Lumbar extension exercises in conjunction with mechanical traction for the management of a patient with a lumbar herniated disc

ABSTRACT

Low back pain resulting from lumbar disc herniation is a common reason for referral for physical therapy. There is no evidence to support the management of lumbar disc herniation and derangement using mechanical traction combined with lumbar extension exercises. Therefore, the purpose of this case report was to describe and discuss the use of mechanical traction in conjunction with lumbar extension exercises for a patient with a lumbar herniated disc. The patient was a 49-year-old male referred to physical therapy with a medical diagnosis of a lumbar herniated disc at L5-S1 with compression of the L5 nerve root confirmed by MRI. The patient's chief complaint was pain over the left lumbosacral and central lumbar region with radiating pain into the left buttock accompanied by numbness and tingling in the left lower leg and foot. The patient was seen for a total of 14 visits. The first 5 days (2 weeks) of therapy consisted of lumbar extension exercises. For the following nine visits (over a 3-week period), mechanical traction was added as an adjunct to the extension exercises. Outcome measures included the Oswestry Disability Questionnaire, Back Pain Function Scale (BPFS), and the Numeric Pain Rating Scale (NPRS). Results from initial evaluation to discharge (Oswestry: 36% to 0%; BPFS: 33/60 to 57/60; NPRS: 7/10 to 0/10) demonstrated that the patient no longer experienced low back pain and improved in terms of functional status and pain-related disability. The patient no longer complained of numbness and tingling in the left lower extremity and the goals for the patient had been attained. The data from this case report suggests lumbar extension exercises in conjunction with mechanical traction facilitated the patient's improvement in pain and return to prior level of function.     

Intraneural ganglion cyst of the lumbosacral plexus mimicking L5 radiculopathy: A case report

BACKGROUNDIntraneural ganglion cysts are benign gelatinous masses that form within the epineurium of a peripheral nerve. Only few cases of intraneural ganglion cyst arising from the hip joint have been reported. CASE SUMMARYA previously healthy 65-year-old woman who had been experiencing left buttock pain radiating to the dorsum of the foot for 2 years visited our clinic. Prior to visiting the clinic, she underwent lumbar spine magnetic resonance imaging and received physiotherapy, pain killers, and epidural injections based on a presumptive diagnosis of spinal stenosis for 2 years in other hospitals. Repeat magnetic resonance imaging revealed joint connection of the articular branch of the hip joint and rostral extension of the cyst along the L5 spinal nerve near the L5-S1 neural foramen. The patient was diagnosed with intraneural ganglion cyst arising from the articular branch of the hip joint based on high-resolution magnetic resonance neurography. Using the arthroscopic approach, a cystic opening within the intra-articular space was detected, and cyst decompression was then performed. The pain in the left leg was significantly relieved during the 6-mo follow-up. CONCLUSIONAlthough intraneural ganglion cysts arising from the hip joint are rare, they can cause typical radicular pain and mimic common L5 radiculopathy. Typical cyst ascent phenomenon starting from the termination of the articular branch on magnetic resonance imaging is a crucial finding indicative of intraneural ganglion cysts arising from the hip joint.     

Management of work-related low back pain: a population-based survey of physical therapists

BACKGROUND AND PURPOSE: Physical therapy often is used in the management of work-related low back pain (LBP). Little information, however, is known about the types of interventions used by physical therapists in the management of this condition. The objective of this study was to describe the interventions used by physical therapists in the treatment of workers with acute or subacute LBP, with or without radiating pain below the knee. SUBJECTS: Clinical management questionnaires for workers without and with radiating pain were returned by 190 and 139 physical therapists, respectively. METHODS: For each treatment session, therapists recorded treatment objectives, interventions, and education provided to 2 workers with LBP, 1 with radiating pain and 1 without radiating pain. RESULTS: The majority of physical therapists used stretching and strengthening exercises, spinal mobilization, soft tissue mobilization and massage, manual traction, posture correction, interferential current, ultrasound, heat, and functional activities education. With radiating pain, the majority of the therapists also used cold and the McKenzie approach. Treatment objectives pursued by the majority of the therapists were decrease of pain, increase of range of motion, increase of muscle strength (force-generating capacity of muscle), decrease of muscle tension, and worker education. DISCUSSION AND CONCLUSION: Physical therapists use an array of interventions with workers with LBP. The effectiveness of most interventions reported has not been well studied.     

Use of neurodevelopmental treatment techniques in a client with kyphosis: A case report

This case report describes use of an intervention developed for patients with neurological diagnoses (neurodevelopmental treatment [NDT]) with a patient with musculoskeletal and pulmonary diagnoses. The patient was a 78-year-old woman referred to physical therapy for gait training, therapeutic exercises, and neuromuscular reeducation. Standing at her most upright, the patient initially had a 30° kyphosis with extreme capital extension to bring her head to vertical. Shoulders were internally rotated, and the medial borders of the scapulae rested near the lateral border of the ribs and the scapular spines were at the level of C₇. To address the postural impairments, I used NDT spinal and scapular mobilization techniques and strengthening in weight-bearing postures with modified bridging as preparation for gait training. At the end of the episode of care, the patient's upright posture had improved to 10° kyphosis with head in neutral extension in both standing and walking.     

Management of Lumbar Spinal Stenosis through the Use of Translatoric Manipulation and Lumbar Flexion Exercises: A Case Series

Abstract

Lumbar spinal stenosis is a narrowing of the spinal canal or intervertebral foramen that can produce low back pain and leg pain and weakness. Surgical intervention is commonly performed to relieve these symptoms. Symptom reduction and longitudinal management of functional deficits with conservative care is less well documented. The purpose of this case series was to describe the outcomes of a conservative physical therapy program consisting of low- and high-velocity translatoric manipulations of T1-T9 and L1-L3, and two lumbar flexion exercises on 6 subjects diagnosed with lumbar spinal stenosis and neurogenic claudication. A treadmill test was repeated on a weekly basis and at discharge for each patient. All six subjects demonstrated improvements in treadmill walking time prior to the onset of neurogenic claudication (range: 1 min 34 sec to 26 min); in Oswestry Low Back Pain Disability Index scores (range: 7.5% to 64.7%); and in McGill Pain Questionnaire scores (range: 25% to 57%). Five subjects were measured using the Schober technique, and all showed improvement in thoracolumbar flexion mobility. Combined use of translatoric manipulation and spinal flexion exercises may have resulted in improved spinal flexibility, ambulatory abilities, and pain and functional status in six subjects with lumbar spinal stenosis.     

Reliability of the McKenzie spinal pain classification using patient assessment forms

Objectives To determine whether case studies presented on a completed McKenzie assessment form, commonly used in the McKenzie educational training programme, contain sufficient information to permit a therapist to reach a classification of the patient.Design An inter-rater reliability study of patient classifications made based upon inspection of McKenzie assessment forms. The assessment forms of 50 patients with spinal pain (25 with low back pain and 25 with neck pain) were examined and classified into McKenzie treatment syndromes and sub-syndromes.Setting Private physiotherapy clinics.Participants Fifty physiotherapists, all with similar training in the McKenzie method.Main outcome measures Classification into McKenzie treatment syndromes and sub-syndromes. The reliability of the judgements was expressed using multi-rater kappa (k) and percentage agreement.Results The reliability of syndrome classification was k = 0.56 (95% confidence interval 0.46-0.66) with a percentage agreement of 91%. The reliability of sub-syndrome classification was k = 0.68 (95% confidence interval 0.67-0.69) with a percentage agreement of 76%.Conclusions The reliability analysis suggests that the patient assessment forms evaluated in this study provided an adequate, but not ideal, clinical simulation because the reliability was less than that obtained from inspection of real patients. Future research comparing various types of clinical simulation is indicated to determine which provides the closest replication of the dynamics of the real patient encounter.     

Directional preference at the knee: a case report using mechanical diagnosis and therapy

Abstract

Knee pain is common amongst the sporting and general population. Numerous examination procedures are used to apply diagnostic labels to knee symptoms, such as McMurray’s test, which is used to diagnose a meniscal injury. However, previously in the literature the validity compared with a ‘gold standard’ and the reliability between examiners of such tests has been questioned. In this case study, we report on a sports woman, diagnosed by her general practitioner with a meniscal injury and demonstrating a positive McMurry’s test, who was examined using repeated movements as in the McKenzie system of mechanical diagnosis and therapy. Following self-application of extension exercises and extension exercises with over-pressure the McMurry’s test became negative, and she returned to full sporting activities. The case study indicates a further caution about the use of single orthopaedic test procedures. Not only is their validity and reliability questionable, but also following treatment using repeated movements if positive tests can be made negative, this provides an additional query to their validity.     

Comparison of the effectiveness of proprioceptive neuromuscular facilitation exercises and shoulder mobilization patients with Subacromial Impingement Syndrome: A randomized clinical trial

IntroductionThe aim of this study was to compare the effectiveness of Proprioceptive Neuromuscular Facilitation (PNF) exercises and shoulder mobilization (SM) in addition to conventional physiotherapy on pain, range of motion (ROM), functionality, and muscle strength in patients with Subacromial Impingement Syndrome (SIS).MethodsForty-four patients were randomly allocated into three groups as conventional physiotherapy (control group; n = 14), conventional physiotherapy + PNF exercises (PNF group; n = 15), and conventional physiotherapy + SM techniques (SM group; n = 15). Pain, ROM, muscle strength, and functionality were evaluated by using VAS (Visual Analog Scale), goniometer, push-pull dynamometer, Constant-Murley score and DASH (Disabilities of the Arm, Shoulder and Hand) score. Patients were received 20 sessions (4 weeks) of treatment. Assessments were performed at baseline, and weeks two, four, and sixteen.ResultsAfter treatment, significant improvements in outcome measurements were observed in all groups (all p < 0.05). PNF or SM groups were not superior to each other in terms of improving pain and functionality. SM group was superior to PNF group for improving shoulder flexion ROM at week 4 (p = 0.009). The improvements in shoulder extension muscle strength were greater in PNF group at weeks 2 and 16 compared with other groups (p = 0.030, 0.035).ConclusionPNF or SM, in addition to conventional physiotherapy, might help to improve pain and functionality more in patients with SIS. It is recommended to add SM or PNF to conventional treatment to maintain the ROM increase gained with SIS treatment after treatment, and to apply this treatment for 4 weeks for muscle strength increase.     

Use of neurodevelopmental treatment techniques in a client with kyphosis: a case report

This case report describes use of an intervention developed for patients with neurological diagnoses (neurodevelopmental treatment [NDT]) with a patient with musculoskeletal and pulmonary diagnoses. The patient was a 78-year-old woman referred to physical therapy for gait training, therapeutic exercises, and neuromuscular reeducation. Standing at her most upright, the patient initially had a 30 degrees kyphosis with extreme capital extension to bring her head to vertical. Shoulders were internally rotated, and the medial borders of the scapulae rested near the lateral border of the ribs and the scapular spines were at the level of C7. To address the postural impairments, I used NDT spinal and scapular mobilization techniques and strengthening in weight-bearing postures with modified bridging as preparation for gait training. At the end of the episode of care, the patient's upright posture had improved to 10 degrees kyphosis with head in neutral extension in both standing and walking.     

In-hospital physiotherapy improves physical activity level after lung cancer surgery: a randomized controlled trial

ObjectivesPatients undergoing lung cancer surgery are routinely offered physiotherapy. Despite its routine use, effects on postoperative physical recovery have yet not been demonstrated. The aim of this study was to investigate whether physiotherapy could improve postoperative in-hospital physical activity level and physical capacity.DesignSingle-blind randomized controlled trial.SettingThoracic surgery department at a University Hospital.ParticipantsPatients undergoing elective thoracic surgery (n = 94) for confirmed or suspected lung cancer were assessed during hospital stay.InterventionDaily physiotherapy, consisting of mobilization, ambulation, shoulder exercises and breathing exercises. The control group received no physiotherapy treatment.OutcomesIn-hospital physical activity assessed with the Actigraph GT3X+ accelerometer, six-minute walk test, spirometry and dyspnea scores.ResultsThe treatment group reached significantly more accelerometer counts (2010 (1508) vs 1629 (1146), mean difference 495 [95% CI 44 to 1109]), and steps per hour (49 (47) vs 37 (34), mean difference 14 [95% CI 3 to 30]), compared to the control group, during the first three postoperative days. No significant differences in six-minute walk test (percent of preoperative 71% vs 79%, P = 0.13), spirometry (FEV1 percent of preoperative 69% vs 69%, P = 0.83) or dyspnoea (M-MRC 2 vs 2, P = 0.74) between the groups were found.ConclusionsPatients receiving in-hospital physiotherapy showed increased level of physical activity during the first days after lung cancer surgery, compared to an untreated control group. However, no effects on the six-minute walk test or spirometric values were found. The clinical importance of an increased physical activity level during the early postoperative period needs to be further evaluated.
Clinical Trial Registration number: NCT01961700.     

Physiotherapeutic methods of treatment of mandibular distal occlusion and the progress of therapy: A case report

BackgroundStudies have demonstrated a relationship between dental malocclusion and posture defects. The aims of the study were to present (1) the effect of a physiotherapeutic approach to a patient with a distal occlusion defect with the use of a set of exercises to strengthen the muscles responsible for mandibular protrusion, and (2) a non-invasive and easy-to-use method to monitor the effects of therapy.MethodsFive year old girl with a distal occlusion and with a low basic postural tone was referred to physiotherapy. A therapeutic program i.a. concerning a strengthening of the temporomandibular joint muscles with the use of a flexible tape was proposed. To assess the functional changes of the masticatory apparatus a photoanthropometric method was used. In side-face photos, proportions of 2 linear measurements and values of two angles on the first day of therapy, after 2 and after 4 months of exercises, with the mandible located freely and in the maximum protrusion were compared.ResultsA comparison of indices and angles showed a marked improvement in mandibular mobility already after two and four months of the exercises. Using the elastic resistance tape in addition to general developmental exercises allowed for increasing the mobility in the temporomandibular joint.ConclusionMalocclusion should not be considered separately, without taking into account the body posture. The work of the physiotherapist can benefit the orthodontist, correcting postural defects and consequently affecting malocclusion. A comparison of linear measurements and angles can be used to assess the progress of the therapy.     

Multimodal physiotherapy treatment based on a biobehavioral approach for patients with chronic cervico-craniofacial pain: a prospective case series

The purpose of this prospective case series was to observe and describe changes in patients with chronic cervico-craniofacial pain of muscular origin treated with multimodal physiotherapy based on a biobehavioral approach. Nine patients diagnosed with chronic myofascial temporomandibular disorder and neck pain were treated with 6 sessions over the course of 2 weeks including: (1) orthopedic manual physiotherapy (joint mobilizations, neurodynamic mobilization, and dynamic soft tissue mobilizations); (2) therapeutic exercises (motor control and muscular endurance exercises); and (3) patient education. The outcome measures of craniofacial (CF-PDI) and neck disability (NDI), kinesiophobia (TSK-11) and catastrophizing (PCS), and range of cervical and mandibular motion (ROM) and posture were collected at baseline, and at 2 and 14 weeks post-baseline. Compared to baseline, statistically significant (p < 0.01) and clinically meaningful improvements that surpassed the minimal detectable change were observed at 14 weeks in CF-PDI (mean change, 8.11 points; 95% confidence interval (CI): 2.55 to 13.69; d = 1.38), in NDI (mean change, 5 cm; 95% CI: 1.74–8.25; d = 0.98), and in the TSK-11 (mean change, 6.55 cm; 95% CI: 2.79–10.32; d = 1.44). Clinically meaningful improvements in self-reported disability, psychological factors, ROM, and craniocervical posture were observed following a multimodal physiotherapy treatment based on a biobehavioral approach.     

Neurodynamic exercises provide no additional benefit to extension-oriented exercises in people with chronic low back-related leg pain and a directional preference: A randomized clinical trial

BackgroundChronic low back-related leg pain may involve mixed pain mechanisms. A strategy to address both neuropathic and nociceptive pain symptoms would be combining treatments.ObjectiveTo assess the effects of adding neurodynamic exercises to extension-oriented exercises in patients with chronic low back-related leg pain and a directional preference.DesignTwo arm, single blind, randomized clinical trial.MethodEligible participants were aged between 18 and 65 years, had low back pain radiating below gluteus for at least 3 months, pain intensity greater than 3 points in the numerical pain rating scale, positive SLR test and a directional preference for lumbar extension movements. Thirty-one participants were randomly allocated into one of two groups: extension-oriented exercises (EE) or extension exercises plus neurodynamic exercises (EEN). Primary outcomes were leg pain intensity and function at 3 weeks. Secondary outcomes were low back pain intensity, disability, global perceived effect and quality of life at 3 weeks and at 1 month.ResultsRetention rate was 100% (n = 14) in EE and 94% (n = 16) in EEN for primary outcome analysis. There was no between-group difference for the primary outcomes and for low back pain intensity, GPE and quality of life at 3 weeks. For some outcomes, EE was superior to EEN.ConclusionsWe found no benefits in adding neurodynamic exercises to extension-oriented exercises for patients with nerve-related leg pain and a directional preference. As this study has a small and very specific sample, results may be interpreted with caution.     

A classification and treatment protocol for low back disorders Part 2 – Directional preference management for reducible discogenic pain

Abstract

Background: It has been widely recommended that clinical trials on people with low back disorders should have a greater focus on subgroup specific treatment in order to increase the likelihood of clinically meaningful effects being demonstrated. The McKenzie approach to assessing and treating patients with a directional preference is a potentially useful and widely used clinical method in providing specific treatment. Studies to date have not used a clearly defined and appropriately detailed clinical protocol for the McKenzie approach that is reproducible in the clinical or research setting.

Objectives: This paper presents a detailed classification and treatment protocol for people with clinical features thought to be indicative of reducible discogenic pain with a directional preference that is responsive to mechanical loading strategies.

Discussion: A pathoanatomical interpretation of the McKenzie approach, classification principles and particular treatment components in the clinical protocol are discussed.

Conclusion: The described clinical protocol will be used in the Specific Treatment for Problems of the Spine trials comparing specific physiotherapy to evidence-based advice.     

The effect of core stability training with ball and balloon exercise on respiratory variables in chronic non-specific low back pain: An experimental study

BackgroundStudies have shown the involvement of respiratory characteristics and their relationship with impairments in non-specific low back pain (NS-LBP). The effects of core stability with a combined ball and balloon exercise (CBB) on respiratory variables had not been investigated.ObjectiveTo evaluate the effectiveness of CBB on respiratory variables among NS-LBP patients.Study designpre- and post-experimental study.ParticipantsForty participants were assigned to an experimental group (EG) [n = 20] and control group (CG) [n = 20] based on the study criteria.InterventionsThe EG received CBB together with routine physiotherapy and the CG received routine physiotherapy over a period of 8 weeks. Participants were instructed to carry out the exercises for 3 days per week. The training was evaluated once a week and the exercises progressed based on the level of pain. Outcome measures: Primary outcomes were maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP) and maximum voluntary ventilation (MVV). The secondary outcomes were measured in the numeric rating scale (NRS), total faulty breathing scale (TFBS), cloth tape measure (CTM) and lumbo-pelvic stability. Results: The MIP increased significantly among the EG when compared with that in the CG (p > 0.05).The EG showed a significant increase in MVV (p = 0.04) when compared to the CG (p = 0.0001). There was a significant reduction in pain for both groups. The MEP, TFBS, chest expansion and core stability showed no changes in either group. Conclusion: CBB was effective in improving respiratory variables among NS-LBP patients.