post operative lumber disc prolapse!!!

[junior_physiotherapist]

please could some one just gice me details at what possible can apply for her!!
Now i have a patient 43 yr.,hypertensive,female ,being have sever muscles spasm of neck(diagnosed as primary disc prolapse at c5,6,7) this post to her post operative lumber disc prolapse since 7 months ,,
there are numbness at upper limbs bilaterally, pain at buttoks down to her leg rigth,all of this post operatively,she cann't walk for long periods(more than 14 minutes) usually she is coming to me with sedatives !!!
i applied to her according to her assessment the following :hot backs at back and neck then TENS,then US then at the end of her session therapeutic exercises
my questions are if plan of treatment is right??
my patint treated with pt care since 3 months just sligth imrovements
her main proplem now that she cann't make her home duties(cleaning,washing ,,,since her operative until now????

please all try to enligthen me
thanks

[angela1]

Hydrotherapy is an option if you can get her to a facility with hoists. Also ice packs are better than heat in reducing muscle spasm - apply for 30 mins every 2 hours. Hope this helps.

[ranjithkumar]

hello junior physiotherapist
i would like to advise you to give abrupt information,
let me know first what kind of operation she underwent( like discectomy or other), the kindor type of pain, how long she is facing all the problems, and whehter she approached her doctor what he sugested, and etc.
if u got all the details u can deal with the patient
one thing u discuss with doctor if possible about do's and dont's for her inphysiotherapy modules

[thabiso]

For the cervical problem have u tried gentle cervical traction sound? (dependent on your xray, scan findings, or absence of any contraindications) there is definitely a component if myalgia that will respond to massage for both the cervical and lumbar pain. Right now anything to help break the cycle of pain is advisable or this lady will be bombed with lots of painkillers and that could mean bad news.

Some extensor exercises also. Hope this helps.

[junior_physiotherapist]

HI All:

many thanks for ur relevant inputs...

*The patient underwented a canal cleaning through surgery -as i told at least-

*Regarding to applying ice packs i thought isn't benefit her muscles spasms need more hot packs..

**we accept to make assessments by refferal from their physicians..


Regards

[asha]

Her cervical disc may or maynot be symptomatic. Dont go by the CT/MR. Since she has undergone a surgical procedure for her lumbar spine, it is unstable. the cervical pain could disappear if the spine is stabilised. Try to stabilise the patients spine using a straight back chair. Give a lumbar roll or a small cushion at the back. The back has to be well supported well in to the dorsal spine. See if the pain disappears. If it does, all that you need to do is to develop the core muscles without putting undue stress at the lumbar, work up the back extensors, & the job is done. If supporting the back does not relieve the pain, just use mckenzie techniques & explore in sagittal & frontal planes. Try retraction first, then exlpore same side flexion or same side rotation. These could be attempted in supine & then sitting or vice versa depending on the clinical picture.
asha

[junior_physiotherapist]

If it does, all that you need to do is to develop the core muscles without putting undue stress at the lumbar, work up the back extensors, & the job is done. If supporting the back does not relieve the pain, just use mckenzie techniques & explore in sagittal & frontal planes. Try retraction first, then exlpore same side flexion or same side rotation. These could be attempted in supine & then sitting or vice versa depending on the clinical picture.
asha[/quote]

Firstly thanks for going bach to me!

secondly,regarding to develope a core muscles .. would u plz feed me more..

thirdly,my patient doesn't tolerate a prone position ..so how i can apply
a Mcenzy!!
Forthly,how i can apply a retraction..

Regards

[thabiso]

Try this in standing for your extension ex.
A. Hands to waist and stretch backwards or if patient unstable,
B. Stand a few cm in front of wall. Hands to the wall then dip pelvis to wall

[asha]

Hi junior physiotherapist, Firstly when I spoke of Mckenzie techniques, I spoke of it in terms of cervical spine. If stabilising the lumbar spine does not help, then mckenzie the cervical spine. First tackling the sagittal plane, then if neccessary the frontal plane. Retraction in unloaded position would be, if you make the pt. lie supine, neck in neutral, & ask the pt. to press down on the couch. Mind it , it is not chin tuck. This procedure can also be done by you by getting the head of the pt. out of the manual therapy table, head stabilised well in your hand.You can progress to retraction in loaded position. its difficult to tell you how to retract online. if you have any Mckenzie trained therapist near you, they could probably show it you. If the sagittal plane does not work, you have to explore the frontal plane, which would include the lateral flexion & rotations.
Your query about core muscles, they are all about training the transversalis reflex back. get the patient to work on stabilizers. these include the transversalis, multifidus,obliques-- all those which are high in isometrics & endurance. Avoid doing these in supine position initially, as these could stress the lumbar level. In this pt. avoid doing these exs on the ball. Once any one has a back problem, the bad news is that the transversalis reflex is lost & it has to be build back. building up the core would take anywhere between 6weeks to 6 months of regular Exs.

[junior_physiotherapist]

Originally Posted by asha

Hi junior physiotherapist, Firstly when I spoke of Mckenzie techniques, I spoke of it in terms of cervical spine. If stabilising the lumbar spine does not help, then mckenzie the cervical spine. First tackling the sagittal plane, then if neccessary the frontal plane. Retraction in unloaded position would be, if you make the pt. lie supine, neck in neutral, & ask the pt. to press down on the couch. Mind it , it is not chin tuck. This procedure can also be done by you by getting the head of the pt. out of the manual therapy table, head stabilised well in your hand.You can progress to retraction in loaded position. its difficult to tell you how to retract online. if you have any Mckenzie trained therapist near you, they could probably show it you. If the sagittal plane does not work, you have to explore the frontal plane, which would include the lateral flexion & rotations.
Your query about core muscles, they are all about training the transversalis reflex back. get the patient to work on stabilizers. these include the transversalis, multifidus,obliques-- all those which are high in isometrics & endurance. Avoid doing these in supine position initially, as these could stress the lumbar level. In this pt. avoid doing these exs on the ball. Once any one has a back problem, the bad news is that the transversalis reflex is lost & it has to be build back. building up the core would take anywhere between 6weeks to 6 months of regular Exs.

Hi asha

Firstly thanks for Very appreciated response
u told me that i have to put pt. in sagittal plane then if not possiple in frontal
,So my question is would u plz explain this for us,(as i mean u want to make movments which occur in sagittal and in frontal plane ??


Regards

[alophysio]

Hi,

A couple of things.

1. The discs in the cervical spine are not fluid filled from the second to third decade onwards so don't expect a reduction via repeated movements ala Mackenzie

2. This lady has YELLOW FLAG written all over her. She is a chronic pain patient. She needs activity, not pain relief via passive treatment. She can put a hot pack and TENS on at home. Get her active.

3. A pain clinic may be of use to her.

4. Her pain may be centrally mediated and physiotherapy / manual therapy not appropriate for her.

5. Any activity sounds like it would be good for this woman

I really think an evaluation by a pain psych is going to be in order. Maybe check to see that there is no pathoanatomical reason for her pain but it is persistent pain so centrally-mediated mechanisms are likely to be in play.

For Yellow flag assessments and the OMPQ, look up this reference of how we do things in NSW Australia...Look up Appendices if you want a short cut!

Lastly, there is significant amounts of research that shows an active approach to chronic pain is the most appropriate treatment - cut the passive stuff out and improve her walking from 14mins to 40 mins over time.

Hope this helps

[asha]

Sorry junior physiotherapist for getting back to you so late. Lost this thread somehow. Side bend & rotations are said to be same movements in different planes in c spine. When you check out the saggital plane the movement testing done is - retraction, retraction with extension, & protrusion. The interpretations would lead you to upper C spine or lower C spine. For frontal plane in unloaded position, sidebent would be difficult to assess if head is on the table. hence check the rotation. While the patient is loaded that is in sitting the frontal plane movements of sidebend & rotations could be assessed. This again leads you to either Upper C spine or lower C spine.
Mckenzie is not only for disc lesions, nor is it only extension. If the patient is a yellow flags candidate, they will surely score high on the questionaire. It is unlikely in this patient. I would prefer to repeat that the cervical symptoms would most likely be due to poor stabilization of her back. A cervical assesment could however be done.

[sdkashif]

For cervical Disc Prolapse follow the suggestions as below.

The physiotherapy management programme has been divided in to the different phases according to the severity of the condition. Have a look over that.

Acute Phase:

During this stage physical therapy involves teaching the patient proper posture, body mechanics, how to implement an effective exercise programme, reducing forces compressing the nerve root by relative rest,avoiding positions that increase arm or neck symptoms, to relive pain and dysfunction, promote healing and recovery. This is achieved by the folllowing.

Passive Modalities:

Passive modalities generally involve the application of heat to the tissues in the cervical region, either by means of superficial devices (eg, moist-heat packs) or mechanisms for deep-heat transfer (eg, ultrasound, diathermy).

Cervical Traction:

Spinal traction has effects of mechanical elongation of spine, facet joint mobilization, promoting muscle relaxation, reduction of pain. Spinal traction is indicated for spinal nerve root impingement, hypomobility of joints from dysfunction or degenerative changes, joint pain from symptomatic facet joints, muscle spasm or guarding, meniscoid blocking, discogenic pain, post compression fracture.

Continuous or prolonged traction is an effective mode of therapy. In it a static traction force is applied for several hours to several days usually in bed. Only small amount of weight is tolerable.

The effective force is influenced by the body position, weight of the part, friction of the treatment table, method of traction used and the equipment itself. Generally for vertebral separation:

In cervical spine, under friction free circumstances a force of approximately 7 percent of the total body weight separates the vertebrae. A minimum force of 11.25 to 13.5KG (25 to 30 l) is necessary to lift the weight of head when sitting and to counteract the resistance of muscle tension. The greatest amount of separation occurs during the first few minutes of treatment at a given force. To avoid treatment soreness, the first treatment should not exceed 10 to 15 lb. Muscle relaxation can be achieved at levels less than those needed for mechanical separation (4.5 to 6.75KG, or 10 to 15 lb) in the cervical spine. Progression of dosage at succeeding treatment will depend upon the goals and patient reactions.

There are controversies that exist between different literatures regarding the dosage applied for the spinal traction. Opinions vary among different authorities.

Have a look over a very useful article on Cervical Traction.

http://www.thesaundersgroup.com/cervical.pdf

Cervical Immoblization:

Cervical Immoblization with Cervical collar and cervical pillow are commom measure to relieve the neck pain and pain from sub occipital region. The collar commonly prescribed are philadelphia collar, soft cervical collar, hard cervical collar. They are usually prescribed for short period of time and as the symptoms improve, their use is often discarded. A home exercise programme of cervical isometric exercises may help to keep improve the tone loss resulting from cervical immoblization.

Exercises:

An exercise programme based on McKenzie Method may improve the early recovery and function.

The McKenzie Method is not merely extension exercises. In its truest sense, McKenzie is a comprehensive approach to the spine based on sound principles and fundamentals that when understood and followed accordingly are very successful. In fact, most remarkable, but least appreciated, is the McKenzie assessment process.

Assessment. Unique to the McKenzie Method is a well-defined algorithm that leads to the simple classification of spinal-related disorders. It is based on a consistent "cause and effect" relationship between historical pain behavior as well as the pain response to repeated test movements, positions and activities during the assessment process.

A systematic progression of applied mechanical forces (the cause) utilizes pain response (the effect) to monitor changes in motion/function. The underlying disorder can then be quickly identified through objective findings for each individual patient. The McKenzie classification of spinal pain provides reproducible means of separating patients with apparently similar presentations into definable sub-groups (syndromes) to determine appropriate treatment.

McKenzie has named these three mechanical syndromes: Postural, Dysfunction and Derangement.

Postural: End-range stress of normal structures

Dysfunction: End-range stress of shortened structures (scarring, fibrosis, n.root adherence)

Derangement: Anatomical disruption or displacement within the motion segment

(All three mechanical syndromes – postural, dysfunction, and derangement – occur in the cervical as well as thoracic and lumbar regions of the spine.)
Each distinct syndrome is addressed according to it unique nature with mechanical procedures utilizing movement and positions. The Derangement syndrome where the phenomenon of "centralization" occurs is most common.

Well-trained McKenzie practitioners will be able to identify those more difficult cases where advanced McKenzie techniques might benefit the patient versus those patients whose diagnosis is non-mechanical in nature, and those patients are then quickly referred for alternate care, thus avoiding unnecessary periods of inappropriate or expensive management.

Treatment. McKenzie treatment uniquely emphasizes education and active patient involvement in the management of their treatment in order to decrease pain quickly, and restore function and independence, minimizing the number of visits to the clinic. And if a problem is more complex, self-treatment may not be possible right away. However, a certified McKenzie clinician will know when to provide additional advanced hands-on techniques until the patient can successfully manage the prescribed skills on their own.

Ultimately, most patients can successfully treat themselves when provided the necessary knowledge and tools. An individualized self-treatment program tailored to the lifestyle of the patient puts the patient in control safely and effectively.

For detail See McKenzie Mechanical Diagnosis and therapy

Recovery Phase:

Once pain and inflammation are controlled, the patient's therapy should be progressed to restoration of full ROM and flexibility of the neck and should girdle muscles. This phase of rehabilitation focuses on soft tissue overload and biomechanical dysfunction. Goals of this phase are to eliminate pain, normalize spinal mechanics, and improve neuromuscular control of the injured cervical spine. Restoration of the resting muscle length and full, pain-free, cervical ROM are necessary. Strengthening exercises start in simple planes and progress to complex muscle patterns. The techniques are methods used are Cervicothoracic stablization, Neuromobilizations (Butler Approach), Cervical Mobilization and cervical manipulation, soft tissue mobilization or massage and functional restoration, aerobic conditioning.

Cervicothoracic stabilization:

It limits pain, maximizes function, and prevents further injury. Such stabilization includes cervical spine flexibility, postural training, and strengthening. This program emphasizes patient responsibility through active participation.

Restoring flexibility prevents further repetitive microtrauma from poor movement patterning. Pain-free ROM is determined by placing the cervical spine in positions that produce and relieve symptoms. Initially, stabilization commences within established pain-free ROM and then progresses outside this ROM as pain diminishes. Soft tissue or joint restriction inhibiting ROM is treated quickly. Anterior and posterior neck muscles are stretched. Indeed, such spine and soft tissue mobilization, passive ROM, self-stretching, and correct posturing collectively restore ROM.

Postural training commences with the patient, supervised by a therapist, in front of a mirror. The patient performs various transfer maneuvers while maintaining a neutral spine (ie, correct posturing) with feedback from the mirror and the therapist. Patient goals include maintenance of neutral spine and demonstrating correct posture during daily activities.

These proprioceptive skills, implemented during strengthening exercises, facilitate stable, safe, and pain-free cervical posture during strenuous activity. Indeed, cervicothoracic stabilization requires strengthening and coordination of neck, shoulder, and scapular muscles. Cervical muscles include extensors, flexors, rectus capitis anterior, rectus capitis lateralis, longissimus cervicis, and longissimus capitis. Primary thoracic stabilizers include abdominals, lumbar paraspinal extensors, and latissimus dorsi. Scapular muscles include the middle and lower trapezius, serratus anterior, and rhomboids. Chest muscles include the pectoralis major and minor. Successful stabilization also requires the training of the lumbar spine and lower extremities, which provide a foundation for the cervicothoracic spine.

Stabilization exercises proceed systematically from simple to complex. Isometric and isotonic resistive exercises employ elastic bands, weight machines, and free weights. Such conditioning distributes forces away from the cervical spine. Exercise repetition ultimately encodes an engram that commands immediate, automatic cervicothoracic stabilization during everyday activity.

Spinal manipulation and mobilization:

It may restore normal ROM and decrease pain; however, no clear therapeutic mechanism of action is known. Some believe that zygapophysial joint adjustment improves afferent signals from mechanoreceptors to peripheral and central nervous systems.

Normalization of afferent impulses improves muscle tone, decreases muscle guarding, and promotes more effective local tissue metabolism. These physiologic modifications subsequently improve ROM and pain reduction.

No evidence exists that manipulation confers long-term benefit, improves chronic conditions, or alters the natural course of the disorder.

Spinal manipulation: Its safety is uncertain

Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity.


Neuro Moblizations:

Butler's therapy techniques treat radicular symptoms by mobilizing the involved nerve. First, the therapist identifies "adverse neural tension," defined as pathological mechanical and physiological responses elicited from a nerve when its stretch properties and ROM are evaluated. Specifically, the therapist performs neurodynamic testing to evaluate a nerve's mechanical properties (eg, its mobilization around neighboring intervertebral discs) and physiological characteristics (eg, its response to ischemia, inflammation). Having tested the nerve in question, the therapist then may institute treatment consisting initially of passive mobilization to provide CNS input without inciting a stress response and neurogenic massage to reduce perineural swelling. Later, the therapist progresses to active neuromobilization because, according to Butler, recovering nervous tissue (like other connective tissue) requires movement to promote healing and restoration of optimum mechanical properties.

Limited evidence suggests that neurodynamic mobilization improves clinical outcomes. However, optimizing tissue health and cardiovascular fitness, as well as minimizing negative beliefs and environmental factors, can be beneficial.

Functional Restoration:

Functional restoration programs assist patients disabled by chronic cervical pain overcome obstacles to recovery. Such obstacles include deconditioning, secondary gain, poor motivation, and psychopathology.

Aerobic Connditioning:

It also plays a role in reduction of Pain.


Maintenance Phase:

This phase requires proper function pain free ROM, proper spinal and shoulder girdle mechanics. Emphasis is placed on continually achieving and improving strength, flexibility and mobility. Neck and shoulder girdle muscles should be stretched and strengthened by routine exercises. Proper head and neck positioning is maintained in every day activities.


For Lumbar Disc Problems Postoperatively:

Please start an exercise programme to regain the mobility, flexibility and strength of lumbosacral spinal region. Strengthen the lumbar flexors and abdominal muscles.