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Lumbosacral Disc Herniation (L5-S1)

Prehab

  • RICE

  • Remain active up to comfort level

  • Prepare the patient mentally for outcomes of rehab

  • No twisting, bending, or lifting after surgery without approval by physician

  • Take NSAIDS

Erin Burges, Kayla Hughes, Taylor Kilmach

Herniated Disc

Evaluation

Return to Sport/Activity Phase ( 2 weeks to 6 months)

  • McKenzie Method

Goals

• Adequate strength and flexibility for return to sport

• Able to move through all planes of motion

Herniation occurs when the nucleus pulpous pushes through the annulus fibrosus ring

Recommended Exercises

• Continue daily exercises, stretching and cardio

• Progress into gym equipment and ball stabilization exercises

Return to sport when checked by PT or MD

  • Straight Leg Raise (SLR): gold standard for patients under 35
  • Anesthesia present in associated dermatomes
  • Manual muscle testing in the lower extermity
  • Knee and achilles (s1) tendon reflex
  • Femoral nerve stretch
  • The mannequin sign
  • Slump test

Guidelines

• Perform exercises 3 times a week, 2 sets of 15-20 reps

• Stretch daily for 2-3 reps of 30 seconds

• Cardio for 3-5 times a week for 20-30 minutes a day

• Sport specific activities and exercises

VanGelder, L. H., et al. (2013)

https://www.physio-pedia.com/Disc_Herniation

The professional athlete spine intiative: outcomes after lumbar disc herniation in 342 elite professional athletes

Lumbar disectomy for disc herniation in the lumbosacral region increased the length of a professional athletes career by 3.4 years. There was no significance difference noted for patients that undergo operative vs those who seek nonoperative treatment.

http://www.mckenzieinstitute.org/patients/what-is-the-mckenzie-method/

Sub-Acute Phase (3 days to 3 weeks)

Hsu, W. K., Mccarthy, K. J., Savage, J. W., Roberts, D. W., Roc, G. C., Micev, A. J., . . . Schafer, M. F. (2011)

Goals

Comparison of lumbar spine stabilization exercise versus general exercise in young male patients with lumbar disc herniation after 1 year of follow-up

Treatment Options

• Progression in activity levels, distance, and time

• Improve spinal flexibility

• Lower extremity strengthening

• Abdominal and pelvic stabilization exercises

Causes of Herniated Disc

Anatomy/Biomechanics

Recommended Exercises

Treatment depends on the symptoms experienced and evaluation and imaging results. The most common way of treating a disc is to begin with self healing and then going into surgery if symptoms continue.

The safest and most effective conservative treatment for patients with lumbar disc herniation (LDH) has not been established. Lumbar Spine Stabilization Exercise (LSSE) and general exercise (GE) can effectively reduce pain intensity in the lower back and legs, and improve functional capacity in patients. It was shown that long term, LSSE is more effective than GE in reducing pain intensity in the lower back, and in improving functional capacity. However, during the acute phase of lumbar disc herniation, physical therapy, such as low power laser therapy (LPL), is needed to relieve pain intensity. These results suggest that LSSE should be an essential component of the treatment plan for LDH patients, and that combination of LSSE with physical therapy, such as LPL, is an effective and performable program.

• Lower extremity stretching

• Spine stretches

• Core stabilization

• Hip exercises

• Bending and squatting

• Walking daily

• Isometric contractions against frontal and rotational movements

Rehabilitation Phase (1-6 weeks)

Medication

Body Healing on its Own

To reduce pain and symptoms and relax muscles that spasm as a result of herniation

  • Sudden forced hyperflexion or torsion
  • Whiplash
  • Poor posture
  • Obesity
  • Gender
  • Smoking
  • Heavy work
  • Driving/sitting for a long time

Goals

  • It is possible for the body to heal a herniated disc on its own
  • Heals with the natural phases of healing
  • Use the RICE method and avoid activities that aggrivate symptoms
  • Use heat to relieve muscle spasms when the inflammation is reduced

- Ibuprofen

- Nerve Pain Medications

- Injections (if oral medication is not effective)

- Muscle Relaxers

Minimally Invasive Microdiscectomy L5-S1

Guidelines

• Maximize strength and flexibility

• Initiate functional activities

Recommended Exercises

Surgery

(Ye, Ren, Zhang, Wang, Liu, Fang, Sun, 2015)

Physical Therapy

• Perform exercises 3 times a week, 2 sets of 15-20 reps

• Stretch daily for 2-3 reps of 30 seconds

• Functional movements

  • Recommended to treat pain and assist with function
  • Help target the cause of the stress on the back and fix those problems
  • Remain active without aggravating symptoms
  • Only for herniations that have a nerve compression or weakness
  • Only when conservative methods have not worked and hernia has gotten worse
  • Although disc herniations are common, surgery is not common in athletics
  • Could take 3 months to heal from minimally invasive surgery and 6 months to a year for open spine surgery
  • Lumbar disectomy vs. microdisectomy

Symptoms

VanGelder et al, (2013)

• Flexibility of spine and lower extremity

• Aerobic conditioning and cardio such as running, swimming, and the elliptical

• Strengthening of the lower extremity and hips

• Lunge and squat progression

• Able to use exercise machines

South Shore Hospital

Biomechanics

Guidelines

  • Central low back pain
  • Pain that radiates into the legs
  • Sensation changes in the hips or legs
  • Weakness in the muscles of the hips or legs
  • Muscle spasms

• Lifting, bending and reaching exercises

• Perform exercises 3 times a week, 2 sets of 15-20 reps

• Stretch daily for 2-3 reps of 30 seconds

• Cardio for 3-5 times a week for 20-30 minutes a day

• Full integration of transverse movement

Anatomy

VanGelder et al, (2013)

  • Lumbar spine is composed of 5 vertebrae and sacral spine composed of 5 vertebrae
  • The intervertebral discs are in between each vertebrae

- Named based on the vertebrae above and below it

- The most common are L4-5 and L5-S1

The spine performs

flexion, extension, rotation and lateral flexion

The sacrum provides strength and stability to the pelvis

Lumbar spine works to support compressive loads

www.youtube.com/watch?v=eW8zI_ib1-w

Return to sport after open and microdisectomy surgery versus conservative treatment for lumber disc herniation: a systematic review with meta-analysis

Return to sport in athletes who have undergone lumbar discectomy is 81% compared to the 76% returning after conservative treatment.

Studied professional athletes from the NFL, NBA, MLB, NHL.

Some studies report that lumbar disectormy results in a higher chance of return to play. However, the ability to return to prior level of play is significantly low at 36%.

Disc Anatomy

Reiman, M. P., Sylvain, J., Loudon, J. K., & Goode, A. (2016).

https://www.researchgate.net/figure/Anatomy-of-the-spine-with-view-of-the-disk-From-Anatomy-of-the-lumbar_fig4_280626099

https://www.southshorehospital.org/Workfiles/Medical_Services/Orthopedics/Lumbar_Disc_Herniation.pdf

Lumbar/Sacral Dermatomes

http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?27/24/28035

Thank You!

Course of Alternative and Integrative Therapy for Lumbar Disc Herniation and Risk Factors for Surgery: A Prospective Observational 5-Year Follow-Up Study

References

Imaging

Herniated Disc Types

Hsu, W. K., Mccarthy, K. J., Savage, J. W., Roberts, D. W., Roc, G. C., Micev, A. J., . . . Schafer, M. F. (2011). The Professional Athlete Spine Initiative: outcomes after lumbar disc herniation in 342 elite professional athletes. The Spine Journal, 11(3), 180-186. doi:10.1016/j.spinee.2010.12.009

Joon-Shik, Lee, Yoon, Me-reiong, Yong-jun, Park, Shin, Meyoung, & In-Hyuk. (2016). Long-Term Course of Alternative and Integrative Therapy for Lumbar Disc Herniation and Risk Factors for Surgery: A Prospective Observational 5-Year Follow-Up Study. Spine, 41(16), 955-963. doi: 10.1097/BRS.0000000000001494

Reiman, M. P., Sylvain, J., Loudon, J. K., & Goode, A. (2016). Return to sport after open and microdiscectomy surgery versus conservative treatment for lumbar disc herniation: A systematic review with meta-analysis. British Journal of Sports Medicine, 50(4), 221. http://dx.doi.org.libproxy.library.wmich.edu/10.1136/bjsports-2015-094691 Retrieved from http://libproxy.library.wmich.edu/login?url=https://search-proquest-com.libproxy.library.wmich.edu/docview/1779912680?accountid=15099

South Shore Hospital. (n.d.). Retrieved March 3, 2018, from http://www.southshorehospital.org/Workfiles/Medical_Services/Orthopedics/Lumbar_Disc_Herniation.pdf

VanGelder, L. H., Hoogenboom, B. J., & Vaughn, D. W. (2013). A PHASED REHABILITATION PROTOCOL FOR ATHLETES WITH LUMBAR INTERVERTEBRAL DISC HERNIATION. International Journal of Sports Physical Therapy, 8(4), 482–516.

Ye,Chaoqun., Ren, Jimin., Zhang,Jianzheng., Wang, Chongwei., Liu, Zhi., Fang, Li., & Sun,Tiansheng.(2015). Comparison of lumbar spine stabilization exercise versus general exercise in young male patients with lumbar disc herniation after 1 year of follow-up. Int J Clinical Exp Med, 8(6), 9869-9875.

In this article it talked about the controversy between the difference in long-term outcomes of conservative and surgical treatment. Long-term results of lumbar disc herniation patients receiving nonsurgical complementary and alternative medicine treatment were more beneficial in this case than patients who had surgery and then went through extensive rehab. The results showed that to assess pain, functional disability, surgical status, and overall health patients sought out complementary and alternative medicine treatment over the risk factors for lumbar surgery.

Bulging

extension of the disc margin beyond the margins of the adjacent vertebral endplates

  • MRI is the gold standard for positive diagnosis

  • CT scan

can report false postitive results in lumbosacral region

Protrusion

the posterior longitudinal ligament remains intact but the nucleus pulposus impinges on the anulus fibrosus

(Joon-Shik, Yoon, Yong-jun, Shin, 2016)

  • Bulging
  • Protrusion
  • Extrusion
  • Seqestrian

Extrusion

the nuclear material emerges through the annular fibers but the posterior longitudinal ligament remains intact

Sequestrian

the nuclear material emerges through the annular fibers and the posterior longitudinal ligament is disrupted. A portion of the nucleus pulposus has protruded into the epidural space

https://www.physio-pedia.com/Disc_Herniation

Acute Phase (1-7 Days)

Goals

• Control pain and inflammation

• Reduce muscle spasms

• Proper body positioning and movements in pain-free ROM

• Stay active

Recommended Exercises

• Stretching

• ROM

• Core muscle activation

• McKenzie Method Exercises

Guidelines

• Perform activities that minimize pain

• Find comfortable positions for sleep and sitting

• Posture education

VanGelder, L. H., Hoogenboom, B. J., & Vaughn, D. W. (2013)

http://www.mckenzieinstitute.org/patients/what-is-the-mckenzie-method/

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