a) Rest: Rest and Anti-inflammatory and analgesics.
b) Reduction: Continue bed rest and traction for just two weeks may lessen the herniation in over 90% cases. If no improvement with rest and traction, epidural injection of corticosteroid and native anaesthetic are given.
c) Chemonucleolysis: dissolution from the Nucleus Pulposus by percutaneous injection of the proteolytic enzyme (chymopapain). This enzyme has got the property of dissolving fibrous and cartilaginous tissue.
Indications for operative elimination of disc.
i) cauda equina compression syndrome that doesn't clear up with Six hours of starting bed rest and traction (emergengy).
ii) Neurological deterioration while under conservative management.
iii) Persistant pain and signs and symptoms of sciatic tension after 30 days of conservative treatment.
The disc is taken away by following techniques.
a) Hemilaminectomy/Partial laminectomy- Area of the lamina and ligamentum flavum on one side is taken away, taking great care to not damage the facet joint.
b) Laminectomy- Laminae on sides with spinous process are removed. Such wide exposure is needed for big, central disc producing cauda equina syndrome.
c) Microdiscectomy- completed with an operating microscope. Exposure is extremely limited. Morbidity and hospitalisation is less.
d) Fenestration- Ligamentum flavum bridging the 2 adjacent laminae is excised and spinal canal at affected level exposed.
e) Laminotomy- Along with fenestration, a hole is made within the lamina for wider exposure.
Physical rehabilitation Management in PIVD
Before planning the therapy, determine the position of comfort or symptom reduction i.e FUNCTIONAL POSITION. The individual may have...
a) Extension bias: Patient's symptoms are lessened in place of extension (bending back) and provoked in flexion (bending forwards) e.g PIVD.
b) Flexion bias: Patient's symptoms are lessened in place of spinal flexion (bending forwards) and provoked in spinal extension (bending backwards) e.g spinal tenosis, spondylolisthesis.
Spinal Extension (bending back) is contraindicated if:
i) when no position or movement decreases or centralizes the pain sensation.
ii) when saddle anaesthesia and/or bladder control problems is present (could indicate spinal-cord or cauda equina lesion because of large central disc herniation).
iii) when patient is within such extreme pain he rigidly holds the body immobile.
Spinal flexion (bending forward) is contraindicated if:
i) when extension relieves the symptoms.
ii) when flexion increases or peripheralises the symptoms.
a) To alleviate pain.
b) To advertise muscle relaxation.
c) To alleviate inflammation and pressure from the pain sensitive or neurologic structures.
d) patient education.
Physiotherapy Rehabilitation Management in Acute Phase of PIVD:
a) CONTROLLED REST- is usually recommended i.e rest as
*Posture and activity modification- Avoid flexed postures, sitting for very long duraton, bending or lifting activities, asymmetric postures ( flexion and rotation). Each one of these increase the disc pressure.
*Local support as corset (lumbosacral belt), abdominal binder, tape etc. These measures will enhance healing and stop reinjury to the healing disc. Within Ten days fibrin is laid down. If spine is maintained in lordosis, the annulus will heal in shortened position and nucleus is going to be retained centrally.
*If symptoms are severe, bed rest (maximum for just two days) on a hard bed is indicated with short periods of walking at regular intervals ( with corset). Walking promotes lumbar extension and stimulates fluid mechanics in lowering swelling in the disc/connective tissues.
*If patient presents with wherewithal to straighten up, make the patient lie prone with 2-3 pillows underneath the abdomen. As the pain subsides, take away the pillows and support the trunk by placing pillows underneath the thorax. By this nucleus pulposus is shifted forwards and relieves pain and gains a lordosis.
b) MODALITIES To lessen PAIN AND SPASM-
*Cryotherapy: reduces muscle spasm and inflammation in acute phase.
*TENS: relieves pain both in acute and chronic phases.
*US: As phonophoresis increases extensibility of connective tissues
*Moist heat: used being an adjunct before applying specialised strategies to decrease muscle spasm.
*SWD- pulsed SWD in acute condition and continuous SWD in chronic cases.
*Soft tissue manipulation- to lessen local muscle spasm and induce relaxation.
*Traction- is a great idea to relieve nerve root compression and radiculopathy or paraesthesias within the acute phase of PIVD. Reduces nuclear protrusion by reducing the pressure on the disc or by placing tension around the posterior longitudinal ligament. Duration of traction should be short in acute phase else there might be an increase in disc pressure resulting in increased pain because of fluid imbibition ( less than Fifteen minutes of intermittent traction and fewer than 10 minutes of sustained traction).
Traction is contraindicated in disc protrussion medial towards the nerve root.
c) EXERCISES FOR HERNIATED DISC- herniated disc exercises play an important role in treatment of inflammation and pain. Extension exercises are beneficial in early treatment of disc related signs or symptoms.
Techniques to mechanically reduce a nuclear disc protrusion- They are used if the test movements reveal that these movements and postures enhance the symptoms.
a) Posterior or posterolateral protrusion
i) Passive Extension- Patient is lying prone (i.e on belly). If patient is within such extreme pain, place pillows underneath the abdomen for support, gradually boost the amount of extension by removing pillows. Progress with the patient prop himself on the elbows, allowing the pelvis to sag. Watch for 5-10 minutes between each increment of extension to match reduction of water content and size bulge. Progress with patient prop around the hands. If sustained postures aren't well tolerated, possess the patient perform passive lumber extension intermittently by repeating the prone press ups.
ii) Lateral shift correction- If patient has lateral shift, first correct lateral shift then begin with extension exercises. Therapist stands quietly to which the thorax is shifted and places his shoulder from the patient's elbow that is flexed against the rib cage. Therapist wraps the arms around patient's pelvis and pulls pelvis towards him while pushing the patient's thorax away.
Self correction: Patient places the hand along the side of the shifted rib cage around the lateral aspect of the rib cage and put the other hand over the crest of opposite ilium. Then gradually push these regions towards midline and hold.
b) Anterior protrusion
i) Correction of lateral shift- Patient stands before a chair and places the lower limb opposite to the shift on the chair so the hip is within about 90 amount of flexion. Leg on the side of lateral shift is kept extended. Patient then flexes a corner onto the raised thigh and applies pressure by pulling around the ankle.
ii) Passive flexion- Bring both knees towards the chest and hold it with arm round the thighs.
c) Active flexibility exercises within painfree range towards the lower limb can be achieved e.g ankle toe movements, heel drag, hip abduction/adduction.
d) Mobilization of thoracic spine Mobilization of segments above and underneath the affected segmental level.
e) Piriformis muscle stretching
f) Maintain/ improve mobility of neural tissues- These exercises ought to be performed with caution in acute stage, usually in recumbent position. These may prevent chronic complications from increased neural tension e.g passive SLR with foot dorsiflexion.
SUB ACUTE STAGE:
Usually acute symptoms reduction in 4-6 days.
a) Follow the exercises done in acute phase e.g prone press ups, nerve mobility exercises, modalities.
b) Simple spinal movements hurting free ranges using gentle pelvic tilts. Pelvic rocking can be achieved in supine, sitting, prone lying, side lying, standing, quadripud (cat and camel exercise). Emphasize on anterior pelvic tilt to ensure that spine is in extension. Pelvic rolling could be added.
c) Isometrics of extensors but caution against holding breath and causing valsalva.
d) Encourage aerobic activities, walking, swimming with patient's tolerance.
Once the disc symptoms have stabilized.
a) Restore flexibility.
b) Restore muscle strength, endurance and performance.
c) Retrain kinesthetic awareness and charge of normal alignment.
d) Patient involvement and education to handle posture to prevent recurrences.
PIVD Exercises In Chronic Stage
a) Gentle active painfree flexibility exercises After 30 days from the onset of PIVD symptoms, start side flexion and extension in standing. Progress to adding flexion only if the disc has healed.
b) Stretching and adaptability exercises Stretching from the lumbar erector spinae and soft tissues posterior towards the spine ( knee to chest position). Following any flexion exercises, conclude with extension exercises for example prone press ups/ standing back extension.
Hamstring stretch: Lie lying on your back with your knees bent. Raise one leg slowly and put your hands behind your knee. Straighten your leg around you can, and gently pull it toward your chest. Hold for some seconds, then go back to the starting position and repeat using the other leg. Don't force this exercise! You need to feel a stretch at the back of your thigh. If you think pain or discomfort elsewhere, discontinue this exercise before you are stronger.
c) Core stability exercises-Whenever there's a slight imbalance within the core muscles, a person suffers from back pain. Core strengthening exercises assist in relieving back pain and make up the base of the core stability training course. The aim of these exercises would be to provide more support for your back by strengthening the muscles of the spine.
*The Bridge: Strengthens several core muscles - e.g buttocks, back, abs for PIVD patients. Lie flat on back; bend knees at 90-degree angle, feet flat on floor. Tighten abs. Raise buttocks off floor, keeping abs tight. Tighten buttocks. Shoulder to knees ought to be in straight line. Hold for any count of five. Slowly lower buttocks to floor. Repeat five to fifteen times.
The Plank:Strengthening exercise for back, abs and neck (also strengthens legs and arms)for PIVD patients.
Lie on stomach, place elbows and forearms on floor. Inside a push-up position, balance in your toes and elbows. Keep the back straight and legs straight. (Just like a plank) Tighten abs. Hold position for Ten seconds. Relax. Repeat 5 to 10 times. If this being active is too difficult (as it often is perfect for beginners), balance in your knees instead of your toes.
*The Side Plank: Strengthens the obliques (side stomach muscles)for PIVD patients. Lie on right side. Place right elbow and forearm on floor. Tighten abs. Push-up until shoulder has ended elbow. Keep your body inside a straight line - feet, knees, hips, shoulders, head aligned. Only forearm and side of right foot take presctiption floor (feet are stacked). Hold position for Ten seconds. Relax. Repeat 5 times. Repeat on left side. If the exercise is too difficult, balance on stacked knees (bend knees and feet off floor) rather than feet.
*The Wall Squat: Strengthening exercise for back, hips and quads in PIVD patients. Stand together with your back against a wall, heels about 18 inches in the wall, feet shoulder-width apart. Tighten abs. Slide slowly on the wall into a crouch with knees bent to around 90 degrees. If this sounds like too difficult, bend knees to 45 degrees and gradually develop from there. Count to 5 and slide support the wall. Repeat 5 -10 times.
*Leg and arm raises:Strengthening exercise for back and hip muscles in PIVD patients. Lie on stomach, arms reached out past your face with palms and forehead on floor. Tighten abs. Lift one arm (while you raise your head and shoulders) and also the opposite leg
simultaneously, stretching them away from one another. Hold for 5 seconds after which switch sides. Repeat Five to ten times.
*Leg lifts: Quad Strengthening Exercise for PIVD patients. Lie flat on back. Bend left knee at 90-degree angle, keeping foot flat on floor. Tighten abs. Keep your right leg straight and slowly lift right foot towards the height of the left knee. Hold for any count of 3. Do 10 repetitions. Switch sides and repeat.
*Basic Crunches: upper abdominal exercise for PIVD patients.
Lie on back, knees bent, feet flat on floor. Don't anchor feet. (Anchoring feet or keeping the legs straight across the floor can strain the low back). Head and back ought to be in neutral position. A rolled away towel may be placed directly under the natural curve from the lower back to provide extra support - the little of the back ought to be about an inch over the floor. Place hands behind head with elbows pointing outward. Both hands are used to support your face (to avoid neck from tiring out before abs) but don't pull head forward. Tighten abs.Lift up your head and shoulders started - three to six inches is sufficient. Look at the ceiling to assist prevent tilting your face. Keep elbows back.Exhale when raising your torso started and inhale when lowering. Do ten - fifteen repetitions.
*Opposite Arm and Leg Extension: balancing / stabilization exercise for PIVD patients:Strengthens muscles running negative aspects of spine, back of shoulders, hips and buttocks. Begin doggystyle, hands directly beneath your shoulders and knees directly beneath your hips. Keep head aligned with spine (to assist avoid tilting head, take a look at floor). Keep buttocks and abdomen tight. Don't arch the back. Lift one arm up and forward until it's level with torso; simultaneously lift the alternative leg in the same manner. Keep arm, spine, and opposite leg aligned as though they are forming a tabletop. Balance yourself for Ten seconds then slowly go back to starting position. Switch sides and repeat. Make sure to breathe. Do five repetitions.
*Leg Lifts:lower abdominal exercise for PIVD patients. Lie flat on back. Bend left knee at 90-degree angle, keeping foot flat on floor. Tighten abs. Keep your right leg straight and slowly lift it until right feet are at the height from the left knee. Hold for any count of 5. Do 5 to fifteen repetitions. Switch sides and repeat.
*Backward Leg Swing:Gluteal exercise for PIVD patients.
(The muscles from the buttocks help offer the spine) Stand, possessing the back of a chair for support. Tighten abs. Swing leg back in a diagonal until you feel your buttocks tighten. Tense muscles around you can and swing leg back a few more inches. Return leg to floor. Do Ten to fifteen repetitions. Switch sides and repeat.
*Abdominal strengthening exercises: Isometric abs, knee to chest, bicycle exercises.
*Teach safe movement patterns and the body mechanics.
*Teach patient preventive exercises and mechanics for relief of mechanical stress in day to day activities.
*Teach relaxation exercises to handle muscle tension.
*Instruct patient regarding how to modify environment e.g bed, chairs, child car seats, work area etc.