Pain Management and Therapeutic Exercise of Lumbar Disc Herniations Hee Sang Kim, M.D. Department of Physical Medicine and Rehabilitation Kyung Hee University College of Medicine & Hospital E mail : Abstract Most people will experience episodes are usually brief, resolve spontaneously, and recur infrequently. The successful management of persistent low back pain requires that treatment be directed to the pain producing structures in the human body. The spectrum of the treatment of low back pain ranges from very simple and straight foreword to very the complex and intricate. Treatments for lumbar disc herniations are conservative (75~90% of patients), invasive (5~10% of patients), and surgical (5% of patients) treatments. Resolution of the first lumbar disc herniation takes place in approximately 75% of patient over a period of 3 months. With recurrent herniations, the chance of spontaneous relief of symptoms is reduced. In a very acute stage, the patient may require hospitalization to control the level of pain. Bed rest should be limited 2 days with the most comfortable position of the knee and the hip flexion about 80~90 degree. A few days of bed rest, adequate analgesics, and muscle relaxants to reduce muscle spasm usually are require. Physical therapeutic modality(included traction, heat, ultrasound, electrical stimulation), mobilization, manipulation, back school, spinal supports, therapeutic exercise and proper position should be used and educated. If the patient did not controled low back pain after above treatments, invasive treatments such as trigger point injection, facet or sacroiliac joint injection, epidural steroid injection, selective nerve root injection with high frequency heat therapy, or intradiscal injection may quickly alleviate symptoms. Every patient should attend a class in spine education as part of the overall treatment. Instruction is given in low back care, especially as related to the activities of daily living. Participants are taught correct posture, pelvic tilting, knee to chest exercise, and exercises to strengthen abdominal and paraspinal muscles. Individual instructions are given to each patient, explaining in more detail the nature of the patient's particular problem and how the individual can take control of the treatment. Keywords : Low back pain; Conservative treatment; Bed rest; Therapeutic exercise; Invasive treatment 726
Treatments for Lumbar Disc Herniations Conservative (75~90% of patients) Bed rest Medications(analgesics, anti inflammatories, muscle relaxants) Physical therapy modalities(traction, heat, ultrasound, electrical stimulation) Mobilization Manual therapy Manipulation Supports Back school Exercise(i.e., balanced aerobic) Activations(i.e., elastic garment) Antigravity methods Chronic pain management Functional restoration Work reconditioning Chronic pain management Invasive (5~10% of patients) Spinal injection [trigger point, facet joint, scaroiliacsi) joint, nerve root, epidural] Intradiscal therapy(chymopapain, collagenase, electrical therapy) Radio frequency heat therapy Surgical (5% of patients) Minimally invasive Operative discectomy Decompression for spinal stenosis Spinal fusion Plan of Treatment in Dysfunctional Low Back Treatment Lesion Conservative Facet joints Yes Sacroiliac joint Yes Manipulation Facets SI & muscle Injection Facet & muscle Joint & muscle Myofascial syndrome Yes Stretch muscle Muscle Piriformins syndrome Yes Muscle Disc Herniation Yes Sometimes Epidural steroid Operation Sometimes 727
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30 cm(12 in) 30 730
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Referred pain patterns of lumbar facet syndrome L5 S1 facet pain distribution Coccyx, hip, posterior thigh, groin, flank L4 L5 facet pain distribution Psterior hip and thigh, coccyx L3 L4 facet pain distribution Upward to thoracic spine, diffuse flank and groin pain, coccyx 732
L 4 L 5 S A B C 733
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A B 735
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A A B C B 738
Exercise Type of Low Back Pain Extension Exercise Subjective Pain in lying & in sitting Flexion Exercise Pain in sitting & in lying or standing Articular stresses on the facet joint Pain Forward bending Backward bending Pain Backward bending Forward bending Neural tension Load on the back Stretching to the dorsolumbar fascia & musculature Disk pressure Opening of the intervertebral foramen Efficacy Strength & endurance of exercise Relief of stenosis of the spinal canal muscle Proprioceptive interference with pain perception Stabilizing effect of the abdomen Intra-abdominal pressure Proprioceptive interference with pain perception Caution Facet joint degeneration Impingement of vertebral foramen Spondyloysis & spondylolisthesis Avoid in acute disk prolapes Shouldn't done after a flat lying rest interval >30 mins 739
Part Way Back Only Lean Back Hold Then Oblique Abdominal Muscles Turn Trunk (Left Right) Hold Return Bring Elbow Towards Opposite Knee 740
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Lower Leg Hold Hold 742
11... 1997 ; 2 : 134-9 12.,. (I). 1995 ; 15(4) : 407-20 743
13.,. (II). 1995 ; 15(5) : 525-48 14...,.. 2., 2002 : 42 7-44 15. Arokoski JP, Valta T, Airaksinen O, Kankaanpaa M. Back & abdominal muscle function during stabilization exercises. Arch Phys Med Rehabil 2001 ; 82 : 1089-98 16. Braddom RL. Physical Medicine & Rehabilitation. 2nd ed. Philadelphia : WB Saunders, 2000 17. Cailliet R. Pain series : Low back pain syndrome. 5th ed. F.A. Davis Company, 1995 18. Cox JM. Low back pain : mechanism, diagnosis and treatment. 6th ed. Boltimore : Williams & Wlikins, 1999 19. Delisa JA, Gans BM. Rehabilitation Medicine, principles and practice. 3rd ed. Philadelphia : Lippincott Company, 1998 10. Kirkaldy Willis WH, Burton CV. Managing low back pain. 4th ed. London : Churchill Livingstone. 1992 11. Leinonen V, Kankaanpää, Luukkonen M, Hanninen O, Airaksinen O, Taimela S. Disc herniation related back pain impairs feed forward control of paraspinal muscles. Spine 2001 ; 26 : E367-72 12. Mannion AF, Taimela S, Muntener M, Dvorak J. Active therapy for chronic low back pain : part 1. Effects on back muscle activation, fatigability, and strength. Spine 2001 ; 26 : 897-908 13. Richardson C, Jull G, Hodges P, Hides J. Therapeutic exercises for spinal segmental stabilization in low back pain, London : Churchill Livingstone, 1999 14. Travell JG, Simons DG. Myofascial Pain and Dysfunction, Barbara D. Commings, 2000 15. van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain : a systematic review of randomized controlled trials of the most common interventions. Spine 1997 ; 22 : 2128-56 16. van Tulder MW, Malmivaara A, Esmail R, Koes BW. Exercise therapy for low back pain. Cochrane Database Syst Rev, 2000 744