Functional restoration for lumbar disc extrusion, Artykuły, badania naukowe
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Functional Restoration for a Chronic
Lumbar Disk Extrusion With
Associated Radiculopathy
Background and Purpose.
The effectiveness of functional restoration (FR) for
patients with lumbar disk herniation with associated radiculopathy (LDHR) is
unclear. This case report describes how an FR program was used to rehabil-
itate a patient with such an injury.
Case Description.
The patient was a
26-year-old female child care worker with a 12-month history of back pain and
a 4-month history of unremitting left leg symptoms. She had clinical and
radiological evidence of an L5–S1 disk extrusion with associated left S1
radiculopathy.
Interventions.
The patient completed a 9-week FR program
supervised by a physical therapist. Exercises then were continued more
independently for a 2-year period at a public gymnasium.
Outcomes.
Follow-
ing 9 weeks of supervised FR, the patient demonstrated marked improvement
in symptoms and functional ability, and resolution of neurological signs.
Fourteen months after commencing FR, a follow-up magnetic resonance
imaging scan demonstrated resolution of the L5–S1 disk extrusion and relief
of S1 nerve root compression. Functional improvements continued and were
maintained 2 years following the start of intervention.
Discussion.
A patient
with chronic LDHR who underwent FR made significant improvements.
Research is needed to determine the efficacy of an FR approach for treating
such patients. [Hahne AJ, Ford JJ. Functional restoration for a chronic lumbar
disk extrusion with associated radiculopathy.
Phys Ther
. 2006;86:1668–1680.]
Key Words:
Back pain, Exercise therapy, Intervertebral disk displacement, Radiculopathy, Rehabilitation
.
Andrew J Hahne, Jon J Ford
1668
Physical Therapy . Volume 86 . Number 12 . December 2006
This case report describes the
T
he annual incidence of lumbar disk herniation
management and outcomes of a
(LDH) has been estimated to be 1% of the
population.
1
When an LDH results in clinical
evidence of radiculopathy, and if conservative
treatment such as medication and physical therapy fails,
diskectomy often is recommended.
1,2
There is no con-
sensus, however, as to the most effective conservative
treatment for lumbar disk herniation with associated
radiculopathy (LDHR). One systematic review indicated
some support for the use of epidural steroids for LDHR,
but insufficient evidence to support the use of non-
steroidal anti-inflammatory medication, traction, or
intramuscular steroids.
3
The use of bed rest for LDHR
appears to be ineffective.
4
A study involving 250 patients
with acute radiculopathy showed no difference in out-
comes among bed rest, physical therapy, and continuing
with daily activities.
5
patient with clinical and radiological
evidence of a chronic L5–S1 disk
extrusion with associated S1
radiculopathy who completed a
functional restoration program
supervised by a physical therapist.
jects) described less favorable outcomes. Tubach et al
16
followed 622 patients with sciatica and found ongoing
leg symptoms in 55% of the patients at a 2-year follow-up
and in 53% of the patients at a 4-year follow-up. Similar
results were reported by Balague et al,
17
with only 29% of
patients reporting a full recovery from sciatica after 12
months, and by Nykvist et al,
18
who reported that 82% of
conservatively treated patients still had sciatica after 5
years. Variability in recovery rates among the studies
cited may be attributable to differences in outcome
measures and definitions of successful outcome
16
as well
as to differences in the treatment interventions used in
the studies.
4.6 months) LDHR who underwent
exercise rehabilitation and epidural steroid injections
reported a 90% success rate and a 92% return-to-work
rate at an average follow-up of 31 months.
6
A subsequent
magnetic resonance imaging (MRI) study on 11 of the
conservatively managed patients with extruded disks
showed that 82% of the disk extrusions had reduced in
size at a median follow-up of 25 months, and all of the
patients appeared to have reduced neural impinge-
ment.
7
Another case series of 22 patients with extruded
or sequestered lumbar disks (median duration
4.5
weeks) who received conservative management includ-
ing active exercise, back school, and epidural steroid
injections reported a 77% successful clinical outcome at
a mean follow-up of 6.9 months.
8
Other case series and
cohort studies have revealed similar clinical or radiolog-
ical success rates between 70% and 90% for patients with
LDH who received various conservative treatments that
were often poorly described and not standardized.
9 –15
Another large cohort study involving 507 patients with
sciatica showed that 56% of conservatively treated
patients reported reduced leg pain at a 1-year follow-
up,
19
60% reported reduced leg pain after 5 years,
20
and
64% reported a reduction after 10 years.
21
These results
suggest that the number of patients improving with
conservative management slows over time, with the
majority of improvement occurring during the first year.
The results of other studies
11,17,22
suggest that the major-
ity of clinical and radiological improvement occurs dur-
ing the first 3 months after onset of symptoms, with
fewer patients recovering after this time frame.
In contrast to the favorable prognosis described in these
studies, other reports of patients with sciatica and poten-
tial LDH (without radiological confirmation in all sub-
In addition to cohort studies and case series, numerous
case reports have been published describing excellent
clinical or radiological outcomes in patients with LDHR.
Notably, however, patients in these studies typically had
AJ Hahne, BPhysio(Hons), is a physical therapist with Spinal Management Clinics, Melbourne, Victoria, Australia. Address all correspondence to
Mr Hahne at: ahahne@primus.com.au.
JJ Ford, PhD, MPhysio, BAppSc(Physio), Cred MDT, is General Manager, Spinal Management Clinics of Victoria, and Lecturer, School of
Physiotherapy, University of Melbourne, Melbourne, Victoria, Australia.
Both authors provided writing, data analysis, and facilities/equipment. Mr Hahne provided concept/idea/project design, data collection, project
management, and the patient. Dr Ford provided institutional liaisons and consultation (including review of manuscript before submission).
This article was received November 18, 2005, and was accepted August 7, 2006
.
DOI: 10.2522/ptj.20050366
Physical Therapy . Volume 86 . Number 12 . December 2006
Hahne and Ford . 1669
The current evidence to support exercise-based rehabil-
itation of patients with LDHR is limited to nonrandom-
ized outcome studies. A case series of 62 patients with
chronic (mean
acute symptoms,
23–28
and studies involving large cohorts
of subjects such as those cited above already confirm that
the prognosis is often good in such patients regardless of
the intervention. Other case reports on patients with a
longer duration of symptoms do not provide convincing
clinical or radiological evidence that the patient had
LDHR.
29 –31
Eight months following the onset of her symptoms, the
patient’s LBP had increased in intensity, and a gradual
onset of left posterolateral leg pain was noted. An MRI
scan was performed that demonstrated significant T2
signal loss involving the T12–L1, L4–5, and L5–S1 disks.
In addition, a 5-mm left posterolateral extrusion of the
L5–S1 disk was identified, with significant displacement
and compression of the left S1 nerve root. The patient’s
physician certified her as unfit for work and prescribed
15 mg/d of meloxicam (Mobic*), a COX-2–inhibiting
nonsteroidal anti-inflammatory drug. She commenced
Bowen therapy, an alternative form of massage devel-
oped by Tom Bowen (1916–1982) in Geelong, Australia,
which consists of “rolling the thumbs and forefingers
over a muscle or tendon at precise locations triggering a
relaxation response.”
37(p32)
She also increased her chiro-
practic treatment to 3 sessions per week. This treatment
consisted of application of ice to the lumbar area and
massage to the lumbar spine and left leg. She said that
she did not receive any manipulative treatment at this
time. An exercise regimen of spinal flexion and lateral
flexion stretches, hip abduction exercises, and general
abdominal bracing without attempting to localize the
contraction to a particular muscle group also was pre-
scribed by the chiropractor. This treatment continued
for 4 months (ie, 12 months after the initial onset of her
LBP). In the final month of this treatment, she noticed
a progressive increase in left leg pain and onset of
peripheral paresthesia. The patient was examined at that
time by a neurosurgeon, who recommended an L5–S1
diskectomy, which she declined because she preferred
non-surgical treatment. She then was referred for phys-
ical therapy by an occupational rehabilitation provider
acting on behalf of the compensable insurer to facilitate
recovery and return to work.
The scarcity of research into the use of exercise-based
interventions such as functional restoration (FR) for
LDHR is surprising, given the good evidence demon-
strating that such interventions can be effective for the
management of nonspecific low back pain (NSLBP).
32,33
In particular, patients with LDHR typically are excluded
from randomized controlled trials (RCTs) investigating
exercise-based interventions such as FR.
Functional resto-
ration
has been defined as “a multimodal pain manage-
ment program that employs a comprehensive cognitive-
behavioural treatment orientation to help patients
better cope with, and manage, their pain...while
undergoing the sports medicine physical approach to
correct functional deficits.”
34(p483)
Although there is
significant variation in the precise content of different
described FR programs, they typically include aerobic
and strengthening exercises (for the trunk, upper limbs,
and lower limbs) specific to the patient’s daily activity
and work demands. A cognitive-behavioral approach is
utilized in FR to address the psychosocial aspects of
chronic injury. Functional restoration programs have
been shown to be effective for people with chronic
NSLBP
32
and subacute NSLBP
35
when conducted by
multidisciplinary teams
32
or when supervised by a sole
physical therapist.
33,36
Advantages of single-discipline FR
programs may include lower costs and wider accessibility
for patients.
The purpose of this case report is to describe the
management and outcomes of a patient with clinical and
radiological evidence of a chronic L5–S1 disk extrusion
with associated S1 radiculopathy who completed an FR
program supervised by a physical therapist.
Reported Symptoms
The initial physical therapy assessment was 1 year follow-
ing the onset of LBP (4 months following the onset of
her left leg symptoms). Her presenting symptoms are
illustrated in the pain drawing completed during the
initial assessment (Fig. 1). Questioning revealed increased
symptoms each morning for up to 3 hours and waking 3
times per night due to lumbar and leg pain. Some
authors
38,39
have suggested that such symptoms may be
indicative of a chemical or inflammatory component to
the pathology. Her symptoms were aggravated by sitting
or standing (limited to a maximum of 20 minutes),
walking (limited to 30 minutes), coughing or sneezing,
and forward-bending activities such as putting on shoes
and socks.
Description
History
The patient was a 26-year-old female child care worker
from Melbourne, Victoria, Australia. Although she had
worked in this capacity for 7 years, she reported a slow
onset of low back pain (LBP) and stiffness, which she
attributed to additional vacuuming, cleaning, and lifting
required of her during renovations taking place at her
workplace. She continued working but commenced peri-
odic chiropractic manipulation, which provided tempo-
rary symptom relief.
* Boehringer Ingelheim Pharmaceuticals Inc, a subsidiary of Boehringer
Ingelheim Corp, 900 Ridgebury Rd, PO Box 368, Ridgefield, CT 06877-0368.
1670 . Hahne and Ford
Physical Therapy . Volume 86 . Number 12 . December 2006
are involved in normal spinal control and are commonly
found to be dysfunctional in individuals with LBP.
40,42,43
Furthermore, retraining these muscles has been shown
to be efficacious in patients with acute and chronic
LBP.
44,45
The patient scored 48% on the Oswestry Low Back Pain
Disability Questionnaire, indicating a moderate level of
perceived pain and disability. This is a valid, reliable, and
responsive outcome measure for patients with LBP
46,47
and has been used extensively on patients with sciatica or
LDH.
46
Figure 1.
The patient’s original pain drawing completed at her initial physical
therapist examination.
Measures of psychosocial status included a pain drawing,
nonorganic signs tests, and the Fear-Avoidance Beliefs
Questionnaire (FABQ). The results of the nonorganic
signs tests, when scored according to reliable and valid
protocols,
48,49
did not reveal evidence of significant
psychosocial distress or elevated pain behavior. How-
ever, 5 out of a possible 6 symptom descriptors were used
when completing the pain drawing (Fig. 1) indicating a
possible influence of psychosocial distress on her
reported symptoms and prognosis.
50,51
In addition, a
score of 46/60 on the FABQ indicated a moderate level
of fear-avoidance beliefs, which in previous studies on
patients with LBP
52,53
was shown to be predictive of
poorer outcomes.
Examination
Visual estimates of lumbar active range of motion
(ROM) revealed flexion and lateral flexion (left and
right) limited to reaching two thirds down the length of
the thigh and extension limited to 15 degrees. All
movements were limited by lumbar and leg pain.
Straight leg raise was limited to 60 degrees on the left by
leg pain, compared with 90 degrees on the right by
hamstring muscle resistance. Moderate-intensity palpa-
tion centrally and to the left of the L4–5 and L5–S1
vertebral segments reproduced pain and muscle guard-
ing. Neurological examination of the lower limbs
revealed normal sensation, an absent left ankle jerk
reflex, and decreased strength (force-generating capac-
ity) of the left gastrocnemius muscle, with the patient
unable to perform a left leg heel raise while standing.
Diagnosis
The patient’s symptoms and examination findings were
consistent with an L5–S1 disk extrusion with resultant
compression and potential inflammation of the left S1
nerve root. Despite 12 months of conservative treatment,
deteriorating leg symptoms, and a moderate degree of
perceived pain and disability, she expressed a strong
preference to avoid surgery. In addition to her physical
injury, she had a moderate degree of fear-avoidance
beliefs and a pain drawing indicative of some psycho-
social distress. After detailed explanation and discussion,
the patient agreed to cease chiropractic treatment and
commence an FR program supervised by a physical
therapist.
The patient’s ability to perform a localized contraction
of the transversus abdominis muscle was assessed visually
with the patient in standing and side-lying positions.
Some authors
40,41
have reported that more localized
activation of the transversus abdominis muscle relative to
superficial abdominal muscles is characterized by an
inward movement of the lower abdominal wall. The
patient demonstrated a technique of global abdominal
wall bracing and was unable to isolate the inward move-
ment to the inferior abdomen. Concurrent palpation
bilaterally and immediately adjacent to the L4 and L5
spinous processes revealed a poor ability to actively
generate tension in the deep fibers of the lumbar
multifidus muscle.
40
Evidence exists that these muscles
Intervention
The physical therapist (AJH) who treated the patient
had graduated from La Trobe University, Victoria, Aus-
tralia, with a Bachelor of Physical Therapy with Honours
degree 3 years earlier. He had worked for 3 years in
private practice at a clinic specializing in exercise-based
management of recalcitrant LBP. He had received
approximately 100 hours of clinical mentoring from a
senior physical therapist ( JJF) with 15 years of experi-
ence treating patients with LBP and a master’s degree in
musculoskeletal physical therapy. A second mentor with
7 years of experience had provided a further 100 hours
of training. The mentoring provided training in clinical
Physical Therapy . Volume 86 . Number 12 . December 2006
Hahne and Ford . 1671
Table 1.
The 3 Phases of Management
Phase 1
Phase 2
Phase 3
Duration
4 wk
5 wk
2 y
No. of physical therapy
consultations
8 (2 sessions per week)
15 (3 sessions per week)
21 over 2 y
Content
Teaching and practice of
appropriate stabilizing pattern
Education regarding injury
and recovery
Implementation of self-management
strategies
Appropriate stabilizing pattern
incorporated into a functional
restoration program supervised
in the clinic by a physical
therapist
Exercise program continued
independently at gymnasium
Reviews in clinic with
physical therapist for
goal setting and guidance
with exercise progression
Table 1. The phases of management
and time frames of key events in the
patient’s history are presented in a time
line in Figure 2.
Phase 1
In phase 1, the patient attended 2
sessions per week for 4 weeks. She first
was educated regarding her injury. A
diagram was drawn to demonstrate her
L5–S1 disk extrusion. Her left leg symp-
toms and neurological findings were
described in terms of inflammation and
mechanical compression of the left S1
nerve root. Reassurance was provided
regarding the potential to improve with
appropriate management, given the
evidence regarding the importance of a
positive patient outlook.
54
Figure 2.
Key events and phases of management. MRI
magnetic resonance imaging.
The patient was taught self-management
strategies aimed at minimizing thera-
pist dependence and empowering the
patient to gain control over symp-
toms.
55
These strategies included self-
application of heat to the lumbar spine
using a microwave-heated wheat bag
with the aim of producing an analgesic
affect and reduction of muscle spasm at
the depth of the skin and superficial
muscles. It is unlikely that the heat
could penetrate to the depth of the disk where inflam-
mation may have been active.
56
Inflammation potentially
present in and around the disk and nerve root was
controlled by continuing with Mobic medication
throughout the program (15 mg/d). Although continu-
ing with daily activity was encouraged, she was advised to
minimize activities that have been shown to increase
intradiskal pressure such as forward flexion activities and
flexed sitting.
57
Such caution may not be necessary for all
patients, but given the serious nature of the pathology,
the avoidance of potentially provocative postures was
reasoning, clinical assessment, and management of LBP
from a biopsychosocial perspective, including the imple-
mentation of basic cognitive-behavioral strategies. The
treating therapist also had attended several conferences
and short professional development courses relating to
LBP, including one by Peter O’Sullivan
45
on assessment
and management of lumbopelvic instability using a
motor skill learning approach (16 hours).
The exercise component of the patient’s program
consisted of 3 main phases, which are summarized in
1672 . Hahne and Ford
Physical Therapy . Volume 86 . Number 12 . December 2006
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