Physical Therapy Protocols

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                      Herniation of the nucleus pulposus occurs when the nucleus pulposus (gel-like substance) breaks through the anulus fibrosus (tire-like structure) of an intervertebral disc (spinal shock absorber).

• A herniated disc occurs most often in the lumbar region of the spine especially at the L4-L5 and L5-S1 levels (L = Lumbar, S = Sacral). This is because the lumbar spine carries most of the body's weight.
• Significant herniation occurs most often through a posterolateral defect, but midline herniation is also common. [1] 
• People between the ages of 30 and 50 appear to be vulnerable because the elasticity and water content of the nucleus decreases with age.
• Associated risk factors for lumbar disk disease include
  • advanced age
  • vigorous exercise for more than 15 years or in persons over 20 years of age, vigorous exercise for less than one year
  • sedentary work
  • history of back trauma
  • male sex
  • obesity
  • cigarette smoking

 ♦ Stages of Disc Herniation:

The four stages to a herniated disc include:

• Disc Degeneration - chemical changes associated with aging causes discs to weaken, but without a herniation.
• Prolapse - the form or position of the disc changes with some slight impingement into the spinal canal. Also called a bulge or protrusion.
• Extrusion - the gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc.
• Sequestration or Sequestered Disc - the nucleus pulposus breaks through the annulus fibrosus and lies outside the disc in the spinal canal (HNP).

 Stages of Disc degeneration as revealed by Discograms: [2]

 ♦ Pathophysiology & Risk Factors of Disc Herniation:

• Prolonged sitting imposes mechanical stress on the spinal column and contributes to general deconditioning of the lumbar musculature. [3]
• Repeated microtrauma may lead to cumulative degeneration of the lumbar disk. [3]
• A history of back injury has been found to be a statistically significant factor in symmetric degeneration of the disk. A history of back trauma also correlates with an increased incidence of annular rupture. [3]
• Chronic inflammation has also been suggested as an etiology of back pain, in addition to chronic mechanical pressure on the annulus and nerve root entrapment.
• Chronic inflammation in the region of a herniated disk may be autoimmune in origin. The annulus pulposus is normally isolated from the body's immune system until a traumatic or disease-associated event results in growth of granulation tissue. As the nucleus pulposus becomes accessible to the vascular system, an autoimmune response occurs, leading to chronic inflammation in the area.
• The mechanical trauma that results in fissuring within the disk and herniation through the annulus fibrosus could stimulate a reparative response, allowing ingrowth of granulation tissue and contact with the immune system. The liberation of phospholipase [A.sub.2] from a herniated disk could also cause direct inflammation in the surrounding region.
• The autoimmune theory for disk degeneration is supported by the frequent coexistence of cervical and lumbar disk disease at various levels. [3,4,5,6,7,8]

 ♦ Symptoms of Disc Herniation:

• Symptoms of a herniated disc vary greatly depending on the position of the herniated disc and the size of the herniation.

• If the herniated disc is:

  • Not pressing on a nerve, you may have an ache in the low back or no symptoms at all.

  • Pressing on a nerve, you may have pain, numbness, or weakness in the area of your body to which the nerve travels.

    • With herniation in the lower (lumbar) back, sciatica may develop. Sciatica is pain that travels through the buttocks and down a leg to the ankle or foot because of pressure on the sciatic nerve. Low back pain may accompany the leg pain.

    • With herniation in the upper part of the lumbar spine, near the ends of the lowest ribs, you may have pain in the front of the thigh.

    • With herniation in the neck (cervical spine), you may have pain or numbness in the shoulders, arms, or chest.

• Leg pain caused by a herniated disc:

  • Usually occurs in only one leg.

  • May start suddenly or gradually.

  • May be constant or may come and go (intermittent).

  • May get worse ("shooting pain") when sneezing, coughing, or straining to pass stools.

  • May be aggravated by sitting, prolonged standing, and bending or twisting movements. [9] 

  Intradiscal Pressure in Various Positions - Upload a Document to Scribd

  • May be relieved by walking, lying down, and other positions that relax the spine and decrease pressure on the damaged disc. [9]

• Nerve-related symptoms caused by a herniated disc include:

  • Tingling ("pins-and-needles" sensation) or numbness in one leg that can begin in the buttock or behind the knee and extend to the thigh, ankle, or foot.

  • Weakness in certain muscles in one or both legs.

  • Pain in the front of the thigh.

  • Weakness in both legs and the loss of bladder and/or bowel control, which are symptoms of a specific and severe type of nerve root compression called cauda equina syndrome. This is a rare but serious problem, and a person with these symptoms should see a doctor immediately.

• Other symptoms of a herniated disc include severe deep muscle pain and muscle spasms.

  ♦ Clinical Examination for Disc Herniation:

• The symptoms related to spinal disorders must be differentiated from those of other potentially serious conditions, including metastatic and rheumatologic disorders, fracture and infection.
• The AHCPR recommendations are based on "red flags" for spinal fracture, cancer or infection which are as follows: [10]

• In general, if a disc herniation is responsible for the back pain, the patient can recall the distinct time of onset and contributing factors, whereas if the pain is of a gradual onset, other degenerative diseases are more probable than disc herniation.
• The onset of symptoms is characterized by a sharp, burning, stabbing pain radiating down the posterior or lateral aspect of the leg, to below the knee.
• Pain is generally superficial and localized, and is often associated with numbness or tingling.
• In more advanced cases, motor deficit, diminished reflexes or weakness may occur.
• Generally, only the relatively uncommon central disc herniation provokes low back pain and saddle pain in the S1 and S2 distributions.
• A central herniated disc may also compress nerve roots of the cauda equina, resulting in difficult urination, incontinence or impotence.
• The medical history and physical examination may disclose bowel or bladder dysfunction.
• Pain caused by low back strain is exacerbated during standing and twisting motions, whereas pain caused by central disc herniation is worse in positions (such as sitting) that produce increased pressure on the anular fibers.
• PHYSICAL & NEUROLOGIC EXAMINATION:
  • Any external manifestation of pain - abnormal stance
  • Patient's posture and gait should be examined for sciatic list, which is indicative of disc herniation.
  • Spinous processes and interspinous ligaments should be palpated for tenderness
  • Range of motion should be evaluated.
    • Pain during lumbar flexion suggests discogenic pain, while pain on lumbar extension suggests facet disease.
    • Ligamentous or muscular strain can cause pain when the patient bends contralaterally.
  • Motor, sensory and reflex function should be assessed to determine the affected nerve root level.
    Dermatomes of Lower Limb - Upload a Document to Scribd

• Examination of the lumbar spine by neurologic levels is helpful in locating the source of the patient's symptoms.
• Specific movements and positions that reproduce the symptoms should be investigated during the examination to help determine the source of the pain.
• Nerve root tension signs are often used in the evaluation of patients suspected of having a herniated disc.
• The straight-leg raising test is performed with the patient in the supine position.
  • The physician raises the patient's legs to approximately 90 degrees.
  • Normally, this position results in only minor tightness in the hamstrings.
  • If nerve root compression is present, this test causes severe pain in the back of the affected leg and can reveal a disorder of the L5 or S1 nerve root.
• A crossed straight-leg raising test may also suggest nerve root compression.
  • In this test, straight-leg raising of the contralateral limb reproduces more specific but less intense pain on the affected side.
• In addition, the femoral stretch test can be used to evaluate the reproducibility of pain.
  • In this test, the patient lies in either the prone or the lateral decubitus position.
  • The thigh is extended at the hip, and the knee is flexed.
  • Reproduction of pain suggests upper nerve root (L2, L3 and L4) disorders.
• Attention should also be paid to any nonorganic physical signs (Waddell signs), which may identify patients with pain of a psychologic or socioeconomic basis.
  • WADDELL SIGNS: [11]
    • Superficial tenderness to light touch in the lumbar region or widespread tenderness to deep palpation in the nonanatomic distributions.
    • Increased symptoms with simulated axial loading or simulated rotation tests.
    • Inconsistent supine and sitting straight leg raising tests.
    • Regional weakness or sensory abnormalities that are not myotomal or dermatomal.
    • Physical overreaction or disproportionate verbalization during assessment. 

   ♦ Diagnosis of Disc Herniation:

  » Radiograpghs:

  The major finding on plain radiographs of patients with a herniated disc is decreased disc height. Radiographs have limited diagnostic value for herniated disc because degenerative changes are age-related and are equally present in asymptomatic and symptomatic persons. [12]

  » CT Scan:

  Neurodiagnostic imaging modalities reveal abnormalities in at least one third of asymptomatic patients. [13] For this reason, computed tomography (CT) also has limited diagnostic value for herniated disc.

  » MRI:

  The gold standard modality for visualizing the herniated disc is magnetic resonance imaging (MRI), which has been reported to be as accurate as CT myelography in the diagnosis of thoracic and lumbar disc herniation. [14] MRI has the ability to demonstrate damage to the intervertebral disc, including anular tears and edema in the adjacent end plates.

  ♦ Conservative Management of Disc Herniation:

                   This topic is related to POST-OPERATIVE REHABILITATION after Surgical Procedures for Disc Herniation, so we will not discuss the conservative management in deep but will have few videos from Dr. Ron (Chiropractor) for this part.

1. Spencer DL. Lumbar intervertebral disc surgery. In: Bridwell KH, DeWald RL, eds. The textbook of spinal surgery. Vol 2. Philadelphia: Lippincott, 1991:675-93.
2. Adams, M.A., Dolan, P., Hutton, W.C. The Stages of Disc Degeneration as Revealed by Discograms. The Journal of Bone & Joint Surgery, 1986, 68 (1), 1035.
3. Vlok, G.J., Hendrix, M.R. The lumbar disc: evaluating the causes of pain. Orthopedics 1991;14:419-25.
4. Deyo, R.A., Loeser, J.D., Bigos, S.J. Herniated lumbar intervertebral disk. Ann Intern Med 1990; 112:598-603.
5. Spencer, D.L. Lumbar intervertebral disc surgery. In: Bridwell KH, DeWald RL, eds. The textbook of spinal surgery. Vol 2. Philadelphia: Lippincott, 1991:675-93.
6. Miller, J.A., Schmatz, C., Schultz, A.B. Lumbar disc degeneration: correlation with age, sex, and spine level in 600 autopsy specimens. Spine 1988;13:173-8.
7. Gordon, S.J., Yang, K.H., Mayer, P.J., Mace, A.H. Jr., Kish, V.L., Radin, E.L. Mechanism of disc rupture. A preliminary report. Spine 1991;16:450-6.
8. Jacobs, B., Ghelman, B., Marchisello, P. Coexistence of cervical and lumbar disc disease. Spine 1990;15:126-4.
9. Humphreys, C.S., Jason, C.E. Clinical Evaluation and Treatment Options for Herniated Lumbar Disc. American Family Physician, 1999, 59 (3).
10. Bigos, S.J. Acute low back problems in adults. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994; AHCPR publication no. 95-0642.
11. Waddell, G., Somerville, D., Henderson, I., Newton, M. Objective clinical evaluation of physical impairment in chronic low back pain. Spine 1992;17: 617-28.
12. Bell, G.R., Ross, J.S. Diagnosis of nerve root compression. Myelography, computed tomography, and MRI. Orthop Clin North Am 1992;23:405-19.

Note: Videos are by Dr. Ron from Heal your Buldging Disc.