On PRI and Patients with HNP…

I am still having difficulty with getting good results using PRI with certain patients.  One of them is HNP (herniated nucleus pulposus) patients who have pain with lumbar/thoracic flexion.

I actually work with two therapists who use the Mckenzie approach.  We discussed how PRI techniques can apply to HNP patients.  That’s when I learned about an email you wrote, “Integrating Mckenzie approach and PRI” (found in recent email archives).  I read your response over and over.  
I am kind of now committed not to use extension exercises because I do not want to lose ZOA like you mentioned in the response.  Now I have a 17 year old patient who has lumbar HNP.  I tried several exercises you recommended in your email but I still have difficulty with getting good results.  He is now considering getting surgery which I really want him to avoid.  By the way, a therapist in the past used the Mckenzie approach with him and he mentioned that he had some good results.  In the past, I have tried PRI to other HNP patients and the result is 50/50 (I actually had incredibly great results with a very severe patient).  So I still feel I need some advice on HNP patients.  Would you ever recommend using lumbar extension exercises to some patients (which honestly sometimes I am tempted to do so since some patients have relief doing extension exercises)?  I would really appreciate your clarification.

Every patient with HNP is different, as you know.  A 17 y/o who has a lumbar HNP, doesn’t automatically make him a “PRI patient”, a “McKenzie patient”, or a “surgical patient”.  What’s his overall system demeanor…is he high strung, anxious, relaxed, limited in SLR, limited in the frontal plane, acute or chronic with symptoms, radiculary impacted, etc…?  If they can’t achieve and maintain ZOA, during extension of the back, they probably are guarding, sympathetically driven and sagittaly inclined…all which forces discs posteriorly.  So, I am not opposed to “extension”…provided the patient can relax during the return to “flexion”.  Too much emphasis is often placed on the “sagittal” issue when the reality of imbalanced hip flexors (transverse plane) and paraspinals, multifidus, quadratus lumborum, latissimus, etc (frontal plane) are a greater issue because of torsional tri-planar patterns (usually Left AIC). 

Regardless if extension, with or without a concomitant ZOA, is first or not…whatever reduces radicular symptoms helps the patient recognize a “change”.  Can this change then be incorporated into a safe neuro biomechanical program?

The etiology or cause of HNP has to be changed regardless of what approach you use to ‘treat symptoms’.  In this case, I truly believe a 17 y/o will not recover only from the use of ‘extension-based’ activity.  The hip flexors and diaphragm crura need assistance from transverse plane oriented abdominals.  Otherwise those lumbar discs are going posterior because of young, strong (17 y/o) anterior longitudinal ligament and high joint intradiscal compression with or without surgery he needs thoracic-lumbar-pelvic stabilization.  The evidence-based literature will tell you passive guidance and lumbar traction is not an effective treatment program for HNP.  What needs to be inhibited on this 17 y/o?  A pattern.