Disc Herniation with Functional Scoliosis - a combined Approach

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~ 1 Year Review ~

This client presented in clinic with a smile on his face, two disc bulges in his low back and staying true to his word...he had "gone sideways" with quite an obvious functional scoliosis to avoid pain and in total has  received three epidural injections for pain. 

I couldn't make any promises, but we agreed to take a look and see what could be done to help his system to unravel. 

We began the PROCESS by having the client fill out a comprehensive injury history, noting details of any physical injuries anywhere in his body, as far back as he could remember. This provides a lovely timeline from which to work and track how his body has structurally setup and avoided certain movements leading to these disc bulges.

Presenting symptoms included:

  • Pins and needles down the right leg that come and go
  • Unable to straighten up
  • Leaning to left
  • If standing for too long the muscles on the right side of my back all tighten up and it gets very uncomfortable and I will have to sit/hunker down/lie depending on where I am and how bad it is
  • When walking I get a pinch in the glut area and the muscle around my hip can become very tight (like a spasm)
  • Right hamstring and both calves can cramp/spasm very easily since this occurred especially after driving/sitting
  • Issues with my calves down through the years playing sport, cramp very easily and can be very tender on outside upper calf
Injury History

In what was quite an extensive injury history, we discovered a number of head traumas - falling backwards off a 4 foot wall and receiving stitches to the back of his head (Age 4), a period of severe nose bleeds, two mild concussions with a knee to right temple and an impact to left eye socket playing sport. 

Multiple injuries to right arm including finger dislocations, wrist sprain, rotator cuff (shoulder) injury, cracked rib on right.

A flake fracture to left ankle and fracture to right big toe. Right knee compression injury. Previous surgery to left groin area.

It was also interesting to note that issues with his back and a disc herniation had begun 17 years previous, with a knee into the back playing sport which left him out of sport for 18 months. 

    Radiology

    MRI findings showed a large right L4/5 disc protrusion with impingement of the adjacent nerve root, similarly with a moderately large protrusion at L5/S1.

    Having access to the clients MRI disc and radiology report is great as it lets me know internally what is going on and to what extent, BUT, it doesn't give any answers as to the real WHY.
    WHY are these discs compromised? What has led this to happen? 
    I can only look to determine that by assessing the whole body, not just the part that hurts.

    Static Stance Observations

    Once we had as much information gathered as possible, I begin a specific assessment of the entire body to find out what movements he had available in his body in 3 planes.

    • Sagittal plane - forward / backward, flexion / extension
    • Frontal Plane - Side to Side, Abduction / Adduction, Side Flexion Left and Right
    • Transverse Plane - Rotation left and right, Internal / External Rotation 

    I chose to observe his body in standing position followed by analysis of his gait (walking) pattern to see how he moved from A to B, what full body movements were restricted/lost and how we could potentially restore them. 

     

    Standing Observations (Before/After) 

    Standing Observations (Before/After) 

    From standing observations, certain postural positions were quite obvious:

    1. Pelvis very much shifted to right and hiked on right,
    2. Ribcage shifted left with Right side flexion
    3. Neck held in flexion and right rotation, Extension of his neck would increase pain
    4. Right foot pronated, left supinated
    5. Right elbow held in flexion
    6. Flatback posture with posterior tilt of pelvis
    7. Notable left side flexion of lumbar spine (low back) causing a right curvature
    8. Left arm held in Internal Rotation at shoulder joint
    9. Knees in flexion

    All of the above give me clues as to what his body has chosen as a position of "least pain" given the movements available to it, as it is hardwired to so.

    Following on from standing posture, I like to know how a persons body moves as they walk, so I began to assess his gait (walking) patterns. In terms of the Anatomy in Motion process, there are 6 different phases of gait that the body will go through. These occur from heel strike to toe off as you walk, where both feet will co-ordinate and synchronise with each other sending movement up through your body. Equally, an injury higher up in the body can impact movement as it filters back down to the ground.

    Note: Gait Analysis is NOT completed on a treadmill, I like to see how you move on the ground as opposed to the ground moving under you at speed. 

     

    Phase 1. Shifting off left foot - Striking into right heel, coupled movement  Before / After

    Phase 1. Shifting off left foot - Striking into right heel, coupled movement

    Before / After

    Phase 2. Left Propulsion (toe off) and Right Suspension (foot Pronation) - Coupled movement   Before / After

    Phase 2. Left Propulsion (toe off) and Right Suspension (foot Pronation) - Coupled movement 

    Before / After

    As was obvious from standing posture assessment, this client appeared to be "stuck" in a right pelvic shift. With scoliosis, it can oftentimes occur where a client gets "stuck" between two gait phases which require two different spinal mechanics.

    In the above pictures, we can see how the pelvis shifts to the right and remains there through the second phase. With the ribcage side flexing on top of it, it drives the spinal curve in two opposite directions exaggerating the scoliotic curve.

    Right shifting pelvis - sends lumbar spine left, Right side flexing Ribcage sends thoracic spine to the right.

    This is due to a timing issue and an inability of vertebra to move as they should. 
    Interestingly, the junction where the low back curve and midback curve have this dysfunction in coupling movement, was the initial injury site where he received an impact to his back years previous.

    interphase.jpg

    Also it is important to note the movement of his head and neck during these two phases above.

    Phase 1 - The skull ideally should Posterior tilt with a cervical spine (neck) extension. We have already established that in standing posture, neck extension would increase neural tension and pain. Also we would like to see hid neck side flex towards the front "striking" foot and rotate left. Here, it is lacking left rotation of the neck. 

    Phase 2 - The skull ideally should Anterior Tilt with neck flexion, side flex to the left and rotate to the left. It remains in a right side flexion, right rotation,. 

    So far, we have identified that the lumbar spine doesn't access a right side flexion - this would further compress the discs in the low back. Factoring in a number of head injuries, fall onto back of skull with stitches, impact to right temple, impact to left eye socket, wisdom teeth causing jaws to swell, it is easy to see why the head and neck can and does play a significant part. 

    In terms of ribcage movement, it is important to factor in the extent of injuries to the right arm, shoulder and rib fracture as arm swing will couple with rotation of the ribcage. Note the elbow flexion from standing observation.

    Lower body, I look at foot function, old knee injuries, flake fracture to left ankle, right big toe fracture and piece these into the overall picture of how his body has set up to do what it does.


    I am also going to expand into a concept called Lovett Reactor Relationships

    According to Lovett Reactor relationship, each vertebra in the spine is coupled in motion with another vertebra and the pelvis is coupled in motion with the cranium (skull).
    C1 (upper neck) and L5 (lower lumbar vertebra), C2 + L4, C3 + L3 move in the same direction also known as coupling movement. The other vertebra pairs, e.g. C4 (neck) and L2 (low back) move in the opposite direction.

    Therefore, movement and/or impact on one vertebra influences other vertebra in the spine.

    Given that the disc bulges were present at L4/5 and L5/S1, both of which couple with the upper two vertebra in the neck C1 and C2, my attention was very much drawn to this area. 

    lovett-reactor.jpg

    Having completed movement and gait analysis, I then look to assess joint structures and articulation, non weight bearing movement, tissue feel etc while on the physio bed. This allows me assess old injury sites through a process of ruling them out so as to identify the main area that would benefit from treatment.

    Treatment consisted of: 

    • Anatomy in Motion movement reintegration 
    • Dry Needling 
    • Kinesiotaping
    • Cranial (Skull) Assessment & Integration (+ one individual session with Jordan Shane Terry) 
    • Referral for Spinal Adjustment to Dr. Lorraine Surdival @ Revive Chiropractic Clinic
      • C2/3 Left Rotation, cross bilateral thoracic adjustment T5/6/7 anteriorly and L4/5/S1 left rotation
      • Interestingly, a left rotation adjustment to C2 vertebra in the neck unlocked a huge amount of movement potential in the lower body. C2 being coupled with L4, the lower lumbar vertebra with the larger disc herniation and enabled us to integrate left pelvic shift back into his movement pattern. 

    Outcome / Overall Feedback:

    The curve can become more visible when I’m very tired or remain in the same position for a long time.
    Sleep is much better and movement has greatly improved. I could jog on the road for up to 8km a day during the summer months and now I go for an hour walk/jog at least 3 times a week. Weight has decreased by 12kg and I’m happy to be able to move again with ease”
    — B.
    Top left: Initial Presentation Top Right: Within 10 weeks  Bottom: 1 Year Review 

    Top left: Initial Presentation
    Top Right: Within 10 weeks

    Bottom: 1 Year Review 

     
    left shift.jpg
    b5.jpg
    Right transition.jpg

    Other comparisons of different gait (walking) phases are shown as this client progressed through treatment.