treatment of acute low back pain with...
TRANSCRIPT
1
Filiz Ekren
USF tDPT Student, #100114
Phone Number: 727-656-2217
E-mail: [email protected]
TREATMENT OF ACUTE LOW BACK PAIN WITH RADICULOPATHY
Advisor
David A. Krause, PT., D.Sc.
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CASE REPORT
Abstract
Background and Purpose: Back Pain Management and Disability is costing the USA
billions of dollars. Focus on timely, and effective intervention options are crucial, to
reduce the cost universally and to improve functional outcomes. Physical therapists must
assess and treat the patients with best treatment strategies to decrease, abolish the pain,
restore patient function, and prevent future recurrences. The key to successful outcomes
includes patients’ understanding of their current problem, their active participation, and
self-management of their condition. The purpose of this case report is to describe the
management of a patient utilizing McKenzie classification, assessment and treatment,
intervention, and outcome of directional preference.
Case Description: The patient was a 55-year old female presented to physical therapy with
a one week history of acute low back pain (LBP). Initial injuries were a result of a motor
vehicle accident (MVA) that took place four years ago. Recurrences over four years were
managed by pain medications and series of epidural injections.
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Initial pain level prior to physical therapy was 10/10 pain. Numerical Pain rating Scale
(NPRS). Oswestry Disability Index (ODI) was 64%, Fear Avoidance Belief Questionnaire,
(FABQ) was 55/66 and she presented with limited lumbar mobility, limited tolerance to
activities of daily living (ADL’s), limited leisure activities and job duties.
Interventions: In this case report, interventions included ultrasound and electrical
stimulation (heat modality), soft tissue mobilization, Maitland segmental joint
mobilization, and McKenzie assessment and treatment to manage pain and inflammation,
improve mobility, strength, and function. Patient education throughout the episode of care
included proper posture, positioning, and a home exercise program (HEP).
Outcome: Oswestry Disability Index (ODI), Fear Avoidance Belief Questionnaire
(FABQ), Numerical Pain Rating Scale (NPRS) as well as overall mobility, strength and
function at home and work improved with 5 visits. When initial and final measurements
were compared at the end, the comparison revealed that the patient successfully
accomplished the goals she had originally set for herself during the initial assessment.
Discussion: Although McKenzie Method efficacy is unclear, the patient resolved her LBP
and leg symptoms with utilization of McKenzie assessment and treatment (extension
protocol), modalities, and patient education. Timely physical therapy intervention,
individualized treatment protocol, and patient education for prophylaxis were instrumental
in her care. Symptoms were resolved in 5 days in a cost efficient manner in terms of loss of
wages and extra medical expenses.
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Introduction:
According to the World Health Organization, low back pain (LBP) is the most common
spinal disorder affecting over 80% people at some point in their life and 4-33% of the
population at any one time (WHO/Chronic rheumatic conditions)1. Frymoyer and Cats-
Baril (1991) 2 reported the total societal cost of back pain in the US was estimated at 75$-
$100 billion in 1990. In 2004, the estimated annual cost of treating back pain was 193.9
billion and the cost of the spine conditions, increased by 49% (S. Terry Canale M.D. (2009)
3. While claims for Musculoskeletal Disorders were $389 million USD in 2007, the
number of claims for low back were the largest and the most used ICD-9 code was 724.2
(Bhattacharya A. 2011) 4. Dageanis S (2007) 5 studied the health care cost in United States
and internationally. The study concluded that the economic burden of LBP is large and
continues to grow. According to the study, direct medical cost spent for low back pain was
the largest for physical therapy (17%) and in patient services (17%).
Robin McKenzie was the first to advocate the use of classification systems to direct
physical therapy spinal disorders. Mechanical Diagnosis and therapy (MDT) previously
referred as McKenzie approach addresses low back pain through examination and
treatment utilizing repeated end range spinal movements. Throughout the course of the
treatment, patient participation and self-management is emphasized at fullest extent. Cook
et al (2005) 6 reviewed the effectiveness of physical therapist directed exercises using
patients response method classification and it was most reliable compared to other
methods. Repeated movements in mechanical examination determines the directional
preference for treatment, and patients who are classified as centralizers during the initial
assessment seem to have better outcome then non-centralizers (Long AL1995) 7
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The McKenzie Conceptual model of Mechanical Diagnosis and Therapy provides us the
understanding of centralization and peripherilization. The model suggests that we can alter
the pain location, intensity with prolonged or repetitive sagittal loading; or offset loading
(off center) when symptoms are unilateral or asymmetrical. Repeated movements provide
the most useful information regarding patient symptoms and guide us to proper
management strategy allowing differentiation between 3 mechanical syndromes. This
model also helps to clarify the directional preference of derangement (McKenzie R, May S.
2003) 8 . Centralization has been shown to have clear prognostic and diagnostic
significance, symptoms response consistency, and reliability. Studies by Donelson et al
(1990)9; Long AL (1995) 7; have concluded that centralization is a valid predictor for
establishing effective prognosis for the patient. The Conceptual Model when applied to
clinical situations, becomes an effective and reliable diagnostic tool. A mechanical
evaluation enables the prediction of discogenic pain and the state of the annular wall.
Patients who have centralized, achieve superior results which has been hypothesized to be
the result of intact annular wall (Donelson et al. 1997) 10. Mechanical Diagnosis and
Therapy (MDT) is widely used by physical therapists, physicians, chiropractors and
surgeons in U.S. and in the many countries around the globe. According to McKenzie, 98%
or more patients are suitable for mechanical evaluation including those with and without
nerve root involvement. Robin McKenzie proposed non-specific mechanical syndromes
that are widely used for musculoskeletal care. The patient characteristics in response to
loading, identifies each syndrome and directs the treatment plan. “The McKenzie Method”
has opened up further research regarding centralization, symptoms response, its reliability
as well as efficacy of MDT. More research is needed in this area. McKenzie describes the 3
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syndromes as Postural, Dysfunction and Derangement. In postural syndrome, mechanical
deformation is due to bad postures or positions sometimes as a result of prolonged loading.
All tests are pain-free and there is no deformity. Patients with postural syndrome hardly
visit physical therapy. In Dysfunction syndrome, there is tissue deformation due to adaptive
shortening and pain is the result of mechanical loading of the affected structure.
Derangement syndrome is the most common out of 3 syndromes and always treated as the
main source of the symptoms. In derangement syndrome, intervertebral disc fails with
repeated flexion and is structurally weakest at the posterolateral annular wall. Most disc
herniation occurs postero-laterally. When spine is in neutral position, nucleus is also
central. As the spine extends the nucleus moves anterior to the path of least resistance. In
flexion, nucleus moves posterior to the path of least resistance (McKenzie R, and May S
2003) 8 Shah et al (1978) 11. Certain movements and postures cause peripherilization and
worsen the condition. Depending on the loading strategies it can reduce, abolish or
centralize the symptoms assisting in recovery of normal movement. Through repeated
movements, patient’s pain response allows the selection of the proper syndrome and the
directional preference for proper management.
Once the derangement is reduced and is stable, an underlying dysfunction can be treated.
Through repeated movements symptoms are either increased, worsened, decreased and not
better, decreased and better, or abolished. Refer to table 1 for McKenzie derangement
categories.
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Table 1. Derangement categories classified by McKenzie:
Derangement Pain
Deformity
D1 Central, symmetrical LBP, rarely buttock or thigh pain
No deformity
D2 Central or symmetrical LBP, may have buttock or thigh pain
Lumbar kyphosis or flat lumbar spine
D3 Unilateral LBP, may have buttock or thigh pain
No deformity
D4 Unilateral LBP, buttock or thigh pain
Lumbar Scoliosis
D5 Unilateral LBP, buttock or thigh pain
extending below the knee
No deformity
D6 Unilateral LBP, with or without buttock or thigh pain, pain extending below the knee
Sciatic scoliosis, neurological deficits common
D7 Unilateral or bilateral LBP, buttock or thigh pain
Accentuated lumbar lordosis
Centralization describes the reduction and abolition of distal symptoms rising from spine,
in response to mechanical loading. When the derangement is fully reduced the full range
and pain-free movement is accomplished. Associated with centralization comes the
concept of Directional Preference (DP) which is the application of MLS (Mechanical
Loading Strategies). These strategies affect the hydrostatic properties of the intervertebral
disc, thus affecting the mechanical responses. It also helps to clarify the directional
preference of derangement. Werneke (2011) 12 study findings suggested DP can improve
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the therapist’s ability to provide a short term prognosis for function and pain, while Bybee
RF (2009) 13 study showed increased lumbar extension ROM with centralization. Clare HA
study (2007)14 supported the use of lumbar extension in McKenzie’s derangement
syndrome.
Peripherilization is the reverse of centralization phenomenon and that occurs only in
derangement syndrome. Pain rising from spine spreads distally and increases distally.
When sustained postures or repetitive movements produce distal symptoms, it needs to be
avoided. While centralization is a favorable prognostic indicator, peripherilization is
associated with poor outcomes. Several studies showed that centralization phenomenon has
about 90% good to excellent reliability when used by different clinicians to assess patient’s
symptomatic response. (location and behavior of pain)
Figure 1. Centralization of pain- the progressive reduction and abolition of distal pain
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The purpose of this case report is to present the successful management of a patient with
acute herniation with left leg radicular symptoms utilizing, McKenzie classification and
treatment paradigm.
Case Description
History
The patient was a 55 –year-old endomorphic female referred to physical therapy with the
medical diagnosis of acute low back pain with radiculopathy. The MRI report described an
L5-S1 HNP and multilevel disc bulging in the lumbar spine. The patient reported MVA 4
years ago with 1-2 times a year of recurrent LBP episodes. She visited the pain
management physician at each recurrence or “flare-up”, and had 1-3 ESI injections which
completely resolved the pain each time. The last injection was on September 2012.
“Flare-ups” are defined as a phase of pain superimposed on a recurrent or chronic course
which consists of a period, usually a week or less, when the back pain is markedly more
severe than usual for the patient (Linda R Van Dillen 2005)15. Although the patient claimed
to be in good health in 2008 she had a right shoulder arthroscopic decompression, a left
shoulder arthroscopic decompression in 2011, and a C3-7 cervical fusion in 2012. She
received physical therapy treatment for the right shoulder in 2008 and for the left shoulder
in 2011, after the arthroscopic decompressions, with satisfactory results. Numbness and
tingling through left arm was also a significant complaint along with low back and left leg
symptoms.
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She also denied any family history of HBP, diabetes, heart disease, stroke, seizures,
osteoporosis and cancer. The patient reported excellent spousal support at home and denied
being depressed. She remained optimistic about recovery and was highly motivated in
following through, to fully recover from this episode. The patient’s goals were to eliminate
constant, daily low back pain, improve her ability to perform daily activities such as yard
work, walking, and most importantly comfortably performing her job duties.
Table 2 summarizes patient characteristics.
Table2. Patient characteristics:
Characteristics Value
Height (inches) 64
Weight (pounds) 162
BMI (kg/cm2) 28 (overweight)
Handedness R Hand
Language English
Race White
Education College
General health Good (non-smoker, social drinker)
Social history Married
Employment Administrative Assistant, Full time
Exercise/Health habits Daily 2-3 mile walking,
yard work, golf
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Table 3. Aggravating and Easing Factors
7 Days prior to Physical Therapy 1/30/13 at Physical Therapy assessment:
Aggravating Factors
Easing Factors Aggravating Factors Easing Factors
Sitting : pain immediate at LB and L leg
Supine Sitting > 30 min, interrupts work
Resting, walking around
Standing >5-10 min
Supine Walking >100 yards Frequent position changing
Walking > 5-10 min.
Changing position frequently
Standing > 30 min Limited walking
Any movement, bending forward
Aleve Sex Aleve, lumbar pillow in sitting
Prior to physical therapy, frequently changing positions gave her some relief. She felt
best in supine and with medication. Pain was worse with any prolonged positioning. Her
work was interrupted and she was unable to attend to her administrative meetings due to
required sitting for 1-2 hours. At the initial visit her tolerance to movement had improved
but was limited to 30 minutes with utilization of a lumbar pillow while sitting. Although
she improved from initial severe pain, she was reluctant to fully engage in household
duties, leisure activities and job duties.
Refer to Table 3 above, which summarizes Functional status before therapy and the day
of the assessment.
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Examination/Systems Review
Cardiovascular / Pulmonary System: Normal. The patient was non-smoker and social
drinker Blood Pressure: 125/80 mmHg Heart Rate: 80 Respiratory Rate: 16
Edema: None
Integumentary System: Pliability, skin color and integrity was normal. Both shoulders
and anterior neck healed scars due to past surgeries were observed.
Communication, Affect, Cognition, Learning Style: The patient was a college
educated, highly motivated individual. She was an effective communicator, alert and
oriented x3, and was not depressed during the episode of care. She had no learning
barriers and best learned by reading, listening and demonstration.
Musculoskeletal System: (Pretest symptoms pain at L buttock. No leg pain). Manual
Muscle testing showed no focal weakness in the lower extremities. Great toe extension
was normal bilaterally. Gross AROM of both upper extremities (UE) and lower
extremities (LE) were normal. Grossly symmetrical
Neuromuscular System: The patient denied any sensation changes to lower extremities.
Gait was normal. She was unable to sit, stand, or walk more than 10 minutes due pain at
her low back and left lateral thigh. She was careful with transfers and transitional
movements, actively guarding her low back to avoid pain.
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Tests and Measures
Pain
The pain was gradual and progressive at the low back after bending over to get something
from bottom cupboard. Her symptoms progressed from ache to sharp, constant, severe
pain 8/10 (NPRS) and radiated to the left anterior lateral thigh intermittently but never
went below the knee. During the first 2 days of the injury (which fell on to Saturday and
Sunday), she was in bed due to severe pain, and was unable to sleep. She was prescribed
Vicoden which did not help the pain; however, Flexoril helped her to sleep few hours at a
time. The patient then switched to Aleve for pain relief and at the initial visit reported
8/10 sharp shooting pain reduced to a dull 5-6/10 pain level. While the patient reported
improvement from the initial severe pain, she continued to work 8 hours a day in front of
the computer which caused the symptoms to fluctuate. Sitting for any length of time
intensified back, left buttock, and lateral thigh pain. She was also taking Lyrica for nerve
symptoms at left arm after recent neck surgery. Refer to table 4 for pain behavior.
Table 4- Behavior of Pain
Pain Better Pain Worse
Standing ,walking, position changes AM/PM, difficult to sleep, bending forward
On her back, pillows under knees; side lying pillow between legs
Sitting for any length of time
Mid-day pain less
Advil helps some of the pain
Yard work, vacuuming, cooking, dishes, mopping, Laundry, bending over
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Table 5: Summary of Disability, Fear-Avoidance, and Pain Intensity
Measure Initial
Disability 64%
Oswestry Disability Questionnaire
(0%-100%)
Fear avoidance beliefs (work)
FABQ work scale (0-42) 35
Fear avoidance beliefs (physical activity)
FABQ physical activity scale (0-24) 20
Pain intensity NPRS scale (0-10) 5/10
Table 5 shows her disability at 64%, FABQ total at 55/66 and pain level of 5/10 during
the initial assessment. The FABQ developed by Waddell et al (1993) 16 assessed patient
beliefs with regard to their pain, and it’s effect on their physical activity and work. The
FABQ is a reliable and valid measurement and the total score has an excellent test-retest
reliability (ICC=0.97) over a 30 minute period Esther Williamson (2006) 17. Study
suggests that outcome measures were appropriate for measuring pain and function in acute
low back pain patients. However, for chronic LBP patients Roland Morris Disability
Questionnaire, ODI, NPRS, VAS (Grottle M)18 were most appropriate. Numerical pain
rating scale indicates “0” as no pain and “10” most extreme pain. It is a self report
measurement tool and is used to indicate the average pain experience. Childs (2005) 19
reported the NPRS is valid and that a 2 point change on NPRS represents clinically
meaningful change that exceeds the bounds of measurement.
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Joint Mobility/Integrity:
The patient presented with decreased and guarded segmental mobility (utilizing the
Maitland approach) at lower thoracic and lumbosacral spine left worse then the right side.
Soft tissue mobilization:
Muscle spasm was palpable at lower thoracic and lumbosacral paraspinales left>right
side. Left buttock deep layers were tender with deeper pressure.
Posture: In standing she presented symmetrical pelvis, no deviation or pelvic shift and
moderate loss of lumbar lordosis noted. In sitting she sat towards the front of the chair stiff
to avoid pain. She felt best in supine with a pillow under her knees or on the side with a
pillow between the legs.
Muscle Performance/MMT
Manual Muscle testing showed no focal weakness in the lower extremities. Great toe
extension was normal bilaterally. She was grossly symmetrical. MMT is used by physical
therapists, neurologists, physicians and chiropractors and it is clinically useful to assess
neuromusculoskeletal dysfunction. A study by Cuthbert (2007)20 showed good reliability
and validity.
Sensory Integrity: The patient’s sensation was intact throughout the episode of care
Self Care, Home Management: The patient’s husband was excellent support at home and
he took care of all house duties while she was under physical therapy care. She followed
through avoiding repetitive bending forward, house cleaning, laundry, and yard work. She
was able to use a shopping cart to do limited grocery shopping.
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Refer to Table 6 below for Neuromuscular and Musculoskeletal Examination
Table 6. Neuromuscular and Musculoskeletal Examination
Test Movements Initial exam 3’rd visit 5th(final) visit
FIS (Flexion in Standing)
Fingers to mid-shin, LBP 5/10 Fingers above ankles, 3/10 LBP, buttock pain
Fingers to ankles
Rep FIS (Repeated FIS)
LBP, buttock and lateral thigh pain
3/10 LBP, buttock pain thigh pain produced
No pain
EIS (Goniometric ) (Extension in Standing)
10º, LBP 7/10, mod. stiffness, buttock and lateral thigh pain
15º, central LBP 3/10, buttock pain, no thigh pain
18 º extension from neutral ; No pain
Rep EIS LBP 7/10, buttock pain, no thigh pain
Central LBP 3/10 No buttock or thigh pain
18º, no stiffness, no pain
FIL(Flexion in lying) No change in symptoms Status quo Status quo
Rep FIL LBP and L lateral thigh LBP 5/10 No pain
EIL Central LBP, left buttock pain Central LBP 3/10 No pain
Rep EIL Increased LBP, decreased L buttock pain
Full extension 2/10 with sag
Full extension, PT overpressure, No pain
SGIS L (Side gliding in
Standing left)
Pain at L buttock and LB Pain-free, normal range Status quo
SGIS R No pain Pain-free, normal range Status quo
Straight leg raise (SLR) R 80º , negative L 80º , negative
80º negative 80º negative
80º negative 80º negative
Sacroiliac joint (SIJ)
Testing
Deep tendon reflexes Quadriceps right/ left Achilles right/ left Sensory examination Motor examination (MMT) L2-3 (hip flexion) L3-4 (knee extension) L4 (dorsiflexion) L5 (hallux extension)
Bilateral PSIS symmetrical Standing flexion test positive Prone knee flexion test (-) FABERE test negative Normal Normal L1-S1 right and left normal Right: 5/5, left: 4/5 due to pain Right: 5/5, left: 5/5 Right: 5/5, left: 5/5 Right: 5/5, left: 5/5
Normal Negative Negative Negative Normal Normal Normal NT
Normal Negative Negative Negative NT NT NT Right: 5/5, left: 5/5 pain Right: 5/5, left: 5/5 Right: 5/5, left: 5/5 Right: 5/5, left: 5/5
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Finger-To-Floor Test was used to measure active lumbar flexion. Ekedahl (2010) 21studied
the Roland-Morris Disability Questionnaire (RMDQ), SLR and Finger-to-floor test and
concluded that there is good validity of finger-to-floor test for both men and women with
radicular symptoms. Lumbar extension was measured by modified Schober test in standing
and was proven to be valid method to use in clinical setting by Clare HA (2007)14 Modified
Schober test in standing was most responsive in measuring lumbar extension and patients
with derangement syndrome showed greater improvement in lumbar extension.
Leisure Integration: The patient was unable to perform her yard work which she used to
do few times a week. She was also reluctant to take her daily walk of 3 miles due to pain
with prolonged walking, standing including use of treadmill.
Gait, Locomotion: The patient presented non-antalgic gait during the assessment and the
course of therapy sessions. Initially her endurance was limited to walking around the house,
and walking 10 minutes at work which later improved to 30 minutes. As pain progressively
reduced, she found walking to be the best activity to control her pain. She frequently
interrupted sitting with combination of EIS and walking to make it through the day.
Ergonomics/Body Mechanics/Risk Factors: The patient’s job demanded 8 hours daily
computer work including 2-3x a week administrative meetings (1-2 hours each time).
Driving to work was 20-30 minutes depending on traffic which also contributed the
symptoms increase and radiculopathy. The patient’s history of MVA and yearly
exacerbations increased her chances to repeat these painful episodes.
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Differential Diagnosis
SIJ dysfunction tests: Sacroiliac joint (SIJ) could be the source of low back pain. In my
patient’s case Gaenslens, Thigh Thrust test, Sacral Thrust/Compression tests were avoided
due to patient’s symptoms. She was irritable but responded to McKenzie repetitive
movement testing, suggesting lumbar derangement. Research done in New Zealand by
Laslett (2008) 22 reported that three or more positive SIJ tests have sensitivity or specificity
of 91% and 78% respectively if those patients were not centralizers. The patients who are
in chronic pain and unable to centralize their pain have three or more positive SIJ tests have
77% probability of having SIJ dysfunction. Review of literature by Peter Cattley and
collegues, (2002) 23 concluded that SIJ is clinically complex to assess. Therefore, series of
tests are required.
FABERE test performed on both hip to rule out SIJ and hip joint and was (-).
SLR was 80º/90º and negative for both legs
There were no Red Flags and Cauda Equina Syndrome was (-)
Clinical Impression: Lumbar Derangement (D3) syndrome per McKenzie classification
(unilateral buttock and thigh pain with no deformity)
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Preferred Physical Therapy Practice Pattern: Musculoskeletal Pattern 4F Impaired Joint
Mobility, Motor Function, Muscle Performance, Range of Motion and Reflex Integrity
Associated with Spinal Disorders
Prognosis: The patient’s prognosis was excellent due to seeking help from physical
therapy within a week rather than 3 months later. Study by Werneke (2011)12 showed
classifying patients with pain pattern and DP helps accomplish short term pain relief and
improve function. Additionally Wand BM (1976)24 in his RCT supported that a short –term
intervention is more effective than advice to stay active. It leads to rapid improvement in
function, quality of life and overall well being. Therefore, assess/advise/treat model was
superior to assess/advise/wait model for care. However, the patient’s past recurrences,
demands of prolonged sitting at her job, increased her risk for repeated flare-ups.
Intervention
Physical therapy for Lumbar disc derangement included the following:
1. Posture correction, proper positioning in sitting, standing, walking and in bed.
The patient was instructed in proper sitting posture maintaining lumbar lordosis. She was
issued a McKenzie slim-line lumbar roll to use when she drove or sat at anytime. She was
educated in importance of maintaining lumbar lordosis when sitting and with transitional
movements. Hands on postural corrections were effective in improving her knowledge of
proper cervical, lumbar neutral positions including lordosis and kyphosis. The patients who
have discogenic pain report increased pain in sitting and reduced pain standing and
walking. Study by Adams in 1994 reported intradiscal increase to 80% in flexion and
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pressure reduction to 35% in extension. Several studies by Harrison et al in (1999, 2000)25
reviewed the literature and reported consensus supporting lordosis in sitting. Optimal
sitting posture achieved by utilizing lumbar support with disc pressure reduced at
minimum. Pynt et al study (2001) 26, summarizes that optimal sitting posture is the lordotic
posture and assists in maintaining lumbar postural health and preventing LBP.
The patient was advised to frequently interrupt sitting and to stand, walk and perform
extension in standing exercises throughout the day to avoid pain radiating distally and
maintaining centralization. Wilke et al (1999)27 concluded that constant position change
promotes the fluid flow in the disc.
The patient was made aware of prolonged sitting at work contributing to her back pain and
importance of following through with frequently standing, changing positions to assist her
recovery rate. Proper sleeping position was explained supine with pillows supported under
her knees as the best position of choice. She was also instructed to sleep on the side with
pillow in between as a second choice as needed.
2. Ultrasound/Electrical stimulation
Heat modality of choice was ultrasound combined with electrical stimulation to assist in
reducing muscle spasm and pain. Frequency of 1.5 w/cm2 utilizing 1 MHz transducer used
for 5 minutes at lower thoracic and lumbosacral region including left buttock to provide
heat and analgesic affect. The ultrasound/electrical stimulation unit used on my patient was
Sonicator 930. Durmus et al (2010) 28 in their study concluded that ultrasound treatment
and electrical stimulation were effective in improving pain. However, Robertson et al
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(2001) 29 in the study concluded that there is little evidence that supports effectiveness of
ultrasound.
3. Soft tissue mobilization
In prone over two pillows Thoracic and lumbar paraspinales and left buttock
was treated with tolerable pressure to decrease tonicity, improve soft tissue mobility and
pain. Furlan AD 30, included 13 RCT to evaluate the effects of massage for non-specific
low back pain. They concluded the benefits of massage in patients with chronic low back
pain lasted at least one year after the end of treatment and massage might be beneficial for patients with sub acute and chronic Low-back pain especially when combined with exercises. 4. Joint mobilization: The patient was placed prone over two pillows to position lumbar
spine in neutral. Maitland Segmental joint mobilization was performed on thoracic and
lumbosacral spine. Started with grade 2/5 for pain and progressed to 3/5 to improve muscle
guarding and segmental mobility Segmental vertebral mobility was introduced by Maitland
in 1977 31
Vertebral Mobilization and Peripheral Mobilization as follows:
• Grade I: Small amplitude, beginning of the range for painful and acute stage for
reduce pain and muscle spasm.
• Grade II: Large amplitude with in the mid- range, no resistance for sub- acute and
painful stage to reduce pain and decrease muscle spam.
• Grade III: Large amplitude, reach limit of the available range, reduce pain and
improve joint mobility
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• Grade IV: Small amplitude, end range mobs reduce pain and improve joint
mobility and increase ROM.
• Grade V: High velocity thrust, has to be used by trained therapist, reduced pain in
end range and gain mobility and restore joint function if other mobilization did
not resolve the dysfunction of the joint..
Hanrahan (2005) 32 in the study with collegiate athletes, concluded grade 1 and 2 joint
mobilizations reduced pain and increased force production in the short term stages of
mechanical acute LBP. Powers (2008) 33 supported the use of posterior anterior (PA)
mobilization and press-up exercise for improving lumbar extension in people with
nonspecific LBP. Following both press-up and PA mobilization there was significant
reduction in pain scores and significant improvement in total lumbar extension.
5. McKenzie lumbar extension exercises-Directional Preference
Examination provided directional preference as Lumbar extension. The patient reported
pain increased with sitting, bending, driving and repetitive flexion produced lateral thigh
pain to the knee. The patient demonstrated rep EIS as a centralizing direction and therefore
pain reducing preference. At first visit, patient performed EIL 10-15 repetition to
centralize pain to low back. She was instructed to perform EIL every 1-2 hour (6-8 times a
day) when not at work and EIS when she was at work until symptoms centralized. Along
with EIL and EIS, she was instructed with left hip extension prone over two pillows,
bridging lumbar spine in neutral. Exercises matching to the subjects directional preference
significantly and rapidly decreased pain and medication use and improved all other
outcomes, by Long A. (2004).34
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6. Home exercise program
The patient performed written home exercise program 2-3 times a day as a routine but EIL
and EIS throughout the day. All the exercises were to be done 2 sets of 10 repetitions per
McKenzie protocol (1981 and 2003). As the symptoms centralized the patient followed the
HEP 2-3 times a day. She was instructed to maintain centralization and if leg symptoms
returned to increase the frequency of EIS and EIL.
7. Proper body mechanics
The patient was educated in proper lifting techniques always utilizing caution when
attempting to lift, pull or push to avoid injury to low back. She was instructed to
incorporate normal breathing during such activities. Importance of EIS exercises following
any sustained flexion postures or activities were reinforced.
8. Prophylaxis
The patient education in understanding the mechanism of the injury and pathology is
important for recovery as well as prevention. During 5 visits the patient was educated in the
mechanism of injury, prevention by following through proper body mechanics, daily home
exercise program including daily 30 minute walking. She was given the McKenzie Treat
Your Own Back book as the resource and fall back guide in treating her back. Research by
Udermann et al (2000, 2001)35 demonstrated the value of the book as an educational tool.
Those who got the book 87% were still exercising regularly nine months later and 91%
were still focusing on using good posture. The study demonstrated the value of self
management. Refer to table below for therapy sessions for details.
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Table 7: Summary of Physical Therapy Sessions
Physical Therapy session 1 Physical Therapy Session 2_________________
Pre-therapy 5/10 LBP, lateral thigh pain Central LBP 6/10. Moved stuff at work ultrasound/electrical
ultrasound/electrical stimulation 5 min. for 5 min
Light soft tissue mobilization Able to tolerate deeper soft tissue
Joint segmental mobilization 2/5 2+/5 joint segmental mobility
Therapeutic Exercise Therapeutic Exercises
Prone press-ups 2x10 Prone press-up with patient sag 2x10
Left hip extension 1x10 Left hip extension 2x10, R hip extension 1x10
Bridging to neutral spine 2x10 Bridging 2x10, LTR to left only 2x10
EIS 2x10 EIS 2x10
Post therapy pain at LB 3/10 Post therapy pain 2-3/10
HEP, education in posture/positioning Reviewed, advised 30 min. walking
Issued Lumbar pillow for sitting Instructed no lifting until she was instructed and disease process
________________________________________________ Physical Therapy Session 3 Physical Therapy Session 4______________________ Pre-therapy pain 4/10 central No pain before therapy Ultrasound/electric stimulation DC Soft tissue mobilization DC Joint mobilization 2+/5 3/5 Therapeutic exercises Therapeutic exercises Prone press-up with PT over pressure 2 x10 Prone press-up with PT over pressure 2 x10 Both hip extension 2x10 each Both hip extension 2x10 each Bridging 2x10, hands on challenge Bridging 2x10 hands on challenge Compliant to HEP Compliant with HEP Using lumbar pillow at work Lumbar pillow helps, sitting causes stiffness Tolerates 30 min sitting walking daily 30 min. LTR to left 20 reps LTR both sides 2x10 total Shuttle single, double leg press with 7 lines Shuttle leg press 8 lines 20 doubles and 20 singles 30 doubles, 20 singles EIS 2x10 EIS 2x10 Walking 30 min., takes pain away Proper lifting, body mechanics Education in injury prevention Final Visit: Re- assessed patient. She had no pain last few days. She was able to sit 1.5 hours without any back pain at work. She followed through with HEP. Issued McKenzie treat Your Own Back book and advised to frequently interrupt sitting at work, continue to walk daily and avoid repetitive bending and any heavy lifting. Patient is advised keep contact through phone if she should have any questions or issues. She was happy with progress in 5 visits and she understood that she can maintain her well being by utilizing what she learned and was happy to avoid ESI injections this time.
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Table 8 summarizes patient’s goals
Table 8 . Patient Goals
Short Term Goals: 3 visits Long Term Goals: 6 visits
Abolish leg symptoms/maintain centralization
Maintain centralization
Maintain proper posture/positioning Gain full lumbar mobility
Independent with HEP Independent (I) with body mechanics
Improve lumbar extension 15º Prophylaxis, education
Decrease pain to 3/10 at central low back Daily walking 30 minutes
Patient education in disease process I with ADL’s, tolerate work
Outcome:
LBP and left leg pain resolved utilizing heat modality, soft tissue mobilization, joint
mobilization, McKenzie extension exercises including proper posture, positioning and
HEP. Frequently changing her positions helped control pain most of the time. Sitting
tolerance had improved to 1.5 hours utilizing lumbar pillow at all times during work hours,
and she frequently performed EIS throughout the day to prevent pain. Stiffness at LB
resolved with daily walking 30 minutes and frequently interrupting sustained positions.
Compare to initial assessment her disability reduced from 64% to 18%, FABQ from 55/66
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to 6/66, pain was eliminated. Refer to table 9 for functional disability, FABQ and pain
intensity at final visit.
Table 9. Final summary of results
Measure 5th visit(DC)
Disability 18%
Oswestry Disability Questionnaire
(0%-100%)
Fear avoidance beliefs (work)
FABQ work scale (0-42) 4
Fear avoidance beliefs (physical activity)
FABQ physical activity scale (0-24) 2
Pain intensity NPRS scale (0-10) 0/10
The importance of controlled activity, proper posture, and proper body mechanics were
emphasized. McKenzie treat Your Own Back book was issued for prevention and self
management of low back and left leg symptoms. Patient advised to keep contact through
phone if she should have any questions or issues.
Discussion
There are many conservative treatment options for patients with lumbar herniated disc with
or without radiculopathy. Many pain generating structures can be involved in back pain
making the diagnosis challenging. Pre-existing conditions, other co-morbidities, injuries, as
27
well as false positive results from imaging studies can further complicate making an
accurate diagnosis. Donelson et al (1997) 10 compared MRI to McKenzie assessment
process and stated “A non-invasive, low-tech, relatively inexpensive clinical assessment
using repeated end-range lumbar test movements can provide considerably more relevant
information than non-invasive imaging studies” , concluding McKenzie assessment was
superior to MRI. Jensen et al 1994 36 study also reported high rate of false-positive
findings of magnetic resonance imaging (MRI) of the lumbar spine and high prevalence
(52%) of abnormal findings such as bulging, herniated disc with patients who were non-
symptomatic.
Riddle in (1998) 37 also analyzed several classification systems and concluded that while
we utilized existing classification systems we have to do more research in developing new
classification systems designed to use commonly accepted treatment principles.
McKenzie method classifies patients to specific subgroups according to the behavior of the
symptoms and many clinical trials evaluated the McKenzie assessment and treatment.
Clare H (2004) 38 in the study concluded that individualized treatments based upon patient
clinical presentation was an effective approach in improving patients’ pain, global
perceived effect, disability, quality of life, work status, medication use, medical visits or
recurrence.
The reliability of MDT and McKenzie classification was challenged by many researchers
through the years. However Clare et al (2005) 39 in her research showed the reliability for
syndrome classification 0.84 with 96% agreement for the total patient pool and Kappa of
1.0 with 100% agreement for lumbar patients. Reported by Long A. (2004).34 , exercises
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matching to the subjects directional preference significantly and rapidly decreased pain and
medication use and improved all other outcomes.
Conclusion
This single case report presented the patient with acute radiculopathy that responded well to
repetitive movement testing and directional preference. Although controversy regarding McKenzie
efficacy exists, timely referral to physical therapy and McKenzie extension protocol successfully
resolved patient’s pain and functional limitations. Effective patient education in disease process and
prevention is an important part of physical therapy. Patient’s first time physical therapy experience
for her low back was effective. While she didn’t miss a day from work, she also avoided series of
ESI injections which prevented extra medical costs. Numerous classification systems exist for
low back pain since 1980’s. To date, there is no classification system that is a gold standard
for all patients with LBP and more research is needed.
Acknowledgements:
I would like to thank my advisor Dr. Krause for his assistance and guidance in this project.
29
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Ultrasound/Electrical stimulation used for the patient for the case report:
Ultrasound /combo unit 930 SONICATOR
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