07 May Role of Physiotherapy in treating Disc Bulge of the Lumbar Spine
Acute low back pain may be associated with a disc bulge/herniation in the lumbar spine, a pulled back muscle; piriformis syndrome and referred pain form the sacroiliac joint. Herniated Disc of the lumbar spine usually results in sudden and severe onset of back pain and may be relieved by changing position but it can be made worse by bending and prolonged sitting. Coughing and sneezing will increase the pressure within the disc and can exacerbate the pain. Disc Bulges occur most often between the fourth and fifth lumbar vertebral bodies or between the fifth and the sacrum.
Physiotherapy is aimed at reducing the degree of inflammation, by incorporating mobilisation and soft tissue release integrated with low back strengthening exercises. Physio has been shown to be an effective modality in treating acute low back pain associated with a discogenic injury in the lumbar spine. Pain relieving medication and/ or anti –inflammatory drugs are also usually necessary. Physiotherapy treatments are safe, effective and based on the most up to date research.
Surgery should only be considered for a herniated disc after a trial of conservative care. Further to acute treatment, Physio will focus on the long term prevention of repeated disc injuries and minimise the degenerative cascade that is intimately linked to an initial herniated disc. Protocols aim to enhance stability, strength and posture, ensuring the injury doesn’t turn chronic.
As Physiotherapists we are seeing an increase in disc bulge & herniated disc injuries; this is associated with increases in the amount of time people sit (at home and the office), weak abdominal strength and poor low back stability. Discogenic injuries are more common when performing repetitive flexion & rotation movements, especially when lifting heavy loads. Increased flexion of the lumbar spine resultant from increased sitting compromises disc tissue and increases the degenerative changes of the annulus fibrosis leaving it more susceptible to a herniation of the nucleus.
Signs and symptoms of a lumbar disc bulge…
Patients with this condition may experience a sudden onset of back pain during the causative activity; however, it is also common for patients to experience pain and stiffness after the provocative activity, particularly the next morning. Symptoms are typically felt in the lower back and may be located centrally or unilaterally. The patient may experience radicular pain into the buttocks, thigh, lower leg or foot. Muscle spasm, paraesthesia, numbness or weakness may also be present. In some cases, patients may have a list as a result of the disc bulge. Symptoms are generally exacerbated with activities involving lifting, flexion, prolonged sitting, or sit to stand. Coughing, sneezing and twisting may also aggravate symptoms. Patients with a lumbar disc bulge often experience pain that is worse first thing in the morning.
Several factors may contribute to the development of a lumbar disc bulge and need to be assessed and corrected with direction from the treating Physio:
• poor core stability
• a sedentary lifestyle
• being overweight
• muscle tightness
• muscle weakness
• joint stiffness
• poor lifting technique
• poor posture
• a lifestyle involving large amounts of sitting, bending or lifting
Diagnosis of a Lumbar Disc Bulge…
A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a lumbar disc bulge. Investigations such as an MRI or CT scan may be required to confirm diagnosis. As experts in human movement and musculoskeletal disorders, we understand how the complex spinal structures of discs, joints, ligaments and muscles work together and how injuries occur. Physiotherapists have the training to correctly assess the problem associated with a disc bulge and provide safe and effective treatment.
Treatment for Lumbar Disc Bulge...
Low Back Pain is one of the most common conditions treated by Physiotherapists and the most costly for society. Lumbar disc bulge or herniation is a common cause of acute and chronic back pain; Physiotherapy treatment is guided by the evidence based clinical statement for management of LBP as developed by the APA using Level I & II Research to ensure best practice protocols. Evidence suggests Physiotherapy treatment for a lumbar disc bulge is vital to ensure an optimal outcome and may comprise:
• activity modification advice – remaining active and encouraging normal activity leads to faster recovery time – avoid bed rest or aggravating activities such as lifting or prolonged sitting
• specific exercise to improve mobility and decrease pain
• biomechanical correction and ergonomic advice
• bracing or taping – not recommended as a standalone treatment
• functional restoration programme and advice
• McKenzie Therapy
• massage therapy as an adjunct to spinal mobilisation
There is a lot of evidence to suggest that bed rest for longer than 2 days is actually detrimental to patients with acute low back pain. Modifying personal habits and lifestyle to prevent future exacerbation of the underlying cause of the pain is also important.
Other intervention for a lumbar disc bulge The recommended amount of non-operative treatment for the herniated disc needs to be individualised for each patient; patients with resolving pain and reasonable function a period of 6-12 weeks of conservative treatment is reasonable.
Despite appropriate physio management, a small percentage of lumbar disc bulges fail to improve and may require other intervention. Further investigations, CT scan or MRI, may be required to determine the extent of damage to the disc, followed by assessment from a specialist.
Epidural local Anaesthetic and Steroid Injection, or Platelet Rich Plasma Therapy (PRP) may be indicated for chronic pain. Surgery may be warranted clinically in cases of persisting or progressive neurological symptoms. When a sudden loss of bowel or bladder control is present due to the disc bulge, immediate surgical intervention is usually required as this is considered a medical emergency.