Diagnosis of prolapsed disk

[Steveman30]

I'd like to share an easy and quick tech' for prolapsed and bulged disk that I learned from an Orthopedic surgeon and a Neurologist.

A very brief history so you see where I'm comin' from.

I work in a hard physical environment which deals daily with knee injuries, prolapsed disk and an assortment of other li'l problems. It has been in my best interest to learn how to both know a problem is in fact prolapsed disk and the general whereabouts of the epicenter(Hope I spelt that correctly) if you like.

Because I am on the front line so to speak being the first therapist on the job as the injury occurs, I can best have more than a fair idea how to proceed. Let me say, too often I have seen paramedics come to work at our place. Instant injuries happen, mainly pinched nerve or crucial ligament. This happens from overwork, fatigue and incorrect timing.

My first consideration is to ice the area. Ice is always good unless the person is also suffering from hypothermia. Then it's a bad thing. Doesn't happen inside a big heated house very often, luckily.

Next I begin working on the peripheral muscles so the problem is, even in my mind not spreading like wildfire.

Here is the test:

The first sign of prolapsed or bulged disk is conducted pain due to the nerves being entrapped. Acute pain is the precursory sign as the sensory pathway is closest (posterial) to the disk than the motor neuron. (anterial)
The person would be seriously in trouble if the motor neuron was damaged.

Prolapsed disk is more common in the lumbar spine, less common than the cervicle vertebrae. I have only seen one case in the thoracic as this is extremely rare.

Testing the cervical vertebrae:

I take the patients hands in mine and ask them to flex their arms using the biceps. I am feeling for an imbalance of strength between left and right arms. This tests C5/C6

Then I ask them to extend arms forward using the triceps. This is for C7.

C7/C8 is a rare injury but if suspect: Spread the patients hands and finger's wide and apply even pressure to the forefinger and the pinkie. If the patient resists in balance, this is not the problem.

So then I'm basically stumped coz I've tried it all. Then I send 'em off to an Orthopedic doctor or Neurologist. When in doubt, I pass it on... Safer that way.

Testing the lumbar:

First I will ask the patient to walk on his or her heels. Power is required from the lower leg flexors and these nerves are fed from L5.

For testing S1, I ask the person to walk on tip toes. This uses the lower leg extensors.

To test L3/L4, I ask the person to stand on one leg and give you his or her knee. Take and support behind the knee and ask the person to extend the lower leg forwards to test the Quadriceps.

These are very simplified and there are other tests like the Laséque, but I thought easy is easier to learn. Besides as massage therapist's we need not know more. Painful and serious problems like this are best passed on to specialists. Best we contain and refer to the right person.

Hope this can help someone.

Regards

Max

 

[Missa]

thanks for the tests.

i will especially try the c-spine test when i work on my dad the next time. he experiences chronic pain in his neck, without restriction in range of motion. i always work posterior and anterior cervicals, as well as shoulders, upper back, pecs.

in my opinion, he needs work in glutes and hip flexors as well, but he is one those clients who feel if it hurts "here" i need massage "here". i am doing my best to re-educate him about massage, and why it works. i am also working with him on the theory that massage doesn't have to HURT to be effective.

i also recommend he see the doctor, get the mri done. his pain is chronic, interference with activities of daily living, as well as sleep, for over 3 months now. he gets massage twice monthly between me and another therapist, and experiences only fleeting relief from pain. i have shown him a few stretches, and basic isometrics to do between sessions, but he does them only rarely.

 

[Tigger]

Wow

That's a difficult one. Poor you and him of course. I would just try whatever works until it does.

The nerve receptors (Skin and deep muscles) from C's runs down the sides over the infraspinatus and delt's. Massage generously, it will feel like you are doing something good and he might ease back on the advice. If you can relax these nerve receptors, chances are those nerve signals will be positive all the way back to the C's.

Try the face up position and try this direct test for the neck.

Lay him down on his back and assist him to gently to lift his head forward, chin to chest. If he has nerve irritation he'll soon let ya know.

But I would also consider a Neurologist here. This is his focus (nerves) and you don't want your Dad's focus taken away by pain for too long. The longer you take to get onto it, the worse it may get.

Problems in the C's should be taken seriously.

Good luck.

M

 

[flexcavano]

Apprecitated info and I hate to be the party-pooper, but in the states an MT cannot diagnose.

I just wanted to make that clear for any MT's who may be unaware of it when reading this thread and come to a conclusion that they can and should do this.

 

[arosentexas]

Oh.

Oh. Thank's for the heads up, Pueppi

As I was unaware of this, I would ask the moderator to either cancel this post or that it will be seen as a possible help to someone?

Thanks

Max

 

[irland1553]

Please don't delete this post. Although I don't diagnose, I find this is very interesting. Not all of us are in the U.S. anyway!

 

[football5680]

Please don't delete this post. Although I don't diagnose, I find this is very interesting. Not all of us are in the U.S. anyway!

Agreed.

 

[AngiO]

Another way

Thanks, both.

Could we perhaps be aware of this issue another way?

I'm not sure why a MT can't diagnose? This is something I've not had to think of. Perhaps because then they might do something silly and hurt the person further?

But if someone was to ask a MT their advice to why their back hurts so badly. Just by asking that person to try to walk on his or her heels, they (MT) will know this person has to see a Neurologist for example. If the MT didn't know and he or she continued to massage the unfortunate person then isn't not knowing dangerous?

It is a simple test and perhaps good to know as a back of the mind knowledge. And it's safe. The test isn't standing on the head and balancing an apple on the toe of the left foot. I don't know how often the average MT sees a prolapsed disk? But when I see one, I like to have more than a fair idea what I am looking at and where to refer this person. This to me is thinking safely not dangerously.

 

[Nelly]

It is a real quandry, Max. We are required to refer out when something is "beyond our scope of practice", but knowing to whom we should refer - and when - does require some real knowledge of the issue. We are required to take A&P, pathology, kinesiology.......we learn a lot of the testing, even, in our initial massage education. But we have to be very, very careful of our wording with clients so that we never appear to diagnose.

 

[Debra Jonasz]

Another way

Thanks, both.

Could we perhaps be aware of this issue another way?

I'm not sure why a MT can't diagnose? This is something I've not had to think of. Perhaps because then they might do something silly and hurt the person further?

But if someone was to ask a MT their advice to why their back hurts so badly. Just by asking that person to try to walk on his or her heels, they (MT) will know this person has to see a Neurologist for example. If the MT didn't know and he or she continued to massage the unfortunate person then isn't not knowing dangerous?

It is a simple test and perhaps good to know as a back of the mind knowledge. And it's safe. The test isn't standing on the head and balancing an apple on the toe of the left foot. I don't know how often the average MT sees a prolapsed disk? But when I see one, I like to have more than a fair idea what I am looking at and where to refer this person. This to me is thinking safely not dangerously.

Old Dog,

I am sure you are well trained, but part of the reason why an MT can't diagnose is due to legal regulations (if they are not also a doctor) and at least one other reason is because of lack of training. In the states MT's in some areas are licensed with as little as 100 hours.

Simple and safe tests are nice, but there is no way to know for sure what one is dealing with, without proper training. And let's not get into the whole differential diagnosis and ruling out of other issues/maladies/injuries and illnesses. There is a reason why doctors are doctors. There is a reason why they diagnose with more than one test. There is even a reason why people are referred to them.

Because of the inexperience many MT's have, they may not realize that heel and toe walking is to "look" a certain way. They may not catch a foot slap or a shuffle that should not be there. And, how about straight leg raising (SLR)? Goldthwait's Test, and Lasegue's Test? Pick a side. Which side tells who... what?! You need to know and you need to be able to clinically have the knowledge to understand what's happening.

I just don't like the idea of cookie-cutter methods, which are diagnostically helpful for the trained eye, being provided as a quick and easy method to know for sure about an injury or pathology, for those who are not trained.

Another part of the problem is that once an MT who is not trained in diagnosing decides to perform said "simple test" as their complete decision as to refer out or not, there stands the chance that the MT tells the client "You are fine, you can walk on your heels, so, no you don't need to see anyone but me". Probably not what you intended in this whole scenario.

In complying to the "no diagnosing" requisite, the MT keeps themselves out of potentially hotter water.

Hmmm.... Here's an interesting note as to why I'd hate to see all MT's trying to diagnose (and I am not saying that we don't have a load of bright people who are probably very capable on this forum). I was in a class a few weeks ago for some acupressure info. To my amazement, we had people in the class who were licensed MT's and did not know what a freakin' trigger point was and why it was not an acupressure point *! :shock: Worse... the class was next to pitiful in content and there were only 11 acupressure points to look at in 6 hours. One of the therapists (and I do use this term lightly) was too "overloaded" with information and had to go home. She would return for another class on another date, not staying for the second 6 hour module. WHY you ask????? Because there was just "no possible way she could look at so many points"! *grumps*
This is not the person I want trying to do a heel/toe test!

Anyhoo, that's my .02 for what it's worth.

* - I would like to mention that I understand that some/maybe more than some MT's may not know this info. The difference is that the MT's in my class are licensed in my state and therefore should know this information. I don't want to sound like I am MT bashing, to those who haven't been taught it.

Edited for "disclaimer" in italics at bottom of post / and a few typos.

 

[MyLILJohhny]

Hmmm, good answer, Pueppi. I think I should clarify my point a bit. :shock: I don't diagnose - or even do much of the testing I was trained to do in school. I do a lot of referring out to someone with a lot more training than I have had - usually to a couple of great chiropractors, because they have enough training to know where to send a client if they are not equipped to deal with the issue, and have enough training to know if massage really is what the person needs and can send them back to me. Though I do sometimes suggest a client see their medical doctor, I generally start with the chiros because they are equipped to know if that is a need and will refer if it is. A medical doctor, generally, at least in my area, assumes that a person in their office is asking for medical care and does not refer to alternative practitioners of any kind. I am very much a believer in "least invasive possible" treatment, and when someone comes to me it is generally because they also feel that way. There *are* things that would concern me enough to say "call your doctor!", but so far I've never had a client present to me with anything like that. Most massage clients are quite intelligent enough to figure that out and start with their physician.

I do, though, completely understand the question. Being required to refer clients to the appropriate specialist is an unrealistic requirement for someone not equipped to diagnose. Our system does seem to expect to have it both ways.

 

[Dr. DOLY]

Points

Both interesting perspectives.

I guess I'm in a bubble so to speak where I am, like I said faced with this situation regularly and I have an Orthopedic doctor and a Neurologist close by for instant referal. They both taught me this as a simple safe test so I can do what I do more effectively. That's my job.

However it is a very simple test and by no means paints a full picture of the injury as this is a very complex issue. That's why I didn't attempt to explain Laséque.

I can see your point, Pueppi some MT's should not. As some cooks should not. Some drivers should not... etc And the point, we are not Doctors. I am happy to be a MT. I learn to the outer edge of the zone but no more.

I agree with, Sharon and firmly believe in safety and referal is always number one for me because I stand by the fact that as a MT, I am limited in my medical knowledge. To realize this is a point of safety for me.

I had the thought that most people out there would go to a doctor anyway. And I don't think many MT's would see this very often. I don't know?

I enjoy learning more from the medical perspective and when I find a helpful tech or theory it helps me in my work. But this info I receive is discussed by myself and the doctors first before I apply. We are working in an educational progressive way together.

In the future, I would like to continue and share some perhaps interesting points for discussion and learning between us. That way I will be also getting your view points as MT's , to what is acceptable and what is not. What is applicable and what is not.

As this post was good natured in intent, I hope it helps someone and I hope MT's have the good sense to read and yet remain safe always. Perhaps the only answer to this is perspective?

I didn't intend to open a can of worms but it has been an interesting discussion and I'm grateful because I have learned something. Thank you.

 

[Danu]

Points

I enjoy learning more from the medical perspective and when I find a helpful tech or theory it helps me in my work. But this info I receive is discussed by myself and the doctors first before I apply. We are working in an educational progressive way together. .

That's the difference between you and many others. You are not only working with athletes, but also their doctors (and with boundaries that many people don't get a chance to go to). Also, you are open to new knowledge and how to apply it.

...I hope MT's have the good sense to read and yet remain safe always. Perhaps the only answer to this is perspective?.

You'd be amazed at the difference between your good sense and some of the "sense" I've seen. Then again, maybe not - surely you must have a few special ones too. *chuckles*

I didn't intend to open a can of worms but it has been an interesting discussion and I'm grateful because I have learned something. Thank you.

As far as I am concerned, I think the discussion is nice, because this is one that could have become heated and yet did not. More power to us!

Happy New Year.

 

[hepmom]

MTs can learn and apply assessment skills. We can NOT determine the cause of an issue, but we can narrow the realm of possibilities enough to provide appropriate advice on who they should see next, and suggest areas for that health professional to investigate.

It is very important that we communicate urgency without inappropriately suggesting a diagnosis. Saying "Your symptoms are similar to those of frozen shoulder; I think you should see a physical therapist ASAP for a diagnosis and treatment plan" is VERY different from saying "You have frozen shoulder; you'd better see a physical therapist too."

I know too many chiros, MDs, and PTs to have any desire to step on their toes. If a client reports something about a diagnosis or treatment that they think is off-base, I suggest they seek a second opinion, or a third. If requested, I refer to appropriate health pros that I trust. If they prefer to stick with their current medical pro (despite misgivings), I may suggest questions for them to ask that person, so they can better understand the treatment plan.

I expect to learn more about orthopedic assessment from Whitney Lowe in March, and am VERY excited! This is an area I really want to understand better, as it will enhance my expertise as an MT, yoga teacher, and personal trainer!

 

[DFW]

Appreciated

Well put, Jason.

I think diagnosis refers to offering specific treatment and medication by a precise insight into the cause and effect of an injury. I cannot do that of course

In the U.S, is it possible for a MT to have an educated guess based on a safe test as above? That would be for the sole reason to control the situation from getting worse by massage (periferal injury site only) and give the best reference advice possible based on the outcome of the test?

I'm completely at a loss when it comes to U.S requirements of law.

 

[naughtydogg70]

Here's one for the "assessment" vs. "diagnosis" tomes.

I have a client who I have been treating for muscle spasms/strains related to an auto accident 3 months ago. She improves for a day or two, then she is right back where she started. Just before Xmas, she came in for her session, and during the assessment, she revealed that a number of her symptoms were more severe than normal, and she had increased dizziness, tunnel vision, nausea, etc. In addition, she has on several occasions passed out from dizziness.

I backed up to the initial assessment tests: Vertebrobasilar Insufficiency, Adson's, Allen, etc. VBI increased dizziness/nausea immediately and dramatically. Adsons/allens resulted in moderately diminished pulse bilaterally...

So, in assessment, I know that these results = NOT GOOD. What degree of NOT GOOD, or what specific NOT GOOD condition she has, I don't know. I am aware that vertebrobasilar compression is a possible answer, scalene compression, perhaps TOS, maybe bone spurs, or stenosis...

There are any one of a dozen conditions, some extremely serious, some a nuisance, that this could be. I have only done an assessment, though. It is up to a physician to make a diagnosis.

In this case, she was given a tentative diagnosis (by a medical professional) of "post concussion syndrome," (something I know nothing about,) and sent for more tests. In addition, any massage that includes lying face down in the face cradle is C/I until a diagnosis is made.

The assessments are important and valuable (as is knowing how to do them correctly.) But I simply don't have the clinical training to be any kind of substitute for proper medical attention.

However, any therapist who works on injured people, should be able to correctly assess injury, including performing these orthopedic tests. While massage therapy is an extremely safe treatment, we need to be mindful of the fact that an injured person already has his/her health compromised. To avoid further injury, we need to assess thoroughly.

(One very good reason why a 5-days-and-youre-certified program is inadequate for treatment of serious soft tissue conditions. beetlejuice.)

 

[Ameer]

Reply

Hi, Breathe

Very nicely put. Looks like you handled that initial test well to be able to refer the best way possible. Difficult case with many variables indeed.

We as MT's should not diagnose for treatment or medication and this has been made clear already, but to safely test for referal is another. I have people come to me with sciatic pain. By a few simple and safe tests, I can basically tell if it is appropriate to refer the person to an accupuncturist or a Neuro. Accupuncture worked really well for me when I had sciatic nerve trouble. Cured completely in one session actually. But obviously in that case it was not too severe.

The biggest concern for me when I wrote this post was that I may be teaching an inexperienced MT something I shouldn't. My heart skipped a beat when Pueppi told me it was not permitted to diagnose in the U.S. I hadn't considered that and yet as our discussion has progressed I believe we all see otherwise now. I'm not permitted to diagnose here either.

This is just one of those fine lines and I appreciate the effort you have all put in to nut this one out.

 

[Sarah Jade]

Hi Max,

I'd love to hear what your sciatic tests are when you have a moment to post it !

The other tests you shared re: disk issues was great. And yes of course we are not supposed to diagnose, and shouldn't do so for professional reasons, therefore the resulting indicators cannot be shared with the client, other than to tell them that they should consider having their doctor check them out for this or that potential problem.

I personally believe that having good information for
ourselves, protects us & our clients. As to how all MT's
make use of information like this, is not something which
is under anyone's control, except for at an individual level.

 

[eir]

Sciatic

Hi again, Riversinger and thanks for joining

It's good to see that we are agreed on the lines drawn and the boundaries we can all safely observe.

Maybe someone else has a different idea but Sciatic to me is a more localized pain and I haven't known it to be like a bulged disk or definately not like a prolapsed disk. So by doing the lower body tests probably I could rule out bulged disk or prolapsed disk, and it's fairly much clear when the nerve pain is running down the leg to the knee and into the foot.

I found by my experience, (it happened to me) it wasn't debilitating pain and after one bizzare experience with a bizzare accupuncturist, the problem completely disapeared and has never been seen again...

 

[Jack]

I was curious if you had a particular test for how you go about treating the problem of sciatic pain, perhaps depending on the location of the pain.

I've personally had sciatica from time to time myself.
The "causes" of course can stem from mulitiple problems.
The pain can be localized or travel either part way or all the way to the heel of the foot.

I know one person who ended up with sciatica from swimming in icy cold ocean water. (which accupuncture cleared out almost immediately). People can get it from
being out on cold damp ground as well, such as those who work on roads, and on other such outside cold weather
jobs.

Others have had it occur due to injuries, such as falling off a horse at a full run (waving hand !) as well as other horse related injuries with other clients. Pressure on the nerve, and or cold entering the nerve have always seemed to me the major causes in my experience.

As a female, I've also experienced it during pregnancy, particularly in the later seforum.xxxes.

As a practitioner, I've done both energetic (Jin Shin Jyutsu
mostly) as well as bodywork to help clear out the pain and
open up the hips as well the legs by working on the meridians to release tension and get the energy flowing again.