Lumbar disc herniation consists of displacement of the
nucleus pulposus through annulus fibrosus, generally in posterolateral region.
Depending on the severity of herniation, there may be compression of the lumbar
nerve roots and dural sac (Luis et al, 2010).
Disc herniation occurs mainly between the fourth and fifth
decades of life (Luis et al, 2010). Mr. Khan is a 50 years old man who work as
a physiotherapist. Many therapists incurred work-related LBP during treatment
of patients, especially in acute care and rehabilitation facilities due to
lifting with sudden maximal effort, bending and twisting (Margaret et al,
1985). He had history of occasional stiffness and pain at low back for past 6
years. According to Latimer et al (1996), individual with LBP showed increased
stiffness when they had pain. His pain become worsen and occasionally radiating
over left posterior thigh and dorsum of foot in the past 2 months. Pain is evoked by ectopic discharges emanating from inflamed
or lesioned dorsal root or ganglion and pain radiates from back and buttock
into leg in dermatomal distribution (Massimo et al, 2016). He was
diagnosed with disc herniation at L4-L5 while lifting a heavy patient. The load
on the L3-l4 level deices in standing position with 20 degrees of flexion was
250% of the total body weight. When the compressive load is acted to the disc,
hydrostatic pressure develops within the inner core of gelatinous nucleus
pulposus, which pushed outward causing the outer ring of annulus fibrosus to
bulge and may compressed nerve (Nozomu and Alejandro, 2011). On physical
examination, there is marked reduced ROM of flexion and left side lateral
flexion at lumbar spine. Nicholas et al (2014) said that pain-related LBP will
lead to fear of movement associated with trunk stiffness. Posterolateral
herniations involve descending nerve root and lateral herniation affect the
nerve root exiting at the segmental level. Thus, L4-L5 lateral herniation would
affect L4 nerve root, while posterolateral herniation would affect L5 nerve
root. He showed numbness over big toe and left foot as well as unable to stand
on his left heel. L4 nerve root included big toe and foot aspect in dermatome
while it contributed ankle dorsi flexion in myotome. The impairment of sensory
fibers causes numbness according to dermatome and blockade of motor fibers
causes weakness according to myotome (Massimo et al, 2016). He also shown
positive SLR test on left leg. SLR test has been found to have high sensitivity
in finding disc herniations leading to root compression (Majlesi et al, 2008).
He stopped playing squash before 6 years and now he only rides bicycle and goes
for walk around park nearby his house. Playing squash required lots of bending
and twisting movement over lumbar. LBP has a significant impact on functional
capacity as pain restricts occupational activities and is a major cause of
absenteeism (Massimo et al, 2016). From my opinion, Mr Khan needs to reduce
pain and prevent symptoms become worsen so that he can get back to work because
he has to take care of his family. He also can go back to sports if the
condition shows improvement.
According to symptomatic and mechanical response to repeated
movements and sustained positions, McKenzie method involves the assessment and
classification of patients into three mechanical syndromes (Cheryl, 2008).
According to Ronald et al (2003), the research is done by
using RCT which is considered as a “Gold Standard” research design for
comparing the effectiveness of McKenzie method and joint mobilization. The
results indicated a significant change in VAS scores at p<0.037 and a significant change in Owestry scores at p<0.047. The characteristic of sample is similar with Mr. Khan which is his age is between 21 and 76 years old and was experiencing back pain with or without neurological signs for more than 7 weeks. In the study, McKenzie exercises consisted of lumbar extension or lumbar extension with hips offset for posterior derangement. Visual Analogue Scale and Oswestry scores of people with lumbar derangement and developed pain and disability were found to improve significantly after 3 visits of McKenzie exercises. Ardiana et al (2014) conducted a research by using RCT to identify the effectiveness between electrophysical agents and McKenzie therapy. Mr. Khan has occasionally stiffness and pain for past 6 years. In this study, 271 subjects were chosen who complained of work related nonspecific CLBP and they had to be between 18-65 years old as well as defined pain more than 3 months with or without leg pain or neurological signs. VAS (p=0.66), Oswestry Low Back Pain Disability Questionnaire (p=0.0678) and Fingertip-to-Floor Distance (p=0.66) were used to measure mobility of spine. Significant improvement of spinal motion was demonstrated in McKenzie group and electrophysical agents group but the result showed the greater improvement in the McKenzie group (p<0.05). According to Petersen et al (2015), a RCT is done to compare McKenzie therapy and spinal manipulation. Mr. Khan experienced radiating pain towards posterior thigh and dorsum of foot in the past 2 months ago. Subjects in the study present centralization or peripheralization of symptoms during screening and suit with condition of Mr. Khan. In this study, McKenzie treatment has the chance of success was relative risk 10.5 (95% CI 0.71-155.43) and 1.23 (95% CI 1.03-1.46) for spinal manipulation. This study concluded that there is no statistically significant effect (p=0.11) in response to compare McKenzie treatment or spinal manipulation. However, result produced differences in McKenzie treatment if nerve root involvement and peripheralization. Chiradejnant et al (2003) conducted a RCT to compare effectiveness between therapist-selected and randomly selected mobilization technique for treating LBP. Mr. Khan had disc herniation at lower lumbar level (L4-L5) and the low back pain in the past 6 years. In the study, 140 subjects with a mean age of 46.4 (range 18 to 89 years) and having symptoms for around 3 months. Percentage of the current pain intensity was reduced by 15% (p<0.001) and global perceived effect was improved on scale (p=0.04). As result they found that mobilization treatment applied to lower lumbar levels had a greater analgesic effect than when applied to upper lumbar levels in the study. Hence, they confirmed that lumbar mobilization treatment has an immediate effect in relieving LBP.