We’ve all had the patient that comes in with low back pain and a huge lateral shift. It looks so uncomfortable!
In this week’s podcast we talk about why this occurs, and some treatment suggestions.
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#AskMikeReinold Episode 295: Treating Low Back Pain with a Lateral Shift
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Show Notes
Transcript
Student:
Today we have a question from Tom from the UK. He’s asking, what are your treatment considerations when assessing and treating an individual with lower back pain with a noticeable lateral shift?
Mike Reinold:
Ah, good question, Tom. I like this. So the lateral shift, I think we’ve probably all seen this in our career, right? Somebody with back pain, and we treat a lot of active individuals, adults and athletes at Champion. And we have over our careers probably that have a lot of back pain. But not all of them come in with that little shift, where their hips shifted to the side a little bit. Why don’t we start with maybe talking about what that is and why? Because I think that will help answer the what do we do when we understand a little bit better. But who wants to talk about that? Why do we see a lateral shift? what is that? Dan, you want to start with that?
Dan Pope:
Sure. Yeah. And I’m just, I did a more recent literature review to try to figure out lateral shifts a little bit. I think what you’re looking at is probably some sort of disc pathology. And this is always a little bit funky, just because the imaging we get, seeing disc pathology on an MRI, doesn’t always correlate with pain. So if you look at things like sensitivities and specificities of certain tests we have, or a lateral shift, maybe it’s not always truly reflective of what’s going on.
Dan Pope:
But when you have a lateral shift, the thought is your body’s trying to position itself in a place that potentially offloads that injury. We think, and this is a theory, and again, it’s a little bit contradictory if you look at some of the research, that you’re trying to move away from some pain. So if you have an irritated nerve root in your spine, your body might try to offload that a little bit by moving in a certain way, shifting to the side. There is a bit of research that shows that people will have a shift in a direction that doesn’t really make sense in terms of offloading that nerve root. So I think that’s where it gets a little bit mixed. But largely when people have this lateral shift is because they have some sort of probably disc pathology, nerve root issue. And because of that, the body’s trying to move in a position offloads that decreased stress on that injury.
Mike Reinold:
It’s interesting that you say that you don’t always shift in a direction. And I wonder either away or towards, or on the side of, for example. I wonder if that’s because the shift is more about muscle guarding and intention than actual relieving. I find that pretty interesting because as somebody with back pain in the past, and I think we all do this, the majority of our back pain, it’s this muscular guarding and spasticity almost that drives you crazy.
Mike Reinold:
So, Dan, or anybody else that may know this, is that in the literature where we see lateral shifts, it tends to be disc pathology. Do we ever shift from fractures or stress reactions or anything else or is it specific to one thing?
Dan Pope:
Yeah, I mean, that’s a good question. I don’t know the answer to that. I just know that in terms of lateral shift, it was pretty specific towards disc issues, nerve root pathology. But in terms of fractures and stuff, I’m not sure. I mean, that makes sense you might do the same thing. Move differently or have certain muscles fire a little differently than they normally do. I think there’s a lot of research to show that. When you have low back pain, everyone has their own little flavor of what fires more, fires less, where their pain is, which very variable from person to person. But I’m not sure. I think the lateral shift is more specific towards a disc issue. At least in my mind, when someone walks through the door, maybe I’m wrong, they’ve got a big old lateral shift, that’s the first thing I’m thinking about.
Mike Reinold:
Yeah. Well, I got to admit. I mean, in our baseball players with stress fractures, spondies, stuff like that, I don’t see a lateral shift with those. Dave, do you? And you probably, you treat a lot of athletic spine stuff. Do you see shifts in your gymnasts or is it one of those things you mostly see with discs?
Dave Tilley:
Yeah, I would say that generally the people who have extension rotation and intolerant back pain, typically is in extreme range of motion where they’re starting to engage the facets and/or put an anterior stress on the pars or the neural arch. So usually those people are needing to extend significantly to feel [inaudible 00:05:20]. And generally the passive elements of your spine are much more mobile in terms of being able to flex quite a bit farther. We can obviously flex and touch our toes and you have much more bandwidth there to flex and rotate versus you can’t really do the exact same extension rotation because of the facets. So typically somebody will feel their back pain only at the extreme motions. And yeah, I see quite a bit of flexion intolerant and rotation intolerant low back pain.
Dave Tilley:
And those people who have shifts generally, yeah, they’re discogenic in nature as the etiology, but also the McKenzie model and some other people like Paul Hodges who have studied what happens when somebody has acute back pain, is that typically they don’t want to load those parts of their spine that are sore. So someone who has laterally shifted and has maybe flexed and rotated away, they’re doing that maybe in particular, because maybe that nerve root has a real high level of no susceptive drive and/or the muscular, the multifidi around that area maybe are acutely irritable and they don’t really want to lean into that quadrant extending and rotating towards it because it’s uncomfortable. Ironically though, typically that’s what makes those people better. So the McKenzie system will try to find some way to get them anti-gravity or without gravity and have them extend and try to restore that plane of motion, because as you do that, if you’re going by the path of mechanical model, the discogenic material itself can move when you move that way.
Mike Reinold:
Yeah. And again, amazing that the human body just inherently does these things on its own. And reflexively and is just so resilient at trying to heal itself. I think that’s impressive. So, yeah. All right. So, sorry.
Dave Tilley:
The last thing I’ll add for people to help is there’s a paper by Paul Hodges that talks about what happens. They injected people with pain in their back, pain solutions and had them do step down tests. And they found that within the muscles themselves, there was a change in activity, but within muscles, there was actually a really large change. Everyone has a different adjusting strategy. That’s why they’ll limp all weird because they don’t want to load that area. So Paul Hodges was really helpful with [inaudible 00:07:09].
Mike Reinold:
Crazy, crazy. Awesome. All right. So we have a lateral shift. What do we do about it now? Kev, what do you think?
Kevin Coughlin:
Yeah, so a couple things, and I’m recalling this stuff from a McKenzie course I took, but I’d like to get Dan’s input too, where we did the lit review, if he came across any of this. But I guess the first thing you want to do is classify the shift as contralateral or ipsilateral, and like Dave and Dan alluded to, ipsilateral shifts. So you have pain going down the right side. You’d see those people, they name it by where your shoulders are shifting. So if your shoulders are shifting to the right, you’d be closing down the right side. And that’s very uncommon. We don’t see Ips … That’s a weird word. Ipsilateral shifts, very commonly. And from what I remember learning is that that type of shift has a worse prognosis. So contralateral shifts, more commonly like Dave said, they shift away from that painful side trying to unload those structures.
Kevin Coughlin:
So what they teach in McKenzie is, when you’re trying to correct these shifts, the first thing you have to do is correct the lateral motion. And once that’s restored, then you go back into the sagittal plane and you work on extension. You can’t really do extension first. It just doesn’t seem to have as good of an outcome.
Kevin Coughlin:
So the other important thing is trying to determine if it is what they call relevant lateral shift, meaning the shift came on at the time of their acute low back pain. If this is something they’ve had for years, and this is one that I like Dan’s input if he came across this at all. But I believe McKenzie said that if it’s a shift they’ve had for a long time, or if you don’t correct the shift in the first five or six weeks, they’ll develop a long term posture where they’ll always be shifted and you might not ever get it back. And that’s where it seems like the urgency is in correcting the shift.
Kevin Coughlin:
So I don’t know for sure if that’s true. I haven’t come across that in the literature myself. But I think the point is you do want to try to correct the shift pretty quickly. And like Dave alluded to, if they have a contralateral shift, it’s going to be side bending to the painful side that seems to get them better. And it’s one of those things like when you have someone who has flexion based low back pain, a first few repetitions of extension might hurt. But if you let them work into that a little bit, it does seem to centralize their pain. And that same thing seems to be true with the lateral shift. So if they do some side gliding, usually you’ll have someone go against the wall, put their shoulder on the wall, their hips, maybe a foot away, and their gliding, closing down that painful side. As they do repetitions of that, they should feel their pain centralize.
Kevin Coughlin:
And then if you have a case where it’s just not centralizing, and it seems like it’s really, really aggravating them. And I did hear Adam Meegans talk about this, where someone was suggesting he correct his lateral shift. And he said, if someone tried to side glide me, I’d punch him in the face, because it was so painful. So I do think sometimes we have to respect our patient’s pain with these. And if it’s not getting better with side gliding, maybe we don’t force it. But it seems like there is some urgency to correct the shift. So I’m wondering if Dave or Dan came across that. Do you see any long term changes in the posture if it’s not corrected quickly?
Mike Reinold:
I’d just jump in real quick because I want to hear their answer, but I like what you just said right there. I mean, sometimes the tissue’s too sensitive to try to force it. It’s like that with any joint. A hot knee that you’re trying to get extension with or shoulder range of motion, sometimes you have to let it cool off a little bit. I like that. But yeah, no, I want to hear this chronicity thing because I will say, I’m not walking around Target and you walk by somebody like, “Whoa, they had a chronic shift that they’re stuck in now. Look at them over there.” I can’t say I’ve seen that in public. But I’d love to hear it. Dan, Dave, have you guys seen that? Is there an urgency to the chronicity of trying to help somebody without them getting this posture maybe adapted?
Dave Tilley:
Yeah. My only two cents is one’s more just a piece of advice is, the McKenzie system, and this actually is a really big shout out to Ersin too, because Ersin has done a lot of studying of the McKenzie system, but he has a really good flare on it. It’s maybe not so hardcore one lane. But the first thing is that the McKenzie system, actually, even if you do have a lateral shift, is that they’ll probably try to exhaust the sagittal plane first with press-ups or some version of that because lateral shifts are really unique to that very, very discogenic population. But if someone has a true lateral herniation, which is rare, that’s when a lateral shift is going to do the most work.
Dave Tilley:
But most people have a posterior lateral herniation. And so if the outer anular wall is intact and the hydraulic mechanism is intact still, just straight up press-ups or some sort of extension is probably going to make them feel better.
Dave Tilley:
And yeah, I agree with what was noted about Adam’s back pain is that when someone has a lateral shift, it feels terrible to do lateral shifting work sometimes because you got to remember that the main lateral shift mobilization is in weight bearing and gravity. So you’re standing and there’s compression on the disc, which also causes some mild bulging and then you’re shearing sideways. So sometimes getting these people on their stomach and just doing either a lateral bend towards the side or doing what they call like a reptile or a roadkill press up where flex your knee up and doing extension first is probably more comfortable for these people for a couple days before you start doing loaded mobilizations.
Mike Reinold:
That was good. Anything else, Dan, on that, on the research of that?
Dan Pope:
Well, yeah. Well, I guess to answer Kevin’s question, I’ve actually seen a few people that maintain a shift after they have their pain go away. And that goes back to the initial discussion we had is that we don’t know why people lateral shift and the idea is you unload a nerve root. But some folks will actually shift into a position where it looks like they’re loading the nerve root further, which makes no sense. So I think that’s what we have to keep in mind.
Dan Pope:
To take a step even further back, because I think this is a question that newer grads or less experienced clinicians going to have. Natural history of most disc issues are good. So you have a nerve root injury or irritation, most of those get better. I say most because a lot of folks that’s not the case, but they get better very quickly. for the first three months, the majority of cases are going to resolve. So a lot of this I think is that, yeah, try to correct the lateral shift. I try to correct a lateral shift if I see it, but I think the other thing to keep in mind is that this will probably get better naturally over the course of time. And if you just push some sort of active approach, obviously it’s going to change a little bit based on the person that you see. You’re probably going to have some good success.
Dan Pope:
I don’t know if doing this early on is going to be something you need to do. But again, it’s not really fair for me because I haven’t taken the McKenzie courses and I’m not reading the research that they push. So I’m not sure. Yeah.
Mike Reinold:
Yeah. Makes sense. Makes sense. But I think good summary of everything I think so far is that there’s a very specific time where we’re probably going to see this more often than not. And some treatments to work towards that and get them back into their functional activities, I think, is going to be the way to go.
Mike Reinold:
So great episode. I thought that was really helpful. Hopefully you enjoyed that, Tom. If you have a question like that, head to mikereinold.com, click on that podcast link and you can fill out the form to ask us more questions. Thanks again. See you on the next episode.
