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treatment of acute lumbar disc herniations
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treatment of acute lumbar disc herniations - February 6, 2003 4:36:00 PM
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Sam Betts
Posts: 37
Joined: January 30, 2003
From: Peoria, IL, USA
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Dear all,
My opinion is that when you have a disk herniation there is nothing you can do physically to alter it in any way. Maybe advise re bed rest positions and monitor neuro signs and symptoms and then refer out for epidurals and/ or surgery. The "toothpaste can't be squeezed back in to the tube"
Agree? Disagree?
Sam Betts
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Re: treatment of acute lumbar disc herniations - February 6, 2003 4:53:00 PM
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Andrew M. Ball PT PhD
Posts: 855
Joined: July 28, 2002
From: Charlotte, NC
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Sam,
That's not a very Ola Grismby way of looking at the low back is it? Is this truly your position or do you have an agenda in trying to spark some kind of discussion on the subject?
Drew
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Re: treatment of acute lumbar disc herniations - February 6, 2003 5:12:00 PM
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Sam Betts
Posts: 37
Joined: January 30, 2003
From: Peoria, IL, USA
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Hi Drew,
you are truly evil, you know that? You must have spies in hidden places.....
I like interesting debate and I don't intend to try and prove myself right. Just trying to drum up some discussion.
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Re: treatment of acute lumbar disc herniations - February 7, 2003 2:21:00 AM
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Andrew M. Ball PT PhD
Posts: 855
Joined: July 28, 2002
From: Charlotte, NC
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Sam,
Opinions about me certainly vary, but before you call me EVIL in public forum, you sure as hell better check yourself.
I didn't want to see some poor sap roped into a debate and then pounded. That's not exactly "sharing experiences," which is the point of this board. That, in my opinion, isn't fair to any RehabEdge.com member brave enough to approach the question you raised in the first place. That will stifle future conversation on notable topics, and I won't allow for you to do that here. I have too much admiration and respect for those RehabEdge.com members brave enough to speak their minds on controversial topics. Want to use the word "evil," that's fine, my ego doesn't bruise that easily --- just be sure you're not living in a glass house when you throw stones.
Tried to e-mail you privately but you weren't kind enough to leave us an e-mail address to do so. You asked the question just fine were this an online DScPT program, but no one here knows who you are, what your motives are, nor do most have the level of professional ego required for a "rope-blast-and defend" convesation that is so common in doctoral level programs. They're certainly not prepared to be blindsided by one. I'm evil for preventing that? I don't think so.
I'm not suggesting that you couldn't emerge and conduct yourself professionally, but starting with a lie about your true clinical opinion isn't a good start. I've heard some great things about you as a CI and CCCE, and tip my hat to you in respect for that, but can't allow for you to raise discussion in this way on this site.
This is NOT a behind closed doors discussion, so more transparency in your true motives is required. I can't allow for you to lie about your true beliefs only to make another therapist look silly for your own gains and interests. I'm sorry that I knew who you were and made the initiation of your topic a little more difficult, but ends don't justify means, and doing what I did doesn't make me the evil one here.
That said, you raise an interesting point for discussion. Would you care to rephrase it so that someone with a thirst for discussion, but a more fragile ego, doesn't get hurt?
Drew
[This message has been edited by Andrew M. Ball PT PhD (edited February 07, 2003).]
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Re: treatment of acute lumbar disc herniations - February 7, 2003 4:15:00 AM
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PTupdate.com
Posts: 1474
Joined: October 8, 2001
From: Pittsburgh, PA USA
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Disagree, for a few reasons:
There are numerous articles regarding spontaneous reductions of disc hernations, not so much the toothpaste anology, but more phagocytosis and resorption. However, it can occur.
Also, PT can be used to maintain dural mobility, and prevent adhesion and scarring of the nerve root.
For those with hernation and compression pain, there is usually a series of positions and motions that relieve symptoms, either pain and/or dural tension (McKenzie et al)
Even resulting muscle spasm and piriformis tightness can be addressed via PT.
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: treatment of acute lumbar disc herniations - February 7, 2003 6:28:00 AM
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coloradojulie
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From: colorado usa
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I have to agree that there seems to be little that we can do to maintain a "centralization" if we indeed get one in the first place. Most patients will feel a reduction in symptoms in non-weight bearing positions, but as soon as they stand up, the positioning is undone. Also compliance with position and movement avoidance is nearly impossible to control.
I agree with John, neural tension can be addressed, stability work can be addressed and general fitness can be maintained. Mckenzie theory seems to make sense, but only when the patient isn't weight bearing.
In our practice maybe 5% of our low back pain population present with true disc bulge/herniation pathology/symptomology, and these are the most difficult to treat...with the poorest prognosis.
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Re: treatment of acute lumbar disc herniations - February 7, 2003 7:33:00 AM
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PTstud
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From: Texas
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We just started touching this subject in PT school, but what about mech or manual traction? The theory behind it makes sense to me, or is this the "toothpaste back in the tube" theory?
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Re: treatment of acute lumbar disc herniations - February 7, 2003 2:13:00 PM
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Sam Betts
Posts: 37
Joined: January 30, 2003
From: Peoria, IL, USA
Status: offline
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Hi Drew,
I am sorry I upset you. I was actually very much kidding about the evil thing... it was definitely truly meant tongue and cheek.I am the last person to be rude to another. I was just curious how you knew I was an OGI instructor, as I don't know you personally. I guess in writing, the sense of humor gets lost. I'll add a just kidding or a smily face next time.
I have since added my e-mail address, the reason for not doing this was for my privacy from unsolicited e-mails, no other motives. But, my e-mail is posted now.
I am a respectful, considerate, honest and non-egotistical person. I am doing a study on the effect of lumbar positioning on resolution of disc herniations and resultant decrease pain. I believe that disc herniations don't "go back in" and neuro signs should be monitored carefully.
I have seen mixed succeses and great success with epidurals and I feel surgery is an option in slow cases or dramatic signs and symptoms.
What i amcurious to know is if anyone has found anything useful clinically to help resolve these, the pain and prognosis. you'll have to take my word on that.
Respectfully,
Sam Betts
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Re: treatment of acute lumbar disc herniations - February 7, 2003 2:57:00 PM
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Andrew M. Ball PT PhD
Posts: 855
Joined: July 28, 2002
From: Charlotte, NC
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Sam,
Apology accepted. My humor gets lost in this media sometimes as well.
I think you've raised a great topic. I just wanted people to know who you were and your true position before debating. It's hard enough to get the timid to speak up 'round here.
I know several other OGI instructors, and I've read a paper on rib mobility that you wrote, or at least published, not too long ago. Good stuff.
I'm nevertheless surprised at your position. The "can't suck it back in" theory isn't one that's often heard from OGI is it?
Drew
P.S. Let me know if you're going to be at CSM, I'll buy ya a beer. No hard feelings.
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Re: treatment of acute lumbar disc herniations - February 7, 2003 3:11:00 PM
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mcap56
Posts: 617
Joined: October 26, 2002
From: New York, NY
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Sam:
I think when referring to herniated lumbar discs we should use less confusing terminology. Disc herniations should be categorized as internal disruption/annual tear, protrusion, extrusion and sequestration. I am assume that you are referring to extrusion where the annulus has been breached. (In the event of neurlogical deficit, the recommendations change).
In acute herniation, I don't think therapy has much to offer in the acute phase. Research, so far, has supported the use of NSAIDs and manipualation for short term pain relief (no long term effects demonstrated yet). And of course, functional activities should be resumed as quickly as possible.
I am a big fan of aggressive pain control and aggressive reduction of inflamation. This includes the use of epidurals and nerve root injections for the appropriate cases. However, many of these measures are invasive and are not necessary for the average patient. The real key in low back pain is identifying the patients who are at risk for disability early on in the process. Remember, most of the low back pain resources are spent on a small number of cases. These people need aggessive tx in acute phase with medications and then aggressive tx with rehab starting in the subacute phase. However, we have not been able to identify these people early enough.
Can the toothpaste go back in.....even as a cert. McK therapist......I think, very strongly, that it doesn't. McKenzie exercises, like manipulation probably have a neurophysiological effect. In some cases, this neurophysiological benefit could conceivably get the patient over the hump and into activity. As a previous poster indicated, a herniation can and probably will resolve with time via immunological mechanisms.
I think a big factor is time. If a herniation happens slowly, there may be time for the neruological/vascular structures to adapt and the herniation could be painless. Even in the case of neurological compression......the real problem may be edema in the nerve root. If the compression in gradual in onset, the vascular and neurological structures may have time to compensate. Perhaps this is the difference between symptomatic and asymptomatic lesions........who knows. In cases where they can't, an epdidural injection may buy them enough time.
Just some thoughts...........
mcap
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Re: treatment of acute lumbar disc herniations - February 7, 2003 3:34:00 PM
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Sam Betts
Posts: 37
Joined: January 30, 2003
From: Peoria, IL, USA
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Dear Drew,
I wish I was going to be at CSM, but my wife is having surgery, so I am going to be her caregiver and my baby daughter's. Hopefully our paths will cross in the future!!
Dear all,
There have been some studies that GAG, once extruded from the disc, either PLL rupture or not, has a 1/2 life of 1-7 days. I need to find that study. In clinical practice, i have found that large disc herniation with no significant motor signs seem to absorb very quickly and the smaller "prolapses" ( maybe I should define it better) seem to go slowly. I personally place the patient in a position of maximal foraminal gapping, ie flexion, side bending and rotation to the opposite side, in a sidelying position. I know a lot of us position patients this way any way, because it hurts less. i have managed to eliminate radicular pain quickly, in this manner, many times.
The way OGI teaches is students, is that once the GAG has resorped, and neurological signs indicate compression no longer, then treatment towards pain inhibition with articulation ( above the area), soft tissue treatment and eventual progression to function to stimulate disc healing. The OGI really, doesn't have one way of looking at things,except maybe as a starting student. They are pretty much driven by new ideas, logic and new evidence and try to create a master "thinking" clinician.
The disk that herniates is most often degenerative with a degenerative and expressable nucleus and I am not sure it goes back in. I have physically seen anulus and nucleus and it just doesn't seem rational that something as soft as nucleus could push back through firm/ ligamentous annulus. I did read a study in Spine that showed that extension locks the neural arches and actually provides a protective space for the thecal sac and i wonder if this is significant, just as a resting position.
Given the new knowledge that compressive signs can be set up from inflammatory mediators, without frank compression, its hard sometimes to differentiate between radicular pain, somatic pain from radicular and neural sheath structures, or both. The question then becomes, if a person has somatic "referred' pain in the leg, can we call it a derangement as a classification, when somatic pain, perceived in the leg ,is multifactorial and proven to come from many intraspinal structures and/ or sympathetic responses in blood flow etc ( perceived as ischaemic pain)
I do think the pain classification system from macKensie has value in pain location geography, and at adifferent level, I am sure is moving away from" tissue as the issue", more, puposeful/ identifiable movement patterns?
Sincerely,
Sam Betts
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Re: treatment of acute lumbar disc herniations - February 7, 2003 4:07:00 PM
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Andrew M. Ball PT PhD
Posts: 855
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From: Charlotte, NC
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I'm going to do something that I was trained while completing my Ph.D. never to do . . . speculate on something that I know nothing about:
Several years ago, Paul Beattie, now (I think) at University of Sough Carolina, rasied the issue of something about the role that the sinovertebral nerve or SVN (which although generally too small to see on MRI, juts almost into the NP), may play in acute LBP.
Could a chemical in the NP be an irritant to the nerve, causing pain? Could the chemical property of the "gel" change over time, or does the SVN accomodate over time? Given the T2 water weighted proton density MRI studies of the early 90's (which showed an over 90% corelation between syptomatic MRI, specifically a radioillucent HIZ or high intensity zone --- and pain), could the SVN actually work as a pressure receptor?
I submit the previous not to distract from Mr. Betts question, but rather raise the plausibility, based upon the evidence, of an alternative pain and relief system than the one that PT's typically think about.
Drew
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Re: treatment of acute lumbar disc herniations - February 7, 2003 8:10:00 PM
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flexion
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No you can't make the nucleus pulposis go back "inside the tube" via a treatment. This doesn't relate to the goal various of forms of physical therapy though.
Did I read this correctly that the suggested treatment is bed rest, injection and surgery? I think better defining the type of herniation along with motor reflex and sensory indiations would be useful in consideration of this protocol.
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Re: treatment of acute lumbar disc herniations - February 8, 2003 3:16:00 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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Perhaps we should remember what the patient really came to us for in the first place...pain, severe pain.
If someone with a 2 day old herniation, with no significant relief via oral steroids and NSAID's and no sleep can be relieved of the pain via simple positioning, traction, some soft tissue or joint manual technique, why NOT do it? Have PT's become so cold that they won't perform some treatment on someone because what "supposedly" happens is not supported (as far as they know) by some study/proof/evidence? I hope not!
There are spine surgeons whom I work with that will openly admit there are only a few PT's they will send these patients to, because even in the most severe cases, there is at least pain relief, and often avoidance of surgery. Other PT's or simple home programs fail much more often.
Most patients with an acute herniation don't have a clue what is happening, and may not even care. They may find that flexion of their spine relieves the back/buttock pain. Granted, their foot just went numb during the process, but to the average person, they might think this is actually better. Why not treat this person and educate them, before they make a bad situation worse?
Far too many PT's have lost touch with the patient, and are (from what I see and hear) avoiding treating patients and helping them for some weird reasons. "Sorry ma'am, I would love to perform this treatment on you which would most likely relieve you of significant pain and allow you to finally sleep through the night, but won't because I can't find anything in the literature to support it, and I am an evidence only PT"
Having personally suffered multiple hernations and a fragmentation, I can attest to this myself. Strong electrical stimulation to my right buttock, either with traditional TENS or the Dynatron 500 significantly relieved the pain for hours. A flexion/rotation position mentioned by Sam completely took away the calf pain that would wake me up at 4am. Do you think I gave a hoot if any of this was supported by some evidence based article? Heck no! I just wanted some sleep and relief, and so do our patients.
As Sam mentions, larger herniations, especially those with extruded fragments, do resolve better than the smaller annoying ones, and an interesting article in Spine covers this (12/15/02).
John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: treatment of acute lumbar disc herniations - February 8, 2003 4:49:00 AM
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Diane
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Ditto John Duffy.
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Re: treatment of acute lumbar disc herniations - February 8, 2003 5:57:00 AM
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mcap56
Posts: 617
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From: New York, NY
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Drew:
As far as I know, the nucleus has no innervation. Even the annulus is only invervated in the outer third.
John:
I don't think I was advocating turning the patient away. Certainly, there are things we can do with positioning and modalities. McKenzie does work well in the acute phase for many paitents.
However, in this context it is not inappropriate to discuss the hypothetical in an evidenced based context. Empathy for the patient is needed but we have all seen how far that can take us with some PTs. As clinicians we may apply a particular philosophy. But as an academic and a researcher we need to look at things differently.
Why not treat and educate them before they make things worse? Great question. The academic in me would have to throw back two questions at you. One, are you sure we can keep them from making things worse? And two.....is there a possiblity that going to PT and learning all of these tricks and maneuvers can make things worse?
You yourself responded very well. But you are not the average patient. You know the importance of restoring function and you probably do not practice fear avoidance as much as the average patient. In working with patients in the acute phase, is it possible that our instructions and our attention to them contributes to the "medicalization" of the patient?
I am not sure if there is a yes or no answer. And.....I don't know the answer. It probably depends on the patient and the therapist. However, I don't think the issue is as simple as this person is in pain.....of course we should do something.
Respectfully,
mcap
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Re: treatment of acute lumbar disc herniations - February 8, 2003 12:37:00 PM
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Sam Betts
Posts: 37
Joined: January 30, 2003
From: Peoria, IL, USA
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Drew,
regarding your question/idea:
"Could a chemical in the NP be an irritant to the nerve, causing pain? Could the chemical property of the "gel" change over time, or does the SVN accomodate over time? Given the T2 water weighted proton density MRI studies of the early 90's (which showed an over 90% corelation between syptomatic MRI, specifically a radioillucent HIZ or high intensity zone --- and pain), could the SVN actually work as a pressure receptor?"
The degenerative disc after having degraded, with a poor quality matrix, absorbing compressive and tensile forces beyond collagen deformation tolerance appears to cause annular tears. Whether these tears all magically line up into a straight line to allow disc that is degraded/ mucoid to squeeze out, still seems an interesting theory, although not convincing.It is widely known that normal disks with artificially produced tears do not herniate under compression.It seems that the nucleus has to be less inherently cohesive to become "sqeezable" It seems that the PLL has a rich innervation and is vascular (posterior and anterior) Granulation tissue grows in to these tears, which contain new blood vessels. blood vessels are know to be nociceptive to changes in PH etc, as well as being lined with nociceptors. Twisting/ torsion may stretch/ compress innervated granulation tissue that may go in a long way, if the tear invades towards the center. Whether the sinuvertebral n comes in along that tear line, I don't know. These predominantly C fibers in blood vessels are sensitive to barometric pressure changes. These is a great debate at noigroup.com on "arthritis pain and weather" The link to pressure/ pain is difficult, because type C fibers are non adapting and only transmit pain. But that dull, deep aching is from C-fibers. The pressure change may evoke pain....but not a sensation of pressure?
So,it becomes logical that the sinuvertebral n and parts of the medial branch of the PPR to the PLL have a role as information carriers.
The nucleus material has been shown experimentally to cause slowing of motor conduction in nerves as well as endoneural oedema and more importantly triggers cytokines tissue necrosis factor alpha and nitric oxide, to send in more macrophages, hence more infllamation. Oldemaker and Rydevik have shown some dramatic results with epidural injections of "anti" TNF-1 ( don't know what the drug is" with incredible results. Given that GAG is highly hydrophilic and is exposued to the vascular system once out through the PLL, reducing fluid and GAG seems optimal. I wonder if this is a way of the future.
PT stud:
My understanding is that lumbar traction does not have distraction effect on the disk, in fact the opposite. Because the annular fibers run obliquly and attach from end plate below to end plate above and are layered perpendicularly at each lamella, that traction cause the middle of the disk to "taper" in the middle. This would be due to the horizontal fibers straighening out and pulling everything to the midline. This would have a net effect of increasing intradiskal compression/ pressure ( in the annulus) Speaking to a surgeon I work with , it takes immense force to separate lumbar vetebrae and the end plate may rupture before any meaningful separation occurs.
Maybe traction works for reasons unknown, but neurological. Maybe it actually causes segmental flexion to increase canal size?
I know that patients do come to us for pain and that as clinician I will do what I can above the level of the lesion for pain inhibition. I wonder, if we use heat/ IFC current at a high setting if it increases the blood flow in the canal and hence more fluid available to extruded GAG that loves to imbibe fluid. Should we avoid heat? We know that heat is just a high intensity afferent stimulus to inhibit pain, but does it make disk herniations bigger? Is the blood flow increase created more than just walking?
As PT's do we actually have a role at all in treating acutely herniated lumbar disks, other than assurance, education and positionin? Yes, we can do all this and it works,but is this more EFFECTIVE than a medrol dose pack, Vicoden, valium and bed rest? Should we be billing for e-stim and positive assurance if it is not more effective to other treatments?
Sorry for the long post. It is an interesting discussion for sure.
Sam Betts
[This message has been edited by Sam Betts (edited February 08, 2003).]
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Re: treatment of acute lumbar disc herniations - February 9, 2003 3:08:00 PM
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Bournephysio
Posts: 585
Joined: April 25, 2002
From: Calgary
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If I remember correctly, the SVN is just the largest of a group of nerves inervating the outer third of the disc. Most of these nerves originate from the sympathetic trunk.
Anyone heard of the DRS? The people who make this claim that it will reduce disc bulges. Its basically a fancy traction unit. They use over 1/2 body weight tension. I haven't looked at their research.
We don't know the cause of back pain in most cases but we treat these people anyway. Why would this change if we actually know the cause?
We can treat the pain with modalities, acupuncture, and manipulation (I don't manipulate discs with neuro symptoms but may go above or below.) We can give exercises to reduce pain. In my experience extension exercises can bring back muscle strength and reflexes. We can eliminate aggravating factors such as leg length discrepencies. We can start retraining the muscles to provide better stability. And of course our most important treatment is educating the patient, on activities, positioning and adl's. As mcap said, we have to be careful not to "medicalize" the patient.
I usually don't mind patients using heat for acute back problems. I highly doubt that the heat reaches the disc. There is too much tissue to go through and too much blood flow to dissapate the heat.
What is OGI by the way?
Doug
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