|Year : 2019 | Volume
| Issue : 2 | Page : 93-100
Physiotherapy management of lumbar disc herniation with radiculopathy: A narrative review
Musa Sani Danazumi
Department of Physiotherapy, Federal Medical Centre, Nguru, Yobe State; Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Kano, Nigeria
|Date of Submission||14-Nov-2019|
|Date of Decision||07-Dec-2019|
|Date of Acceptance||27-Dec-2019|
|Date of Web Publication||02-Apr-2020|
Musa Sani Danazumi
Department of Physiotherapy, Federal Medical Centre, Nguru, Yobe State; Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Kano
Source of Support: None, Conflict of Interest: None
Introduction: Lumbar disc herniation with radiculopathy (LDHR) has been one of the most difficult conditions to manage among low back disorders. Individuals with chronic or recurring lumbar radiculopathy experience difficulties returning to work due to poor lower limb neuromuscular control. Given the consequences of LDHR, there is the need for effective treatment approaches that will be helpful in the amelioration of the problem. Objectives: In this study the most recent physical therapy literature in the management of patients with LDHR was evaluated. Methods: A literature review was conducted from inception to January 2019 in the PubMed, PEDro, and OTseeker databases. Results: Fifteen studies relating to the physiotherapy managements of LDHR were identified and discussed. Out of these studies, 1 study was a cohort study and 14 studies were randomized controlled trials. 5 studies examined the effects of physical therapy modalities, 6 studes examined the effects of physical therapy/exercises and 4 studies examined the effects of spinal manipulation (SM) in the management of LDHR. Conclusion: The findings of this study concluded that extension-oriented treatment approach, SM and lumbar stabilization exercise in combination with low power laser therapy are better than any physiotherapy intervention in the management of LDHR.
Keywords: Lumbar disc herniation, narrative review, radiculopathy
|How to cite this article:|
Danazumi MS. Physiotherapy management of lumbar disc herniation with radiculopathy: A narrative review. Niger J Exp Clin Biosci 2019;7:93-100
| Introduction|| |
Low back pain (LBP) has been one of the serious complaints of the working age population afflicting the life styles of individuals in one way or the other. LBP is the second leading reason why primary care consultation is sought and one of the most common reasons for LBP is the herniation of intervertebral disc in the spinal canal., Lumbar disc herniation (LDH) is believed to be a major contributor to the estimated 60%–80% of lifetime incidence of LBP in general population and is among the most common causes of sciatica.
Sciatica which commonly referred to as lumbar radicular pain, accompanies approximately 10% of cases of LBP with a life time incidence ranging from 13% to 40%. Symptoms of sciatica may be difficult to deal with because over 50% of people reporting sciatica indicate a pattern of intermittent presentation, with relapsing being not uncommon. This pattern has been estimated to increase prevalence of long-term disability by 10% and to triple the likelihood that people will seek additional medical care.
The importance of identifying effective treatments for sciatica is emphasized by research indicating that the presence of sciatica is associated with delayed recovery, persistent disability, increased health care system utilization and costs. To this extent, various operative and nonoperative treatment strategies have been tried for LDH with varying degrees of success. Treatment often involves surgery, patient education, physical therapy, alternative medicine options, and pharmacotherapy. However, during the past several decades, the paradigm regarding the best treatment with which to treat LDH has shifted between surgery and physical therapy.
Physical therapy is one of the significant components of nonoperative treatment. Literature,, is readily obtainable for the beneficial effects of physical therapy in the management of LDH with radiculopathy (LDHR). In addition, studies demonstrate that in the absence of cauda equine syndrome, neither medical, nor surgical interventions are better than physical therapy methods in the management of patients with LDHR. Furthermore, Weber found that a period of 3 months was necessary to decide whether nonoperative therapy would provide satisfactory results. If no or little improvement occurred during this period, then the patient would be a good candidate for surgical intervention.
Furthermore, due to the varieties of physical therapy interventions that have been used over the years in the management of LDHR, there is the need to review the current literature for the most effective interventions and to create a premise for further researches in this field to help ameliorate the problem of LDHR. This study therefore, evaluated the recent studies of physical therapy literature for the management of individuals with LDHR.
| Methods|| |
PubMed, PEDro, and OTseeker databases were searched from inception to January, 2019 using a predefined strategy for the following key words: Physical therapy OR physiotherapy AND management OR intervention OR treatment AND LDH OR lumbar disk prolapsed OR herniated lumbar disk AND radiculopathy OR Sciatica. Further publications were identified by examining the reference list of each selected article. All studies of any design written in English were included in the study. A widely accepted definition of lumbar disk herniation as the localized displacement of disc material beyond the limits of the intervertebral disc space resulting in pain, weakness or numbness in a myotomal or dermatomal distribution (Maitland et al., 2005) was used. The level of evidence was determined using the standardized criteria recommended by the Oxford Center for Evidence-Based Medicine [Table 1].
| Results|| |
Fifteen studies relating to the physiotherapy managements for LDHR were reviewed. No further relevant studies were identified by examining the reference list of each selected article. Study designs including prospective cohort (1 study) and randomized clinical trials (RCTs) (14 studies) were identified and described. Of these studies, 1 study was a cohort study and 14 studies were randomized controlled trials. 5 studies examined the effects of physical therapy modalities, 6 studies examined the effects of physical therapy/exercises, and 4 studies examined the effects of spinal manipulation (SM) in the management of LDHR. All the identified studies were presented and discussed below.
| Discussion|| |
The studies identified in this review were categorized and discussed in three groups and the outcomes of the studies were presented in tabular forms. In addition, each study was graded based on the level of evidence described above.
Effects of physical therapy/modalities in the management of lumbosacral radicular pain
Abou Shady and EL-Homran conducted an RCT to examine the effect of low level laser therapy (LLLT) on sciatic pain in discogenic patients. Thirty patients diagnosed with sciatica due to disk pathology participated in this study. Patients were assigned into two equal groups; Group A which was the study group and Group B which was the control group. Patients in Group A were treated with LLLT while patients in Group B were treated with placebo laser therapy. In addition, a designed and selected physical therapy program (IR, strengthening exercises for back muscles and physical therapy advices) were used for both groups. Data of visual analog scale (VAS), Modified Oswestry Disability Questionnaire, and straight leg raise (SLR) were collected from each patient pre- and post-treatment. The results showed significant improvement in pain intensity, functional disability, SLR and speed of walking in Group A patients as compared with those in Group B after 3 months. The authors concluded that LLLT is an effective physical therapy modality for treating chronic sciatic patients with discogenic lesion and should be recommended in physiotherapy program. Due to limited sample size and lack of follow-up, this study provided Level II therapeutic evidence.
In another study, López-Díaz et al. analyses the efficacy of manual oscillatory therapy, following the pulsation oscillation long duration (POLD) technique, for acute LDH and compares it to usual treatment in a randomized controlled triple-blind pilot clinical trial. A sample of 30 patients was included in the study and was divided into two homogeneous groups to receive usual treatment (A) or treatment with the POLD technique. The protocol for the control group was: Microwave thermotherapy of the lower back (15 min), analgesic electrotherapy of the lower back (transcutaneous electrical nerve stimulation 15 min), ultrasound (US) applied to the painful area (continuous: 1.5w/cm2 10 min) and self-directed muscle stretching exercises during the session (column and legs posterior chain, psoas, and quadratus lumborum). The protocol for the intervention group (B), was identical for all of Group B individuals and consisted of a series of maneuvers in the prone position: Rhythmic oscillation of the spine, transverse rhythmic mobilization of the lumbar and paravertebral muscles, oscillatory spinal decompression from the sacrum, lateral opening of the affected level by oscillatory inclination and symmetric oscillatory rotation at the vertebrae of the affected level. A total of 9 sessions (3 sessions/week, 3 weeks in total from the beginning to the end of the study) with the treatment in each session lasting between 45 and 60 min were performed. Outcomes were assessed before and after treatment using lumbar goniometry and subjective variables such as the severity (VAS) and extension of the pain (centralization phenomena). With the application of POLD therapy, patients presented significant changes on range of motion (forward flexion with P < 0.05) at completion of the trial in comparison with the control group. They showed a significant reduction in the severity of pain with a mean VAS scale for lumbar, gluteus and thigh pain, which improved from 5.09 to 0.79, 5.07 to 0.97 and 4.43 to 0.49 respectively (P < 0.05), and also when compared to usual treatment (P< 0.05) for all body regions. Moreover, the authors observed a reduction in pain extension (centralization phenomena) (P < 0.001) in POLD treatment group as compared with usual treatment group. In this study the POLD Method was shown to be an effective manual therapy approach for reducing the severity and irradiation of the pain in LDH patients with sciatica, and more efficient than usual treatment. Due to limited sample size and lack of follow-up, this study provided Level II therapeutic evidence.
In addition, Unlu et al. conducted a prospective randomized controlled trial comparing the outcomes of traction, US and low power laser (LPL) therapies in patients with acute lower back pain and leg pain caused by LDH. Of the 60 consecutive patients included in the study, 20 were assigned to each treatment group: mechanical traction with 35%–50% body weight, US and LPL. Outcomes were assessed at 3 months using VAS, Roland Morris, clinical signs and magnetic resonance imaging (MRI) disc morphology. There were significant reductions in pain and disability scores between baseline and follow-up in all three groups. There was a significant reduction in the size of the disc herniation on MRI after treatment. There was no correlation between clinical findings, pain and disability scores, and change in LDH size among groups. The authors concluded that traction, US and LPL therapies were all effective in the treatment of this group of patients with acute LDH. Because of limited sample size and lack of follow-up, this potential Level I study provides Level II evidence that pain and disability due to acute lumbar radiculopathy secondary to LDH may improve over 3 months in patients undergoing mechanical traction with 35%–50% body weight; however, it is equal in effectiveness to LPL and US.
Similarly, Ozturk et al. conducted a prospective RCT to investigate the effect of continuous lumbar traction on the size of herniated disc material measured by computer tomography (CT) in individuals with lumbar disk herniation. In this study, 46 patients with LDH were included and randomized into two groups as the traction group (24 patients), and the control group (22 patients). The traction group was given a physical therapy program (hotpack, continuous US, and diadynamic currents) and continuous lumbar traction. The control group was given the same physical therapy program without traction, for the same duration of time. Data for the clinical symptoms and signs were collected before and after fifteen treatment sessions together with calculation of a herniated index from the CT images that showed the size of the herniated disk material. In the traction group, most of the clinical findings (LBP, SLR angle, motor/sensory deficit) significantly improved with treatment. Size of the herniated disk in CT decreased significantly only in the traction group. In the traction group the herniated index decrease from 276.6 ± 129.6 to 212.5 ± 84.3 with treatment (P< 0.01). In the control group, pretreatment value was 293.4 ± 121.1, and it decreased to 285.4 ± 115.4 after the treatment (P > 0.05). Patients with greater herniations tended to respond better to traction. In conclusion, lumbar traction plus conventional physical therapy are both effective in improving symptoms and clinical findings in patients with LDH and also in decreasing the size of the herniated disc material as measured by CT. Due to limited sample size and lack of sufficient follow-up, this Level I study provided Level II therapeutic evidence that continuous lumbar traction in combination with physiotherapy is effective in the reduction of the size of the herniated disk material in patients with LDH.
Furthermore, Chang et al. evaluated the effect of bipolar pulsed radiofrequency (PRF) on the dosal root ganglion (DRG) for the management of lumbosacral radicular pain. In this study, the effects of bipolar PRF was compared with the effects of monopolar PRF. Fifty patients with chronic lumbosacral radicular pain were included in the study and randomly assigned to 1 of 2 groups, the bipolar or monopolar PRF group (n = 25 per group). Pain intensity was evaluated using a numeric rating scale (NRS) at pretreatment, and 1, 2, and 3 months after treatment. The results of this study showed that when compared to the pretreatment NRS scores, patients in both groups showed a significant decrease in NRS scores at 1, 2, and 3 months after treatment. Reductions in the NRS scores over time were significantly larger in the bipolar PRF group. Three months after treatment, 19 patients (76.0%) in the bipolar PRF group and 12 patients (48.0%) in the monopolar PRF group reported successful pain relief (pain relief of ≥50%). The authors concluded that the use of bipolar PRF on the DRG can be an effective and safe interventional technique for chronic refractory lumbosacral radiculopathy, particularly in patients whose pains are refractory to epidural steroid injection or monopolar PRF stimulation. Because of insufficient sample size and lack of long term follow-up, this potential Level I study provided Level II therapeutic evidence [Table 2].
|Table 2: Effects of physical therapy modalities in the management of lumbosacral pain|
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Effects of physical therapy/exercise in the treatment of lumbar disc herniation with radiculopathy
A cohort study conducted by Svensson et al. evaluated the effects of a structured physiotherapy treatment model (mechanical diagnosis and therapy [MDT]: The McKenzie method) for 41 patients who qualified for lumbar disc surgery by having severe, long-standing pain and an MRI-verified LDH. The study protocol was divided into three phases. Phase 1 comprises MDT including side glide and trunk rotation in flexion during week 1 and 2. The second phase included home-based stabilization exercises during week 3 of the study. The third phase included stabilization training with equipment at the physiotherapy department during week 4–9. The outcome of the study showed that the patients had already improved significantly 3 months after the structured physiotherapy treatment model in all assessments: Disability, leg and back pain, kinesiophobia, health related quality of life, depression and self-efficacy. The improvement could still be seen at the 2-year follow-up. The overall conclusion from this study was that a structured physiotherapy treatment model for patients with pain and disability due to a LDH should be recommended before surgery is considered. Due to limited sample size, this cohort study provided Level II therapeutic evidence.
In another study, Bakhtiary et al. reported the results of a prospective randomized controlled trial investigating the effects of lumbar stabilizing exercise in patients with LDH. Of the 60 patients included in this crossover design study, 30 were assigned to each treatment group. Patients in Group A received 4 weeks of lumbar stabilizing exercise, followed by 4 weeks of no exercise. Patients in Group B received 4 weeks of no exercise, followed by 4 weeks of lumbar stabilizing exercise. The lumbar stabilizing exercise protocol included four stages of stabilizing exercises from easy to advance. Outcomes were assessed at 4 and 8 weeks using VAS; range of trunk flexion; range of left and right SLR and time required to complete the following activities of daily living (ADL); laying prone on the floor from standing position, standing up from laying prone on the floor, climbing steps (five steps), 10 m walking (fastest pace possible, without pain). Significant differences between Groups A and B were seen in the mean changes on all outcome measures at the end of 4 weeks. After crossover, there were no significant differences between the groups in any of the outcomes measured at 8 weeks. The authors concluded that a lumbar stabilizing exercise protocol may increase lumbar stability and improve ADL performance in patients who have suffered with a herniated lumbar disc for more than 2 months. The results of this study may encourage physiotherapists to use graded lumbar stabilization exercise (LSE) to treat patients with lumbar herniated disc. However, due to lack of sufficient follow-up, this Level I study provides Level II therapeutic evidence that 4 weeks of LSE results in decreased pain and improved function in patients with LDHR.
Similarly, Thackeray et al. performed a prospective randomized controlled trial to investigate the therapeutic outcomes of physical therapy after selective nerve root blocks (SNRBs) and of SNRBs alone in people with LBP and sciatica due to disc herniation. Of the 44 patients included in the study, 21 received SNRB in combination with physical therapy, described as end range directional exercises with or without mechanical traction, strengthening, flexibility, stabilization and cardiovascular exercise. The remaining 23 patients in the control group received only SNRBs. Outcomes were assessed at 6 months using the LBP Disability Questionnaire, Numeric Pain Rating Scale, Global Rating of Change, Fear Avoidance Belief Questionnaire, Sciatica Bothersome Index, and body pain diagram. Intention-to-treat analysis (adjusted) and as-treated analysis both showed no significant difference in outcomes between the control and treatment groups. The authors concluded that the results of this pilot study failed to show that physical therapy interventions, intended to centralize symptoms after SNRBs, were more beneficial than SNRBs alone. Due to the small sample size, this potential Level I study provided Level II therapeutic evidence that supervised exercises intended to reduce symptoms after SNRBs were no more beneficial than SNRBs alone.
In addition another study was conducted by Thackeray et al. which included 120 patients with LBP with nerve root compression. Using predefined sub-grouping criteria, patients were stratified at baseline and randomized to receive an extension-oriented treatment approach (EOTA) with or without the addition of mechanical traction. During a 6-week period, patients received up to 12 treatment visits. Primary outcomes of pain and disability were collected at 6-week, 6-month, and 1-year follow-up. No significant differences in disability or pain outcomes were noted between treatment groups at any time point. The authors concluded that patients with lumbar nerve root compression presenting for physical therapy can expect significant changes in disability and pain over a 6-week treatment period. There is no evidence that mechanical lumbar traction in combination with an extension-oriented treatment is superior to extension-oriented exercises in management of these patients, nor within predefined subgroups of patients. Because of proper randomization, large sample size and sufficient follow-up, this study provided Level I therapeutic evidence.
In another study, Ye et al. conducted an RCT to compare the effectiveness of general exercise (GE) and LPL therapy (LPLT). Sixty-three young male adults aged 20–29 years with the diagnosis of LDH were enrolled and divided into lumbar spinal stabilization exercise (LSSE) group (n = 30) and a GE group (n = 33). Patients in both groups received LPLT during the 1st week of the onset of LDH. Patients in the GE group underwent a GE program. Patients in the LSSE received LSSEs followed by LPL program for 3 months. All of the patients were subjected to pain intensity and functional capacity evaluations four times: At pre- and post-LPLT, and at 3 months and 1 year postexercise. Pain intensity of the lower back and legs was evaluated with the VAS, and functional capacity was evaluated with the Oswestry Disability Index (ODI). The results of this study showed that both groups have a significant reduction in VAS and ODI scores at 3 and 12 months postexercise compared with before treatment (P< 0.001). The LSSE group showed a significant reduction in the average score of the VAS for LBP (P = 0.012) and the ODI (P = 0.003) at 12 months postexercise compared with the GE group. The authors concluded that LSSE is more effective than GE in individuals with LDHR. Due to proper randomization, sufficient sample size and follow-up, this study provided Level I therapeutic evidence.
Moreover, Shahid et al. in their study compared the effect of LSEs and conventional physical therapy in 100 participants. Patients were randomized into two groups using lottery method. Patients in Group A were managed with LSEs and patients in Group B were managed with conventional physical therapy (including heat, US, manual therapy, postural care advice and William's flexion or Mackenzi's extension exercises). Final assessment was based on Oswestry Disability Scale only. The authors concluded that 6 months of LSEs provide significantly better results compared with conventional physical therapy regimen in patients with LDH. Due to lack of sufficient follow-up and limited outcome measures, this potential Level I study provided Level II therapeutic evidence that LSEs are effective in LDHR [Table 3].
|Table 3: Effects of physical therapy/exercise in the management of lumbar radiculopathy|
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Effects of spinal manipulation/spinal mobilization in the treatment of lumbar disc herniation with radiculopathy
Santilli et al. described a prospective randomized controlled trial assessing the short- and long-term effects of SM on acute back pain and sciatica with disc protrusion. Of the 102 patients included in the study, 53 were treated with SM and 49 received sham manipulation. Outcomes were assessed at 180 days using VAS 1 (back and buttock), VAS 2 (leg), SF-36, disc morphology and Kellner Rating (psychological profile). A significantly greater number of patients treated with SM had no back, buttock or leg pain at 180 days (VAS 1: 28% vs. 6%, VAS 2: 55% vs. 20%). There was no significant difference in the SF-36, psychological testing and disc morphology between the groups. The authors concluded that active SMs have more effect than simulated manipulations on pain relief for acute back pain and sciatica with disc protrusion. This study provides Level I therapeutic evidence that SM is significantly more effective than sham treatment for the relief of back and leg pain due to acute (<10 days) LDHR.
In another study, Burton et al. performed a prospective randomized controlled trial to test the hypothesis that manipulative treatment provides at least equivalent 12 month outcomes when compared with treatment by chemonucleolysis for patients with sciatica due to confirmed LDH. Of the 40 patients included in the study, 20 were treated with manipulation and 20 with chemonucleolysis. Outcomes were assessed at 12 months using the Roland Morris Disability Questionnaire, a pain thermometer (back and leg) and lumbar range of motion. By 12 months both groups had significant improvements in mean scores on back and leg pain and Roland Morris without significant differences between groups. The authors concluded that osteopathic manipulation can be considered a safe and effective treatment option for patients with a lumbar radicular syndrome due to LDH, in the absence of clear indications for surgical intervention. Although this study is a Level I therapeutic evidence, it provided Level II evidence (due to smaller sample size) that SM is beneficial in treating patients with LDHR.
Similarly, Sahiba and Megha conducted a randomized controlled trial on 30 patients with lumbar radiculopathy. Participants were randomized into two groups; experimental group and conventional treatment group. Both the groups received back extension exercises, hot pack, precautions and ergonomic advice. The experimental group received Spinal mobilization with leg movement (SMWLM) technique in addition to the conventional treatment. Outcomes included leg pain intensity, Roland Morris Questionnaire and body diagram by Donelson. After 3 weeks of interventions, the results revealed that there was significant improvement in VAS (P = 0.000), body diagram (P = 0.000 for experimental group and P = 0.003 for conventional group) and Roland Morris Questionnaire score (P = 0.000) within the groups. Between group analysis showed significant improvement in VAS (P = 0.000) and body diagram score (P = 0.000). Although there was significant improvement in Roland Morris Questionnaire score within the groups but there is no significant difference between the group (P = 0.070). The authors concluded that SMWLM technique in addition to conventional physical therapy produced significant improvement in leg pain intensity, location of pain and back specific disability in patients with lumbar radiculopathy due to LDH. Due to limited sample size and lack of follow-up, this Level I study provided Level II evidence.
In addition, McMorland et al. conducted a prospective randomized controlled trial to compare the clinical efficacy of SM against microdiscectomy in patients with sciatica secondary to LDH. Of the 40 consecutive patients included (patients must have failed at least 3 months of nonoperative management) in the study, 20 were treated with spinal manipulative therapies and 20 received microdiscectomy. Crossover to the alternate treatment was allowed after 3 months. Outcomes were assessed at 12 weeks and 1 year using the SF-36, McGill Pain Questionnaire, Aberdeen Back Pain Scale and Roland Morris. Of patients with lumbar radiculopathy due to LDH, 60% who failed 3 months of medical management obtained comparable relief to those patients that underwent successful surgery. The authors concluded that of patients with sciatica that fail 3 months of medical management, 60% will benefit from SM to the same degree as if they undergo surgical intervention. For the 40% that are unsatisfied, surgery provides an excellent outcome. Although this study is a randomized controlled trial, it provides case series (Level IV) therapeutic evidence that SM is beneficial in treating patients with LDHR [Table 4].
|Table 4: Effects of Spinal manipulation in the management of lumbar radiculopathy|
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| Conclusion|| |
Based on the level of evidence, the findings of this study concluded that EOTA, SM and LSEs in combination with LPLT are better than any physiotherapy intervention in the management of LDHR. However, due to limited sample size and insufficient follow-up in most of the primary studies, it is recommended that future studies should include large sample sizes and data should be taken for long term follow-up periods.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]