Alternating lumbar lateral shift: a case report

ABSTRACT

Background

A lumbar lateral shift (LLS) is a common clinical observation in patients with low back pain (LBP), and a shift contralateral to the side of pain is the most common presentation. An LLS that can rapidly alternate sides presents several treatment difficulties and has rarely been described. The purpose of the current case report was to describe the presentation and management of a patient with an alternating LLS.

Case Description

A 39-year-old male with a 7-week history of LBP and previous lower extremity radicular pain was referred to physical therapy. An alternating LLS was present.

Outcomes

The patient was treated for six visits over 37 days. Treatment included modified self-correction of the LLS, motor control and trunk muscle endurance training, and development of an activity management program. The patient’s LLS resolved, his worst pain improved from 3/10 to 0/10, and the Oswestry Disability Index improved from 26% to 4% disability. The patient reported maintenance of improvement at 6-month follow-up.

Discussion

The current approach produced a positive outcome in a patient with an alternating LLS. The current understanding of mechanisms and optimal treatment of an alternating LLS is limited.

Level of Evidence

4

Background

A lumbar lateral shift (LLS) or lumbosacral list is commonly observed in patients with acute low back pain (LBP) [1,2]. Although an LLS may disappear as the pain settles, the deformity can persist for years [3]. A lateral shift deformity is different from idiopathic scoliosis in appearance and significance [4,5]. An LLS is not a single clinical entity, and its side of pain and the presence of radicular symptoms varies. The trunk may shift away from (contralateral shift) or toward (ipsilateral shift) the side of pain [4–6]. The pain may be present in the midline (symmetrical) [7] or, in rare cases, change sides (alternating lateral shift) [5,8].

An acute onset lateral shift is usually accompanied by pain and has an unclear response to conservative care [9]. However, a manual correction and exercise approach developed by McKenzie may have positive benefits, particularly with shifts less than 3 months’ duration [1,10]. Evidence suggests an LLS can be treated with surgery [9] or with McKenzie’s manual correction and self-treatment protocol [6,11,12].

Few reports of an alternating LLS exist [5,8,13,14], but they are decades old and do not describe successful conservative treatment for this presentation. Perhaps because of its apparent rarity, mechanisms explaining the alternating LLS or best practices for treatment could not be found. Therefore, the purpose of the current case report was to describe the presentation and management of a patient with an alternating LLS.

Case description

Patient characteristics and history

The patient of the current case was a 39-year-old male. He was a married stay-at-home father of two children. He self-referred to a private orthopedic physical therapy practice in May 2019 for low back and buttock pain of 7 weeks’ duration. The patient reported a long history of LBP starting when he was 17 years old and a lineman for his high school football team. Since then, he reported 3–4 episodes per year of severe back pain and immobility lasting approximately 7 days. The present episode was different because pain intensity was lower, allowing him to move more easily. It was also longer in duration, and he was more aware of being ‘crooked.’ Symptom location is depicted in a body chart filled out by the clinician (Supplement 1). Pain was described as right-sided, ‘dull aching’ low back and buttock pain that occasionally switched sides or occurred in both sides. Using the 11-point Numeric Pain Rating Scale [15], he reported 1/10 pain at best and 3/10 pain at worst. He scored 13/50 on the Oswestry Disability Index (ODI), indicating 26% disability [16]. He could not recall a specific injury, but pain began the day after working in his yard. Back pain was accompanied by radiating right lower extremity pain to the foot. After about 3 weeks, radiating leg pain resolved, but he occasionally experienced radiating pain just below the right gluteal fold. The patient also reported ‘catches’ in his back, where he felt his back would ‘go out’ and he would become ‘crooked’ and need help bending forward to take his shoes on and off. More than 10 minutes of sitting increased pain in the buttock although buttock and back pain abated quickly after standing and walking. The patient was avoiding yard work, picking up his daughters, and exercising because he thought bending over would cause his back to ‘go out.’ He had been having chiropractic manipulations, which provided temporary benefit only.

The patient took no medications. He did not have a previous history of cancer, unexplained weight loss, or long-term use of corticosteroids, and he did not notice any sudden weakness or clumsiness of gait. At initial evaluation, his primary goal for physical therapy was to reduce pain at rest and during forward bending so he could return to daily activities.

Physical examination

Initial observation revealed left LLS right-sided back pain (Figure 1(a)). As part of a neurological examination, myotomes from L1 to S1 were strong and equal bilaterally, and the patient could walk on his toes and heels. Patellar and Achilles deep tendon reflexes were 2+ bilaterally. Light touch and pinprick sensation were intact and equal from L1 to S1. Lumbar active range of motion (AROM) was visually estimated in standing. Extension AROM was limited to about 25% of anticipated range with right-sided LBP. Left lateral flexion was full and did not change symptoms. Right lateral flexion was limited to about 25% of anticipated range with pain and difficulty coordinating movement. Forward bending was assessed, and midway through the available range, the trunk deviated markedly to the right in a painful arc. Upon returning to neutral, the lateral shift had moved to the right side with no worsening of symptoms (Figure 1(b)). Pain had not worsened and remained on the right side. No resistance was felt to shift correction in either direction, except for a momentary ‘twinge’ when correction was first initiated. Because of the ease with which the shift switched directions, the posterior shear test [17] was performed to assess for potential passive instability, such as that seen with a spondylolisthesis, and the test was found to be negative. Segmental mobility was assessed in prone, and LBP was reproduced during central and unilateral posterior-to-anterior pressure at L4 and L5. Although segmental mobility assessment has moderate interrater reliability [18], hypermobility detected during this assessment has validity in determining patient response to a stabilization program [19]. To assess for segmental hypermobility [20] and, thus, direct treatment [21], the prone instability test was performed and was positive. Passive hip flexion, internal rotation, external rotation, and abduction were full and within normal limits bilaterally. Straight leg raise testing was 80° and painless on the left and 65° on the right with the reproduction of buttock pain.

Figure 1.

Lumbar lateral shift of the current case. (a). The patient appears shifted to the left. (b). The patient appears shifted to the right. (c). The patient does not appear to have an observable lumbar lateral shift

The patient reported a shift was usually away from the side of pain (i.e. contralateral). However, if the shift changed quickly, the pain did not immediately switch sides, so he would occasionally have an ipsilateral shift. At times, he would appear shifted to one side, but the shift would disappear after a few seconds.

Diagnosis

Based on the absence of red flags or signs of radicular syndrome, the patient could be classified as having nonspecific LBP [22]. At an initial consultation, a clear picture of centralization [23] was not apparent, but pain responded in a directionally specific manner, given the rapid reversibility of the LLS and variability of pain location. A directional preference for extension also appeared to be present. Thus, the presentation was classified in the McKenzie method of Mechanical Diagnosis and Therapy (MDT) [24] as a lumbar derangement. Inconsistencies with the classic derangement presentation (not having an obstructed shift) [24] were noted by the clinician, and additional factors were considered in his diagnosis and subsequent treatment. Since the patient’s condition was associated with extremity symptoms, segmental hypermobility, and increased symptoms with mid-range and end-range spinal positions, the impairment-based diagnosis provided was subacute LBP with movement coordination impairments [25]. The patient’s age, positive prone instability test, and aberrant movements further supported the presence of motor control impairments [21,26].

Psychosocial factors were considered when making the diagnosis, planning initial interventions, and developing a complete plan of care. He felt unable to control episodes, and there was a pattern of recurrences without trauma or loading events. This information was thought to indicate low self-efficacy, which may predict long-term outcomes in patients with chronic LBP [27].

Intervention

Initial treatment consisted of manual LLS correction to a neutral (midline) spinal position while monitoring symptoms. Sustaining this position for 30 seconds did not change resting symptoms. Spinal extension with the correction manually sustained in upright standing was added to the intervention. The patient had increased range but after 2–3 repetitions were unable to maintain the shift correction while extending. Afterward, the LLS had again changed from left to right, despite efforts to avoid this; and his LBP remained on the right. Another weight-bearing attempt was made to correct the lateral shift, soliciting active self-correction with the clinician restraining the patient from overcorrection (Figure 2). On return to neutral, the pelvis moved slightly under the fixated trunk into a more vertical position, and active correction was solicited again. This was performed until no more movement occurred and pain was closer to midline. After this technique, the LBP was abolished, and spinal extension was full and painless. A unique home exercise was prescribed based on lateral shift correction, and involved using a ball as resistance to constrain movement, prevent overcorrection, and provide a sensory cue to guide the patient to the correct position (Figure 3).

Figure 2.

Technique used in the current case to facilitate correction of a lumbar lateral shift. The image depicts correction of a left lumbar lateral shift. The arrow shows the direction of force produced by the patient. Note that the patient is actively moving into the clinician’s resistance, and the clinician is restraining overcorrection and has a direction of force opposite to that of the arrow

Figure 3.

Exercise used for self-correction of a lumbar lateral shift. The patient is pushing laterally into the ball, which provides resistance and restrains overcorrection. The position depicted here would be used to correct a right lumbar lateral shift

Maintenance of LLS correction is an important part of the educational program [6,28]. Thus, the patient’s education after initial treatment was framed positively to the patient and included advice to stay active but minimize lumbar flexion (including sitting), twisting, and lateral flexion toward the side of any shift (Table 1). Education, along with the effective home program, was implemented to improve self-efficacy [29].

Table 1.

Patient education provided during the first visit and reinforced throughout treatment

Education concept	Rationale	Example
Avoid in-depth pathoanatomical explanations of the patient’s pain	To decrease the risk of fear and catastrophizing, patient education prioritized metaphors over specific pathoanatomic structures [25].	“Our backs can be sensitive after an injury. Just like a sunburn, if you give it some space and allow it to calm down, it will eventually be able to tolerate the same stresses as it did before.”
Stay active	In accordance with best practice recommendations [25]	“You should continue to stay active. We know this helps improve your chances of recovery.”
Temporarily avoid flexion, rotation	In the recovery phase of a lumbar lateral shift, these movements should be avoided to allow symptoms to stabilize [6,10].	“Taking some time away from aggravating activities can allow your back to feel better. With this type of injury, it usually helps to avoid rounding and twisting your spine for a short period of time.”
Planned resumption of normal activities	To guard against the development of fear avoidance behaviors, it was stressed that flexion avoidance was temporary.	‘Minimizing the amount of rounding in your spine is something you’ll only have to do for a short period of time. Let’s start with 9 days and follow up at your next session.’
Reinforce the overall favorable prognosis of low back pain	Reassurance of a positive outcome is recommended [25], and this patient acknowledged the contribution of stress to his pain.	“The good news is, while it can be distressing, episodes of back pain are so common as to be normal and almost always resolve in a matter of weeks.”
Home program frequency and dosage; concept of centralization	Consistent with previous lumbar lateral shift cases [6,10], the patient was advised to perform exercises as needed to resolve shift and centralize symptoms.	“You should perform the exercises when you notice symptoms have increased or moved away from your spine or when the shift has worsened. The number of repetitions is based on those things improving.”

At the second visit 9 days later, he presented with 0/10 pain, no detectable lateral shift, and full range of motion without pain in extension, lateral flexion, and flexion. The patient was taught a supine posterior pelvic tilt exercise and to assess for return of symptoms or lateral shift after 10 repetitions. He was told to perform the lateral shift correction only if necessary and to follow the posterior tilt exercise with lumbar extension exercises to ensure no loss of extension. The patient was allowed to pick up light objects as long as he maintained relative lumbar extension and was instructed to return to initial exercises if symptoms recurred.

At his third visit, which took place 5 days later, the patient had a return of symptoms and his LLS. He admitted to disregarding instructions to avoid lumbar flexion while erecting a tent for his daughter’s birthday party. He reported 2/10 right-sided lumbar and right buttock pain and was shifted to the left. Correction of the shift and prone lumbar extension press-ups were repeated, again centralizing symptoms from the right buttock to midline and reducing his shift. His home program was reviewed, and strict orders were established to avoid lumbar flexion for maintenance of reduction of the derangement [10]. A prolonged period of flexion avoidance was considered necessary, so he was instructed to return to the initial flexion avoidance routine for 14 days.

The fourth visit was 7 days later. He reported 0/10 pain before treatment, and no shift was observable. Extension-biased exercises were added, including prone hyperextension over a pillow to improve motor control and endurance of the spinal extensors.

During the fifth visit 6 days later, he again had no pain or return of LLS. He had full and painless AROM in all directions. Because of his frequent episodes of LBP and apparent hypermobility, improving the motor control, strength, and endurance of trunk muscles was deemed important. Lower abdominal strength was measured at 3/5 [30]. He sustained a prone plank for 48 seconds, a bridge for 1 minute, a right lateral plank for 35 seconds, and a left lateral plank for 15 seconds. Asymmetry in side plank endurance was considered important since it has been associated with LBP in certain populations [31] and may lead to asymmetrical holding postures, such as a lateral shift. Therefore, side and front planks were added to improve his ability to hold his spine in a neutral position. Prone hyperextension was progressed from a flat surface to an exercise ball to allow movement into lumbar flexion eccentrically and to improve the endurance of the spinal extensors. Based on his painless response to squatting and lumbar flexion, he was allowed to perform some flexion during daily activities.

The sixth visit was 9 days later. The patient reported feeling 95%-100% better and denied the recurrence of pain or lateral shift. He had returned to doing house and yardwork without having to avoid lumbar flexion. His home exercise program was reviewed. At his request, the patient was provided with a gym-based strengthening program to begin losing weight.

Outcomes

The patient was seen for six visits over 37 days. Outcomes are detailed in Table 2. At discharge, he had not experienced leg symptoms or LBP in 2 weeks. His posture was notably improved from the initial visit (Figure 1(c)), and AROM was full and painless with overpressure. On his final visit, he scored 2/50 on the ODI, which reflects 4% disability. This improvement more than doubles the minimal clinically important difference of a 30% change from baseline [16] and surpasses previously suggested cutoffs indicating a successful outcome [32,33]. At a 6-month follow up, conducted by phone, the patient scored 0/50 on the ODI, indicating 0% disability. However, he reported one 2-week episode of mild LBP in the previous 6 months, which did not cause a lateral shift and improved with his home exercise program. He had sought no other medical care for LBP since discharge.

Table 2.

Outcomes in a patient with an alternating lateral lumbar shift

Outcome measure	Baseline (Visit 1)	Discharge (Visit 6)	6-month follow-up
Numeric Pain Rating Scale, Worst (0–10)	3/10	1/10	0/10
Oswestry Disability Index (0–50 scale, 0–100%)	13/50, 26%	2/50, 4%	0/50, 0%
Lumbar active range of motion	Flexion, extension, and right lateral flexion painful and limited	Full and painless	-
Straight leg raise	Right: 65° with right buttock pain. Left: 80° and painless	Equal and painless bilaterally	-

Discussion

The purpose of the current case report was to describe the presentation and management of a patient with an alternating LLS. To our knowledge, this report is the first to describe conservative management of this condition. After six visits, the patient of the current case had nearly no pain and had met all of his functional goals. The follow-up period for this patient was 6 months, at which time he reported maintenance of gains.

In the current case, treatment was targeted toward relevant impairments. The patient was identified as having a potential lumbar derangement and movement coordination impairments. When using the treatment-based classification algorithm, Stanton et al. [34] suggested a similar finding may occur 25.2% of the time and recommended beginning with the treatment indicated by the algorithm. Because of the presence of an LLS, directional preference, previous radicular pain, and AROM deficits, the clinician decided to begin with an MDT approach for this case.

The MDT approach is effective for improving pain and disability in patients with chronic LBP [35]. When correcting an LLS, there is usually resistance to correction. In the current case, no resistance was felt to manual correction and the patient’s LLS easily changed sides although he was unaware of its having done so. A similar case reported a female patient could cause her LLS to change directions at will [8]. Capener [8] also reported a patient with an LLS that ‘snapped’ to the other side during lumbar flexion. In another patient, the LLS alternated between visits but was not directly observed doing so [8]. An LLS that alternates sides so easily presents several treatment challenges. In the current case, manual shift correction in weight-bearing position caused the LLS to quickly switch sides even when the clinician did not overcorrect the shift. When a more active and constrained shift correction was attempted, the patient’s symptoms and range of motion improved.

Several findings led the clinician to consider targeting motor control impairments early in treatment. Once the patient’s shift no longer alternated, trunk muscle endurance testing was conducted, following practice guidelines [25], and was found to be deficient. The ease with which the LLS alternated sides and positive tests of hypermobility also supported the presence of a motor control impairment [21]. The alternating LLS could itself be a type of aberrant movement, such as the Gower sign or reversal of lumbopelvic rhythm. Given that motor control impairments can present as an LLS [36–38], the astute clinician should determine the underlying nature of the patient’s LLS during the physical examination and throughout the course of care. While individually the clinical tests for instability may have questionable diagnostic utility [39], some (aberrant movements, prone instability test) may be predictive of recovery when patients are matched to a motor control program [40]. However, the general application of motor control exercises in patients with chronic LBP appears to be no more beneficial than other interventions [41].

The cause of rapidly developing and painful LLS is usually attributed to intervertebral disc disturbances [5,6,8,10,42,43]. However, muscle activity imbalance [44] or a protective mechanism mediated by muscle spasm [45] have also been suggested. Developed by Finneson [42] and described by Weitz [46], the protective mechanism was considered to relieve tension or pressure on a spinal nerve as it exited the spinal canal. However, this explanation was not supported by Porter and Miller [43], and another study failed to find relationships between herniation topography and exiting nerve roots [47].

One explanation for the contralateral LLS is the dynamic disc model (DDM) [48]. The DDM suggests migration of nuclear material posteriorly within a midline posterior fissure can limit extension and cause midline pain (Supplement 2). If this mass effect moves laterally, the pain can as well. If the mass effect is large enough, the spine laterally flexes away from the painful side, and a contralateral shift is observed (Supplement 3). The ipsilateral shift may be a mass deficit effect caused by a large posterolateral annular fissure, rather than a space occupying mass effect that produces the contralateral shift [6] (Supplement 4).

However, the alternating LLS appears to directly challenge the DDM. Sometimes the pain changes sides with the shift and sometimes not. The current case had both behaviors at different times. Falconer et al. [45] described 5 cases of alternating shift, and 3 of them reported leg pain changing sides with the shift [45]. If pain changes sides with alternating contralateral shift, a T-shaped annular fissure pattern may provide a pathway for the movement of nuclear material consistent with the DDM (Supplement 5). However, the current case may best be explained by Falconer’s model [45] of a protective response mediated by muscle spasm since the patient’s shifts rapidly changed sides without a corresponding change in pain location.

There were several limitations in the current case. Because it is a case report, conclusions about cause and effect cannot be drawn. Further, the treatment rationale was based solely on symptom response. Although the patient’s pain and disability improved, it is unclear which component was most beneficial, why this approach was beneficial, and to what degree natural history was responsible for his recovery.

Conclusion

The current case report described the presentation and successful treatment of a patient with an alternating LLS. Little is known about the successful treatment of this presentation or its underlying mechanism. Future cases of alternating LLS should be reported to strengthen our understanding of this seemingly rare presentation.

Biographies

Seth Peterson is a physical therapist practicing in Oro Valley, Arizona. He is the founder of The Motive Physical Therapy Specialists and an adjunct faculty member at A.T. Still University’s Arizona School of Health Sciences. Seth is a board-certified orthopedic clinical specialist (OCS) and a fellow of the American Academy of Orthopaedic Manual Physical Therapy (FAAOMPT). He is a coauthor of the Academy of Orthopedic Physical Therapy’s Screening for Referral monographs and has numerous peer-reviewed publications, mostly related to differential diagnosis and management of spinal conditions.

Mark Laslett is a New Zealand Board Registered Musculoskeletal Physiotherapy Specialist (NZRPS). He completed doctoral studies at Linköping University (Sweden) in 2005, which were based on diagnostic accuracy research with chronic low back patients. He is a former instructor for the New Zealand Manipulative Physiotherapists Association (NZMPA) and Auckland University of Technology (AUT) and former international instructor for the McKenzie Institute. He has been a tutor in biostatistics and study design for AUT University, and a supervisor advisor for masters and doctoral students undertaking diagnostic accuracy research. He retains an adjunct status with AUT. Mark has about 40 scientific publications, many of which relate to diagnosis and management of low back pain. His book, Mechanical Diagnosis & Therapy: The Upper Limb, was published in 1996. Mark is an honorary life member of the NZMPA, Physiotherapy New Zealand, and the Swedish branch of the McKenzie Institute and is a past president of the NZMPA.

Mark is in part-time specialist musculoskeletal practice and is a triage consultant for the Canterbury Initiative Low Back Pain Health Pathway. In 2015, he cofounded ‘Southern Musculoskeletal Seminars’ with Dr. Angela Cadogan, which provide structured online education courses for clinicians on musculoskeletal diagnostics and clinically focused workshops.

Funding Statement

No funding was provided for this case study.

Disclosure statement

The authors report no conflicts of interest or potential conflicts of interest.