Effect of lumbar stabilization exercise on disc herniation index, sacral angle, and functional improvement in patients with lumbar disc herniation

Non-Surgical Approaches to the Management of Lumbar Disc Herniation Associated with Radiculopathy: A Narrative Review

Lumbar disc herniation associated with radiculopathy (LDHR) is among the most frequent causes of spine-related disorders. This condition is triggered by irritation of the nerve root caused by a herniated disc. Many non-surgical and surgical approaches are available for managing this prevalent disorder. Non-surgical treatment approaches are considered the preferred initial management methods as they are proven to be efficient in reducing both pain and disability in the absence of any red flags. The methodology employed in this review involves an extensive exploration of recent clinical research, focusing on various non-surgical approaches for LDHR. By exploring the effectiveness and patient-related outcomes of various conservative approaches, including physical therapy modalities and alternative therapies, therapists gain valuable insights that can inform clinical decision-making, ultimately contributing to enhanced patient care and improved outcomes in the treatment of LDHR. The objective of this article is to introduce advanced and new treatment techniques, supplementing existing knowledge on various conservative treatments. It provides a comprehensive overview of the current therapeutic landscape, thereby suggesting pathways for future research to fill the gaps in knowledge. Specific to our detailed review, we identified the following interventions to yield moderate evidence (Level B) of effectiveness for the conservative treatment of LDHR: patient education and self-management, McKenzie method, mobilization and manipulation, exercise therapy, traction (short-term outcomes), neural mobilization, and epidural injections. Two interventions were identified to have weak evidence of effectiveness (Level C): traction for long-term outcomes and dry needling. Three interventions were identified to have conflicting or no evidence (Level D) of effectiveness: electro-diagnostic-based management, laser and ultrasound, and electrotherapy.

Clinical effects and biological mechanisms of exercise on lumbar disc herniation

Lumbar Disc Herniation (LDH) is a syndrome in which lumbar disc degeneration, rupture of the annulus fibrosus, and herniation of the nucleus pulposus irritate and compress the nerve roots and cauda equina, resulting in the main manifestations of lumbar pain and/or lower extremity pain. There is evidence in various clinical areas that exercise is effective in treating LDH, and exercise intervention for more than 2 weeks reduces disease activity in LDH. However, the mechanism of exercise's action in reducing disease activity in LDH is unclear. In this article, we first summarize and highlight the effectiveness of exercise in treating LDH and provide guideline recommendations regarding exercise type, intensity, frequency, and duration. Then, we integrate the existing evidence and propose biological mechanisms for the potential effects of exercise on neuromechanical compression, inflammatory chemical stimuli, and autoimmune responses from the perspective of LDH pathogenesis as an entry point. However, a large body of evidence was obtained from non-LDH populations. Future research needs to investigate further the proposed biological mechanisms of exercise in reducing disease activity in LDH populations. This knowledge will contribute to the basic science and strengthen the scientific basis for prescribing exercise therapy for the routine clinical treatment of LDH.

Does motor control training improve pain and function in adults with symptomatic lumbar disc herniation? A systematic review and meta-analysis of 861 subjects in 16 trials

OBJECTIVE

To evaluate the effectiveness of motor control training (MCT) compared with other physical therapist-led interventions, minimal/no intervention or surgery in patients with symptomatic lumbar disc herniation (LDH).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Eight databases and the ClinicalTrials.gov were searched from inception to April 2021.

ELIGIBILITY CRITERIA

We included clinical trial studies with concurrent comparison groups which examined the effectiveness of MCT in patients with symptomatic LDH. Primary outcomes were pain intensity and functional status which were expressed as mean difference (MD) and standardised mean difference (SMD), respectively.

RESULTS

We screened 6695 articles, of which 16 clinical trials (861 participants) were eligible. Fourteen studies were judged to have high risk of bias and two studies had some risk of bias. In patients who did not undergo surgery, MCT resulted in clinically meaningful pain reduction compared with other physical therapist-led interventions (ie, transcutaneous electrical nerve stimulation (TENS)) at short-term (MD -28.85, -40.04 to -17.66, n=69, studies=2). However, the robustness of the finding was poor. For functional status, a large and statistically significant treatment effect was found in favour of MCT compared with traditional/classic general exercises at long-term (SMD -0.83 to -1.35 to -0.31, n=63, studies=1) and other physical therapist-led interventions (ie, TENS) at short-term (SMD -1.43 to -2.41 to -0.46, n=69, studies=2). No studies compared MCT with surgery. In patients who had undergone surgery, large SMDs were seen. In favour of MCT compared with traditional/classic general exercises (SMD -0.95 to -1.32 to -0.58, n=124, studies=3), other physical therapist-led interventions (ie, conventional treatments; SMD -2.30 to -2.96 to -1.64, n=60, studies=1), and minimal intervention (SMD -1.34 to -1.87 to -0.81, n=68, studies=2) for functional improvement at short-term. The overall certainty of evidence was very low to low.

CONCLUSION

At short-term, MCT improved pain and function compared with TENS in patients with symptomatic LDH who did not have surgery. MCT improved function compared with traditional/classic general exercises at long-term in patients who had undergone surgery. However, the results should be interpreted with caution because of the high risk of bias in the majority of studies.

PROSPERO REGISTRATION NUMBER

CRD42016038166.

Correlation Analysis Between Pain Intensity, Functional Disability and Range of Motion Using Low-Level Laser Therapy in Patients With Discogenic Lumbar Radiculopathy: A Cross-sectional Study

Introduction: Low-level laser is a pain-free and non-invasive treatment modality. It is used in many acute and chronic painful conditions. This study aimed to determine the correlation between pain intensity, functional disability, and range of motion using low-level laser therapy (LLLT) in patients with discogenic lumbar radiculopathy. Methods: This cross-sectional study was conducted as a part of a randomized controlled trial of LLLT to treat patients with discogenic lumbar radiculopathy in physical therapy departments of three different hospitals in Islamabad, Pakistan, from August 2021 to September 2021. The study was conducted according to STROBE guidelines. Fifty-Five patients from the experimental group of the trial were invited to participate in this study. The outcomes of the treatment were recorded on a semi-structured questionnaire on the first day and last day of their treatment from each patient's pain intensity, functional disability, and Lumbar range of motion (L-ROM) (flexion and extension) by using the visual analogue scale (VAS) for pain intensity, Oswestry Disability Index (ODI) for functional disability, and dual inclinometer for L-ROM. The data were analyzed through SPSS version 26.0. Results: The results of the correlation coefficient/Pearson's correlation of VAS, ODI, and dual inclinometer were varied. The strength of correlation between variables was weak to moderate (r=0.033 to 0.425) with statistically insignificant correlation coefficient (P > 0.05, 95% CI) except for lumbar flexion (P<0.05, 95% CI). Conclusion: For acute low back pain (LBP) with discogenic lumbar radiculopathy, LLLT at a wavelength of 830-nm and a dose of 3J/point in conjunction with conventional physical therapy had no significant correlation, but rather weak to moderate values with pain intensity, functional disability, and L-ROM.

Effectiveness of Low-Level Laser Therapy in Patients with Discogenic Lumbar Radiculopathy: A Double-Blind Randomized Controlled Trial

Purpose

To determine the effectiveness of low-level laser therapy (LLLT) in patients with discogenic lumbar radiculopathy and correlation among pain intensity, functional disability, and lumbar range of motion (LROM). Study Design/Setting. A double-blind RCT was conducted at physical therapy departments of different hospitals of Islamabad, Pakistan. The study period was March 2020 to August 2021. Patient Sample. The study comprised 110 patients with acute LBP and unilateral discogenic lumbar radiculopathy. Outcome Measures. The outcomes of the treatment were measured on the first day and then after 18 sessions from each patient's pain intensity, functional disability, L-ROM, and straight leg raise by using visual analogue scale, Oswestry disability index, dual inclinometer, and straight leg raise test.

Methods

A total of 110 participants with a mean age of 38 ± 7.4 years were randomly assigned into two groups of 55 each. The experimental group of 55 patients was treated with LLLT and conventional physical therapy. The control group of 55 patients was treated with conventional physical therapy alone. Both groups had received 18 treatment sessions. The data were analyzed through SPSS-21.0.

Results

The results of the Wilcoxon signed-rank test score as well as Mann–Whitney U test indicated a statistically significant difference in values (p < 0.05 in all instances) within the groups and between the groups, respectively.

Conclusions

The LLLT is proved as an efficient adjunct therapy to conventional physical therapy for discogenic lumbar radiculopathy.

Effect of Nonsurgical Spinal Decompression on Intensity of Pain and Herniated Disc Volume in Subacute Lumbar Herniated Disc

OBJECTIVE

Nonsurgical spinal decompression therapy (NSDT) is a conservative treatment for the lumbosacral herniated intervertebral disc (L-HIVD). This study aimed to evaluate the clinical effectiveness of the NSDT and change in disc volume through magnetic resonance imaging (MRI) in subacute L-HIVD.

METHODS

Sixty patients with subacute L-HIVD were randomized into either the decompression group (group D, n = 30) or the nondecompression group (group N, n = 30). In group D, NSDT was performed ten times in eight weeks. In group N, pseudodecompression therapy (no force) was performed with the same protocol. Lower back and lower leg pain intensities and functional improvements were measured by the visual analog scale and the Korean Oswestry Disability Index (K-ODI). The change in the lumbosacral disc herniation index (HI) was evaluated through a follow-up MRI three months after the therapy.

RESULTS

The lower leg pain intensity in group D was lower than that in group N at two months (p=0.028). Additionally, there were significantly lower K-ODI scores in group D at two and three months (p=0.023, 0.019) than in group N. The change in HI after the therapy was -27.6 ± 27.5 (%) in group D and -7.1 ± 24.9 (%) in group N, with a significant difference (p=0.017). Approximately 26.9% of patients in group D and no patients in group N showed over 50% reduction in HI (p=0.031).

CONCLUSION

NSDT may be a suitable treatment option for conservative treatment of subacute L-HIVD.

Role of the Lumbosacral Transition Vertebra and Vertebral Lamina in the Pathogenesis of Lumbar Disc Herniation

OBJECTIVE

To investigate the prevalence of lumbosacral transition vertebrae (LSTVs) in both the normal population and the lumbar disc herniation (LDH) population and to determine the risk factors for LDH.

METHODS

Between January 2019 and September 2020, all patients aged 18-39 years and underwent an anteroposterior (AP) X-ray of the lumbar vertebrae were retrospective reviewed in our institution. Those patients who were diagnosed with LDH were eligible for inclusion in the LDH group. During the same period, those patients admitted to our hospital who underwent an anteroposterior X-ray of the lumbar spine and had not been diagnosed with LDH were included in the control group. Those patients with disease that might affect the lumbar anatomy were excluded from both groups. The type of LSTV was classified according to the Castellvi classification. The height of the lumbar vertebral lamina was evaluated through the h/H index. The inter- and intra-observer reliability was evaluated by one senior radiologist and one senior orthopedist using intraclass correlation coefficient (ICC). The association between the LSTV and the herniation level was also investigated. Binary logistic regression was used to explore the association of different factors between the LDH group and the control group.

RESULTS

Two hundred LDH patients (115 male and 85 female) and 200 individuals (108 male and 92 female) were investigated retrospectively. The prevalence of LSTVs was 71.5% (n = 143) in the LDH group and 34.0% (n = 68) in the control group. The most frequent LSTV types were type Ib and type IIa. The inter- and intra-observer ICCs of the measurement of "h/H" index and the classification of LSTV were all "excellent" (ICC > 0.90). The median h/H index in the control group was significantly higher than that in the LDH group (0.28 (0.26, 0.31) vs 0.34 (0.31, 0.37), P = 0.000). The distribution of the Castellvi classification in the L4/5 and L5/S1 herniation patients was significantly different (P = 0.048). LSTVs, BMI and the h/H index were closely associated with LDH, with odds ratios of 3.06 (95% CI: 2.12-4.43), 1.23 (95% CI: 1.13-1.33) and 0.09 (95% CI: 0.05-0.15), respectively. The incidence of L4/5 disc herniation in patients with an LSTV was significantly more common than that in patients with L5/S1 disc herniation (P = 0.048).

CONCLUSION

The prevalence of LSTVs was 34.0% in the control group and 71.5% in the LDH group; LSTVs and BMI were positively correlated with LDH, and h/H was negatively correlated with LDH.

Analysis of the effect of traction combined with paraffinotherapy on lumbar function in patients with lumbar disc herniation

OBJECTIVE

To explore the effect of traction combined with paraffinotherapy on lumbar function in patients with lumbar disc herniation (LDH).

METHODS

100 LDH patients treated in our hospital (from April 2018 to April 2020) were enrolled and randomized into a control group and experimentalexperimental group, with 50 patients each. The control group adopted traction, and the experimentalexperimental group adopted traction combined with paraffinotherapy. Pain symptoms, lumbar function, range of motion (ROM) and isometric muscle strength (IMS) of lumbodorsal muscle, quality of life, and clinical efficacy were compared before and after treatment.

RESULTS

① After treatment, the effectiveness rate of 96% in the experimental group was higher than the 84% in the control group (P=0.046). ② Visual analogue scale (VAS) score in both groups after treatment was lower than that before treatment, and the experimental group was lower compared with controls (P < 0.05). ③ ROM and IMS of lumbodorsal muscle in both groups after treatment were higher than those before treatment, and the experimental group was higher compared with controls (P < 0.05). ④ The Japanese Orthopaedic Association (M-JOA score) and Oswestry disability index (ODI) in both groups after treatment were lower than those before treatment, and the experimental group was lower compared to controls (P < 0.05). ⑤ After treatment, the life quality indexes of both groups were higher than those before treatment, and the experimental group was higher compared to controls (P < 0.05).

CONCLUSION

The treatment of traction combined with paraffinotherapy for LDH patients has significant therapeutic efficacy, and can alleviate lumbocrural pain, improve lumbar function and life quality, and is worthy of application.

Isolated Lumbar Extension Resistance Exercise in Limited Range of Motion for Patients with Lumbar Radiculopathy and Disk Herniation-Clinical Outcome and Influencing Factors

(1) Background: Reconditioning of the paraspinal lumbar extensor muscles by isolated lumbar extension resistance exercises (ILEX) has shown good clinical results for patients with chronic unspecific low back pain. However, the clinical value and safety for patients with specific spine pathologies is unclear. In this study, clinical outcome and influencing factors were retrospectively analyzed for patients with lumbar disk herniation (LDH) and radiculopathy. (2) Methods: 189 consecutive patients (123 men and 66 women; mean age, 36 years) with clinically diagnosed LDH and relative indications for surgery started a 9-week rehabilitation program (2x/week) including ILEX in limited range of motion (ROM) adjusted to patients’ symptoms. Patients diagnosed with advanced levels of spine degeneration were excluded. Pain/radiculopathy (PR), influence on mental health (IOMH), satisfaction rates were measured via Numeric Rating Scales (NRS, 0–10), and overall clinical outcome was stated in % (100% = full recovery). Isometric extension strength was tested before and after the program. (3) Results: 168 patients (88.9%) completed the program. For 162 out of 168 patients (96.4%) there was a significant reduction of clinical symptoms, whereas 6 patients reported no changes in symptoms. Scores (mean) for symptom intensity decreased from 4.2 (±1.5) to 1.9 (±1.5) (p < 0.001), the impact on mental health decreased from 5.9 (±2.3) to 2.4 (±2.0) (p < 0.001). There was a (weak) correlation between lower scores for PR and IOMH before the study and better clinical outcomes; PR also weakly correlated with satisfaction. Other factors such as age, strength increase, level/location and number of LDH did not have a significant impact on the clinical results. (4) Conclusion: The results indicate that ILEX in limited ROM can be an effective treatment for the majority of patients with LDH. For patients with high pain levels, the results are less consistent, and surgery may be considered.

Effectiveness of additional deep-water running for disability, lumbar pain intensity, and functional capacity in patients with chronic low back pain: A randomised controlled trial with 3-month follow-up

BACKGROUND

Aquatic exercise (AQE) programme is commonly used as an alternative to the chronic low back pain (CLBP) treatment. The addition of aquatic aerobic exercises to AQE may be beneficial to patients with CLBP.

DESIGN

Randomised controlled trial.

OBJECTIVES

To assess the effectiveness of AQE with the addition of aerobic exercise - deep-water running (DWR) - compared to exclusive AQE in improving disability, lumbar pain intensity, and functional capacity in patients with CLBP.

METHODS

Fifty-four adult patients with CLBP were randomised either to the experimental group (AQE + DWR) or the control group (AQE). An assessor who was blinded to the group allocation performed both pre- and post-interventions assessments. Both treatments lasted 9 weeks, with a 3-month follow-up. The primary outcome was disability, as evaluated using the Roland Morris Disability Questionnaire. The secondary outcomes were pain and functional capacity; pain was assessed using a visual analogue scale (VAS), and functional capacity (travelled distance) was measured using the 6-min walk test (6WT).

RESULTS

A significant difference in pain was observed between groups after intervention in favour of DWR (mean difference -1.3 cm [95% confidence interval (CI) -2.17 to -0.45], d‾ = 0.80 [95% CI 0.22 to 1.33]).

CONCLUSION

Treatment with DWR was effective in the short term for achieving the desired outcome of pain reduction when compared with AQE only but not for disability and functional capacity.

Comparison of two different electrotherapy methods in low back pain treatment

OBJECTIVE

To investigate the efficacy of High Intensity Laser Therapy (HILT) and Transcutaneous Electrical Nerve Stimulation (TENS) in low back pain (LBP).

METHODS

Forty patients aged between 18 to 60 were included in this study. The patients were randomized into two groups as TENS (Group I) and HILT (Group II). The severity of pain was measured by Visual Analog Scale (VAS), and the range of motion (ROM) of the joint was measured by goniometer. The Oswestry Disability Questionnaire (ODQ) was used to assess the effect of LBP on daily living activities, and the Beck Depression Inventory (BDI) was used to assess depression. All patients were taken into physical therapy program for 5 days a week for a total of 20 sessions. Patients in Group I received ultrasound, hot pack and HILT, while the patients in Group II received ultrasound, hot pack and TENS.

RESULTS

In the comparison of post-treatment improvements, among all parameters only VAS score had a significant difference in favor of Group I.

CONCLUSIONS

The study demonstrated that HILT is more effective than TENS in terms of pain reduction and that HILT can be used as an alternative to TENS.

The Effect of Suspension and Conventional Core Stability Exercises on Characteristics of Intervertebral Disc and Chronic Pain in Office Staff Due to Lumbar Herniated Disc

BACKGROUND

The purpose of this study was to identify the effects of eight weeks of conventional and suspension core stability exercises by use of the designed device on characteristic of intervertebral discs in low back pain.

METHODS

A total of 27 men with chronic low back (CLB) pain due to lumbar disc herniation in L4-L5 and L5-S1 regions were enrolled in this quasi-experimental study. After assessing the pain intensity using a visual analog scale (VAS) and determining the disc herniation index using MRI, each group of patients were asked to perform either conventional or suspension exercises for eight weeks, each week consisting of three training sessions. The pain intensity was assessed at the end of the first, second, third, fourth and eighth weeks and the disc hernia index was determined again at the end of the eight weeks of exercises.

RESULTS

The results indicated significant changes in the intensity of pain in both groups through the period of eight weeks of exercise with a remarkable pain relief. In relation to the structural characteristics of the intervertebral disc, data analysis did not reveal any significant change between the pre- and post-test.

CONCLUSION

Considering the beneficial effects of the stability exercises and specially suspension stability exercises with respect to pain alleviation and reduced use of sedatives and anti-inflammatory drugs, this method can be helpful at early stages of treatment for chronic pains.