|
|
Re: treatment of acute lumbar disc herniations
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
Re: treatment of acute lumbar disc herniations - February 9, 2003 6:36:00 PM
|
|
|
Sam Betts
Posts: 37
Joined: January 30, 2003
From: Peoria, IL, USA
Status: offline
|
Hi Doug,
I am curious as to why , from a theoretical point of view, extension exercises bring back muscle strength and reflexes, given that reduced reflexes means compression or irritation of the spinal nerve/ thecal sac?
Also, have you ever had patients have less pain after doing extensions, but subsequent decreased reflexes and sensation? i.e, how do you chose which disc prolapses you extend? Do you base it on response to repeated or sustained positions giving centralization of pain? Or, response via improvement in reflexes, sensation, SLR testing etc.... Because, I wonder, how much, from an objective point of view relief of leg pain has to do with the prognosis for one with a prolapsed disk.
From a functional point of view , when you say "eliminate any leg length discrepancies", do you mean via a heel lift, or by reducing spasm causing an apparent leg length discrepancy from a scoliotic shift?
It is interesting that it works, and puzzles me as to "how' it does. I know a lot of astute clinicians say that it does work, as you have pointed out.
The "OGI" stands for the Ola Grimsby Institute.It is a consortium of Manual Therapists from around the world, and Ola Grimsby founded it. Ola helped set up the AAOMPT with Stanley Paris, Mike Rogers, Dick Erhard and some others that I apologize forgetting the names of. You can learn about it at [URL=http://www.olagrimsby.com]http://www.olagrimsby.com[/URL]
Looking forward to your input again.
Sam Betts
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 9, 2003 10:00:00 PM
|
|
|
Bournephysio
Posts: 585
Joined: April 25, 2002
From: Calgary
Status: offline
|
I usually default to neurophysiologic mechanisms but for extension exercises my pet theory (read: I probably don't have a clue) is that the repetitive extension "pumps" out some of the swelling.
I don't think that I've had a patient who responded with less pain but decrease strength or reflexes. If I did I probably wouldn't get the patient to do the exercise. I usually only use repeated movements if they decrease pain/centralizes but if the pain doesn't get much worse doesn't peripheralize and reflexes/strength is better, I would get them to do the exercises at home and reassess in a couple of days.
I was talking about using leg lifts. I've seen a study that correlated radiographic lld with back pain. Ideally a lift would "correct" the discrepancy and remove the stress it puts on the back. Considering that it is hard to measure leg length at the best of times and even more difficult in listed patients, it probably just changes the distribution of forces enough to take the stress off the damaged tissues.
I've heard of Ola Grimsby just didn't recognize the initials.
Doug
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 11, 2003 4:49:00 AM
|
|
|
Inspired
Posts: 36
Joined: April 11, 2002
From: Biddeford, ME, USA
Status: offline
|
My participation in this discussion is only for my information - my early student status disqualifies my from adding intelligently to this thread. BUT, I was told yesterday by a rehab MD that I'm seeing that I have a small herniation in my L5-S1. He suggested IDET - I've done a bit of research but thought mayboe someone would like to comment on it here as it pertains to decreasing pain caused by herniation. Thanks!
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 11, 2003 6:42:00 AM
|
|
|
PTupdate.com
Posts: 1477
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
I guess the first question to ask is "are you sure the pain is coming from the small hernation?"
Numerous studies have indicated that bulging/herniation does not always correlate to symptomology. In fact, just yesterday I reviewed my own recent MRI and compared it to one 2 years ago. Sure enough, the large L5-S1 fragment is completely gone. There is still decent bulging of L4-5 and L5-S1, and even some white uptake in the vertebral end plates. Do I have any pain? Nope.
There is still far too many questions as to what is the cause of a persons pain. Is it the simple physical contact? Probably not, but rather a mixture of physical contact, deformation, edema in the DRG, and histochemical alterations.
How does/can our PT alter any of these? That part is what we are discussing. However, I think most of us believe there are roles we can play, and we do not all agree on these roles. However, the trend remains: People with HNP have pain and dysfunction, and in cases where it does not change on its own or with meds, PT quite often helps.
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 11, 2003 10:10:00 AM
|
|
|
Sam Betts
Posts: 37
Joined: January 30, 2003
From: Peoria, IL, USA
Status: offline
|
Ditto John! [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 11, 2003 11:35:00 AM
|
|
|
mcap56
Posts: 619
Joined: October 26, 2002
From: New York, NY
Status: offline
|
Inspired:
You should never hesitate to share your opinion......no matter where you are in your career.
As for your Physician's suggestion of IDET.......it was, in my opinion, very, very inappropriate for a variety of reasons.
1. We don't know whether your small herniation is even causing your pain. The false positive rate is very high. Furthermore, size of the herniation often has very little relationship to prognosis. A large one can be asymptomatic and a small one can be disabling and visa versa. IDET candidates require a discogram to rule in or rule out the disc in question. A discogram is an invasive, sometimes very painful procedure.
2. The natural history of lumbar disc hernaitions is very, very favorable. Especially if you are in the acute phase, there is NO way IDET should even be considered in the acute or subacute stages.
Read the article on the natural history of lumbar disc herniations by Saul (the actual inventor of IDET). They usually do well over time. Indications for more aggressive treatment usually include significant neuro deficits, progressive neuro deficits, red flags and/or severe disabling pain. In 10 years, there is usually no difference between those who had surgery and those who didn't.
3. IDET is used in cases of internal disc disruption where there is no surgical access to the disc. In the case of a herniation, a microdiscectomy is the procedure of choice. But no aggressive intervention is warrented without the indications listed above.
4. IDET is a relatively new, unproven procedure. They have no idea what long term effects the damage to disc will have and how the biomechanics change.
5. As studies get more and more rigorous, the results become less and less promising. Recently, in a study by Bogduk et al, a similar treatment using radiofrequency to heat the disc demonstrated no significant improvement over sham procedure.
6. The post-IDET protocol is very restrictive and the patient will have to avoid flexion for months. Makes me wonder what would happen if you took IDET candidates, didn't do the procedure, but still kept them from flexing for a few months.
7. At a spine conference last summer one of the physician presenters called the procedure "awful."
8. IDET, in my opinion, should be considered in cases of chronic internal disruption as an alternative to fusion. That's it.
As for this thread.........IDET has no place in the treatment of acute lumbar disc herniation.
Just my 5 cents!!!!
mcap
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 11, 2003 4:24:00 PM
|
|
|
JSSSH
Posts: 45
Joined: September 10, 2000
From: Kingston, Ontario, Canada
Status: offline
|
I just want to add that I taught core stabilitzation ex (multifidus and transverse ab) to people with non-reducible herination and with chronic back pain in my last placement.
Could someone explain again why ext ex is used if the "toothpaste can't be squeezed back"? I thought ext increases pain for people with extrusion of nucleus and so they should do repeated flexion (in lying, sitting and standing) to get some relief of nerve compression.
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 11, 2003 5:18:00 PM
|
|
|
PTupdate.com
Posts: 1477
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
I personally don't try to get stuck in the "extension only" mindset, as I think that gets a lot of PT's into trouble (..."But they taught me at school that this is what I am supposed to do...")
While some patients fit nicely into that model where extension reduces their pain, and flexion increases it, others may fit somewhere inbetween. Some can get into a POE position and feel great, then try a PPU and get increased symptoms. Perhaps a larger hernation is being pinched off with this maneuver, or the foramen is already filled, and cannot handle the reduced size with extension.
I treat what I see. If I can find a mechanical maneuver that reduces the symptoms, I do it, be it flexion, extension, or some rotational combination.
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 11, 2003 7:05:00 PM
|
|
|
Sam Betts
Posts: 37
Joined: January 30, 2003
From: Peoria, IL, USA
Status: offline
|
Dear JSSSH:
Regarding your question/ comment:
"Could someone explain again why ext ex is used if the "toothpaste can't be squeezed back"?
That is the question I am stuck on too. I can't get my stiff brain to bend to that idea yet.
I loved the study in Spine, where centralization of leg pain was a good prognostic sign, and peripherilzation meant a breached annulus. The study stated that the prognostic ability to detect a ruptured annulus was equal to that of an MRI. I am sure if I had a sequestered disk fragment compressing the dural sleeve, that repeated extensions would be a good indicator of poor outcome. Just as if I had just a torn annulus with a contained herniation, I would initially perhaps have unilateral pain, but as I kept extending the heck out of that disk, the sinuvertebral nerve, which crosses to the contralateral side of the spine also, I would make the pain central and much worse. Does that mean that because I replaced unilateral somatic referred pain from a torn annulus with severe central pain that I actually helped that patient, by reducing the leg pain? Or, did I just prove that extension hurts, and thats all I proved?
How many patients will actually come back to the clinic after we flare up their disk to such an extent? I am not that good of a salesman! [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
I see patients hobbling in that have been doing extensions with unstable spondylolisthesis, painful facet arthritis, post laminectomies. Not every practitoner uses repeated movements incorrectly, but a huge majority have no idea what they are doing and should expand their horizons a little.
Cheers,
Sam B.
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 11, 2003 7:20:00 PM
|
|
|
johnjfraser
Posts: 102
Joined: June 11, 2000
From: Staten Island, NY
Status: offline
|
From my understanding of the MDT concepts, extension in a derangement 1-6 would respond to extension because the nuclear material is still contained within the capsule, even though it is herniated. The nucleus pulposis supposedly does not run out like a cracked egg as it is still in the confines of connective tissue. Mechanically pushing of the "yoke" of the disc occurs when the posterior portion of the vertebral bodies approximate. Its more of a pushing and not a vacuum sucking effect.
------------------
John J Fraser, PT, MS
johnjfraser@yahoo.com
[URL=http://www.geocities.com/johnjfraser]http://www.geocities.com/johnjfraser[/URL]
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 11, 2003 7:56:00 PM
|
|
|
Sam Betts
Posts: 37
Joined: January 30, 2003
From: Peoria, IL, USA
Status: offline
|
John,
How can a material of low pressure ( GAG) be pushed back, along a higher pressure gradient. Sucking toothpate back into a tube would be more feasible than trying to push it back into the tube wouldn't it? Then, the pressure gradient in the tube must have dropped enough to suck fluid back in along a pressure gradient ( vaccuum). If GAG in the nucleus is constantly trying to imbibe fluid, then there is no vaccum in the nucleus.
Studies actually show that the nucleus goes posterior in extension and anterior in flexion, whereas in some, it is in the reverse pattern. The posterior motion of the nucleus during extension is due to buckling of the posterior annulus, allowing the nucleus to expand posteriorly ( due to less pressure on the posterior annulus) I need to dig that article up, was in Spine 1998 somewhere. It was an MRI article, showing variances among the population in nucleus motion, some went posterior and some went anterior with extension. I am sure disk height and fluid content has a lot to do with nucleus motion. Do normal height discs really compress down as much as we think they do in flexion and extension? Seems like a pretty unstable situation if a disc were that compressable.
Sam Betts
[This message has been edited by Sam Betts (edited February 12, 2003).]
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 13, 2003 7:24:00 PM
|
|
|
johnjfraser
Posts: 102
Joined: June 11, 2000
From: Staten Island, NY
Status: offline
|
There is a video that I watched on my McKenzie part A course where they show human cadaveric models of the L/S. It indeed migrated as I described above. People sometimes describe the reduction of an HNP as a sucking effect. Even though I do not have the references at hand, an anterior nuclear migration occurs because the posterior vertebral bodies squeeze the nuc pulposus, pushing it anteriorly.
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 13, 2003 7:51:00 PM
|
|
|
Sam Betts
Posts: 37
Joined: January 30, 2003
From: Peoria, IL, USA
Status: offline
|
Hi John,
I think I may have seen that video too, on a cadaveric lumbar spine, which was sliced in half to see it from side on.
I don't disagree that these things may happen, I just haven't seen anything that exciting from a research standpoint yet and I also wonder if it happens on evry patient and also what happens with DDD. I just question the theory yet, but know many that swear by its effectiveness. I think a suction effect can only occur when there is a low pressure system inside the nucleus ( like an air bubble in the toothpaste tube) Did cutting the disk, as well as the fact that it was non weightbearing and lacking compression reduce the pressure inside the nucleus I wonder?
I may have seen a different video. Did yours have a guy with a british accent moving a vertebra manually, showing nucleus motion? If not, I would like to order the one you've seen, if its available.
Best wishes,
Sam Betts
[This message has been edited by Sam Betts (edited February 14, 2003).]
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 14, 2003 6:18:00 AM
|
|
|
Tyler29
Posts: 11
Joined: August 1, 2002
Status: offline
|
Interesting discussion so far.
I came across a paper by Di Fabio et al that looked at PT outcomes for pts w/herniated lumbar dics (JOSPT, Mar 1996). Diagnosis was provided by MD and confirmed by neuro exam and MRI/CT scan when indicated. Small n (22), all pts were worker's comp, and 75% of pts had sx > 6 wks (so the acute herniated disc question not answered). Pre-PT Oswestry scores = 41. After a mean of 12 treatments over an average of 40 days, Oswestry scores dropped to 38 (not significant, in fact pretty crappy outcomes).
Does anyone know of any other studies that have looked at the effect of PT in treating pts w/herniated lumbar discs??
Thanks.
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 14, 2003 6:55:00 PM
|
|
|
mcap56
Posts: 619
Joined: October 26, 2002
From: New York, NY
Status: offline
|
John:
I think the video is done by Kuslich (not sure of spelling). Although, I may be thinking of the one where they stimulate the various parts of the l-spine to check for pain reproduction.
In any case, it doesn't matter. In the McK system, the disc is a model for derrangement, it is not to be taken literally. Particularly in the C-Spine, there are often other structures involved. Assessing the mechanical and symptomatic response to repeated movements has to be done precisely and correctly. Some of your posterior derrangements will end up with flexion or lateral movements. With unloaded flexion, tension on the PLL may actually cause anterior migration.
In one wants to look at this literally, then it is true, the nucleus can migrate foward during extension and visa versa. However, in some patients who have herniated far enough posteriorly or laterally, extension may exacerbate the herniation.
As far as I am concerned, the real question isn't what happens with end range loading. Clearly you can migrate the nucleus in one direction or another (given annular competence, even without it in some cases). But.......DOES IT STAY THERE???? The answer, I think, is NO. It goes right back to where it was pre-exercise. If you look at some of the video accompanying the Donelson study, you will notice that there are pictures of nuclear material migrating during endrange flexion and extension. The nucleus in these cases does indeed move as McKenzie predicts. However, they don't show you want happens in neutral......after loading. Therefore, extension, flexion, or other techniques including manipulation, muscle energy.......probably have a neurophysiological effect as has been discussed in other threads. If this is the case, then the case for long term improvement and significant lasting change is questionable. It also would lead one to question the need to go to absolute end range in every case.
Best,
Mcap
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 15, 2003 12:17:00 AM
|
|
|
johnjfraser
Posts: 102
Joined: June 11, 2000
From: Staten Island, NY
Status: offline
|
[QUOTE]Originally posted by mcap56:
[B]John:
I think the video is done by Kuslich (not sure of spelling).[/QUOTE]
Thanks MCAP, you got it on the nose. But there was two videos, the one described by Betts as well as the Kuslich video. Interesting stuff.
------------------
John J Fraser, PT, MS
johnjfraser@yahoo.com
[URL=http://www.geocities.com/johnjfraser]http://www.geocities.com/johnjfraser[/URL]
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 19, 2003 5:27:00 PM
|
|
|
JSSSH
Posts: 45
Joined: September 10, 2000
From: Kingston, Ontario, Canada
Status: offline
|
If extension does not always push nucleus back to centre, and if nucleus does not stay there after extension exs, does this mean we need to send pts back to GP for surgery??
My (new) CI said people with extruded nucleus need surgery IMMEDidately. And he also does not believe the body absorbs the extruded nucleus material, but my last CI said the body does. I remember in an earlier post, the person said the larger the extruded material, the more likely it will get reabsorbed. Does anyone have a reference for this?
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 19, 2003 5:49:00 PM
|
|
|
johnjfraser
Posts: 102
Joined: June 11, 2000
From: Staten Island, NY
Status: offline
|
Wow, thank you Yahoo search. Here is a good article:
[URL=http://www.jointbonespine.com/pdf/2002/issue2002-2/155.pdf]http://www.jointbonespine.com/pdf/2002/issue2002-2/155.pdf[/URL]
------------------
John J Fraser, PT, MS
johnjfraser@yahoo.com
[URL=http://www.geocities.com/johnjfraser]http://www.geocities.com/johnjfraser[/URL]
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 19, 2003 6:09:00 PM
|
|
|
Sam Betts
Posts: 37
Joined: January 30, 2003
From: Peoria, IL, USA
Status: offline
|
Hi,
good article for you here:
Komori HK et al. Spine 1996. The natural history of herniated nucleus pulposus with radiculopathy. 21: 2, pp 225-229
MRI study showing resorption of disk material, primarily from exposure to vasculature, probable autoimuune and inflammatroy mediated responses.
probably your CI and you need to agree onterminology. Extrusions sometimes imply ( to some people) that annulus and nucleus or fibrocartilage is involved. The GAG usually gets resorped, but sometimes I find the small extrsions that are more central can be very resistant. Its all a metter of terminology and morte importantly, monitoring neurological signs and symptoms, so that you don't let a bad situatio worsen quickly. I think there is ample evidence that laminectomy is not the only answer for disk prolapses and extrusions, depending on the response to treatment. I thin we owe it to patients not to waste their money if we cannot see improvements, however.
Try and get this article..it is very very interesting,
Good Luck
Sam
|
|
|
|
|
Re: treatment of acute lumbar disc herniations - February 20, 2003 3:19:00 AM
|
|
|
PTupdate.com
Posts: 1477
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
|
JSSSH,
Perhaps your CI should be a little more in turn with the literature and even clinical observation. Just because one has an extrusion does not mean surgery!
I am a perfect example. 3 years ago I fragmented L5-S1 and herniated L4-5. Complete loss of L5 strength and weakness in L4 within a few days, along with loss of reflex, dural tension, and all that stuff. With my own program and steroids, DTR's and strength began to return, and the MRI showed a very large loose fragment. However, with pain diminishing and all objective signs returning steadily, why risk going in and hunting that fragment? It was against the nerve root and maybe beginning to adhere, so there was no need to risk surgery. Also, the damage was done by that point, surgery would not have facilitated any increase in function.
A repeat MRI done for the heck of it was just reviewed by myself and the surgeon last week. Guess what? No fragment anywhere...completely gone. Also, even the degree of bulging left at both levels was less.
When you have an acute hernation patinet or extruded patient with profound weakness, just monitor them closely. If you don't get anywhere within the first week, maybe two, then surgery is indicated to prevent permanent damage. We have not seen any long term detrimental results from waiting this week or two compared to immediate surgery, so we take that shot and patients are always given the choice and understand the risks, etc.
Here is an article that also provides some of the same observations that Sam was indicating regarding the size of fragments, etc.
MULTIPLE INDEPENDENT, SEQUENTIAL, AND SPONTANEOUSLY RESOLVING LUMBAR INTERVERTEBRAL DISC HERNIATIONS: A CASE REPORT. Spine, Vol. 27, No. 5
Regards,
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
 Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.109
|
Printable Version
All Forums >> [RehabEdge Forum] >> Open Forum >> Re: treatment of acute lumbar disc herniations 
