Lumbar disc herniation protocol (Full Version)

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Kaden -> Lumbar disc herniation protocol (April 4, 2008 8:05:46 PM)

Okay so protocol, implying cookie cutter, is a bad word but couldn't think of a better one.

Anyway, I have been at multiple clinics over the last several months and seen different approaches to treating lumbar disc herniation with radiculopathy.

Curious what approaches everyone uses to treat this patient.....Mckenzie, traction, core work etc.

In general how would a typical PT program look like from the acute patient to discharge.  Just curious what others are doing and find most beneficial.  Most treatment of disc herniations seems to be anecdotal making selecting the most appropriate intervnetions difficult.



annpsu25 -> RE: Lumbar disc herniation protocol (April 4, 2008 8:19:23 PM)

Hi Kaden,

Clinically, I cannot tell you certain protocols, but I have gone over this quite a bit in my classes. Everything you said sounds like what I have learned in class. Our instructor, who is a PT, is all about Mckenzie exercises.

In the acute phase of rehab, she suggested using Mckenzie, addressing posture, traction. Subacute and Chronic is going more into core stabilization (prone, quadraped) and still continuing postural exercises and Mckenzie to assure the disc stays where it needs to be.  And of course patient education, and making sure the patient is following their HEP.



proud -> RE: Lumbar disc herniation protocol (April 4, 2008 8:54:25 PM)

What is your definition of "disc herniation"? By that do you mean complete sequestration? If so, then you have hard neurological signs.

Otherwise is becomes pretty difficult to definitively implicate the disc even with radiological evidence of disc protrusion with and without thecal impingement.

Then you move towards clustering the signs and symptoms to come up with the most likely cause. Exacerbation with cough/sneeze tends to be suggestive of discogenic pain. As does a positive crossed SLR. And although centralization through directional preference exercises is more a prognostic indicator...I tend to think the disc model is a reasonable explaination at that point.

But really, it depends on what you mean by disc herniation....that would help guide the responses.




Kaden -> RE: Lumbar disc herniation protocol (April 4, 2008 9:00:59 PM)

Proud,

I am not talking complete sequestration.   And you are right should have used the term discogenic versus disc herniation as it is difficult to totally implicate the disc as the source of the pain.  But to your point, yes think more along the lines of those with pain on SLR, cough, etc



proud -> RE: Lumbar disc herniation protocol (April 4, 2008 9:16:49 PM)

Thanks Kaden,

Alright then. I think directional preference resulting in centralization SHOULD always be a starting point for any PT. Centralization is one of the few positive prognostic indicators we have in Physiotherapy that has stood up to some research rigors. Foolish not to look for that sign first and foremost.

A few things that people need to know about looking for directional preference in acute stages. Often times, centralization is not possible for the first few days after onset due to the chemical state( read inflammation). I often hear of PT's that do a pretty lame McKenzie evaluation and when centralization is not present day one...they abandon and start into some form of traction etc or whatever else, often further irritating the neural structures. Just a hint from my playbook....I often tape to offload the neural structures, recommend ice and avoiding any movement or position that tends to peripheralize the symptoms for 48 hours. I then bring them back and re-evaluate looking for centralization and often...voila....centralization.

That is how I start.



rwillcott -> RE: Lumbar disc herniation protocol (April 4, 2008 9:53:12 PM)

I follow the same approach as proud.  I attempt to seek out the direction of preference.  I follow the treatment based classification system.  However, when using this system I will perform a more indepth McKenzie evaluation if the person responds to a specific direction.  For example, if someone reports that they feel better in standing versus sitting yet doesn't centralize with repeated extension in lying I will progress with overpressures as per Mckenzie. 

Also, you may have someone with symptoms of a possible disc herniation that is an extension responder, however, their symptoms are not past their knee and maybe they're in the acute stage.  If they meet the CPR's for manipulation I will manipulate this person and send them home with hand-heel rock exercises.

Again, this is all based on the treatment based classification system.  Before beginning an assessment I always perform a thorough subjective and lower quadrant scan. As proud mentioned there are many specific questions that are indicative of a disc hernitation. 

Rob



SJBird55 -> RE: Lumbar disc herniation protocol (April 4, 2008 9:57:59 PM)

For the lumbar spine, recent research indicated that centralization occurred about 17% of the time especially for acute (0-21 days) and more frequently in 18-44 year olds.  This was from about 300 patients with low back pain.  Centralization didn't occur at a really high rate.  It was also interesting that basically 26% of the time the 2 therapists (with post graduate education in MDT) were unable to classify the patient.  84% of the time, the patients classified as having symptoms that centralized improved functionally and 88% of the time they had improved pain intensity scores.  (Improved was defined as having at least minimal clinically important difference change). 

From that data, it seems to me that those with acute symptoms have a pretty decent likelihood of responding to directional preference intervention for those classified as having symptoms that centralize.  Now, this study only classified patients on the initial visit, so proud, you do have a point that for those patients that didn't have centralization occur or have any classification determined, the situation may have changed during the course of the episode of care, but data wasn't collected to assess if patients changed in presentation.



Kaden -> RE: Lumbar disc herniation protocol (April 5, 2008 3:37:09 AM)

Thanks for the replies.  I agree with starting with directional preference and do so myself.  Proud, good point about not giving up to soon on directional preference system, especially in those that are more acute.

So where does one go from here.  I often head down the path of core stabilization as these patients tend to fit into that classification down the line.

Curious if other do the same and when in the process you attempt to re-educate TA and multifidus and then progress to dynamic work if needed.



Kaden -> RE: Lumbar disc herniation protocol (April 5, 2008 3:41:55 AM)

one more thing

Does McKenzie advocate active extension such as prone straight leg raise in this situation or primarily passive extension with typical prone on elbows and prone press ups.



SJBird55 -> RE: Lumbar disc herniation protocol (April 5, 2008 7:48:37 AM)

I actually tend to spend that first visit talking and educating more than considering directional preference or what interventions will be provided.  Most of the time these folks with leg symptoms are scared.  I let them know that I know they have thoughts about their situation and we talk about it.  Many of them have freaked themselves out mentally.  I downplay MRI results; I talk about the study that was on NPR that helps everyone understand that generally with surgery or without surgery after 2 years everyone is the same boat with regard to level of pain and function; I specifically tell them when to worry and in those instances to go to the hospital;  I let them know that what they have is nothing new or scary to me - I see it ALL the time and when I get worried, I will honestly tell them I am worried.  If they fit the CPR, I manipulate; if there was a response to directional preference, I do that.  The sensitivity of the neural structures is what guides me in giving them "something" to do.  I always give the patient one thing to do... something that decreases symptoms - whether directional preference, positional, neural slumping stuff - but just one thing - and whatever it is is easy for them, easily controlled by them and didn't freak them out but gave them some relief. 

9 times out of 10 the majority of my patients are quite a bit better on their next visit 2-7 days later.  I honestly believe the best things we can do right from the get go is educate, calm fears, provide expectations, answer their questions by responding to whatever thoughts have been bouncing around in their heads and give them "something" active to do to 1) empower them AND 2) get them physically involved in their experience so they have ownership in their problem and ownership in eliminating their problem.



proud -> RE: Lumbar disc herniation protocol (April 5, 2008 10:52:30 AM)

quote:

ORIGINAL: SJBird55

I actually tend to spend that first visit talking and educating more than considering directional preference or what interventions will be provided.  Most of the time these folks with leg symptoms are scared.  I let them know that I know they have thoughts about their situation and we talk about it.  Many of them have freaked themselves out mentally.  I downplay MRI results; I talk about the study that was on NPR that helps everyone understand that generally with surgery or without surgery after 2 years everyone is the same boat with regard to level of pain and function; I specifically tell them when to worry and in those instances to go to the hospital;  I let them know that what they have is nothing new or scary to me - I see it ALL the time and when I get worried, I will honestly tell them I am worried.  If they fit the CPR, I manipulate; if there was a response to directional preference, I do that.  The sensitivity of the neural structures is what guides me in giving them "something" to do.  I always give the patient one thing to do... something that decreases symptoms - whether directional preference, positional, neural slumping stuff - but just one thing - and whatever it is is easy for them, easily controlled by them and didn't freak them out but gave them some relief. 

9 times out of 10 the majority of my patients are quite a bit better on their next visit 2-7 days later.  I honestly believe the best things we can do right from the get go is educate, calm fears, provide expectations, answer their questions by responding to whatever thoughts have been bouncing around in their heads and give them "something" active to do to 1) empower them AND 2) get them physically involved in their experience so they have ownership in their problem and ownership in eliminating their problem.


This is the best point I think so far in the thread and one I should have touched on. In actuality, the education occurs first for me once I have ruled out any sinister things.

Crucial if not manadtory SJ.....good point.

One question. When you say you "will give them one exercise....something that decreases symptoms"....I am assuming you mean so long as the "decreasing symptom" is not the one that peripheralizes things( as is the case in the grand majority).

I think people in general would rather have calf pain then back pain( Some of it pschologically driven fear of any pain in the back area).

Here is a classic example:

About a month ago, I had a fellow who had severe back pain with "tingling" along the lateral border of his foot. I did my best to educate this individual about peripheralization etc. Day one all his leg symptoms were gone. He was moving better( mechanical change). I felt I explained the centralization/peripheralization thing well. He left the clinic. I booked him for the next day.

He no showed the next day. Turns out that he felt he needed to see a "doctor". He was worried that his back pain seemed a little worse( although he had no leg symptoms). The "doctor" told him to lay on his back with feel up so hips were at 90 degrees.

Viola! NO BACK PAIN! He felt great. The trade off was that his foot went completely numb but that was nothing compared the the back pain. Did this for 48 hours....then on the third day when he went to get out of the position, not only was his foot numb....he had a drop foot.

Full herniation. The man is now a wreck. Scheduled for surgery. Part of me wanted to tell him I told you so and rip the Physician a new one. But alas,I'm just a lowly PT...a popper if you will( sarcasim yes).

That's the one thing them Chiro's got right anyway...they are "doctors"( at least in the eyes of the ill-informed public).....



cclem2000 -> RE: Lumbar disc herniation protocol (April 5, 2008 11:38:45 AM)

Good point on education especially in the subacute/chronic phases of the condition. If this person is 3-4 months out from "injury" when they get into your clinic and are scared to move, then you will not be able to get a good mechanical evaluation anyway. During the acute phase I can usually start with midrange movements until chemical pain settles down, then perform full mechanical eval when able

Kaden, Extension in lying (McKenzie extension!) is typically passive so that you can get to end range



Kaden -> RE: Lumbar disc herniation protocol (April 5, 2008 1:03:07 PM)

I agree with the educational component and much of the things regarding education mentioned above.  I typically take an approach similar to SJ's. 

Sometimes I find though that I may even need to scare the patient a little bit about peripheral symptoms.  These are the patients who don't take any of the original education advice to heart. 

I.E.  Patient with numbness, palsy, etc coming into the clinic for next visit saying they are worse and when I probe find out they decided to shovel the driveway last night.  Now I find sometimes this person needs a little fear to help get there atention.

Any thoughts on stabilization progression or otherwise after education and positional preference (and maybe manip if meet CPR.)



proud -> RE: Lumbar disc herniation protocol (April 5, 2008 1:36:35 PM)

Kaden,

I'm likely to get grilled here for saying what I am about to say but....

Lumbar stabilization. I have my significant doubts that it plays any role really in recurrent LBP. There I said it.

And yes, I'm familiar with the work of Jull, Richardson, Hides , Stuart McGill etc etc.

Did you know that fear of movement can actually result in some of those changes in Tra/multifidus function?

I do feel that educating patients to live an active lifestyle MAY be more important than giving them planks and all that "stuff". Often just helping a person find that one physical activity that they actually LIKE and encouraging them to do it is more important. Inactive patients often equate "getting active" with treadmills and weights( uggg). But it does not have to be that.

Yes...manipulation CPR I will use.

Stabilization CPR I use as well but I seem to find people who meet this CPR are the ones that are generally inactive anyway. And I tell that as much...point blank.

But specific tra/multifidus re-education/planks/etc etc....I just have a sneaking suspicion that it's not all that important in the grand scheme.Activity in any format is the most important.

Fire away...



SJBird55 -> RE: Lumbar disc herniation protocol (April 5, 2008 2:24:22 PM)

Umm, proud... you thought you communicated well with that patient up above, but did you?  Did you remember to communicate expectations?  With every patient that I treat who responds by having symptoms centralize, I communicate that I am excited that there is a response of less leg pain, but I also give them a nice smile and tell them that the next thing that might happen will probably be major back pain.  It goes away in a few days, just stick with whatever activity I've suggested.  As long as the leg pain maintains being reduced or eliminated, everything will work out in the wash - the new back pain WILL go away. 

What I honestly think lumbar stabilization does has nothing to do with "stabilization."  What I believe it does is neurophysiologically allows the body/brain to learn that it can move - the movement is obviously very small, but the movement occurs from a slightly extended to a slightly flexed position when in hooklying.  Generally speaking, the movement is quite painless.  So, the patient learns awareness of movement between segments and learns some motor awareness of the abdominal muscles AND at the same time the patient is overly focused on remembering to breathe.  It's almost like the brain is being bombarded with so much "stuff" that somehow the brain might get somewhat overwhelmed and begin to divert it's attention in determining that something is harmful to instead to all the new crap entering the brain and all the motor output leaving.  You all can fire away at that because I haven't read anywhere anything that parallels my guesstimate of what happens with lumbar stabilization.



proud -> RE: Lumbar disc herniation protocol (April 5, 2008 6:57:26 PM)

quote:



Umm, proud... you thought you communicated well with that patient up above, but did you?  Did you remember to communicate expectations?



Umm, SJ...You've been reading posts here for a while. I guess my posts have not impressed you much. Because otherwise....you would know how well I'd have communicated things.

Yes SJ...yes I idid communicate it well. This patient still held the notion that doctor knows best....he saw no "dr" by name and made assumptions about the information I gave him.

It happens.


quote:


What I honestly think lumbar stabilization does has nothing to do with "stabilization."  What I believe it does is neurophysiologically allows the body/brain to learn that it can move - the movement is obviously very small, but the movement occurs from a slightly extended to a slightly flexed position when in hooklying.  Generally speaking, the movement is quite painless.  So, the patient learns awareness of movement between segments and learns some motor awareness of the abdominal muscles AND at the same time the patient is overly focused on remembering to breathe.  It's almost like the brain is being bombarded with so much "stuff" that somehow the brain might get somewhat overwhelmed and begin to divert it's attention in determining that something is harmful to instead to all the new crap entering the brain and all the motor output leaving.  You all can fire away at that because I haven't read anywhere anything that parallels my guesstimate of what happens with lumbar stabilization.


Then you agree that lumbar "stabilization" is not really "stabilization"....but something else. Something less precise and more complex than "work this muscle....more stability....less stress on the lumbar spine".

To me...that is just NOT happeneing and any PT who thinks it is....needs to read...more...lot's more.



kiwi PT -> RE: Lumbar disc herniation protocol (April 5, 2008 8:54:14 PM)

quote:

ORIGINAL: proud

A few things that people need to know about looking for directional preference in acute stages. Often times, centralization is not possible for the first few days after onset due to the chemical state( read inflammation). I often hear of PT's that do a pretty lame McKenzie evaluation and when centralization is not present day one...they abandon and start into some form of traction etc or whatever else, often further irritating the neural structures.That is how I start.


Just a question to proud and others, when you see pts in this acute intractable stage in either a direct access environment or from a family doc: Do you ever call their physician and ask them “what their thoughts on a steroid dose pack are”?

Kyle PT



SJBird55 -> RE: Lumbar disc herniation protocol (April 5, 2008 9:36:17 PM)

proud, I was just asking, not judging.  I've been in positions with time constraints and have experienced the could have "kicked myself" for not taking the time to make my job easier because back pain is back pain and it is a common thing I see day to day, but forgot for the patient in front of me, the back pain wasn't a common experience.  I apologize for my lack of communicating my thoughts better than they were perceived.

proud, the outward effect of those muscles when activated may create "stabilization" but I don't think the "stabilization" is really the relevant aspect of the activity.  I think we're agreeing.

Kyle, I don't immediately believe prescription medications should be the first intervention.  If I'm not seeing any improvement at all after 7 days, then I'm on the phone discussing the objective findings and lack of response with the referring physician.



Kaden -> RE: Lumbar disc herniation protocol (April 5, 2008 11:30:06 PM)

SJ and Proud,

How do you explain "stabilization" training to your patients.  From your posts it seems that you both use it in practice.  Just curious how you convey to your patients why you are having them fire these muscles.

...and I agree with both of you that it is not really stabilization that is happening.  I think by doing these little precise exericses it forces patients to focus on that area of the spine and bring attention to it prior to initiating movment, ultimately allowing them to learn how to move pain free or with reduced pain.



SJBird55 -> RE: Lumbar disc herniation protocol (April 6, 2008 8:56:25 AM)

Kaden, honestly.  I explain the original theory and then tell them that I really don't think that the theory is correct because we, and even I, don't go walking around thinking about contracting those muscles all day long.  I tell them that the biggest problem they have is that they have pain and these particular exercises are a nice first step in teaching their body that it can move and a nice little fringe benefit is that they will strengthen their muscles in the abdominal area.  I honestly think that the last little part is what sells the patient - the majority of people in society today have a dream of tight abdominals.  So... most patients are compliant with the stabilization exercises, at least initially, because they can see themselves with a nice, flat stomach.  LOL  Unless the patient has further questions or comments, I let them keep that vision in their heads because the end justifies the means.  If they do ask further questions, then I am honest and tell them that for what they envision they also definitely need to incorporate aerobic activities into their lives blah, blah blah and expend more energy than they intake with eating or drinking.  (I'm in MI and the majority of my patients are obese...)



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