAM!  Immediate results with no pain during light touch to the same region.  I was then able to prescribe this as a self-care approach at home (using her other hand) and then a more effective desensitization routine.  She was satisfied and I was satisfied.  I can’t remember how many visits it took, but I can assure you she recovered much quicker this way.

I have since used this technique on patients s/p ulnar nerve transposition (using other muscle groups of course) with again good results.  I encourage you to try!  Let me know what you think, especially those out there who are more well-versed and trained in neurodynamics.  

Nerve Regeneration from PT perspective

As you know, nerves are the slowest healing structures of the human body.  This can make time really slow down for patients who have had nerve injuries!  Functional recovery can take weeks to months. It can be frustrating for the patientfor obvious reasons, but also the clinician as I tend to get the same question day in and day out, “is my nerve healing and how much longer?”.  Now everyone is different, but I have posted several pictures of examination procedures I proceed with and rationale in order to better answer this question for us, but also the patient.

To get a better background that is beyond the content of this post, check out nerve injury definitions here.

General rule is that nerves re-grow at about 1 mm a day, which is about the depth of a dime, or simply one inch a month.  Some literature say 0.5mm to 9mm but I typically go with 1mm in clinical practice. This depends obviously on age, amount of time the nerve was compressed prior to decompression (either surgically –which can hamper growth–or through physical therapy), comorbidities, site of lesion, etc.  You can also read more about “Rule if 18” here but typically used for peripheral nerves.

So in case a patient arrives to your clinic after surgery to decompress the L5 nerve root,  the following is examples of examination assuming a positive response to surgery and nerve has started to regrow:

Reflex hammers do not get used in physical therapy practice as much as I would like to see!  Bring them out!  Not a huge reliability source but does add significant value (in my opinion) to the neurological exam.

L4 Reflex

S1 Reflex

Motor Function

Manual muscle testing again does not give very reliable data but can be of significant benefit in this case.  We all can pick up differences with experience, and I feel performing MMT on the following muscle groups is the most reliable (more difficult to determine important differences in more proximal muscles in my opinion, as well as pain from low back can hinder results).  Don’t press down for 1-2 seconds, but perform a short-duration testing of at least 5 seconds to actually pick up differences.

Anterior Tibialis--L4

Peroneals--L5-S1

Extensor Hallucis Longus--L5

Sensory Disturbance

I find that motor regeneration occurs prior to sensory.  However, the sensory disturbances can be usually what you hear most from the patient (meaning, still having numbness in a particular area, etc).  The symptoms can be allodynic to mild palpation.  I do not have any hard evidence on measuring the sensory disturbance from most proximal region using monofilament (or you can also use two-point discrimination) and tape measure (such as starting from bony prominence as fibular head) but find it can be useful.

Testing sensory disturbance change using monofilament and tape measure

Functional recovery following nerve injury can be very difficult to measure.  I use these neurological tools as appropriate to help with determining nerve growth.  What are your thoughts?  Any comments on what you use to educate patients about this slow process?  Any other measuring guides available (other than EMG/NCV)?