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Conservative Management of Lumbar Disc Herniation with Radiculopathy: a Case Report Mary Joyce Barthel University of North Dakota

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Conservative Management of Lumbar Disc Herniation with Radiculopathy: a Case Report Mary Joyce Barthel University of North Dakota University of North Dakota UND Scholarly Commons Physical Therapy Scholarly Projects Department of Physical Therapy 2018 Conservative Management of Lumbar Disc Herniation with Radiculopathy: A Case Report Mary Joyce Barthel University of North Dakota Follow this and additional works at: https://commons.und.edu/pt-grad Recommended Citation Barthel, Mary Joyce, "Conservative Management of Lumbar Disc Herniation with Radiculopathy: A Case Report" (2018). Physical Therapy Scholarly Projects. 520. https://commons.und.edu/pt-grad/520 This Scholarly Project is brought to you for free and open access by the Department of Physical Therapy at UND Scholarly Commons. It has been accepted for inclusion in Physical Therapy Scholarly Projects by an authorized administrator of UND Scholarly Commons. For more information, please contact [email protected]. CONSERVATIVE MANAGEMENT OF LUMBAR DISC HERNIATION WITH RADICULOPA THY: A CASE REPORT by Mary Joyce Barthel Bachelor of Arts in Biology Saint Mary's University of Minnesota, 2015 A Scholarly Project Submitted to the Graduate Faculty of the Department of Ph ysical Therapy School of Medicine University of North Dakota in partial fulfillment of the requirements for the degree of Doctor of Physical Therapy Grand Forks, North Dakota May 2018 This Scholarly Project, submitted by Mary Joyce Barthel in partial fulfillment of the requirements for the Degree of Doctor of Physical Therapy from the University of North Dakota, has been read by the Advisor and Chairperson of Physical Therapy under whom the work has been done and is hereby approved. clhnwon !UdM- (Graduate School Advisor) ( Chairperson, ) 11 PERMISSION Title Conservative Management of Lumbar Disc Herniation with Radiculopathy: A Case Report Department Physical Therapy Degree Doctor of Physical Therapy In presenting this Scholarly Project in partial fulfillment of the requirements for a graduate degree from the University of North Dakota, I agree that the Department of Physical Therapy shall make it freely available for inspection. I further agree that pem1ission for extensive copying for scholarly purposes may be granted by the professor who supervised my work or, in her absence, by the Chairperson of the department. It is understood that any copying or publication or other use of this Scholarly Project or part thereof for financial gain shall not be allowed without my written permission. It is also understood that due recognition shall be given to me and the University of North Dakota in any scholarly use which may be made of any material in this Scholarly Project. Signature Date 111 TABLE OF CONTENTS LIST OF FIGURES .. ........... ... ......... ..... .... ............ .... ... .................. v LIST OF TABLES • •.. • ..• .• . • . • ..• • . .. •. ... • . .. • .. • . .•.. ..•..• ..• .. ...• ..• ...... VI ACKNOWLEDGEMENTS .............. ............ ... ..... .. .......... ...... .. ..... ..vii ABSTRACT ... ... ................... ... ....... ... .. ........... ..... .. ... ....... .... ...... Vill CHAPTER I. BACKGROUND AND PURPOSE ........................... 1 II. CASE DESCRIPTION ..... ..... .... ....... .. ....... .... ....... 4 Examination ..... .. ...... .... ...... .... .............. ..... .........6 Evaluation and Diagnosis .... ... ... .. ... ..... ......... .. .... .... 8 Prognosis and Plan of Care .............. ... ... ... ... ..... ... ...8 III. INTERVENTION ... .... ......... ..... ... .. .. ................. 10 IV. OUTCOMES ..... .. ...... .. .. .. .... .... ..... ... .... ... .. ... .. .. 14 V. DISCUSSION ...... ........... ... .... ... ... ... .... .. ...... ... .. .17 Reflective Practice .. ..... .. .... ... .... ..... .. .. ... ..... ... .. ... 19 REFERENCES .... ........ .......... .... .... ..... ... ... .... ... .... .. ... .... .. ............. 21 ) --~ IV LIST OF FIGURES 1. OSWESTRY SCORE VARIATION DURlNG EPISODE OF CARE ............. 14 v LIST OF TABLES 1. SUMMARY OF SPECIAL TEST FINDINGS .... ... ...... .. ... ... ... .. ... .. ...... ... .7 2. SUMMARY OF DIRECTIONAL PREFFERENCE TESTING .................. .. .. 8 3. THERAPEUTIC EXERCISES PERFOMRED DURING INTERVENTION .. .. lO 4. INTERMITTENT MECHANICAL TRACTION PROTOCOLS ......... .... ...... 12 Vi ACKNOWLEDGEMENTS I would like to thank my advisors, Schawnn Decker and Michelle Labrecque, for their knowledge and guidance throughout this project. I would also like to extend a thank you to Kelsie Gunnufson for her assistance in editing this case report. Finally, to my family, friends, and classmates, thank you for your endless love and support throughout my many years of education. Vll ABSTRACT Background and Purpose: Low back pain affects millions of people annually. The most conmlon cause of low back pain is intervertebral disc hemiation and is often accompanied by radiculopathy symptoms in one or both lower extremities. Patients with disc hemiation are typically prescribed conservative management prior to surgical intervention. Case Description: The patient in this case report was a 53-year-old female diagnosed with a posterior-lateral hemiation of the L5-S 1 vertebral disc. Her chief complaint was pain in her low back with radiating pain into the right buttock, with occasional peripheralization of symptoms down her right lower extremity to the lateral knee and toes. Intervention: The patient was seen in physical therapy 2 times a week for 5 weeks for conservative management. Interventions used during the episode of care included therapeutic exercise, mechanical traction, and patient education. Outcomes: At the end of 5 weeks of treatment, the patient did not see any functional improvement and was discharged to undergo elective spinal surgery. The patient did, however, report improvement of pain symptoms following the use of mechanical traction. Discussion: Conservative management prior to surgical intervention remains a controversial topic. The patient in this case reported satisfaction following application of mechanical traction which may suggest possible clinical benefits of this intervention for pain relief in patients with intervertebral disc pathologies. However, the length of conservative treatment such as mechanical traction and therapeutic exercise required to show successful functional recovery from disc hemiation needs further research. VUt CHAPTER 1 BACKGROUND AND PURPOSE Low back pain is a common musculoskeletal problem faced by many people. In 2002, the National Health Interview Survey (NHIS) 1 showed that 26.4 percent of Americans surveyed reported at least one episode of back pain within the last three months. This corresponds to approximately 54 million adult Americans with low back pain each year. The origin of low back pain varies and may include: structural changes in the spine or pelvis, neurological lesions, congenital deformities, and/or systemic diseases. 2 J The most common cause of low back pain in adults is intervertebral disc herniation. 3 The term herniation is used to describe the displacement of disc material (nucleus pulposus and/or annulus fibrosus) beyond its natural border and into the spinal column which may result in spinal cord or nerve root compression that can manifest into neurological symptoms.4 Patients with lumbar disc herniation may experience a variety of symptoms depending on the level of lesion and severity of nerve root compression. In addition to pain in the low back, patient may experience radicular pain and numbness that travels distally into one or both lower extremities, following the distribution of the nerve root indicating neurological involvement. Patients may also exhibit motor deficits such as muscle weakness, matching the myotome pattern corresponding to the level of disc herniation. Patients diagnosed with lumbar disc herniation are often referred to physical 1 therapy by their primary care physicians for evaluation and trial of conservative treatment, prior to attempting more invasive treatment options.4 Effective treatment for low back pain remains a controversial topic among therapists. Some research suggest that non-pharmacologic therapies show effective moderate relief of symptoms for patients with low back pain. These therapies include exercise therapy, massage therapy, yoga, progressive relaxation, and spinal manipulation.5 Another source has shown that many conservative therapies, apart from therapeutic exercise, are not as effective as once previously thought. In 200 1, a Philadelphia Panel6 performed a review of many popular treatment prescriptions for patients with low back pain. The treatments they reviewed included: thermotherapy, therapeutic massage, therapeutic exercises, electromyographic biofeedback, mechanical traction, ultrasound, TENS, electrical stimulation, and combined rehabilitation interventions. They found that therapeutic exercise was beneficial for patients with chronic, subacute, and postsurgical low back pain. Continuation of normal activities was shown to be superior to bedrest. There was insufficient evidence to support the inclusion or exclusion of the other 8 therapies in the treatment of low back pain in physical therapy. Traction is another conservative treatment approach common for patients with low back pain, especially those with herniated lumbar disc. 7 Sari Akarirmak and colleagues8 evaluated structural changes to the lumbar spine during mechanical traction in patients with lumbar disc herniation. They found a 25% reduction in disc herniation as well as a 22% increase in spinal canal area and 27% widening of the vertebral foramina. I~ 2 These
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