CASE STUDY

TITLE: Prolapsed Intervertebral Disc: is exercise works?

ABSTRACT

Background: Prolapsed Intervertebral Disc is the protrusion of a portion of the nucleus of an

intervertebral disc into the spinal canal. The purpose of this case study is to highlight the

effectiveness of exercise therapy for the patient with Prolapsed Intervertbral Disc that included

in chronic low back pain.

Clinical features: There is acute pain, tenderness and paraspinal muscle spasm; pain also may be

noted in the leg, below the knee, or both. There also may be a sharp burning stabbing pain

radiating down the posterior or lateral aspects of the leg below the knee. Prolonged pressure on

the nerve root can lead to weakness in the muscles of the leg.

Intervention: Exercise therapy is the main intervention in this case study, where the exercises

that have been included are McKenzie exercise, Lumbar stabilization, stretching exercise and

strengthening exercise.

Evaluation of outcome: There are two outcome measures that are used; Numeric Rating Scale

(NRS) and Oswestry Questionnaire.

Conclusion: Exercise therapy is effective treatment for patient with Prolapsed Intervertebral

Disc.

INTRODUCTION

Musculoskeletal disorders, of which back pain accounts for more than half the number of cases,

are the most common cause of chronic incapacity in industrialized countries (Akbari, Khorashadizadeha

& Abdi, 2008). There are many different kinds of low back pain that can be caused by numerous

problems for instance prolapsed intervertebral disc (also known as herniated or slipped disc) problem.

According to Hirsch, Singh, Falco, Benyamin & Manchikanti (2009), there are less than 5% for lumbar

disc prolapse, protrusion, and extrusion to occur in low back problems but is the most common cause

of nerve root pain (“sciatica”).

Besides, low back pain affects at least four out of five people at some time in their lives and up to

90% of the population may have significant back pain at some time in their lives (Alvarez, 1998).

Nevertheless, Gibson and Waddel (2007) said that 90% of low back pain will be treated itself

spontaneously within six to twelve weeks without any medical intervention.

Anatomically, our spine is made up of a series of connected bones called “vertebrae.” The disc is

a combination of strong connective tissues which hold one vertebra to the other vertebrae, and acts as a

cushion between these vertebrae. The disc is made of a tough outer layer called the “annulus fbrosus” and

a gel-like center called the “nucleus pulposus.” As we get older, the center of the disc may start to lose

water content, making the disc less effective as a cushion. This may cause a displacement of the disc’s

center through a crack in the outer layer. Thus, prolapsed intervertebral disc can be explained as the

protrusion of a portion of the nucleus of an intervertebral disc into the spinal canal (Adams & Roughley,

2007; Selby & Saal, 2006). Most disc prolapsed occur in the bottom two discs of the lumbar spine, at and

just below the waist (Selby & Saal, 2006).

Pathophysiology

There are many ways to describe a herniated disc; it can either be “a contained disc” or “a

noncontained disc.” According to Ito (2001), in a “contained disc” also known, as a nuclear protrusion the

annulus fibrosus is still intact although a bulge in the nuclear pulposus weakens it, yet it does not come

into contact with the epidural tissue. Meanwhile, in a “noncontained disc” or a nuclear prolapse, the

nucleus pulposus has escaped from the annulus fibrosus which is completely torn and is now a free

fragment in the spinal canal that has come into contact with the epidural tissue. Nevertheless, either way

that a disc is herniated a nerve root is usually impinged.

A protrusion of the disc can go laterally to the nerve root, medially to the nerve root, under the

nerve root, or in a central position. When it goes centrally, the patient may assume a flexed posture

without leaning to either side and with a disc protrusion under the nerve root the patient may not assume a

lean (Cox, 1999).

According to Cox (1999), about 90% of herniated discs occur either at L4-L5 or L5-S1 disc

levels. The L4-L5 disc usually compresses the fifth lumbar nerve root resulting in pain sensations down

the fifth lumbar nerve root innervations. The L5-S1 disc usually compresses the first sacral nerve root

resulting in pain distribution down the first sacral dermatome of the lower extremity. Generally, a

herniated lumbar disc will press on the nerves in the spine and may cause pain, numbness, tingling or

weakness of the leg called “sciatica.” Sciatica affects about 1-2% of all people, usually between the ages

of 30 and 50.

Etiology

Herniation occurs when the nucleus in the center of the disc pushes out of its normal space. The

nucleus presses against the annulus causing the disc to bulge outward. Occasionally, the nucleus herniates

completely through the annulus and squeezes out of the disc. Although daily activities may cause the

nucleus to press against the annulus, the body is normally only able to withstand this pressure. However,

as the annulus ages, it tends to crack and tear. It is repaired with scar tissue. This process is known as

degeneration. Over time, the annulus weakens, and the nucleus may begin to herniate (squeeze) through

the damaged annulus. At first, the pressure bulges the annulus outward. Eventually, the nucleus may

herniate completely through the outer ring of the disc.

At the same time, risk factors such as heavy physical work, frequent bending, twisting, lifting,

and prolonged static postures can place abnormal pressure on the shock-absorbing nucleus of the disc. If

great enough, this increased pressure can injure the annulus, leading to herniation. Meanwhile, people

who live a sedentary lifestyle that include too much sitting, too little activity, and weight gain are also at

high risk of developing herniated disc. Being overweight is an added risk factor for potential back injury.

Besides, smoking can also contribute to the possibility of low back pain because it leads to bone

loss (Tunick, 2000). Psychological factors such as anxiety, depression, somatisation symptoms, stressful

responsibility, job dissatisfaction, negative body image, poor drive satisfaction, and mental stress at work

can also put you at risk for developing low back pain. As a result, patients that are suffering from low

back pain may be suffering from a number of different disorders such as; muscle strains and spasms, torn

tendons, piriformis syndrome, spinal stenosis, or a number of other problems.

Clinical features

The patient with herniated disc will usually be able to identify the exact episode that initiated

their problem (low back pain). Generally, there is acute pain, tenderness and paraspinal muscle spasm

will be noted at the level of the prolapsed. Patient also may have pain in the leg, below the knee, or both.

Besides, patient will usually have a sharp burning, stabbing pain radiating down the posterior or lateral

aspects of the leg below the knee. The pain will regularly exacerbated by coughing, sneezing, straining

and moving (bending and stooping) and the pain is usually relieved by extension or laying down

(Porter &Tidy, 2008).

Treatment

As mentioned before, 90% of low back pain will be treated itself spontaneously within six to

twelve weeks without any medical intervention. There are many treatments that can be used but one

certain treatment is not going to be good for everyone. Treatments are usually custom made for the

patient to get the most effective results. The goals for treatment are to lessen pain, facilitate the return to

normal activities, and to reduce the likelihood of recurrence (Starz, 2000).

Basically, symptoms are relieved by bed rest (lying in a position of most comfort on a firm

mattress for several days) and non-steroid anti-inflammatory drug (Vroomen, de Krom & Slofstra, 2000).

Recovery occurs as the protruding material dies and withers away whilst the ruptured annulus fibrosis

(outer layer of ligament) heals over, over a period of 6-8 weeks.

As pain relieved, patient will be allowed out of bed and undergo physical therapy treatment that

may include: heat, traction, ultrasound, massage, mobilisation (small rhythmic oscillations), special

exercises and the prescription of a supportive brace (Vroomen, de Krom & Slofstra, 2000).

An epidural injection of local anaesthetic (with or without cortisone) may be recommended to

relieve sciatica, allow earlier physical therapy and help prevent adhesions of the nerves. It is useful in

about 70% of cases allowing earlier recovery and return to work. The injection may need to be

repeated once or twice. If unsuccessful, another type of epidural may be performed under X-ray control

called a transforaminal epidural injection (Buchner, Zeifang & Brocai, 2000).

Sometimes, if the sciatic pain is persistent and severe, or if there is muscle weakness and

reflex changes, or if the bladder or bowel function is impaired, surgery may be recommended.

The usual indication for surgery is to provide more rapid relief of pain and disability in the minority of

patients whose recovery is unacceptably slow. The primary goal of surgical treatment for disc herniation

is the relief of nerve root compression by removing the herniated nuclear material (Hirsch, Singh, Falco,

Benyamin & Manchikanti, 2009). The surgery that may included; Chymopapain injection which is an

injection of enzyme material into the disc nucleus to shrink the disc and discectomy where it done by

laser or open operation to remove the prolapsed portion of the disc. Besides, there is a laminectomy,

which is combination of discectomy and removal of part of the posterior bony part of the spinal canal to

allow extra room for the compressed nerve (Gibson & Waddel, 2007; Weinstein, et al, 2006).

LITERATURE REVIEW

Prolapsed Intervertebral Disc: is exercise works?

Over the last few decades, exercise has been promoted with increasing enthusiasm for the

treatment of back pain. This has prompted a systematic review of the evidence concerning the

effectiveness of exercise, with the conclusion that exercise may be helpful for patients with chronic low

back pain in terms of return to normal activities and work (van Tulder, Malmivaara, Esmail & Koes,

2000).

The scientific rationale for exercise therapy in low back pain is based on the fact that impaired

trunk muscle performance, manifested as deficiency in endurance, strength, mobility and coordination.

Several studies have demonstrated that patients with low back pain have lower endurance and strength

than healthy people. As a result, exercise is considered an important part of low back pain management.

However, is exercise really works?

Accordingly, van Tulder, Malmivaara, Esmail & Koes (2000) evaluated the effectiveness of

exercise therapy for low back pain with regard to pain intensity, functional status, overall improvement,

and return to work. In this review, they have found that for acute low back pain, there is strong evidence

that exercise therapy is not more effective than inactive or other active treatments available. Meanwhile,

for chronic low back pain, there is strong evidence that exercise therapy is more effective than the usual

care by general practitioners, and there is equally effectiveness for exercise therapy and conventional

physiotherapy (consisting of hot packs, massage, traction, mobilization, short-wave diathermy,

ultrasound, stretching, flexibility and coordination exercises, and electrotherapy). Nevertheless, it still is

unclear whether exercise therapy is more effective than inactive treatment for chronic low back pain, and

it also remains unclear whether any specific type of exercise (flexion, extension, or strengthening

exercises) is more effective than another. Finally, they concluded that exercises may be useful in the

treatment of chronic low back pain if they aim at improving return to normal daily activities and work.

Thus, based on this study, it shows that exercise was an effective treatment for patient with acute and

chronic low back pain.

There are many types of exercise that can be included in the management of low back pain

(prolapsed intervertebral disc); however, which exercise is the most effective?

While, based upon research, a recent focus has been on exercises that aim to restore dynamic

stability (Saal, 1997; Vezina & Hubley-Kozey, 2000) and improve sensory-motor of the lumbar spine and

pelvis (Ebenbichler, Oddson, Kollmitzer & Erim, 2001) for patient with low back pain.

Liddle, Baxter and Gracey (2004) investigated current evidence for the type and quality of

exercise being offered to chronic low back pain (CLBP) patients, within randomised controlled trials

(RCTs), and to assess how treatment outcomes are being measured. They stated that the most recent

systematic review concluded that exercise might help CLBP patients improve return to work rates, and

activities of daily living. However, it remains unclear what types of exercises are best; therefore, trials

(experimental and pragmatic) involving any type of exercise were sourced.

In this review, they found that based on in all 16 included RCTs, exercise was the primary

intervention for CLBP patients and exercise resulted in positive outcome. The most common type of

programme was in the category of strengthening/flexibility. Strengthening was the predominant exercise

in 12 out of 16 trials, where the lumbar spine and lower limbs were the most commonly targeted body

sites as Rainville et al. (1997) have stated that importance of strengthening for CLBP patients, especially

at the lumbar spine extensors. Finally, Liddle, Baxter and Gracey (2004) suggest that supervised trunk

strengthening or stabilisation exercises, incorporating flexibility may improve back specific function.

They also concluded that exercise-based treatments aim to utilize the benefits of exercise to promote

wellness rather than illness behavior. Patients need to understand why, not just what to do, to facilitate

empowerment and commitment to change and most importantly they must play an active role in their

treatment to obtain optimum benefit. Thus, according to Liddle, Baxter and Gracey (2004), in chronic low

back pain, it’s essential for supervised trunk strengthening or stabilisation exercises, incorporating

flexibility to improve back specific function and they strongly support that exercise was an effective

treatment in low back pain.

Meanwhile, stability of the lumbar motion segment also considered to be important in chronic

low back pain. Panjabi (1992) proposed that instability of lumbar motion is a loss of control or excessive

motion in the spinal segment's neutral zone, which may be caused by injury, degenerative disc disease, or

muscle weakness. Thus, exercise to strengthen the local stabilizer muscles should be done in patient with

low back pain.

Regarding that matter, Akbari, Khorashadizadeha & Abdi (2008) compared the effect of motor

control exercises with general exercises on the lumbar local stabilizing muscles thickness, activity

limitation and pain in patients with chronic low back pain (LBP). In this study, they included forty-nine

patients with chronic LBP were randomly assigned to either a motor control (n = 25) or a general

exercises group (n = 24). Before and after intervention, they assessed the lumbar multifidus (LM) and

Transversus abdominis (TA) muscles thickness (mm) using a 7.5 MHz B-mode transducer ultrasound,

pain through visual analog scale and activity limitation through Back Performance Scale (Ordinal).

After treatment, there was no significant difference between two groups which are the motor

control exercises and general exercises increased TA and LM muscles thickness and lumbar mobility in

patients with chronic LBP. However, after treatment, the mean score of pain significantly decreased in the

motor control group compared with the general exercise group (P = 0.015). Thus, it shows that the motor

control exercises were more effective than general exercises in pain decreasing.

Based on Akbari, Khorashadizadeha & Abdi (2008), the findings support that the motor control

and general exercises are effective in increasing TA and LM thickness and reducing pain and activity

limitation in patients with chronic LBP without any signs of instability. However, the motor control

exercises are more effective in reducing pain than the general exercises.

In the meantime, exercise that included in low back pain management should be safe when done

by the patient. Besides supporting that exercise is vital and effective in treating patient with low back

pain, Rainville, Hartigan, Martinez, Limke, Jouve & Finno (2004) also have reviewed the several key

aspects about the safety of exercise that may help therapist understand its utility in treating chronic back

pain. In this study, they found that there is no evidence that exercise increases the risk of additional back

problems or work disability for patient with low back pain (acute, subacute and chronic). Moreover,

current medical literature suggests that exercise has either a neutral effect or may slightly reduce risk of

future back injuries.

Besides, they also stated that exercise can be prescribed for patients with chronic low back pain

with three different goals. First and foremost is to improve in back flexibility and strength, and improve

performance of endurance activities. The second goal of exercise is to reduce the intensity of back pain.

Most studies of exercise have noted overall reduction in back pain intensity that ranges from 10%to 50%

after exercise treatment. The third goal of exercise is to reduce back pain related disability through a

process of desensitization of fears and concerns, altering pain attitudes and beliefs and improving affect.

As well as strengthening and flexibility exercise, there is also the most popular exercise that

always being done for patient with low back pain which is McKenzie exercise. However, is there any

difference of effectiveness between McKenzie exercises with any other exercise?

Petersen, Tom, Kryger, Peter, Ekdahl, Olsen, Steen, Jacobsen & Soren. (2002) compared the

effect of the McKenzie treatment method with that of intensive dynamic strengthening training in patients

with subacute or chronic low back pain. There were 260 consecutive patients with chronic low back pain

were randomized into two groups: Group A was treated with the McKenzie method (n = 132), and Group

B was treated with intensive dynamic strengthening training (n = 128) with treatment period for both

groups was 8 weeks at an outpatient clinic, followed by 2 months of self-training at home. At the end of

study, they found that no statistically significant differences between McKenzie treatment and

strengthening training with regard to change of disability at any follow-up assessment. Besides, mo

differences in reduction of pain were observed at any time between the groups. Thus, they concluded that

the effectiveness of McKenzie treatment equaled that of intensive strengthening training, a widely

recommended treatment for patients with chronic low back pain.

Furthermore, Marchado, Souza, Ferreira & Ferreira (2006) also evaluated the effectiveness of the

McKenzie method for low back pain (LBP). In this review, there is some evidence that the McKenzie

method is more effective than passive therapy for acute LBP; however, the magnitude of the difference

suggests the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie

method in chronic LBP. The effectiveness of classification-based McKenzie is yet to be established. At

the end of the study, they suggest that there is still a need for further research in order to clarify whether

the McKenzie method as a classification-based treatment differs from a generic McKenzie approach.

Thus, from these two studies, it shows that no strong evidence support that McKenzie is an effective

exercise compared to other exercises.

In conclusion, from these six studies that I have showed, generally all the studies support that

exercise therapy is an effective treatment for patient with low back pain. It’s only that Liddle, Baxter and

Gracey (2004) have concluded that in chronic low back pain, it’s essential for supervised trunk

strengthening or stabilisation exercises, incorporating flexibility to improve back specific function.

Akbari, Khorashadizadeha & Abdi (2008) stated that the motor control and general exercises are

effective in increasing TA and LM thickness and reducing pain and activity limitation in patients with

chronic LBP. Meanwhile, studies from Peterson, et al (2002) and Marchado, Souza, Ferreira & Ferreira

(2006) shows that McKenzie exercise is equally effective with other exercise and there is limited

evidence for the use of McKenzie method in chronic LBP.

CASE HISTORY

When diagnosis a patient one of the fist things that needs to be performed is an in-depth history

of the patient. This history will help to determine what physical examinations to do, which will hopefully

lead to a successful diagnosis.

Madam J is a 53-year-old female who works as Kindergarten’s Kitchener in Malacca. She

attended Malacca Hospital complaining of low back pain, back spasm and radiating pain down to the

right leg (only above the knee). On October 2010, she was having history of falling down at the

kindergarten (falling down in sitting position) and she cannot stand immediately after the injury (about 20

minutes after injury). For now, she having lower back pain (on/off) and feeling more pain when prolong

standing and walking while doing her work. Previously, patient already having history of lumbar pain

since August 2010.

Subjective Assessment

Generally, she came into department in good and healthy condition. However, she was having

Diabetes Mellitus (under control) and depends on medication. On November 2010, magnetic resonance

imaging (MRI) done and the finding is she having prolapsed intervertebral disc (patient not know which

level affected). Then, she was referred to physiotherapy underlying the problem. For this moment, she

only took painkiller whenever she unable to stand with the pain.

In subjective assessment, for patients complain of pain, I’m using the Numeric Rating Scale

(NRS) to measure the pain or quantify the patient’s subjective pain. The ability to quantify pain intensity

is essential when caring for individuals in pain in order to monitor patient progress and analgesic

effectiveness. There are three scales are commonly employed: the simple descriptor scale (SDS), the

visual analog scale (VAS), and the numeric (pain intensity) rating scale (NRS). I’m using NRS because

based on study that have been done by Paice, Judith, Cohen & Felissa (1997), the verbally administered

0-10 NRS provides a useful alternative to the VAS, more easier and practical to be administered. During

rest position, patient having pain at 5/10, 7/10 when doing aggravating movement and 4/10 during easing

state. Besides, it is important to determine the location of the pain, its mechanism of onset, and the

relation to body movement (Drenzner, 2001). The area of pain is at lower back pain and sometimes

radiating to the right leg (only above knee). Patient claimed that the feelings of pain are dull aching pain

and pulling pain. The aggravating factor is when patient prolong standing and walking (more than 2

Hours) and the easing factor is patient applying ointment at lower back when feeling pain. The pain will

go away for about after 30 minutes and there is no specific time that pain will be felt.

Furthermore, there are certain signs or “red flags” that may come up when doing the patients

history that might be an indication of a larger problem. For instance, the presence of fever, malaise, and

the inability to establish a comfortable position may indicate serious conditions like diskitis,

osteomyelitis, or malignancy. Serious underlying disorders may be suspected if the patient is experiencing

pain at rest, weight loss, or fever. The presence of night pain may show an infection or a more serious

problem like a tumor. Bowel or bladder dysfunction, saddle anesthesia, and progressive neurological

deficits may indicate cauda equina or nerve root compression and the need for immediate lumbar

decompression. A major trauma such as an automobile accident or fall, and minor trauma in a patient with

osteoporosis can result in a spinal fracture. For this patient, there are no certain signs that noted from the

patient’s history (subjective assessment).

PHYSICAL EXAMINATION

When all information has been collected, the subjective examination is completed; the next

important process is to perform a physical examination of the patient. This examination helps to pinpoint

the location of the pain and weather neurological components exist.

The information from the subjective examination helps the therapist to plan an appropriate

physical examination. The severity, irritability and nature of the condition are the major factors that will

influence the choice and priority of physical testing procedure.

First of all, I have to observe the patient in dynamic and static situation (Petty, 2006); the quality

of movement is noted, as are the postural characteristic and facial expression. Informal observation will

have begun from the moment I begin the subjective examination and will continue to the end of physical

examination.

From my observation of patient’s posture, she was having lower crossed syndrome (Jull & Janda,

1987) where the increase in lumbar lordosis noted. The shoulder level is symmetry, spine of scapula and

inferior angle of scapula in same alignment (symmetry). In addition, no scapula winging noted and iliac

crest and PSIS in same alignment.

From the observation of muscle form and soft tissue, she having no abnormality in muscle bulk

and muscle tone for both sides and there also no sign of redness and swelling noted. Besides the

observation of physical appearance, observation of the patient’s attitudes and feelings also important in

the physical examination (Petty, 2006). From my view, she was a motivated patient, very cooperative and

believes that she can return to her normal life without back pain.

Next, I’ve done with the palpation on patient’s back area. There is muscle spasm noted at both

sides of paravertebral muscle area (around L2-L5). Meanwhile, tenderness also noted in deep palpation at

right side of lumbar area (around L4 and L5). Then, I precede the physical examination by examining

patient’s active physiological movements. For the active physiological movement, therapist have to note

the quality of movement, range of movement, behavior of pain through the range of movement, resistance

through the range of movement and at the end of the range of movement and provocation of any muscle

spasm. (Petty, 2006). For this patient, when doing flexion, lumbar rotation to the right and left, there is

active full range of motion with no pain noted. There is active full range of motion with pain at end range

noted at lumbar area when she was doing extension, lumbar side flexion to the right and left sides.

Overall, there is no reducing range of motion of lumbar spine movement.

Moreover, it may be necessary to examine other regions to determine their relevance to the

patient’s symptoms; they may be the source of the symptoms, or they may be contributing to the

symptoms (Petty, 2006). The joints within these regions can be tested fully or partially with the use of

clearing test. In this case, I’ve done the joint clearing test for thoracic, hip, knee and ankle movement.

Generally, there are no reducing in range of motion of thoracic, hip, knee and ankle movement.

After that, the next physical examination is by examining the muscle strength and muscle length.

Muscle strength usually tested manually with an isotonic contraction through the available range of

motion and graded according to the Medical Research Council (MRC) scale (Medical Research Council

1976). The muscles that have tested are the muscle that prone to be weak which are gluteus maximus,

gluteus medius, quadriceps, tibialis anterior and peronei muscle (Jull & Janda 1987, Sahrmann 2002).

From my examination of this patient’s muscle strength, there is reduce in muscle strength of right gluteus

maximus muscle noted (4/5, which means active movement against gravity and resistance).

Meanwhile, muscle length may be tested, in particular for those muscles that tend to become tight

and thus lose their extensibility (Comerford & Kinetic Control 2000, Janda 1994, 2002, Jull & Janda

1987). Muscle that prone to be tight or shorten (Janda 1994); that is: erctor spinae, quadratus lumborum,

piriformis, iliopsoas, rectus femoris, tensor fascia latae, hamstring, tibialis posterior, gastrocnemius and

soleus. From the examination, she was having reducing in muscle length at right side of piriformis,

iliopsoas, hamstring, gastrocnemius and soleus muscles. The reducing in muscle length is because of

shortening or tightening of the muscles affected, it occurs when the muscle cannot stretch to its normal

length. This state may occur with overuse, which causes the muscle initially to become short and strong

but later, over a period of time, to become weak (because of reduced nutrition). This state is known as

stretch weakness (Janda, 1993).

Furthermore, the next physical examination is the neurological test, which includes neurological

integrity testing, neurodynamic test and some other nerve test. A neurological test should be done to

pinpoint the exact nerve root affected if any. It is also good to determine whether there is motor

weakness, sensory loss, and poor reflex response occur or not. Firstly, for dermatome testing, I’m using

hot and cold test and pin prick test on the dermatomal area (from level L2 unti S2). There is no abnormal

response noted. Next, the myotome testing, I’m testing each movement of the level where L2 is for hip

flexion, L3 for knee xtension, L4 for foot dorsiflexion, L5 for extension of big toe, S1 for foot eversion,

S2 for knee flexion, toe standing. There is no abnormality of the movement noted. Then, for the reflex

changes, the deep tendon that need to be tested are knee jerk (L3-4) and ankle jerk (S1) (Petty, 2006).

Finally, there is no neurological deficit noted.

Nevertheless, there are neurodynamic tests that may be carried out in order to ascertain the degree

to which neural tissue is responsible for the production of the patient’s symptoms; straight leg raise, prone

knee bend and slump test. This test is done to determine what nerves may be involved in the low back

pain.

A straight-leg test is a test that can detect tension on the L5 and/or S1 nerve roots (Petty, 2006).

This test is frequently used to determine if a patient is suffering from a herniated disc. This test stretches

the nerve roots that may be irritated by a herniated disc and produced pain. When doing straight leg raise

of right leg on this patient, there is pain noted at lower back area and radiating pain down to the right leg

with less than 70 degrees of straight-leg raising and the pain is aggravated by dorsi flexion and relieved

by plantar flexion. Thus, it is suggestive of tension on the L5 or S1 nerve root, which indicates a herniated

disc.

After that are the prone knee bend and slump test. Prone knee bend is test for determine if there is

impairment of the femoral nerve (Petty, 2006). There is negative result noted when doing prone knee

bend for this patient at the both sides of leg. Thus, there is no impairment of femoral nerve noted. Next,

another test that is commonly performed on patients who are thought to be having tension in the

neuromeningeal tract is the slump test. It is beneficial to use the slump test on patients that are describing

low back pain, leg pain, radicular symptoms, trauma, spinal cord symptoms, headaches, cervical pain, and

thoracic pain (Miller, 1999). When doing slump test for this patient, there is no pain noted at any area. It

show s that no impairment of the neural mobility noted.

Last but not least, the other test that very important in this assessment is the passive accessory

intervertebral movements (PAIVMs). Accessory movements are defined as those movements which a

person cannot perform actively but which can be performed on that person by an external force (Maitland

et al, 2001). Accessory movements are important to examine because they occur during all physiological

movements and, very often if there is a limitation of the accessory range of movement this will affect the

range of physiological movement available (Petty, 2006). Thus, when doing PAIVMs on this patient,

there are pain noted when doing central posterior anterior and unilateral posterior anterior at level L4 and

L5 (localized pain only). However, all lumbar spine mobility is normal and no increase or reduces

mobility noted.

Physiotherapist’s impression

Based on the subjective and objective assessment that I have done just now, there are several

impressions that I can make. Firstly, there is pain noted at right side of lumbar area and down to the right

leg due to the nerve irritation which may be involved at level L4 and L5. It is because according to

PAIVMs that I have done, there is pain noted when doing central posterior anterior and unilateral

posterior anterior at level L4 and L5. Besides, the nerve that may involved is sciatic nerve. It is because

there is pain noted at lower back area and radiating pain down to the right leg when doing straight leg

raise test which shows the sciatic nerve is affected (impaired). In addition, there are muscle tightness of

piriformis, iliopsoas, hamstring, gastrocnemius and soleus due to overuse of these muscles. Furthermore,

reduce muscle strength of the right gluteus maximus muscles noted due to imbalance of the lower limb

muscles where illiopsoas and erector spinae were tight , thus, abdominal and gluteus muscle will become

weak, as the lower crossed syndrome already explained ( according to Janda’s approach ).

Thus, for the short term goals in my management, first is reducing the pain that noted at right side

of lumbar area within two weeks. Then, reduce the muscle tightness of piriformis, iliopsoas, hamstring,

gastrocnemius and soleus within three weeks and lastly increase the muscle strength of the right gluteus

maximus muscles within three weeks.

Last but not least, for the long term goal, at the end of the treatment patient will be able to pacing

to her routine work activities without any restriction/without any pain and limitation of movement.

INTERVENTION

According to Mittrach, Grill, Bonjean, Scheuringer, Boldt, Huber and Stucki (2007),

physiotherapy intervention is based on a process of problem identification, relation between the problem

and factors of the person, goal setting, treatment planning, and assessment. Clinical decision making

framework used in treating spinal cord injury is the ICF (International Classification of Functioning,

Disability and Health).

Mittrach et al. (2007) stated that, “ICF provides a model of functioning and a classification to

describe and classify functioning, health and disability”. ICF composed of body functions and structures,

activities and participation, and contextual factors which are expected to become a universal framework

in rehabilitation (Mittrach et al., 2007).

The impairments that noted for this patient are pain that noted at right side of lumbar area, muscle

tightness of piriformis, iliopsoas, hamstring, gastrocnemius and soleus and reduce muscle strength of the

right gluteus maximus muscles. From these impairments, it will affect the patient’s activities for instance;

patient unable to sitting, standing and walking for prolong period (more than 2 hours). Because of the

limitations that occur in her activities, she was having restriction in her participation for example; she

unable to do her work as kindergarten’s kitchener as usual. She needs to have a rest in between her work

because of the pain.

There are many treatments for low back pain that can be used. One certain treatment is not going

to be good for everyone. Treatments are usually custom made for the patient to get the most effective

results. The goals for treatment are to alleviate pain, facilitate the return to normal activities, and to

reduce the likelihood of recurrence (Starz, 2000).

Pain management

The first treatment in this low back pain is reducing the pain. Pain management that may include

is the use of modalities. The modalities that are usually used in cases of low back pain are ice, superficial

heat, ultrasound, massage, traction, and electrical stimulation. For this patient, I’m using superficial heat

(hot pack) to reduce pain and relieve the muscle spasm. Heat therapy produces effects to a depth of 1 to 2

cm and has been shown to reduce muscle spasm and pain (Vroomen, de Krom & Slofstra, 2000). Besides,

heat wrap therapy has been shown to be more effective than placebo in short-term pain relief and

functional status (French, Cameron & Walker, 2006).

McKenzie exercise

McKenzie exercises are used to classify patients as having 1 of 3 syndromes (postural,

dysfunction, and derangement syndromes) and to guide treatment. These exercises include repeated

flexion and extension movements performed in different body positions as part of a routine lumbar spinal

assessment and exercise program (McKenzie, 1990). McKenzie exercise is believed to be a very

beneficial exercise which emphasizes to minimize and centralize the radiating pain (Humphreys, 1999).

The main objective of McKenzie exercise is to eliminate back pain and to restore range of motion.

There are seven main exercises that included in McKenzie exercise (Bodger, 1999). For this

patient, I’m only prescribing the patient to the first and second exercise of McKenzie. The exercises start

with the patient lying face down is just lying on her stomach with her hands at her side and her head

turned to one side and just relaxing. Then, the second exercise is lying face down in extension. Patient lies

on her stomach with her elbows under her shoulders so that she can rest on her forearms and then ask her

to slowly extend her neck and lift up the shoulder without extending the elbow. Without sustaining, teach

patient to do 8-10 repetitions and breathe normally.

Stretching exercise

Stretching and exercise is an important key to recovery. Exercise should begin early to help

control pain, avoid de-conditioning, and restore function. Some even very little exercise is always better

than no exercise at all. Exercise helps to reduce pain by triggering endorphins in our brain, which act as

the body’s natural painkillers. The initial exercises that are prescribed should be directed away from any

movement that aggravates the patient’s pain and symptoms. For a patient who is limited by pain with

flexion such as a patient with a herniated disc their rehabilitation program should start with exercises

aimed at extension. If the patient’s pain is aggravated by extension then flexion exercises should be

started with.

Stretching exercise that included for this patient are piriformis stretching, iliopsoas stretching,

hamstring stretching and calf stretching. Piriformis stretching has done by asking patient to supine lying

and cross the left leg over the right knee. Then, clasp hand behind of right thigh, pull the right leg towards

body and hold in that position in 15 seconds, do for 10 repetitions, 3 sets and 3 sessions per day.

Then, iliopsoas stretching has done by asking patient to prone lying with pillow under the

abdomen.Therapist stands on the side opposite the side of iliopsoas to be treated, right hand supporting

the thigh with knee flex 90 degree and the left hand stabilize the pelvic. Stretching was hold in 15 seconds

and does for 10 repetitions.

Hamstring stretching has done by asking patient to supine lying. Then, teach patient to do

hamstring stretching by using towel with hip flexion, knee full extension, ankle dorsiflexion; hold 15

seconds, 10 repetitions, 3 sets, and 3 sessions per day.

Calf stretching has done by asking patient to long sitting with back supported well. Teach patient

to do calf stretching by using towel with ankle dorsiflex and then hold for 15 seconds, 10 repetitions, 3

sets, and 3 sessions per day.

Strengthening exercise

Weak muscles are often at the root of lower back pain (eg: prolapsed intervertebral disc). The

muscles of the back, the abdomen, and the gluteus muscle; all these muscles are supporting the spine and

are called the core muscles.

Muscles are the spine's main defense against gravity. Strengthening the muscles that support the

spine with exercises, can prevent, reduce and in some cases eliminate back pain. Strong abdominal

muscles (especially the deep abs) are as crucial as strong back muscles for supporting the lower back and

preventing lower back pain.

For this patient, I taught the patient to do gluteus maximus strengthening exercise as the gluteus

maximus muscles are weak. Firstly, patient in prone lying position. Ask patient to do hip extension with

knee flex 90 degree and then lift up the leg. Hold for 10 seconds, 10 repetitions, 3 sets and 3 sessions per

day.

Lumbar stabilization exercise

Lumbar stabilization is the ability to transfer loads, disassociate movement of the extremities

from the spine and perform motion that is smooth and effortless. This involves muscle balance,

coordination, flexibility, endurance and strength. The goal of a lumbar stabilization training program is to

facilitate function, resolve and prevent symptoms thru education and progressive exercise (Scalone,

2007).

There are three basic phases in the lumbar stabilization exercise. Phase one focuses on specific

localized stabilization training in which the patient learns to find and maintain neutral, begins abdominal

draw in maneuver (ADIM) and multifidus isometrics in multiple positions. Phase two builds on phase one

with general trunk strengthening while maintaining neutral and activating local muscles with gradual

increase in challenges to spinal position control. Phase three transitions the patient into functional and

sport or work specific training (Scalone, 2007).

For the first visit, I taught the patient to do the phase one of lumbar stabilization by holding the

contraction within 10 seconds, 10 repetitions, 3 sets and 3 sessions per day.

Posture education

Other predisposing factors such as poor posture when sitting or standing, faulty lifting techniques,

and abnormal biomechanics also need to be addressed and corrected. It’s important to teach the patient in

posture education to prevent further low back problem.

Proper standing posture

Maintaining a proper standing posture is important in helping to prevent future back pain. Teach

patient to do proper standing posture in standard posture; it should be that of easy balance, where the

normal curves of the spine are present and the bones of the lower extremities are in ideal alignment with

weight bearing. One point that may be helpful to remember is that chest should be the farthest point

forward and the buttocks and heels should be the farthest point backwards. Straighten up by keeping the

chest up, stomach in, and buttocks tightened (Braggins, 2000).

Proper Sitting posture

Proper posture in sitting is also important. During sitting, pelvis will rotate posteriorly with the

lumbar spine going into flexion. This can be especially hard on the lumbar intervertebral discs because

they are being compressed anteriorly and stretched posteriorly. It is important that if prolong sitting, we

need to change positions frequently or get up and walk around or stretch as much as we can.

Besides, it’s essential to look for a chair that is going to help promote good posture. When sitting,

make sure to move or at least shift the weight frequently. Most important, avoid slouching during sitting

because slouching is not a good habit to start because it overstretches your muscles and ligaments and

causes your muscles to get tired. It is important that change positions frequently by getting up and

stretching at least once every twenty to thirty minutes (Bodger, 1998).

Proper body mechanics

There are three main areas of lifting, pulling, and pushing. When lifting something, make sure

that it is something that we are capable of lifting and if not then get people’s help. The first thing to do

when lifting something is to stand with a firm, wide adaptable base, which allows shifting of weight

backwards, forwards, or sideways, allowing easy flexion and extension movements of the knee. This

helps to keep balance and give a solid base of support. Besides, make sure to use legs to provide

momentum and energy for the movement. Hold the object with a firm, comfortable hand or arm grip.

Hold the weight close to the body. Last but not least, avoid holding the weight for a long time. Avoid

twisting and stooping while holding the weight (Braggins, 2000).

EVALUATION OF OUTCOMES

At the end of treatment, I review back all exercises I have been given. Liddle, Baxter, Gracey

(2004) acknowledge that there is no ‘ideal’ set of outcome measures for patient with chronic low back

pain.

In this case study, I was using two types of outcome measure which are Numeratic Pain Scale

(NRS) and back specific function questionnaire.

I’m using NRS because NRS is highly accurate for quantifying a patient’s subjective pain. It has

the highest diagnostic yield for the chronic pain population, and its accuracy is followed closely by the

accuracy of the visual analog scale (Johnson, 2005; McKechnie, 1993; Jensen, Karoly & Braver, 1986;

Downie, 1978).

There is improvement noted in reducing pain from the first visit until the third visit. For the first

visit, the NRS during rest is 5/10, during easing factor is 4/10 and during aggravating factor 7/10. At the

second visit, NRS during rest is 4/10, during easing factor is 3/10 and during aggravating factor is 6/10.

At the third visit, NRS during rest is 4/10, during easing factor is 2/10 and during aggravating factor is

5/10. Thus, it shows that there is reducing of pain noted from the first visit until the third visit by using

the NRS as the measurement tool for pain.

Besides, I’m also use other outcome measure which is the back specific function questionnaire

called Oswestry Questionnaire. These instruments reflect the level of activity limitation that patients

experience as a result of their back pain (Liddle, Baxter, Gracey, 2004).

According to Jeremy, Fairbank & Pynsent (2000), the Oswestry Questionnaire has become one of

the principal condition-specific outcome measures used in the management of spinal disorders. They also

stated that Oswestry Questionnaire remains a valid and vigorous measure and has been a worthwhile

outcome measure. 

For this patient, I’m using Oswestry Questionnaire to see patient’s improvement and ability in her

functional daily life. Based on the Oswestry Questionnaire, the patient shows the improvement and

reduce the disability in her daily activity where at the first visit, the total score of Oswestry Questionnaire

was 15 marks, at the second visit was 9 marks and third visit was only 4 marks. Thus, it shows that

patient already improve in her independently doing her activity.

DISCUSSION

This 53-year-old female with a four-month history of constant low back pain, pain radiating down

to the right leg (only above the knee) was examined and found to have a Prolapsed Intervertebral Disc.

The impairment was indicated and monitored through a thorough physical examination that

included observation, palpation, range of motion, muscle strength, muscle length testing, passive

accessory intervertebral movement (PAIVM), neurological test and neurodynamic test.

According to the subjective and objective assessment that have been done, I can conclude that

this patient may have Prolapsed intervertebral disc with posterior derangement D3 and she was having

Lower Crossed Syndrome.

My reasons why I said so because, firstly, based on McKenzie (1981), a person will be having

posterior derangement D3, when the patient is having the clinical presentation such as no deformity of

lateral shift noted, there is unilateral or symmetrical pain across L4/5 and patient will have buttock and

thigh pain. So, according to the clinical presentations that have been stated, this patient having all the

symptoms, it means that she may have posterior derangement D3.

In addition, I conclude that she may have Lower Crossed syndrome is because based on my

physical examination (observation, muscle strength, muscle length testing), I found that this patient have

the signs of this syndrome.

As Chaitow (2006) showed that, when a person having Lower Crossed Syndrome, there will be a

pelvis anteriorly rotated, an increased lumbar lordosis, tightness and weakness of certain muscles.

Muscles that will be tight are iliopsoas and erector spinae muscles and muscles that will be weak are

gluteus maximus and abdominal muscles.

Thus, based on my observation on this patient, I found that, she was having increase in lumbar

lordosis and at the same time, the pelvis was anteriorly rotated. Besides, from the muscle length testing,

she was having tightness of iliopsoas muscle and erector spinae muscle. From the muscle strength testing,

she also was having weakness of gluteus maximus muscle and abdominal muscle. In consequence, from

this physical examination, it shows that she was having lower crossed syndrome.

Based on the impairments that have been listed, the patient has received the interventions which

are pain management, exercise therapy, posture education and patient education.

For pain management, I’ve decided to use heat therapy (hot pack) as Vroomen, de Krom &

Slofstra (2000) have stated that heat therapy produces effects to a depth of 1 to 2 cm and has been shown

to reduce muscle spasm and pain. Besides, after the application of hot pack for 15 minutes on patient’s

low back area, she claimed that there is feeling of relaxation and pain have reduce compared to before

treatment.

For the exercise therapy, I have chosen the McKenzie exercise and lumbar stabilization exercise

as the priority for this patient as according to Petersen, et al (2002), McKenzie exercise and strengthening

exercise are equally effective and widely recommended treatment for patients with chronic low back pain.

Exercise therapy is the most vital intervention for this patient because according to van Tulder,

Malmivaara, Esmail & Koes (2000), they already stated that exercises give benefits in the treatment of

chronic low back pain in improving patients’ return to normal daily activities and work.

The McKenzie method was shown to be as effective as an isotonic strengthening program in a

recent randomized, controlled trial of subacute and chronic patients (pain duration of at least 8 weeks)

(Petersen et al., 2002). However, Marchado, et al (2006) has said that there is limited evidence for the use

of McKenzie method in chronic low back pain patient. Thus, Marchado et, al (2006) suggest that future

research should be done in this McKenzie method.

Besides, she needs to do a lot of lumbar stabilization exercise as the motor control exercise to

improve the back strength (increase the strength of tranverse abdominis and lumbar multifidus muscle’s

strength) and in order to prevent further back injury. It was according to the study that have been done by

Akbari, Khorashadizadeha & Abdi (2008), where they have found that motor control and general

exercises are effective in increasing Transverse Abdominis and Lumbar Multifidus thickness and

reducing pain and activity limitation in patients with chronic low back pain without any signs of

instability.

SUMMARY

This case study highlights the effectiveness of exercise therapy for the patient with Prolapsed

Intervertebral Disc that included in chronic low back pain. The 53 year old female with a 4 month history

of low back pain and decreased function in activity daily life showed significant improvement following

three times intervention.

After following treatment, patient claimed that pain have reduce (can be measured by using

NRS), reduce muscle tightness (muscle length testing) and increase muscle strength (manual muscle

testing). Most importantly, patient has reduced her restriction in her participation; patient able to do her

work (cooking and serving the foods) without extra pain and any limitation.

Moreover, patient also claimed that her condition becomes better and pain reduces after doing

exercise especially McKenzie exercise and lumbar stabilization exercise. Thus, it proves the aim of this

case study where to determine whether exercise was effective or not for patient with prolapsed

intervertebral disc.

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