Introduction
- S. Josh Bell, MD
- Stephanie Niño, PT, DPT, FAAOMPT, OCS
- Cheryl Kathleen Obregon, PT, DPT, FAAOMPT
- Stephanie Niño, PT, DPT, FAAOMPT, OCS
Epidemiology
Age
- •
All ages can be affected.
- •
Predominance of patients between ages 30 to 50.
- •
Trials, such as SPORT trial, have mean enrollment of ages between 40 and 43.
Gender
- •
Predominance of males
- •
Males twice as likely to have than females
Sport
- •
Any sport can cause a disc herniation
- •
Increased risk with improper technique
- •
Contact sports
- •
Repetitive twisting of the back
Position
- •
Can occur in any position
- •
Bending and twisting with load cause higher load to disc
- •
Lifting mechanics, especially with load in front of body away from center axis
Pathophysiology
Intrinsic Factors
- •
Previous disc herniation
- •
Male gender
- •
2 : 1 dominance
- •
Ages 30 to 50
- •
- •
Congenital spinal abnormalities
Extrinsic Factors
- •
Poor mechanics
- •
Improper technique
- •
Lifting
- •
Sport-specific
- •
- •
Smoking
- •
Sedentary lifestyle
Traumatic Factors
- •
High levels of force (traumatic collision sports, such as football)
- •
Repetitive motions
- •
Loading of the back (twisting with load)
- •
Improper technique
Classic Pathological Findings
- •
Numbness in a dermatomal distribution
- •
Dermatomal patterns in the lumbar spine
- •
L2—Anterior thigh, medial thigh and groin
- •
L3—Anterior thigh and medial knee/calf
- •
L4—Anterior knee and medial calf/foot
- •
L5—Anterior leg and dorsum foot
- •
S1—Posterior leg and lateral/sole foot
- •
- •
- •
Unilateral weakness
- •
Leg pain is greater than back pain
Clinical Presentation
History
- •
Leg pain is greater than back pain
- •
Greater back pain indicates the possibility of a lumbar sprain/strain
- •
- •
Weakness or numbness
- •
Specific to muscle groups/nerve distributions
- •
- •
Low back tightness/spasm
Physical Examination
Abnormal Findings
- •
Straight leg raise
- •
When lifting the straight leg from a supine position pain radiates according to the nerve distribution of the involved nerve
- •
- •
Numbness in a dermatomal distribution ( Figure 19-1 )
- •
L3—Medial knee
- •
L4—Medial leg and medial foot/ankle
- •
L5—Anterior leg and anterior foot/ankle
- •
S1—Lateral foot/sole of foot
FIGURE 19-1
Dermatomal pattern of a patient with right L5 radiculopathy (hash marks represent dermatomal pattern of decreased sensation).
- •
- •
Loss of relevant reflex ( Figure 19-2 )
- •
L3—Knee reflex
- •
L4—Knee reflex
- •
S1—Achilles reflex
FIGURE 19-2
Knee reflex testing.
- •
Pertinent Normal Findings
- •
Normal bowel and bladder function
- •
Predominance of leg pain and less back pain
- •
To differentiate pathology from nerve root compression and lower back pain
- •
- •
No evidence of hip pathology
- •
Normal motion
- •
No pain in groin with resisted hip flexion
- •
No pain with log roll maneuver of the leg
- •
Imaging
- •
Radiographs of lumbar spine
- •
AP/LAT
- •
Possible flexion/extension (to rule out instability)
- •
- •
MRI of lumbar spine ( Figure 19-3 A,B )
- •
Evaluate for compression of nerve roots
- •
Should correlate to dermatomal pattern on physical examination
FIGURE 19-3
A , Axial MR image of S1 lumbar disc herniation. B , Sagittal MR image of S1 lumbar disc herniation.
- •
- •
Potential radiograph of hip to rule out hip pathology
Differential Diagnosis
- •
Infection
- •
Fever may be present
- •
- •
Tumor
- •
Weight loss unexplained
- •
Pain at night/rest
- •
- •
Fracture
- •
Significant trauma should be evaluated with radiographs of the spine
- •
- •
Musculoskeletal back pain (without disc herniation)
- •
Lumbar sprain/strain
- •
No radiation to legs
- •
- •
Hip pathology
- •
Evaluate with range of motion
- •
Evaluate with provocative testing
- •
Resisted straight leg raise
- •
Muscular strength
- •
Log roll
- •
- •
Potentially evaluate with radiographs
- •
- •
Cauda equina syndrome
- •
Compression of multiple nerve roots from a large or central disc herniation
- •
Present with abnormal bowel or bladder function (retention or loss of control)
- •
- •
Saddle anesthesia (loss of sensation in the groin area)
- •
Loss of sensation to bilateral lower extremities
Treatment
Nonoperative Management
- •
Medication (antiinflammatory: NSAIDS vs. oral steroids or pain medication)
- •
Stretching and early active rehabilitation
- •
Workplace and activity restrictions
- •
Physical therapy
- •
Epidural steroid injection (ESI)
Guidelines for Choosing Among Nonoperative Treatments
- •
No evidence of cauda equina syndrome
- •
Symptoms managed with medication and activity restrictions
- •
No progressive weakness or neurological loss
Surgical Indications
- •
Absolute:
- •
Progressive motor and sensory loss
- •
Cauda equina syndrome
- •
- •
Relative:
- •
Progressive or persistent symptoms after 6 weeks of nonsurgical care
- •
Significant loss of motor strength (e.g., quadriceps)
- •
Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment
- •
Progressive neurologic findings affect the decision to proceed to surgery
- •
Significant weakness in quadriceps or other major motor group
- •
If patient has persistent or worsening pain that is not relieved with nonoperative treatment
Aspects of Clinical Decision Making When Surgery is Indicated
- •
Progressive loss of motor function
- •
Failure of appropriate trial of 6 weeks to 3 months of nonoperative treatment
- •
Progressive pain not responsive to treatment.
Evidence
Multiple-Choice Questions
- QUESTION 1.
A patient has a disc herniation causing decreased sensation to the area of the right medial malleolus and a decreased knee reflex on the right side. The most likely nerve root effected by this herniation is:
- A.
Right L2
- B.
Left S1
- C.
Right L4
- D.
Left L4
- A.
- QUESTION 2.
Based on demographics, the most likely patient to get a symptomatic lumbar disc herniation is:
- A.
20-year-old female
- B.
40-year-old male
- C.
65-year-old female
- D.
10-year-old male
- A.
- QUESTION 3.
Signs of cauda equina syndrome may include all of the following except:
- A.
Shortness of breath
- B.
Loss of normal bowel or bladder function/control
- C.
Saddle anesthesia
- D.
Weakness
- A.
- QUESTION 4.
Risk factors for lumbar disc herniation include the following except:
- A.
Smoking
- B.
Previous lumbar disc herniation
- C.
Male
- D.
Physically fit
- A.
- QUESTION 5.
Appropriate nonoperative treatment for lumbar disc herniation includes the following except:
- A.
Physical therapy
- B.
Medication management
- C.
Work/activity restrictions
- D.
Trigger point injections
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Pathophysiology )
- QUESTION 2.
Correct answer: B (see Pathophysiology )
- QUESTION 3.
Correct answer: A (see Treatment )
- QUESTION 4.
Correct answer: D (see Pathophysiology )
- QUESTION 5.
Correct answer: D (see Treatment )
Nonoperative Rehabilitation of Herniated Lumbar Disc
- S. Josh Bell, MD
- Stephanie Niño, PT, OCS, FAAOMPT
- Cheryl Kathleen Obregon, PT, DPT, FAAOMPT
- Stephanie Niño, PT, OCS, FAAOMPT
- •
Pain control
- •
Pain free mobilization of the spine
- •
Lower extremity and core strengthening
- •
Patient specific progression of activities, modalities
Phase I (Weeks 0 to 2, Postinjury)
Goals
- •
Pain control, decrease of inflammation
- •
Mobilization, unloading as necessary
- •
Education
| PHASE I (weeks 0 to 2) | PHASE II (weeks 2 to -6) | PHASE III (weeks 6 to 12) | Phase IV (weeks 10 to 18) | Phase V (weeks 18 to 52) |
|---|---|---|---|---|
|
|
|
|
|
Protection
- •
Protect with walker as needed
- •
Use of lumbar support, such as lumbosacral orthosis (LSO), as necessary
Management of Pain and Swelling
- •
Pharmacologic treatment
- •
NSAIDs
- •
Oral steroid
- •
Pain medication
- •
- •
Ice or cryotherapy
- •
Avoidance of painful spinal motions (rest)
- •
Taping and therapeutic modalities (electrical stimulation)
- •
Education on log rolling, proper bed mobility, sit to stand transition, hip-hinging exercise for sit to stand and squatting
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Manipulation of thoracolumbar (T/L) junction for lower extremity pain modulation
- •
Side-lying manual distraction
- •
Grade I, II mobilization (pain control)
- •
Neural mobilizations
- •
Correction of standing lateral shift, if present ( Figure 19-4 )
FIGURE 19-4
Correction of lateral shift; pain-free manual correction (by therapist) of pelvis to correct left lateral shift in this patient.
- •
Exercises
- •
Pelvic neutral and transverse abdominal bracing, progression with LE movement with brace (start with 5 min then progress to 15 min total time with LE movements)
- •
If patient has an extension bias, begin with prone lying (start 5 min base time on patient’s symptoms decreasing)
- •
Body weight support unloaded walking on treadmill ( Figure 19-5 )
FIGURE 19-5
Body weight support walking on treadmill.
- •
Supine mechanical traction or inversion table for symptom relief (start with 25% of body weight for 20 to 30 min intermittent holds)
- •
Lumbar spine pain-free ROM
- •
Unloaded squats (using functional gym) (i.e. Total Gym)
- •
Soft Tissue Techniques
- •
Paraspinals myofascial release (MFR)
- •
Soft tissue mobilization (STM) to paraspinals ( Figure 19-6 )
FIGURE 19-6
Soft tissue paraspinal mobilization (STPM).
- •
Nerve gliding (patient directed) ( Figure 19-7 )
FIGURE 19-7
Patient-directed sciatic nerve gliding.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Stretching to limit of pain allowable
- •
Gentle hamstring and/or hip flexor stretching with protected spine position, being cautious of radicular symptoms
Other Therapeutic Exercises
- •
Encourage functional walking to tolerance
- •
Lower extremity strengthening to pain tolerance
- •
Education on wearing and removing LSO brace (as needed)
- •
Avoid sitting greater than 20 minutes
Activation of Primary Muscles Involved
- •
Lower extremity strength exercises are encouraged, as tolerated by pain level
- •
Proper activation of transverse abdominal, external obliques, multifidus, and gluteals
Milestones for Progression to the Next Phase
- •
Oswestry disability index (ODI), between 20% and 40%
- •
Able to sit and stand with spinal neutral mechanics
- •
Pain-free transitional movements (i.e., sit to stand, supine to sit)
- •
No lateral shift or acute lumbar kyphosis can be present (correct spinal position)
Phase II (weeks 2 to 6, Postinjury, variable progression dependent on herniation and patient factors)
Protection
- •
Retrain protective movement patterns (i.e., using lumbar roll with sitting, avoiding truck flexion with squatting and sit to stand)
- •
Wean from LSO brace (if used)
Management of Pain and Swelling
- •
Use of modalities (heat, electrical stimulation, taping)
- •
Decrease use of walking aids
- •
Pharmacological treatment
- •
NSAIDs
- •
Decrease use of narcotics
- •
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Mobilization and manipulation of thoracic spine, lumbar spine (opening, closing, and gapping techniques) ( Figure 19-8 )
FIGURE 19-8
Side-lying manual mobilization of lumbar facet joints (gapping).
- •
Mobilization of SI joint (supine, side lying, prone techniques), hips to correct hypomobility, and for pain modulation
- •
Muscle energy techniques (METs) for muscular recruitment or inhibition
- •
Side-lying lumbar distraction
Soft Tissue Techniques
- •
Paraspinals myofascial release (MFR), soft tissue mobilization (STM) surrounding neural tissue
- •
STM with movement to restore functional movement patterns
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Supine hamstring, hip flexor
- •
Figure four piriformis stretches
- •
Repeat Phase I with progressing to sitting, standing, and quadruped exercise
- •
Hip/back dissociation exercise (using biofeedback for proper spine alignment while moving at the hips) ( Figure 19-9 )
FIGURE 19-9
Hip/back dissociation using a stick to give biofeedback for proper spine alignment to allow hip to hinge in normal pattern and allow for proper spine mechanics.
Other Therapeutic Exercises
- •
Hip strengthening exercises
- •
Continue functional unloading on body weight support treadmill
- •
Body mechanics training and education
Activation of Primary Muscles Involved
- •
Lower extremity strength exercises are encouraged, as tolerated by pain level
- •
Proper activation of transverse abdominus, external obliques, multifidus, and gluteals
Sensorimotor Exercises
- •
Balance on unstable surfaces (rocker board, foam with neutral spine)
- •
Single leg balance (SLB) with resistive bands or pulleys four-way directions ( Figure 19-10 A,B )
FIGURE 19-10
A, B, Single leg balance with resistive bands.
Open and Closed Kinetic Chain Exercises
- •
Pelvic neutral using blood pressure cuff for biofeedback, advancing with lower extremity movements
- •
Quadruped neutral ( Figure 19-11 )
FIGURE 19-11
Quadruped neutral position.
- •
Pelvic neutral on the door with mini squats progressing to upper extremity movements with resistive bands
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Mini squat in pelvic neutral
- •
Total or Vigor Gym in pelvic neutral
- •
Standing lat pulldown with pelvic neutral
Neuromuscular Dynamic Stability Exercises
- •
Refer to OKC and CKC exercise
Functional Exercises
- •
Hip hinging series: sit, stand, squat, and stagger squat (keeping spine in position and movement comes from hinging at the hips as opposed to motion through spine)
- •
Proper log rolling for bed mobility
- •
Gait training
- •
Education on getting on/off floor
Milestones for Progression to the Next Phase
- •
Minimal daily symptoms
- •
Reduce ODI score <20%
- •
Able to perform ADLs
Phase III (weeks 6 to 12, Postinjury)
The majority of patients treated in a nonoperative treatment protocol will be advanced to return to sport after this phase. If they require additional treatment/cannot progress, they may require further evaluation and consideration for other treatment modalities (i.e., epidural steroid injection, surgery).
Protection
- •
Proper protective spine mechanics for high functional activities, return to work, and sport
Management of Pain and Swelling
- •
NSAIDs as needed
- •
Ice or cryotherapy prn
- •
E-stim/TENS, as necessary
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Mobilization and manipulation of thoracic spine, lumbar spine, SI joint, hips to correct hypomobility and for pain modulation
- •
Side-lying lumbar distraction
- •
Muscle energy techniques (METs) for muscular recruitment or inhibition
Soft Tissue Techniques
- •
Neural tissue mobilization
- •
Paraspinal MFR
- •
STM functional movement patterns
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Supine hamstring, hip flexor and piriformis stretches
Other Therapeutic Exercises
- •
Standing upper extremity exercises with cable with pelvic neutral ( Figure 19-12 )
Related posts:
Epiphyseolysis and Osteochondritis
Cervical Spine Disc Injuries
Lateral Collateral Ligament and Posterolateral Ligament Injuries
Superior Labral Pathology (SLAP/Long Head Biceps)
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
