Protocol: Low Back Pain/Herniated Disk

This is our protocol for managing back pain.  This, of course, encompasses a wide scope of potential problems necessitating a diversity of treatment methods within this protocol. 

A disc bulge or herniation will demonstrate a characteristic “derangement” pattern of symptoms and test movement responses.  These include flexion stresses, episodic history, reduced lumbar lordosis with lateral shifts, distal symptoms with flexion, proximal symptoms with extension.  This would indicate a McKenzie approach of passive extension stretches and mobilizations, with lateral shift corrections, as the first level of treatment. 

Disc problems are often accompanied by sacro-iliac problems due to reduced ilio-lumbar ligament support between L4-L5 and ilium.  Sacro-iliac problems can also exist as a primary issue independent of disc problems. SI testing is done through inspection of pelvic landmarks, abnormal shifts at the sacrum during test movements, and stress tests across the SI structures.  These are treated quite effectively with joint mobilizations using Muscle Energy Techniques (MET) to re-align sacrum, ilium and L5 relationships.

Facet joint problems may be demonstrated by specific test movements.  These can respond to joint mobilization, traction, electro-modalities, stability exercises.  Mobilization includes manual techniques such as MET, Mechanical Link (ML) techniques, and low-grade joint oscillations.

These problems may be complicated by muscle trigger points, spasms, fascia and connective tissue scar-adhesions, and secondary changes at the piriformis muscle and hip joint.  These can make a back problem become chronic.  Fascia and connective tissue changes are addressed with Myofascial Release (MFR) and other soft tissue manipulation.  Spasm and trigger points are addressed with Strain-Counterstrain (SCS) techniques applied to trigger points.  Electro-modalities assist this effort. 

Other stresses can aggravate or even cause back problems.  Pronated (flat) feet can cause abnormal weightbearing stresses through hips and low back.  Simple foot orthotics can correct this.  A tight piriformis muscle (deep to buttocks) pulls abnormally between hip and low back and create sacroiliac pain or trochanteric bursa stresses.

Another issue is visceral adhesions.  Adhesions following abdominal surgery or inflammatory problem can adhere one organ to another or to abdominal walls.  This can alter torso movement mechanics, or refer pain to the spine.  Visceral Manipulation (VM) employs gentle manual stretching of soft structures in the abdomen to free the adhesions and restore visceral mobility.  This not only can reduce back pain but can also help some visceral functions compromised by restrictive adhesions (e.g. bladder control).

Biomechanics are corrected for discs, facet joints, sacroiliac, hips, feet, connective tissue and fascia… then muscle flexibility, strength, coordination, stability and control are restored by a precise sequence of exercises.  Stretching exercises establish prerequisites for strengthening.  This allows for stabilization and closed chain exercises, followed by gym reconditioning and protective body mechanics.

PROTOCOL: LOW BACK PAIN

ACUTE INTERVENTION:

1.         Pain control modalities and procedures:

             Ice, interferential E-Stim, microcurrent, TNS, Neuroprobe acu-point stim.

               Corrective rest positions; Jacobsen’s relaxation training.

2.         Initial patient education

3.         Correct mechanical derangements: 

                 McKenzie protocol of lateral shift correction and passive extension; Or passive flexion or positional facet distraction-mobilization, per exam results.

4.         Sacro-iliac correction:

             Muscle Energy Technique (MET), mobilization, strain-counterstrain.

              Lumbosacral support, sacropelvic belt; positional correction.

5.         Neuro referral via referring MD as indicated per exam results.

SUBACUTE or CHRONIC RECOVERY:

1.         Correct disc biomechanics and function: 

             McKenzie protocol: progress passive extension with lateral shift correction, progressing to passive flexion, progressing to strength and stabilization

             Protective supports, cushions, ADL, rest-work postures.

2..        Restore joint function:

              Joint Mobilizations (Paris- Maitland), Muscle Energy Technique (MET), Mulligan mobilization techniques, positional distraction 

3.         Restore soft tissue function:

              soft tissue mobilization, stretching, Myofascial release (MFR), trigger point myotherapy, craniosacral technique (CST), strain-counterstrain (SCS).

4.         Restore muscle function;  home exercises:

              Progression through stage I (mobility and flexibility), stage II (strengthening at obliques, gluteals, multifidus),  stage III (closed chain stability strengthening), TheraBand strengthening at thoracic, hip and lumbar extension, and lift-task .

5.         Traction in flexion or extension; autotraction; positional distraction.

6.         Contributory stresses correction: 

                        Hip rotator flexibility and function

                        Correct foot biomechanics with orthotics

                        Visceral mobilization

                        Body mechanics correction.

7.         Advanced patient education.

RECURRENCE PREVENTION:

1.         IMPACC BACK SCHOOL training class

2.         Reconditioning exercise plan; home and gym

3.         Self-care skills discharge plan.

4.         Ergonomic Job Evaluation and Modification for return to work plan.

Patient Education:  IMPACC BACK SCHOOL (Hebert), YOUR BACK FOR LIFE (Hebert), SEX AND BACK PAIN (Hebert), FOR YOUR BACK (Saunders).