Intervertebral Disc Herniation of an Asian Female

A twenty-two year old Asian female was recommended by her physician to seek physical therapy for a back injury. She lives with her husband in a rented room with access by elevator. Currently, she works in her home full-time as a freelance artist. Personal history indicates a humeral head fracture at age thirteen, which was not surgically repaired. No surgeries are in her history to her knowledge. Family history presents high blood pressure and diabetes of paternal grandfather. Patient has been in fair health, decreased by current condition.

Patient was in a car accident on 5/26/04. Three months after the date of injury, she sought out medical attention due to increase in pain. Her car was struck from the driver's posteriolateral end by a speeding vehicle. No symptoms noted on impact, however, back pain developed the following day. Progressively, she has been exhibiting difficulty functioning in normal activities of daily living (ADL's). She is limited to forty minutes of walking and standing due to poor coordination and weakness. On a scale of one to ten, she exhibits a pain level of approximately seven in her right leg and five centralized in her low back. No assistive devices are currently in use. Her major concern is the inability to sit for extended periods of time, which is affecting her work as an artist. She has numbness in the lateral aspect of her right lower extremity and occasional right calf cramping. She is currently unable to drive due to persistent numbness and slow reaction time in the right lower extremity. Over-the-counter NSAIDS are taken regularly as needed, which decreases symptoms. Her physician indicates a possible herniated intervertebral disk (L4-S1). Her X-ray concluded negative for fracture.

Low back pain is prevalent in society, "disability accounts for 70% to 90% of all costs related to health care" (Frymoyer, 1993). Over half the population at one time or another has some form of low back pain in their life-time. An intervertebral disk herniation can be associated with major or minor trauma, or an asymptomatic condition (Peters, 2004). The common etiology of the creation of a disk herniation is a compressive force. The tissue in the center of the disk known as the nucleus pulpous is forced out of the surrounding annulus fibrosus. It then leaks posteriorly, creating inflammation and pressure on the spinal nerve root. This herniation may be do to a weakness in the annulus fibrosus, unable to hold compressive forces, but the posterior positioning of the nucleus pulpous leading to posterolateral defects(McGill,pp54; Deyo,1990;Dynomed2000). It was identified that, "more than 95% of lumbar disk herniations occur at the L4-5 and L5-S1 nerve roots" (Deyo, 1990; Peters, 2004). Symptoms of a herniated disk may have a gradual or acute onset from initial injury. Low back pain is soon followed by radicular pain, or leg pain. Other symptoms, such as labored breathing during exertion, muscular control and strength deficits, along with proprioception degeneration may be attributed to a nerve root compression created by a herniation (Deyo,1990, McGill,pp129-131).

Upon analysis of my patient, the major problem identified is pain radiating down the right leg and low back. This situation is affecting her work and normal activities of daily living. It is my theory that extension exercises will aid in decreasing pain and increasing functional abilities. In the current literature it has been proven that, "exercise may be useful in the treatment of chronic low-back pain if they aim at improving return to activities of daily living" (Antler, 2004). Extension exercises are specifically used to decrease stress on the intervertebral disc which will aid in creating a centralizing phenomenon to decrease radiculopathy and central back pain. The article by Fritz identifies the centralizing phenomenon created by extension based exercise. This decrease or elimination of radicular pain will aid in controlling her pain to achieve normal function. In Peterson's article, there was a reduction of disability at the two month mark in favor of McKenzie. Research shows, "pain scores were consistently lower in McKenzie subjects" (Peterson, 2002). To identify improvements in pain effecting disability, I will use an Oswestry pain disability index. This is index of choice in physical therapy clinics, and has been proven most effective. In a pain disability index analysis Fritz found, the Oswestry had a higher level of responsiveness to change in patients with low back pain. Exercise is verified in the literature.

Van Tulder wrote a systematic review on low back pain and exercise therapy. The population was a broad range with multiple variables grabbing from a variety of articles. It verified exercise is effective in the treatment of back pain. The review identified its value on a global, pain, and functional level although I found it inadequate. The differing variables in each article did not allow for a meta-analysis to be performed. The data gathered was noted for changing variables. The article was also very good at pointing out their faults. Only eight articles were considered strong or moderate in evidence. Many were biased. A clear cut evaluation of information was something I would have really like to have seen. I found this review extremely difficult to assess practical use in relation to the evidence supplied. The analysis of evidence in each article was identified on a scale of: strong; moderate; limited; and no, to identify reliability. A clear analysis of the data found, rather than just relying on the reports of each individual article, was needed. My intervention is exercise, specifically lumbar extension to decrease pain and thereby improve function. The results of this review indicate, "Exercise may be useful in the treatment of chronic low-back pain if they aim at improving return to activities of daily living" (VanTulder, 2004). The evidence was not very reliable, so this would not be a good source to follow. It does however evaluate the importance of therapeutic exercise in the treatment of low back pain.

Fritz identified the effectiveness of starting exercise during the acute phase of low back pain and early intervention opposing the recommended by the clinical practice guidelines, and identifying that it is classification based. This experimental model measurement tool, the Mann-Whitney U-test, used to analyze the change in impairment and satisfaction of the patient and the data proved to be reliable. This was appropriate since a non-parametric statistical test is needed to compare the two variables with in the multi-factorial design. The Oswestry pain disability index was used to identify function in ADL's. Taking account individual patient's signs and symptoms this study proved that classification based physical therapy was more effective. This is relevant to my case because it identifies the effectiveness of physical therapy in comparison to rest. It was also using the Oswestry pain disability index which is the measure I decided was best used to assess my patient's pain condition. The evidence in this article specifically identifies the centralizing phenomenon created by extension based exercise, which is directly relevant to my case as the main intervention. I felt the article was easy to read, standardized and helpful. It indicated that I need to create a program specifically geared to my individual patient and the use of my desired treatment has been proven to be effective.

Backward bending exercise has been used without full understanding. Adams' study on lumbar extensions and distribution of compressive forces within the intervertebral disc, aids in identifying factors on why this exercise decreases pain in some patients but not others. A linear regression analysis was used to explain the extension-stress relationship. It is an examination of two analysis and is reliable by keeping the actual plots along with the linear line and easy to read. Results and analysis indicate that a neural arch in extension may shield the posterior annulus, but the effect is variable. It was found that "two degrees of extension decreases maximum compressive stress in posterior annulus relative to neutral postures by up to 40%" (Adams, 2000). Extension movements may relieve pain by reducing the forces acting on pain sensitive tissues, transferring compressive force from the disc to the joint lying posterior to it. This may serve to aid in proving my intervention but it also is not functional in a clinical environment. Negative effects were noted for four degrees of extension, so it would be difficult to make sure two degrees of extension is all that is being achieved. This experimental literature was excellent at proving how the phenomenon of centralization is created. By decreasing compressive forces for some back patients and protecting the posterior annulus in the neural arch. This study was extremely important in gathering the "why" of using my intervention however it was not done in a clinical setting. The low back intervertebral discs used were that of cadavers.

The McKenzie extension method has not been proven in a nonbiased printed article focusing on the efficacy for low back pain. Petersen in a pre-test post-test model compared dynamic strength training to the extension method and the reduction of disability, pain and improvement in function. The population of individuals was Dutch. The Manniche's low back pain rating scale was used to assess pain disability. There was an intention-to-treat analysis where subjects are randomly assigned to groups, but subject can switch groups, dropout, or be removed due to change in patient condition and efficacy of treatment. This analysis may minimize bias arising from loss of patients that might contaminate the balance of treatment groups but, it allows for movement and poor clarification of effects. A post hoc analysis was done for a multiple comparison exploration of outcomes that were unplanned, but pain reduction was expected. This made the use of the post hoc inapplicable to some degree. It was not clear what who was included in the clinical trials. Gender and age were eliminated from the characteristic aspect of the experimental intervention. Out of 135 subjects in each group, 94 and 86 respectively finished the study. The results 30% of subjects dropped out. A reduction of disability at the two month mark was in favor of McKenzie. Throughout the whole physical therapy treatment pain scores were lower in McKenzie subjects. Although highly relevant to my case, because of the poor subject consistency and poor choice of analysis the validity of this article is in question.

Clinical use of evidence-based research is important in identifying how effective a particular intervention will be in the actual environment. A case study of a lumbar intervertebral disc herniation of a juvenile girl was treated with nonsurgical intervention techniques. All though there is a decade between my patient and the case subject they both had similar radicular pain down the right leg with decreased proprioception and weakness. The child was treated with rotational manipulation, which is something very risky for a child. Since there musculature is still growing and if a disk is herniated and you give extra torsion to the lumbar spine more damage can be created. The next step was to try epidural injections of non-steroidal anti-inflammatory drugs, which failed. Exercise and rest spontaneously aided in her recovery after a month in the hospital. A child cannot be treated like an adult body because further injury and pain may ensue. Exercise is specifically the intervention chosen to assist in decreasing pain for my patient. The case study was non specific to McKenzie extension exercises; however exercises were proven effective in this case. The difficulty in treating a juvenile and identifying reliable analysis tools was a struggle in this case study. A basic pain rating scale was given, not quite like the Oswestry but suitable for the age of the individual. There was an identification of failed attempts with other modalities. The clinical implementation of therapeutic exercise is effective in this isolated case. It is difficult to compare a twelve year old to a twenty-two year old but the similarity in symptoms identified the relevancy of applying the general information on treatment to my patient. It is possible that on my patient the epidural injections and the spinal mobilization techniques may be effective. It is extremely important to keep the thought of evidence-based literature and experience from a clinical environment or case studies to apply to the treatment plan. This is not the only factor that is necessary for the treatment of a patient. It is important to take into account specific things that may attribute to adherence and performance of an individual based on their personal thoughts and beliefs.

To be an effective physical therapist it is important not to neglect possible patient issues regarding personal beliefs, values and culture. The cultural article by Chi assessed Chinese American medical care options and whether there is utilization of Eastern medicine or Western medicine. For Chinese Americans, "Chinese medicine is likely to be a complement instead of a substitute, to modern Western medicine" (Chi, 1998). This directly affects my patient care. My patient is Chinese American, and given her ethnic background, I would want to be aware of any alternative treatments that may be obtained. Although not related to low back pain specifically, it is important to know there is a strong belief in Western medicine, and alternative therapies may be utilized in addition to standard care. This is essential knowledge in the identification of possible interactions with herbal remedies, or broken skin that may prevent the ability to use certain physical therapy treatments.

Communication is a major aspect of bridging the gap against cultural conflicts. As her physical therapist I would use active listening skills, questioning in a non-threatening manor the possible difficulties which may arise with treatment, and program adherence. To alleviate possible conflict regarding treatment a discussion of my patient views on complementary medicine, and her utilization of them would be discussed. Upon discussion with my patient the knowledge that acupuncture treatments are received once a month to aid in minimizing her back pain was established. Incorporating understanding the need of alternative remedies is important in respecting cultural beliefs. If the alternative medicine is not causing detriment to the individual there is still a strong placebo effect, if not a proven effect, which may improve the patient's well-being.

I recommended if my patient felt that acupuncture was helping her she should continue the treatments in addition to the physical therapy program I establish. It has been proven in the literature that, "acupuncture has been advocated as an effective treatment of low back pain" (Kerr, 2003). The cultural incorporation will aid in understanding and possibly further communication on culturally accepted moors. It will not only build better physical therapist-patient relations, but it may also have a placebo effect, if the actual effects are ineffective.

Using the McKenzie extension program in conjunction with the acupuncture should aid in decreasing pain. The centralizing phenomenon that has been established by Fritz indicates that extension will aid in decreasing or eliminating the radicular pain. Petersen, preaches the benefit of decreased pain and disability on the Oswestry scale for McKenzie patients in comparison to dynamic exercise patients. Extension patients have a quicker decrease in pain, which is a start to recovery. Adams cadaver study analyzed the actual stresses put on the back in extension based programs. He established that some lumbar spines made a vertebral arch decreasing pain on the herniated disc. I believe this treatment may be effective in minimizing the pain and increasing the function for my patient. The journal articles obtained and the case study all link the importance of application in a clinical environment. A couple of articles on a small demographic is not always applicable if the environment is not the same. Conflicting information is always found if data bases are search. This is why future clinical analytic studies should be done to further establish the relationship of increased function and decreased pain with the extension program.

Further inquiry is always needed unless you achieve the perfect experiment that is completely reproducible. For this particular case I would want to have an experiment of over 800 female participants, in each experimental group there would be a middle class, urban demographic. At least 100 volunteers would be Asian-American females. The study would identify the efficacy of McKenzie Extension Method and women in clinical practice. Although probably not feasible in real research pools, I would first establish a participant pool of twenty to forty year olds. I would achieve gain their participation through the urban university graduate program setting as well as advertisements in city newspapers for free physical therapy to be involved in this back study. Using a younger population would decrease the amount of multiple back problems, hopefully eliminating stenotic individuals, and the spine should be in fairly good condition. I would eliminate those with prior injury in the lower extremity, to verify radicular pain was real. Subjects would not have pain for longer than five months and no less than a month. There would be equal amount of Asian, African American, Hispanic, and Caucasian women. They would all have a herniated intervertebral disc at the L4-S2 region in addition to radicular pain for at least one hour a day. The groups would be divided into a neutral core stabilization group and McKenzie extension group. I would document for the exact progression of the two exercise programs. The physical therapists would be well trained in both exercise programs and non-biased in their technique of administering to subjects. Each physical therapy experience would be on an individual basis so as to blind subjects on what study they are in. An Oswestry would be given on the initial evaluation and then each month for four months an additional Oswestry would be given as well as a follow up mailed to the patient after two months passed discharge. This experimental study would be of multi-factorial design comparing both intervention groups, pain over time. The measurement tool used to analyze the change in disability and pain of a patient must be non-parametric. The Mann-Whitney U-test is a statistical tool for this very purpose; it analyzes non-parametric statistical test data comparing the two variables. Pain and time established in the multi-factorial design that is established.

This project made me understand the importance of being evidence based. There are a lot of articles out there that on face value look as though a certain treatment may be effective, but delving deeper into analysis the evidence maybe mediocre. To be an effective physical therapist we want to gain as much knowledge as possible from a variety of sources to be able to help our patients and give good reason for the patients to follow treatment. In the age of the internet when so much information is accessible to our patients it is important to stay updated and be able to answer questions. Being able to refer to evidence of why you are doing a particular treatment may also aid in patient adherence to programs. I felt it was unclear how we were to go about doing this paper, and with the intensity of the program it made it very difficult and more time consuming than it had to be. Getting feedback promptly would have helped out in identifying whether I was on the right track.

Bibliography

Adams et al. Effects on Backward Bending and Intervertebral discs. Spine.2000; 25(4): 431-437.
Chi, Chunhuei. An Event Count Model for Studying Health Services Utilization. Med Care.1998;
36(12): 1639-1659.
Fritz, Julie M and Piva Sara R. Physical Impairment Index: Reliability, Validity, and Responsiveness in
Patients with Acute Low Back Pain. Spine.2003;28(11):1189-1194.
Fritz et al. Comparison of Classification-Based Physical Therapy With Therapy Based on Clinical
Practice Guidelines for Patients with Acute Low Back Pain. Spine.2003;28(13):1361-1372.
Deyo, Richard A. Herniated Lumbar Intervertebral Disk. Annals of Internal Medicine.1990; 112:598-
603.
Frymoyer, John W. An International Challenge to the Diagnosis and Treatment of Disorders of the
Lumbar Spine. SPINE.1993; 15:2147-2152.
"Herniated Lumbar Disk." Dynomed.com. 2000.Online.
http://www.dynomed.com/encyclopedia/encyclopedia/spine/herniated_lumbar_disk.htm.9Sept.2
004 .
Kerr, Daniel et al. Acupuncture in the Management of Chronic Low Back Pain: A Binded Randomized
Controlled Trial. Clin J Pain 2003; 19(6):364-370.
McGill, Stuart. (2002). Low Back Disorders: Evidence-based prevention and Rehabilitation.
Champaign: Human Kinetics.
Peters, Claudia A. "Lumbar (intervertebral) disk disorders." Online.
Http: //www.5mcc.com/assets/SUMMARY/TP0445.html. 9 Sept.2004.
Petersen et al. The Effect of McKenzie Therapy as Compared with that of Intensive Strengthening
Training for the Treatment of Patients with Subacute or Chronic Low Back Pain: A Randomized Controlled Trial. Spine.2002;27(16): 1702-1709.
Smantha, Ash and Beardsley, Jo. BMJ.1999; 1122-1123.
Van Tulder et al. Exercise therapy for low-back pain. The Cochrane Library.2004; 2004.2.