Anyone experienced foot drop ?

[douglasr]

I have a slight scoliosis of the spine and have suffered occasional back trouble since I was 18 (I'm 44 now). I see a Chiropractor fairly regularly. About 3 weeks ago, after some strenuous chopping of bushes in the garden my back seized up on me on one side. Usually this resolves itself in a few days and true to form it got better, only to come back a few days later.
On Saturday I was at a party and while dancing, felt what is best described as a release of tension - my back felt much better, however the next day my big toe was numb, I had loss of sensation in my ankle and I was suffering from foot drop (when your foot slaps on the ground when you walk as you cannot control it). I was also in a lot of pain later in the day, but that subsided after a visit to the Chropractor.
I also went to my GP who is worried I have a prolapsed disk and wants me to have an MRI scan (I was on the phone within an hour to my private health cover and I will hopefully get one soon). I was aware before I went that this was a possible cause.
My question is, have any of you experienced foot drop? If so did it resolve without surgical intervention (via rest/chiro/physio etc). If so, how long did it take ?
Thanks for reading...

[K77 CTR]

I was always of the understanding that foot drop associated with back pain was a Red Flag (ie/ needed urgent orthopaedic assessment) I am concerned that your GP has treated it so casually.

Edited by K77 CTR on Wednesday 13th October 14:28

[Bill]

It does sound like a disc and rapidly worsening neurological signs (as you have) is an indication for surgery. It may recover spontaneously but removing the pressure from the nerve aSAP is your best bet.

Basically get yourself in to see an orthopod and talk through your options with them.

In the meantime if you get numbness around your groin or anus, get sexual dysfunction or can't pee when you feel you need to get yourself to A&E as caudal equine syndrome is not something to cock about with.

FWIW (and I know some would disagree) I'd avoid forceful manipulation of your back.

[E21_Ross]

Bill said:

It does sound like a disc and rapidly worsening neurological signs (as you have) is an indication for surgery. It may recover spontaneously but removing the pressure from the nerve aSAP is your best bet.

Basically get yourself in to see an orthopod and talk through your options with them.

In the meantime if you get numbness around your groin or anus, get sexual dysfunction or can't pee when you feel you need to get yourself to A&E as caudal equine syndrome is not something to cock about with.

totally agree

Bill said:

FWIW (and I know some would disagree) I'd avoid forceful manipulation of your back.

just out of curiosity, why? i'm genuinely curious..."forceful"...do you know how much forces are transmitted to the spine in lumbar or SI adjustments? it's very minimal. plenty of studies and RCT's regarding manipulation and disk protrusions have shown manipulation to not only be safe, but also beneficial.

just digging around on pubmed found these

http://www.ncbi.nlm.nih.gov/pubmed/16517383
http://www.ncbi.nlm.nih.gov/pubmed/15129202

however, as said, imaging first would be important. and i also wouldn't fancy manipulating on a patient with cauda equina syndrome.


i can't recall, but are physios classed as primary health care professionals? if so, isn't it your duty to give advice and treatment that is evidence based?

i'll stop there before we get side tracked again but i implore you bill, please, please, please do some reading on spinal manipulation. there seems to be some consensus that chiropractic is still living as it was back in the '50's. luckily (thank god) it's not. it's progressed a long, long way thanks to plenty of research. it's been found beneficial for many things, and not for others. disk herniation is one it's been found to be fine for. so why say avoid it, against evidence? i can get more RCT's as well as systematic reviews for you if you'd like? i'm not arguing, i just want you to read and learn before making comments like that.

thank you.

to OP -

as has been said, the fact it (appears that way anyway) a single event of spinal trauma caused it, it's highly unlikely to be something like peripheral neuropathy, brain lesion etc etc, so nerve root impingement/irritation etc is quite likely. hopefully something simple and hope you get better soon.

Edited by E21_Ross on Wednesday 13th October 21:18

[BlackVanGirl]

Bill said:

It does sound like a disc and rapidly worsening neurological signs (as you have) is an indication for surgery. It may recover spontaneously but removing the pressure from the nerve aSAP is your best bet.

Basically get yourself in to see an orthopod and talk through your options with them.

In the meantime if you get numbness around your groin or anus, get sexual dysfunction or can't pee when you feel you need to get yourself to A&E as caudal equine syndrome is not something to cock about with.

FWIW (and I know some would disagree) I'd avoid forceful manipulation of your back.

Also totally agree. Not to be fked with.

I had foot drop early on, doc martens or similar will help protect your toes short term.

[douglasr]

Hopefully not cauda equina then. This just adds insult to injury - I suffer from multiple meningioma (benign brain tumours) and have recently had two seizures. I've been seeing the same Neurosurgeon for 12 years and I'm due to see him in 4 weeks for my annual check. I have asked my GP to refer me to him just in case the actual cause is a tumour and not a disk prolapse as he is also a respected spine specialist. Hopefully I'll get the scan soon.
BTW, no loss of bladder function etc, just the symptoms as described above. I had an MRI of the spine 10 years ago to check for spinal canal meningioma and there were none present. Fingers crossed.

[E21_Ross]

douglasr said:

Hopefully not cauda equina then. This just adds insult to injury - I suffer from multiple meningioma (benign brain tumours) and have recently had two seizures. I've been seeing the same Neurosurgeon for 12 years and I'm due to see him in 4 weeks for my annual check. I have asked my GP to refer me to him just in case the actual cause is a tumour and not a disk prolapse as he is also a respected spine specialist. Hopefully I'll get the scan soon.
BTW, no loss of bladder function etc, just the symptoms as described above. I had an MRI of the spine 10 years ago to check for spinal canal meningioma and there were none present. Fingers crossed.

you said your back seized up on one side, is this the same, or different side you are experiencing the foot drop? hopefully it's just related to something like spinal trauma and not tumour.

could, technically, be something simple like muscle irritation causing irritation of sciatic nerve. does sound like herniated disc around L4/L5 could be the cause.

to be honest, shed load of things cause foot drop, including brain tumours. hope you get your scan asap and all turns out ok. keep us updated.

Ross.

[BliarOut]

I had it for a year or so thanks to a badly managed Thomas splint. Foot was all fine and dandy then suddenly it just went all floppy

I had to wear a caliper for a year or so but I was fortunate in that I got the use of it back. My toes are a bit weak but it's not a hindrance. Whatever you do keep your Achilles stretched.

[douglasr]

E21_Ross said:

douglasr said:

Hopefully not cauda equina then. This just adds insult to injury - I suffer from multiple meningioma (benign brain tumours) and have recently had two seizures. I've been seeing the same Neurosurgeon for 12 years and I'm due to see him in 4 weeks for my annual check. I have asked my GP to refer me to him just in case the actual cause is a tumour and not a disk prolapse as he is also a respected spine specialist. Hopefully I'll get the scan soon.
BTW, no loss of bladder function etc, just the symptoms as described above. I had an MRI of the spine 10 years ago to check for spinal canal meningioma and there were none present. Fingers crossed.

you said your back seized up on one side, is this the same, or different side you are experiencing the foot drop? hopefully it's just related to something like spinal trauma and not tumour.

could, technically, be something simple like muscle irritation causing irritation of sciatic nerve. does sound like herniated disc around L4/L5 could be the cause.

to be honest, shed load of things cause foot drop, including brain tumours. hope you get your scan asap and all turns out ok. keep us updated.

Ross.

Same side. Muscles have eased now, and the sciatic pain has subsided, although sitting for longer that 30 minutes gets uncomfortable.

[Bill]

douglasr said:

I suffer from multiple meningioma

Well, that changes things. It sounds like it's settling, and it sounds like a disc but I'd rather be safe than sorry. Call the consultant's secretary and get your appointment pulled forward. If necessary the consultant can get the scan expedited but he's the best person to make that decision.

[E21_Ross]

douglasr said:

E21_Ross said:

douglasr said:

Hopefully not cauda equina then. This just adds insult to injury - I suffer from multiple meningioma (benign brain tumours) and have recently had two seizures. I've been seeing the same Neurosurgeon for 12 years and I'm due to see him in 4 weeks for my annual check. I have asked my GP to refer me to him just in case the actual cause is a tumour and not a disk prolapse as he is also a respected spine specialist. Hopefully I'll get the scan soon.
BTW, no loss of bladder function etc, just the symptoms as described above. I had an MRI of the spine 10 years ago to check for spinal canal meningioma and there were none present. Fingers crossed.

you said your back seized up on one side, is this the same, or different side you are experiencing the foot drop? hopefully it's just related to something like spinal trauma and not tumour.

could, technically, be something simple like muscle irritation causing irritation of sciatic nerve. does sound like herniated disc around L4/L5 could be the cause.

to be honest, shed load of things cause foot drop, including brain tumours. hope you get your scan asap and all turns out ok. keep us updated.

Ross.

Same side. Muscles have eased now, and the sciatic pain has subsided, although sitting for longer that 30 minutes gets uncomfortable.

hmmm, hopefully it's just something like torn and inflamed muscle causing a little irritation of the nerve and nothing serious.

[Bill]

E21_Ross said:

i can't recall, but are physios classed as primary health care professionals? if so, isn't it your duty to give advice and treatment that is evidence based?

Indeed, which is we learn to assess the quality of research as part of our training. I'd hope chiropractors would do the same, so I have to assume you haven't done that module yet.

As I have stated in the past I use manipulations. However, given the presence of neurological symptoms in the OP in this case I would be more circumspect.

This decision is based on the lack of evidence regarding the efficacy of manipulation in disc reduction (You'll note that the first paper you cite fails to mention the MRI results... You can't ignore results that don't go your way) and my clinical experience. I have seen countless ex-chiro patients where manipulation has resulted in worsening of their symptoms* and three I can think of off the top of my head who have had neurological symptoms develop following manipulation**

So you'll forgive me for taking the second paper's assertion of a risk of adverse events as 1 in 3.7 million with a pinch of salt.

I am not throwing the baby out with the bath water and rejecting manipulation per se, I am simply erring on the side of caution.

FWIW both those papers are short on detail regarding the methods used and fall short IMO of the standards I'd like to see. If you compare the abstracts with others linked on the same page you'll see a marked difference.

*Admittedly this group is self selecting, so I'd be unlikely to see patients for whom treatment by a chiro has worked.

**I can't say for sure it wouldn't have worsened anyway, which is why we need decent research on manipulation of people with neurological symptoms.***

***Assuming the ethics commitee will allow it

[Bill]

This is a good quality review. You'll note the level of detail in the abstract and the conclusion:

Someone less partisan said:

There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue.

So, adverse events happen, but we don't know how often. And that's good grounds for caution in someone who already has neuro signs IMO.


ETA: This should make you squirm

This article said:

The core concepts of chiropractic, subluxation and spinal manipulation, are not based on sound science. Back and neck pain are the domains of chiropractic but many chiropractors treat conditions other than musculoskeletal problems. With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition.

Edited by Bill on Thursday 14th October 10:10

[E21_Ross]

there was a paper recently (perhaps '09, but may have been earlier this year) by bronfort which was a massive review of osteopathic and chiropractic manipulations and their benefits for a wide variety of cases (i can't recall how many RCT's were included in the study, but it was somewhere in the region of 70 IIRC) which showed some interesting results for disc herniations by spinal manipulation vs mckenzie method vs surgery there have been cases (i don't recall reading RCT's about it though...maybe it's an area of research not properly done yet...?) where MRI have shown a reduction in herniation following manipulation and a reduction of neurological symptoms. but, as you know, any imaging modalities can give false +ve's and -ve's. at the end of the day, if it relieves the patient for even a little while, it's worth it. the OP even said after a visit to the chiro he felt better for a while. again, for a we know it could be a simple muscular case (in which case manipulation will help calm down local spastic musculature etc which would give short term relief).

i understand your point regarding avoiding manipulation for certain things such as cauda equina, which is why a thorough case hist. and physical are so important (and, in this case i'm sure, imaging) before undertaking certain procedures.

i don't want another argument so i'm going to leave it there this time.

all the best,

Ross.

[Bill]

E21_Ross said:

Stuff about a paper

Please find it. I've had a look on pubmed and can't, although the conclusion here is interesting: There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.

E21_Ross said:

if it relieves the patient for even a little while, it's worth it.

True. But it's important to be able to differentiate between placebo and effect and to minimise harm.

E21_Ross said:

the OP even said after a visit to the chiro he felt better for a while. again, for a we know it could be a simple muscular case (in which case manipulation will help calm down local spastic musculature etc which would give short term relief).

It's unlikely that spasm would cause weakness. That requires substantial nerve compression which leads me to suspect a disc (or given the history meningioma.)

E21_Ross said:

i understand your point regarding avoiding manipulation for certain things such as cauda equina, which is why a thorough case hist. and physical are so important (and, in this case i'm sure, imaging) before undertaking certain procedures.

In which case why differentiate between cauda equina and more peripheral nerve compression? ETA for clarity: Surely the mechanism that might worsen a cauda equina is the same for a preipheral nerve compression. Ignore for a second that cauda equina is a medical emergency.

E21_Ross said:

i don't want another argument so i'm going to leave it there this time.

Well don't come across as condescending then, and I'll try to do the same.

I am genuinely interested in the view from the other side, and I'm not trying to put people off manipulation just to understand the evidence (Such that it is.)

Edited by Bill on Thursday 14th October 10:38

[E21_Ross]

Bill said:

Please find it. I've had a look on pubmed and can't, although the conclusion here is interesting: There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.

again, that's just a literature review. it's not saying it's bad, it's saying the evidence isn't out there, not that those symptoms are contraindications. apologies for sounding condescending mate.

re the placebo effect, there is a placebo effect in all treatments, does this differ from other manual (or even surgical - not spinal related but there was a funny case about a bodged heart bypass, they put him under anaesthesia, gave him the scar etc etc, and he recovered ) therapies/treatment? the article earlier had people receiving "fake" manipulations, these did not have a reduction in symptoms as great as those who got proper manipulations....

that 2nd article is very odd. but, it's by ernst. he has a thing against chiropractic. ALL his reviews are clearly biased and are not traditional evidence based. seriously, ernst as it against chiropractic. he seems to think every cervical manipulation will give a stroke etc (it's shown at approx 1:5 million or more. more people die from aspirin each year. and from CVA's, spinal manipulation is far from the most common cause. i'll admit there has been a time factor between the 2, but it's not been shown as a causative factor (e.g. you're at a similar risk of CVA from going to the hair dressers...) but ernst doesn't mention things like that. he'll just say it's really dangerous.

there have been plenty of studies using things like EMG to see post-manipulation muscle responses etc etc showing decreased activity of muscle spasticity, changes. "subluxation" - that's chiro back in the 50's, a subluxation is a partial loss of apposition between articular surfaces (i.e. not a full dislocation), that's the term we use. not the stupid term chiro's 100 years ago used.

i'll agree there is far, far more evidence out there showing manipulation works, than how it works. but, if it helps the patient and it's safe to do so (very important, but there is plenty of research showing it's very safe, but obviously some cases manipulation is a contra-indication) then why not do it?

again, sorry for sounding condescending earlier.

all the best,

Ross.

Edited by E21_Ross on Thursday 14th October 10:59

[Bill]

E21_Ross said:

again, that's just a literature review. it's not saying it's bad, it's saying the evidence isn't out there, not that those symptoms are contraindications.

It is, but it's a good quality review and it's currently the best we have. And I realise it's not saying it's bad, but given that we can't say it's good either caution seems sensible. So I do consider neurological signs like weakness and reflex loss as a contraindication.

E21_Ross said:

apologies for sounding condescending mate.

Likewise, let's move on.

E21_Ross said:

re the placebo effect, there is a placebo effect in all treatments, does this differ from other manual (or even surgical - not spinal related but there was a funny case about a bodged heart bypass, they put him under anaesthesia, gave him the scar etc etc, and he recovered ) therapies/treatment?

Yep, and I court the placebo effect as it helps people move on but it's still important to recognise that that's what's happening.

E21_Ross said:

that 2nd article is very odd. but, it's by ernst. he has a thing against chiropractic. ALL his reviews are clearly biased and are not traditional evidence based. seriously, ernst as it against chiropractic. he seems to think every cervical manipulation will give a stroke etc (it's shown at approx 1:5 million or more. more people die from aspirin each year. and from CVA's, spinal manipulation is far from the most common cause. i'll admit there has been a time factor between the 2, but it's not been shown as a causative factor (e.g. you're at a similar risk of CVA from going to the hair dressers...) but ernst doesn't mention things like that. he'll just say it's really dangerous.

That may be, but you need to recognise bias both ways rather than ignoring it when it suits you. Ernst's reply to the president of the American Chiro Association disagrees with you mind.

E21_Ross said:

there have been plenty of studies using things like EMG to see post-manipulation muscle responses etc etc showing decreased activity of muscle spasticity, changes.

But where are the studies showing it's better than mobilisations, NSAIDS, heat or ice, TNS or any of a miriad other treatments?

E21_Ross said:

"subluxation" - that's chiro back in the 50's, a subluxation is a partial loss of apposition between articular surfaces (i.e. not a full dislocation), that's the term we use. not the stupid term chiro's 100 years ago used.

Is it? Again, given the substantial limitations in imaging, where's the evidence for this.

It's great that chiro is looking forward and trying to develop an evidence base but far too many practioners are persisting with the "putting your joints back into place" nonsense.

[E21_Ross]

bill - TOTALLY agree with that last statement. there still are too many chiro's out there who just manipulate and think the patient is going to get better. they manipulate regardless of the patient too. it's ridiculous and gives chiropractic a bad name. each patient should be treated according to their individual needs.

subluxation as defined by WHO - "...the presence of an incomplete or partial dislocation (Latin: luxatio) of a joint..."

it's basically a partial dislocation.

manipulation vs mobilisation - generally very little in outcome between the 2 treatments in terms of outcome and patient satisfaction etc. one is quicker than the other is the main benefit (in terms of treatment, not necessarily response, which is usually quite similar). again, this depends on the patient. regards cryotherapy and heat treatments, these aren't going to effect joints as much as mobs or manipulations, but are both very useful treatment methods for certain conditions.

we also use ultrasound and interferential therapies here which are also very good.

cheers.

[Bill]

E21_Ross said:

subluxation as defined by WHO - "...the presence of an incomplete or partial dislocation (Latin: luxatio) of a joint..."

it's basically a partial dislocation.

I know that, but does it regularly occur in the spine? Particularly given the forces require to sublux an AC joint for example (Not to mention the pain involved.)

E21_Ross said:

manipulation vs mobilisation - generally very little in outcome between the 2 treatments in terms of outcome and patient satisfaction etc. one is quicker than the other is the main benefit (in terms of treatment, not necessarily response, which is usually quite similar). again, this depends on the patient. regards cryotherapy and heat treatments, these aren't going to effect joints as much as mobs or manipulations, but are both very useful treatment methods for certain conditions.

Sorry, you mentioned manips reducing spasm which is why I compared it to heat etc.

[E21_Ross]

Bill said:

E21_Ross said:

subluxation as defined by WHO - "...the presence of an incomplete or partial dislocation (Latin: luxatio) of a joint..."

it's basically a partial dislocation.

I know that, but does it regularly occur in the spine? Particularly given the forces require to sublux an AC joint for example (Not to mention the pain involved.)

with facet joints it can yes. regularly, no. but this is why we rarely use the term subluxation these days but for sure, other joints mainly limited to extremities. having said that, i'd probably still say partial dislocation instead of subluxation, but hey ho.

cheers.