Lumbar Intervertebral Disc Syndrome

Synonyms

Definition

A condition involving nerve root irritation as a result of lumbar disc pathology.

Patient History

Patient history may include

Patient Data

Specific Considerations

Red Flag

Possible Consequence or Cause

Severe trauma

Fracture

Onset following minor fall, or heavy lifting in elderly or osteoporotic patient

Fracture

Direct Bbow to the back in young adult

Fracture

Saddle anesthesia

Cauda equina syndrome

Severe, or progressive neurologic complaints

Cauda equina syndrome

Global, or progressive motor weakness in the lower extremities

Cauda equina syndrome

Recent onset of bowel dysfunction, or acute onset of bladder dysfunction in association with low back pain

Cauda equina syndrome

Unexplained weight loss

Malignancy

Prior history of cancer

Malignancy

Pain that is worse with recumbency, or worse at night

Malignancy

Fever, or recent bacterial infection

Infection

Intravenous drug abuse, or immunosupression

Infection

Prolonged steroid use

Osteoporosis

Symptoms that do not change with change in position

Kidney disease

Presentation

Subjective Findings

Objective Findings

Objective Findings may include

Scope of Examination

Examine the musculoskeletal system for possible causes, or contributing factors to the complaint.

Note

  • Extra spinal diseases that may refer pain to the back include: aortic aneurysm, colon cancer, endometriosis, hip disease, kidney stones, ovarian disease, pancreatitis, pelvic infections, tumors or cysts of the reproductive tract, uterine cancer.

  • The most serious cause of low back pain is malignant tumor. Most malignant tumors are metastatic and some may cause bony collapse and paralysis. Primary cancers that most commonly metastasize to bone consist of adrenal, breast, kidney, lung, prostate, and thyroid.

Specific Examination Considerations

The following standardized tests may be used to assess functional limitation such as lifting, walking, sitting, standing, sleeping, social life and vocation.

 Results if Lumbar Intervertebral Disc Syndrome

Differential Diagnoses

Physical/Occupational Therapy Management

Therapy must show measurable functional progress.

Requirements for Physical/Occupational Therapy Visits

Two or more of the following findings must be present to establish medical necessity. At least one of the findings must address functional limitation.  Degree of abnormality should be specified at initiation of therapy, and periodically, to establish an objective response to therapy:

  1. Significant Functional Limitations (i.e. social, recreational, vocational activities) - Practitioners are strongly encouraged to utilize peer reviewed, standardized tools to quantify Functional Limitations.

  2. Strength: <4/good (5 = normal; 4 = good; 3 = fair; 2 = poor; 1 = trace)

  3. ROM: limited >30% (norms: flexion = 60; extension = 30; lateral flexion = 30; rotation = 30)

  4. Pain: limiting function and at least 3/10

  5. Neurological signs: altered reflexes and/or sensations

Treatment frequency and duration must be based on:

Treatment Methods

Discharge Criteria

Referral Guidelines

Refer patient to their primary care provider for evaluation of alternative treatment options if:

Appropriate Procedures/Modalities

Use of modalities and /or passive treatments should be limited. The goal is to transition patient as quickly as possible to active care, self-management and functional independence.

The following table lists the procedures for Early Phase presentation:

Expected Outcome

Procedures/Modalities Such As

Decrease pain/muscle spasm

  • Modalities to relieve pain e.g. Cryotherapy, TENS, Interferential

Improve lumbar flexibility

  • Segmental mobilization-Grade I

  • Gentle Flexibility exercises (hamstring stretch, Hip flexors stretch, back muscle stretch, Quadriceps stretch)

Improve strength and power of back musculature and ability to stand for at least 30 minutes

  • Isometric exercises of abdominal and back muscles

  • Stability exercises in side-lying, 4-point kneeling and standing

  • Strengthening exercises to lower extremity

Patient education and initiation of home exercise program

  • Physician protocol may require lumbar orthotics/brace

  • Avoid bending, twisting, or lifting more than 5 pounds

  • Application of ice or hot-packs

  • Remain as active as possible

  • Body mechanics

  • Weight management

  • Smoking cessation

  • Teach home exercise program

The following table lists the procedures for Mid Phase presentation:

Expected Outcome

Procedures/Modalities Such As

Decrease pain/spasms

  • Thermotherapy

  • Soft tissue mobilization (e.g Myofascial Release, Muscle Energy Techniques)

Restore flexibility of the lumbar musculature and facet joints

  • Segmental joint mobilization-Grade II

  • Flexibility exercises (hamstring stretch, Hip flexors stretch, back muscle stretch, Quadriceps stretch, pelvic mobilization)

Increase strength and endurance of lumbar spine and lower extremities

  • Isotonic exercises

  • Dynamic stabilization exercises

  • Upper extremity strengthening

  • Functional training

Improvement in body mechanics and postural stabilization

  • Body mechanics training

  • Postural stabilization activities

  • Postural Control

Ability to perform physical actions, tasks or activities related to self-care, home management, work, community and leisure

  • Gradual tolerance of activities and positions related to self-care and home management

  • Self-management of symptoms

  • Functional training

  • Teach home exercise program

The following table lists procedures for Final Phase presentation:

Expected Outcome

Procedures/Modalities Such As

Restore flexibility of lumbar spine

  • Segmental joint mobilization-Grade III

  • Flexibility exercises (hamstring stretch, Hip flexors stretch, back muscle stretch, Quadriceps stretch, pelvic mobilization)

Increase strength and endurance of Lumbar spine and lower extremities

  • Advanced dynamic stabilization exercises

  • Functional training

Improvement in body mechanics and postural stabilization

  • Postural stabilization activities

  • Postural Control

Ability to perform physical actions, tasks or activities related to self-care, home management, work, community and leisure

  • Gradual resumption of activities relating to work, community and leisure

  • Self-management of symptoms

  • Work hardening or vocational rehabilitation to learn different job skills

  • Postural control and body mechanics

  • Teach home exercise program

Note

Not all of the above modalities are appropriate for each individual case; they require the skill and judgment of persons properly trained and licensed for safe use. Use of diathermies, including microwave, shortwave, and ultrasound, is controversial and may be contraindicated in the presence of metals, and prior to neurological, and/or orthopedic maturity. Landmark recommends following all manufacturer and educational guidelines in the use of electrotherapeutic modalities.

Home and Self-Care Techniques

The patient can be taught to use medical equipment and administer self care at his residence.

Home Medical Equipment

None indicated

Self-Care Techniques

Alternatives/Adjuncts to Physical/Occupational Therapy Management

References

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Bischel, Margaret D., The Managed Physical/Occupational Therapy and Rehabilitation Care Manual, Apollo Managed Care Consultants, 2002.

Cherkin Ph.D., Daniel C., Deyo M.D., M.P.H., Richard A., Battie Ph.D., R.P.T., Michele, Street, M.N., C.P.N.P., Janet, and Barlow Ph.D., William, A Comparison of Physical Therapy, Chiropractic Manipulation, and Provision of an Educational Booklet for the Treatment of Patients with Low Back Pain, The New England Journal of Medicine, Volume 339:1021-1029, Number 15, October 8, 1998

Di Fabio R, Mackey G, Holte J. Physical therapy outcomes for patients receiving workers' compensation following treatment for herniated lumbar disc and mechanical low back pain syndrome. Journal of Orthopaedic & Sports Physical Therapy [serial online]. March 1996;23(3):180-187.

Dutton, Mark, Orthopaedic Examination, Evaluation, & Intervention, McGraw-Hill Medial Publishing Division, 2004.

Eck, J.C, Clinical evaluation and treatment options for herniated lumbar disc, American Family Physician, 1999

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Jette AM, Smith K, Haley SM, Davis KD, Physical therapy episodes of care for patients with low back pain. Phys Ther. 1994 Feb;74(2):101-10; discussion 110-5

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Magee, David J., Orthopedic Physical Assessment, Fourth Edition, W.B. Saunders Company, 2002.

Moffett JK, Torgerson D, Bell-Syer S, Jackson D, Llewlyn-Phillips H, Farrin A, Barber J.  Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences.  BMJ. 1999 Jul 31; 319(7205): 279-283.

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Placzek, JE, Boyce, DB, Orthopaedic Physical Therapy Secrets, Hanley & Belfus, Inc, Philadephia, 2001.

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Turek, S.L., Orthopaedics Principles and Their Applications, J.B. Lippincott Co.What factors explain the number of physical therapy treatment sessions in patients referred with low back pain; a multilevel analysis. Swinkels IC, Wimmers RH, Groenewegen PP, van den Bosch WJ, Dekker J, van den Ende CH. BMC Health Serv Res. 2005; 5: 74. Published online before print November 24, 2005.