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 discs 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, exibility 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 specic type of exercise (exion, 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/exibility. 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 exibility may improve back specic function.

They also concluded that exercise-based treatments aim to utilize the benets 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 benet. Thus, according to Liddle, Baxter and Gracey (2004), in chronic low back pain, its essential for supervised trunk strengthening or stabilisation exercises, incorporating exibility to improve back specic 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 multidus (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 signicant 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 signicantly 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 ndings 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 exibility 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 classication-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 classication-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. Its only that Liddle, Baxter and Gracey (2004) have concluded that in chronic low back pain, its essential for supervised trunk strengthening or stabilisation exercises, incorporating exibility to improve back specic 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 Kindergartens 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, Im using the Numeric Rating Scale (NRS) to measure the pain or quantify the patients 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). Im 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 patients 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 patients 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 patients 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, Ive done with the palpation on patients 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 patients 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 patients 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, Ive 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 patients 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, Im 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, Im 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 patients 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. Physiotherapists 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 Jandas 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 patients 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 kindergartens 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, Im 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, Im 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 bodys natural painkillers. The initial exercises that are prescribed should be directed away from any movement that aggravates the patients 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 patients 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. Its 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, its 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 peoples 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. Im using NRS because NRS is highly accurate for quantifying a patients 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, Im also use other outcome measure which is the back specic function questionnaire called Oswestry Questionnaire. These instruments reect 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, Im using Oswestry Questionnaire to see patients 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, Ive 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 patients 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 muscles 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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