Dr. Jordan Berry // #TechniqueThursday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses five different ways to work on correcting lateral shifts in patients demonstrating low back pain with radiculopathy, including standing, sidelying, and prone variations.
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EPISODE TRANSCRIPTION
INTRODUCTION
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account.
JORDAN BERRY
All right, what is up? PT on Ice Daily Show. This is Dr. Jordan Berry, lead faculty for cervical management and lumbar spine management, as well as our T and D content over all the spine division. I've got Jenna here with me today from the fitness athlete division, and we're talking lateral shifts again. So a few weeks back, we talked about the lateral shift and how we have to be able to pick that up in order to oftentimes move forward with the planned care. So when someone comes in that has really severe back and back related leg symptoms, oftentimes the lateral shift is the number one thing that you have to be able to pick up. and clear up, because if you don't, you're not oftentimes going to be able to work into this agile plane and start resolving those symptoms. So a few weeks back, we talked about the main ways from an objective and a subjective standpoint that we could pick up on the lateral shift. Today, we're going to change gears and talk about actually correcting it. So a few ways during our treatments that we can correct the lateral shift. Now, by far, the most common is the standing variation. or we're shifting the person that we'll talk about in just a second. But oftentimes the irritability is too high to allow for that. So we can't use that variation. We have to go to something in a non-weight-bearing position. So we'll talk about a few ways based on irritability that we can regress the standing lateral shift correction to be able to match that person's irritability and move forward during the plan of care, okay?
CORRECTING THE LATERAL SHIFT IN STANDING
So I'll have Jenna stand for just a second. and we'll demo as if she has symptoms on let's say the left side. Okay, so oftentimes we turn the camera just a bit here. If we have symptoms on the left side, almost always, 90 plus percent of the time, the shift is gonna be away from the side of symptoms. So we're gonna assume today that the shift is away from the side of symptoms. And Jenna would then, if she has symptoms on the left side here, right, would be shifted away from those symptoms. So for the standing variation, I would be standing on the opposite side of symptoms. So I would be in a staggered stance here, right? She's going to have arms either across like this or at least up away from her hip so that I can get around her hip. And I'm going to have my head on the backside of her shoulder blade with my arms wrapped around the very top of the hip. And so we're right here. And then I'm going to shift over and load towards this side of symptoms, right? So she's avoiding that side. And I'm wrapped around shifting towards the side of symptoms, okay? So we covered that technique in a lot of detail during our lumbar spine management weekend course, so we're not gonna spend a lot of time on the standing variation right now. But what I do wanna do is show you a few non-weight-bearing variations, because if you go to test that out, and the irritability's high, and that person either starts to peripheralize or pain increases, we have to have a variation in a non-weight-bearing position that is a little bit less vigorous that we're gonna start from.
CORRECTING THE LATERAL SHIFT: SIDELYING
Okay, so immediately if that's not working, my first regression here is in the sideline position. So now we're going to have Ginego on the table here. And I'm actually, I'm going to change sides for the video, but it'll be easier to see here. So Jenna is lying on her side, and we're going to say that the side that's up on the table, in this case, the right side, is the side of symptoms. And so for their side-lying technique, we're going to do a side-lying lateral glide. Again, during our lumbar spine management weekend course, we cover this in depth and we typically refer to it as a way to improve range of motion and mobility, just generally speaking in the stiff back. But it's a great technique for a lateral glide or a lateral shift correction as well. And so the way that we set up is I'm facing the bottom corner of the table and I have my contact hand that weaves through Jenna's arm here. and right around my hypothenar eminence rests along the paraspinal right here that's on the top. So I'm just hooking my hand in, facing the bottom corner of the table, and I just drop my weight down here. So again, we're saying that the top leg here is the side of symptoms, and we are gliding down towards the table or away from the symptoms if you want to think of it like that. And oftentimes that, because we're not in the weight-bearing position that we were in standing, the patient will be able to tolerate that much better.
CORRECTING THE LATERAL SHIFT: PRONE
Now, what if they can't tolerate the side-lying version or they're peripheralizing or not seeing the changes that you would expect? Well, we could then go to a prone variation. And so appreciate for that last technique, right? I was standing above the side of symptoms and we were gliding away from the symptoms. So we're doing the exact same thing in this prone position now. I'm going to bring the camera slightly closer here. And the same idea here in the prone position. So we're going to say that the side that I'm standing on right now, right, the side towards me or closest to me is the side of symptoms. In this case, it would be Jenna's right side. So instead of having my hand fully on dropping down into the lateral glide, I'm still going to glide laterally or away from the symptoms here. But I've got my thumb pads here together. and they're on the side of the spinous process that the symptoms are on. So again, for those listening and for those watching, just to make sure we're on the same page, if we have right-sided symptoms, the pads of my thumbs are on the side of the spinous process on the right side. And I am just gently gliding away. This is the exact same thing as the sideline lateral glide. It's just a less aggressive version. So again, my thumbs are together like this on the side of the spinous process where the symptoms are and I'm gliding away. And oftentimes just that very, very gentle, soft mobilization is enough to start to get some centralization. Okay, but what if we can't tolerate that, right? What if, for example, the actual spinous process or the area in the low back is too sensitive to actually be able to put contact or pressure on the spinous process? So then we could do the exact same thing, only now we're contacting the torso and the hip. So our contact hands are above and below the lumbar spine. So with the exact same setup that we had, again, the side of symptoms or the right side, the side that's closest to me, I'm going to have one hand on the right glute, right to the glute on the side of symptoms. And then I'm going to have my other hand on the torso on the opposite side. and I'm pushing the glute away and pulling with the torso towards me. So again, it's the exact same thing that we're doing the previous two techniques in the lateral glide. We're just not contacting the actual lumbar spine now. So we push away with the glute and pull towards with the torso here. Push away at the glute and pull towards on the torso. And now we can do the exact same mobilization in the lumbar spine without actually having to contact the lumbar spine.
CORRECTING THE LATERAL SHIFT: BELTED MOBILIZATION
OK, I've got one more. So this is my my go to if someone cannot tolerate any of those other variations. It's very, very rare that someone would not be able to tolerate one of the ones that we just went over. But I want you to have a technique in your arsenal where if the person really isn't tolerating anything at all, where you're going right at that area where they're having to cross that leg over on the table that's painful. I want to give you a version that is completely passive on the patient's end where we're actually going to use a belt around the person to lift the hips. So for the setup here, the painful side now is actually down. So this is the opposite of that first version that we showed. So we move the camera so we can see here. Jenna's painful side would be down towards the table. And what I'm going to do is take a belt here, mobilization belt, you could use a gait belt, and I'm going to wrap it underneath Jenna's hips. So we're going to weave this through. And I'm just making a loop with the belt. And so what I can do now is actually get on the table. I'm going to be up above the person and I can lift Jenna's hips up while she's completely passive and does nothing. And what that's doing is the exact same thing as what we were doing with the lateral glide, right? When the painful side was up and we were gliding down. Well, now the painful side's down and we're the ones that are pulling up. So I would be on the table above pulling on the belt. here. And Jenna can stay completely relaxed. She doesn't have to do anything at all. And I can do a lateral glide with the painful side down. Again, very rare that I would ever have to go to that technique, but it does happen and it's nice to have that in your arsenal.
SUMMARY
So those are five ways, five of my most used ways to correct a lateral shift in the clinic. The one that we're probably all familiar with, again, is the standing variation. That's the one that you see in most courses. That's the one that you see in most textbooks. And it's a great technique when it works, right? It's a great technique when the irritability allows for that weight bearing position to be used. But plenty of times in the clinic, the person's not going to tolerate a weight bearing or a loaded shift correction. So we have to go to a non loaded or non weight bearing position. I love the lateral glide that we started with. You can also go prone and do that really small, gentle lateral glide with the pads of your thumbs on the side of the spinous process. We could also go above and below the area if it's too hot to actually get your hands in there and contact it. You could go one hand on the glute, one hand on the torso, push and pull to do the exact same loading to the lumbar spine. Or you could go painful side down, belt around, lift the hips up. All right. Well, those are five variations. Hopefully that helps you out in the clinic with managing some of these folks with back and back related leg symptoms. If you're going to be at a cervical spine or lumbar spine management course in the future, we will see you there. Have a great day in the clinic. Thank you, team.
OUTRO
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