Vous êtes sur la page 1sur 1
L5/S1 Disc Herniation in a 22-year-old Army ROTC Cadet Alice S Jose, ATS Indiana University, Bloomington,

L5/S1 Disc Herniation in a 22-year-old Army ROTC Cadet

Alice S Jose, ATS Indiana University, Bloomington, Indiana

L5/S1 Disc Herniation in a 22-year-old Army ROTC Cadet Alice S Jose, ATS Indiana University, Bloomington,

INTRODUCTION

UNIQUENESS

The purpose of this report is to present the successful nonsurgical treatment of a L5/S1 disc herniation used on a 22 year old male ROTC cadet at Indiana University. Common signs and symptoms of a herniated disc are low back pain that can also radiate to the lower limbs, loss of function, and numbness and tingling in the lower extremities. MRI’s are the visual means used in to officially diagnose a disk herniation in the spine. While, the use of surgery versus nonsurgical procedures for treatment of disc herniation remains controversial as to which method is better, in the United States lumbar discectomy is the most common surgical procedure performed for back and leg symptoms. 1 The choice between surgery and conservative, non-operative procedures, such as a rehabilitation program, should be individualized and dependent upon the severity of the patient’s signs and symptoms. Conservative, nonsurgical treatment has an advantage over surgical treatment because of the absence of surgical related complications. 2 However, research indicates that surgery is better and faster for short term recovery, however in the long run, there is no substantial evidence proving one is better than the other. 3 This case study utilized a rehabilitation plan in order to correct the patient’s herniated disc.

BACKGROUND

A 22-year-old Caucasian male Army ROTC Cadet and National Guard member experienced low back pain with radicular pain down the right leg. The patient has no previous history of back pathology. He noticed symptoms following dancing at a concert with his girlfriend on his shoulders approximately mid-April 2012. A week later he was seen by a doctor at the University Health Center. He was prescribed muscle relaxants and pain medications, which were ineffective. The patient reported back to the doctor early May and was prescribed an at home rehabilitation program including Mackenzie extension exercises to complete 1-2 times a week. While symptoms initially decreased, by mid-July he noted decreased sensation, numbness and tingling in his right lower extremity. Upon physician follow up, an MRI was ordered and showed L5/S1 right lateral disc extrusion compressing the S-1 nerve root. On August 29th the patient saw the IU ROTC Athletic Trainer, reporting that he hadn’t experienced pain for two weeks but felt pain with sudden movements and with increases in activity. Initial findings by the Athletic Trainer were: full but painful flexion, a positive straight leg raise, and a decreased right Achilles reflex. Dermatome testing for L5/S1 was positive in the right leg because patient reported a difference between sensations when compared bilaterally. All other dermatomes and myotomes were within normal limits.

DIFFERENTIAL DIAGNOSIS

Possible injuries included Disc pathology, Spondylosis/Spondylolisthesis, Tumor, Erector Spinae strain, or Osteomyelitis

TREATMENT

The physician diagnosed the patient with a L5/S1 disc herniation through the use of an MRI. Since being seen by the Athletic

Trainer, a rehabilitation program was put in to place for the patient. The program first focused on minimizing pain, working on core stability, extension exercises, and increasing lower leg strength. The next phase focused more on core strength, improving

proprioception and neuromuscular control, and cardiovascular strength. Following the patient’s release from physician’s care

cardiovascular activity should be progressed and strength and power may be addressed. However, the patient discontinued his attendance to treatment after the physician cleared him for full participation in ROTC and phase three was never completed. Overall, after 5 months the patient was able to regain full and painless range of motion and now participates fully in all ROTC activities.

Table 1: Phase Specific Rehabilitation Protocol

 
 

Goals:

Rehabilitation plan:

Phase I

  • 1. Decrease Pain

Pain: NSAIDs and Ice

  • 2. Increase ROM

ROM: McKenzie Extension Exercises

  • 3. Strengthen Core and Lower Extremity

Strengthening: Pelvic Neutral Exercises, Quadraped, Eccentric Calf Raises, Heel Taps

Phase II

  • 1. Decrease Pain

Pain: Ice

  • 2. Strengthen Core and Lower Extremity

ROM/Core: McKenzie Extension Exercises, Planks, Quadraped, 3 way

  • 3. Increase Cardiovascular Fitness

calf-raises

  • 4. Increase proprioception

  • 5. Maintain Neuromuscular Control

1

CV fitness: Stair Stepper

Proprioception/NM Control: CKC standing 4way tubing kicks, one legged balancing, Bosu-Ball Hip Bridging

2

Phase III

  • 1. Maintain Cardiovascular Fitness

CV Fitness: jogging progressing to running, swimming if available

 

1

  • 2. Increase Sport Performance

Sport Performance: Marching form, PT testing Form (pushups, sit-

  • 3. Maintain Core strength

ups)

Core: V-sits, Oblique Twists

When diagnosed by the physician, it was suggested to the patient that he have a tubular discectomy, however, the patient believed he was too young to have back surgery and opted for conservative therapeutic approach because of the benefits in the past. Through this conservative approach to his injury and despite the patient’s noncompliance, the patient is almost back to full activity. As of January 2013 the patient is able to participate completely in ROTC physical training.

DISCUSSION

During herniated disc treatment, the first concern addressed in phase 1 should be pain. Pain should be minimized and centralized. In other words pain caused by a sustained movement or stance is reduced to the only the site of the disc herniation. 4 This can be accomplished through the aid of exercise, specifically extension exercises, which are a part of the McKenzie Method, a method directed towards relieving pain caused by disc pathologies. 4,5 When pain can be centralized the chances for fast and complete recovery are good. 6 It is also important to avoid positions and motions that aggravate or reproduce the patient’s signs or symptoms. 5 In this case, the patient avoided flexion, which caused him pain. Medication can also be used as a method for pain relief. Initially, through his physicians care, the patient was prescribed and used muscle relaxants and analgesics but shortly discontinued use since they should only be used in the beginning of care and for a short period of time. 5, 7 Once the muscle relaxants and analgesics were no longer needed, the patient used non-steroidal anti-inflammatory drugs (NSAIDs) as needed to help control pain. Another option to control pain would be PreModulated electrical stimulation or high frequency sensory TENS application if the paraspinal muscles were not in spasm. 5 It also would have been beneficial to include traction which was not available for our patient. Traction decompresses the intervertebral disc and other neural structures that are pressing on the nerve root causing the patient’s pain. 8 Thus, traction can help to accelerate the centralization and diminishment of radicular pain, especially if combined with extension exercises. 9 Traction can also minimize the amount of bed rest needed in the beginning of treatment. 10 In addition to pain relieving efforts, our patient also completed core exercises during phase 1 of treatment and continued these throughout all phases of rehabilitation. One of the primary functions of the core muscles is trunk stabilization. Posture and spine stabilization are improved with the improvement of core strength. 11 By not stressing or putting the spine in a vulnerable position, proper postural alignment allows for the performance of activities of daily living (ADLs) without pain. 12 Another reason for improving core stabilization in patients with herniated discs is that the amount of force being applied to the spine is reduced by improving and maintaining proper posture through intervertebral stabilization. 11 Since our patient had limited time for treatment in the Athletic Training room we instructed him provided him with a home exercise plan that includes an emphasis on core and that coincides with the rehabilitation being done in the athletic training room. 13 The home exercise plan was beneficial for our patient as he was inconsistent with attending rehabilitation appointments in the clinic. After our patient had reduced his pain and progressed in his core exercises he was progressed to phase 2. During this phase two key elements that were concentrated on were proprioception and neuromuscular control. These elements are critical to restore in a patient with a low back injury in order to prevent future re-injury. These concepts should be continued into phase 3 as well. We had our patient utilize unstable surfaces while performing exercises because it is believed to enhance proprioception. Proprioception occurs because the unstable surface stimulates sensory input to the CNS, thereby evoking an efferent response that improves specific muscle activation and dynamic stability. 14 It is also thought that an unstable surface causes the body to work harder at maintaining a stable position. 14 Bosu ball activities and closed-kinetic-chain (CKC) tubing kicks are specific examples of such neuromuscular control exercises utilized by our patient. CKC tubing kicks activate the core muscles to help the body maintain stabilization which will then improve coordination and awareness of the body. 15 During the course of the rehabilitation process, maintaining cardiovascular fitness and strength is important to help the patient to return to his previous level of performance in a timely fashion. Cardiovascular (CV) fitness can be started only once cleared by the patient’s physician but typically in phase 2 of the rehabilitation plan. In this case, the patient utilized the stair stepper because CV activities with minimal load on the spine are best. 7 In addition to CV fitness, maintaining strength in the extremity effected by nerve inhibition is important. In our case, the lower leg musculature was weakened due to neuromuscular inhibition so exercises were incorporated such as calf raises and heel taps to maintain strength.
3 In phase 3 CV fitness, power, and strength are typically addressed. However, due to our patient’s noncompliance, his care was discontinued when he stopped coming into his scheduled treatment times. The treatment of this patient was highly successful despite the lack of compliancy. He was released from physician’s care, as well as the Athletic Trainer’s, and participates fully in all ROTC activities without reproducing signs or symptoms.

CONCLUSION

Goals of lumbar disc herniation rehabilitation should be individualized and based symptomatically. Surgical treatment is not necessary for patients showing success with conservative treatment. Overall focus of the conservative rehabilitation program should be to reduce pain, strengthen the core, improve proprioception and neuromuscular control, as well as maintain fitness and strength. If a patient is noncompliant or does not have the ability to access an Athletic Training room the presiding Athletic Trainer should supply his or her patient with an at home rehabilitation program.

L5/S1 Disc Herniation in a 22-year-old Army ROTC Cadet Alice S Jose, ATS Indiana University, Bloomington,
L5/S1 Disc Herniation in a 22-year-old Army ROTC Cadet Alice S Jose, ATS Indiana University, Bloomington,
L5/S1 Disc Herniation in a 22-year-old Army ROTC Cadet Alice S Jose, ATS Indiana University, Bloomington,

Figure 1: Quadraped Bird/Dog, Forward Plank, & Bosu Ball Hip Bridging performed by the cadet patient for Core Stabilization. Taken by: Alice Jose

REFERENCES

  • 1. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs Nonoperative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial. JAMA. 2006;296(20):2441-2450. Accessed January 22, 2013.

  • 2. Cakir B, Schmidt R, Reichel H, Käfer W. Lumbar disk herniation: what are reliable criterions indicative for surgery?. Orthopedics. 2009;32(8):589.

  • 3. Jacobs W, van Tulder M, Peul W, et al. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. European Spine Journal [serial online]. April 2011;20(4):513-522. Available from: Academic Search Premier, Ipswich, MA. Accessed January 22, 2013.

  • 4. May S, Donelson R. Evidence-informed management of chronic low back pain with the McKenzie method. Spine J. 2008;8(1):134-41.

  • 5. Kolar K. Lumbar-Disk Herniations: Conservative Clinical Applications. Athletic Therapy Today [serial online]. September 2005;10(5):26-30. Available from: SPORTDiscus with Full Text, Ipswich, MA.

  • 6. Skikid EM, Suad T. The effects of McKenzie exercises for patients with low back pain, our experience. Bosn J Basic Med Sci. 2003;3(4):70-5.

  • 7. Deyo R, Loeser J, Bigos S. Herniated Lumbar Intervertebral Disk. Annals Of Internal Medicine [serial online]. April 15, 1990;112(8):598. Available from: Academic Search Premier, Ipswich, MA.

  • 8. Gay RE, Brault JS. Evidence-informed management of chronic low back pain with traction therapy. Spine J. 2008;8(1):234-42.

  • 9. Gagne AR, Hasson SM. Lumbar extension exercises in conjunction with mechanical traction for the management of a patient with a lumbar herniated disc. Physiother Theory Pract. 2010;26(4):256-66.

    • 10. Cyriax J. Refresher course for general practitioners: the treatment of lumbar disk lesions. J Orthop Sports Phys Ther. 1990;12(4):163-9.

    • 11. Hibbs A, Thompson K, French D, Wrigley A, Spears l. Optimizing Performance by Improving Core Stability and Core Strength. Sports Medicine [serial online]. December 2008;38(12):995-1008. Available from: SPORTDiscus with Full Text, Ipswich, MA.

    • 12. Bakhtiary A, Safavi-Farokhi Z, Rezasoltani A. Lumbar stabilizing exercises improve activities of daily living in patients with lumbar disc herniation. Journal Of Back & Musculoskeletal Rehabilitation [serial online]. July 2005;18(3/4):55-60. Available from: SPORTDiscus with Full Text, Ipswich, MA.

    • 13. Petrofsky J, Batt J, Rendon A, et al. Improving the outcomes after back injury by a core muscle strengthening program. Journal Of Applied Research [serial online]. February 2008;8(1):62-75. Available from: CINAHL Plus with Full Text, Ipswich, MA.

    • 14. Harrison B, Hart J. Reactive Neuromuscular Training in Low-Back Pain Rehabilitation: Part One. Athletic Training & Sports Health Care: The Journal For The Practicing Clinician [serial online]. November 2010;2(6):253-254. Available from: SPORTDiscus with Full Text, Ipswich, MA.

    • 15. Imai A, Kaneoka K, Shiraki H, et al. Trunk Muscle Activity During Lumbar Stabilization Exercises on Both a Stable and Unstable Surface. Journal Of Orthopaedic & Sports Physical Therapy [serial online]. June 2010;40(6):369-375. Available from: SPORTDiscus with Full Text, Ipswich, MA.