Manual Therapy 15 (2010) 126129

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Manual Therapy
journal homepage: www.elsevier.com/math

Case Report

An adherent nerve root Classication and exercise therapy in a patient diagnosed with lumbar disc prolapse
Martin Melbye*
Department of Physical Therapy, Aalborg Hospital/University Hospital of Aarhus, Hobrovej 18-22, DK-9100 Aalborg, Denmark

a r t i c l e i n f o
Article history: Received 8 April 2009 Received in revised form 17 April 2009 Accepted 28 April 2009 Keywords: Nerve root Classication Exercise McKenzie

1. Introduction In Denmark the McKenzie method is one approach frequently used by physical therapists treating back pain patients, including those with lumbar disc prolapse. Previous studies indicated that 8388% of low back patients can be classied into one of the McKenzie syndromes and thereafter managed successfully with conservative care (May, 2004; Hefford, 2008). The most common classication was Derangement syndrome (80%), whereas Dysfunction syndrome was found in only 36% of patients (May, 2004; Hefford, 2008). A subgroup of the Dysfunction category is adherent nerve root (ANR) (McKenzie and May, 2003). Thus, the ANR subgroup is a relatively rare nding in low back patients and therefore difcult to conduct randomized clinical trials on (Ellis and Hing, 2008). No previous case reports have described McKenzie assessment and management of patients classied as ANR. The criteria for ANR classication are (McKenzie and May, 2003):  History of recent sciatica.  Symptoms present for at least 68 weeks.

 Intermittent leg pain produced only when loading structurally impaired tissue.  Major limitation of exion in standing.  Consistent movement produces pain that abates within minutes after the movement has stopped. Hypothetically, pain from an ANR is caused by mechanical deformation of structurally impaired soft tissue. Experimental studies have shown that adherences between disc and nerve root can occur after disc injury or prolapse (Key and Ford, 1948). According to OConnell (1951) the common nding of adhesions between the posterior longitudinal ligament and the nerve root found during discectomy is a consequence of tissue healing, and is sometimes the only obvious cause of symptoms. These adherences and contractions of the connective tissue in and around the nerve could cause symptoms, until remodelling of the affected structures has occurred (McKenzie and May, 2003). Remodelling is achieved through a regular exercise programme, repeatedly stressing the tissue. Studies on soft tissue remodelling have been performed on achilles tendons (Alfredson et al., 1998) and has been found to increase collagene synthesis (Langberg et al., 2006). A recent study indicate that tension type mechanical loading may be able to inhibit structural changes related to disc degeneration (Lotz et al., 2008). The main purpose of this case report is to describe the physical therapy classication and treatment process of a patient, subgrouped into the ANR category by a McKenzie assessment.

* Tel.: 45 99 32 11 87. E-mail address: mamek@rn.dk 1356-689X/$ see front matter 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2009.04.010

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2. Patient presentation 2.1. History The patient was a 31-year old male referred to an outpatient spine unit. The patient presented with intermittent sciatica (Fig. 1), maximum pain intensity 7 points on a 11-point numeric pain rating scale (Childs et al., 2005). Previous treatment during this episode was physical therapy with massage and general exercises over an 8week period without any effect on symptoms or functional abilities. As a result of the present problem, the patient had stopped bending his back more than absolutely necessary as he was afraid to worsen his problem. His walking was impaired as he was limping and unable to take full strides with his left leg. He works as a software engineer and his work involves sitting at a computer desk and in meetings. Two years ago he was rebuilding his house, which involved heavy lifting and stooped work positions. During these activities he gradually started to experience back pain that progressed with radiating symptoms into the left leg over some months. When he consulted for the rst visit, his symptoms had not changed for 12 months. His leg pain is produced whenever he walks or bends over. Back pain is produced immediately when he sits down. Relieving factors are standing up straight or lying down. He had less than ve earlier episodes of low back pain over the last couple of years. These episodes had been of a few days duration and never before accompanied by sciatica. His general health is good. He lives with his wife and he has not been off work. When necessary he takes paracetamol tablets. A recent lumbar MRI (Magnetic Resonance Imaging) study revealed a disc prolapse compressing the rst sacral nerve root on the left. Based on the patient history, three different McKenzie classications could be hypothesized: a reducible derangement with a potential for symptom centralization and favorable prognosis (Aina et al., 2004), an irreducible derangement with a suspected longer recovery rate and a higher likelihood of discectomy (Skytte

et al., 2005) or an ANR that expectedly would resolve with a remodelling exercises over months (McKenzie and May, 2003). The fact that sciatica is consistently produced temporarily when bending over or taking long strides may indicate an ANR, as these positions place longitudinal stress on the nerve root. Sitting down and bending over increase the intradiscal pressure (Sato et al., 1999), and the fact that these activities provoke back pain may indicate a disc derangement as the cause. 2.2. Physical examination The patient was examined using the McKenzie method and studies have shown good intertester reliability of this classication system in clinicians with Credential or Diploma training (Kilpikoski et al., 2002; Clare et al., 2005). Baseline neurological ndings were decreased sensation on the lateral left foot, decreased left Achilles reex and a positive left straight leg raise at 20 degrees elevation. Right-sided Straight leg raise was negative and motor function was normal. All neurological ndings were consistent with rst sacral nerve root involvement. Range of motion assessment revealed a pain-related major loss of lumbar exion, with a Schober measure of 10/11 cm (Tousignant et al., 2005) and nger-to-oor-distance of 35 cm. Lumbar extension and lateral exion range of motion to each side was within normal range and did not produce symptoms. The patient had a slouched sitting posture and upon correction, into an erect posture, the back pain subsided immediately only to return once the patient was allowed to slouch again. During the structured McKenzie-testing, it was not possible to identify a position or movement that centralized or peripheralized symptoms. Previous studies concluded that the ability to centralize or peripheralize was associated with a sensitivity of 94% (95% CI: 8199%) related to a positive discograms (Donelson et al., 1997; Young et al., 2003). In other words these clinical ndings indicated that the disc prolapse, found on the MRI was only 6% likely (95% CI: 119%) to be the cause of sciatica, in accordance to the SnOut-rule (Davidson, 2002). According to the Snout-rule a negative test result, from a test with high sensitivity, will rule out the disorder. 2.3. Provocative testing In order to evaluate the patients tolerance to exion loading, he was instructed in a programme consisting of 15 repetitions of lumbar exion in supine lying, 56 times each day, as this has been found to increase the intradiscal pressure (Sato et al., 1999) and to be the direction of movement that most frequently worsen symptoms from a derangement syndrome (Long et al., 2004). The patient was instructed to abort this programme if it produced concordant symptoms that did not subside within 5 min or he experienced obstruction of lumbar extension, as a mechanical sign of a symptomatic derangement. 2.4. Classication On follow up 7 days later, he had been performing exercises as instructed. His symptoms and physical ndings were unchanged. Data from the patients history and physical examination t into the criteria for an ANR and a derangement was ruled out by failure to centralize as well as lack of response to provocative testing strategies. 3. Treatment second to third visit Day 7 to week 4 In the prescribed treatment for ANR the patient must perform exercises that produce concordant leg symptoms temporarily to

Fig. 1. Body chart showing symptom distribution.

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6. Discussion This paper reported the McKenzie classication and management of a patient with an 18 month history of low back and sciatica, functional disabilities and fear related to bending. MRI showed a disc prolapse and the physical examination led to the conclusion that symptoms were caused by nerve root adhesions. Over 5 months, during which he performed regular end range lumbar exion exercises, aiming to remodel the ANR, the patient regained normal range of motion, full functional ability, freedom of symptoms and condence in bending his back. A causal relationship between the exercise intervention and the improvements cannot be conclusively established by this type of report. Previous reports have documented spontaneous resorption of lumbar disc prolapses although these cases were resolved within a shorter timeframe from symptom onset (Birbilis et al., 2007; Sakai et al., 2007) compared to the 18 month history in this case. Due to the novel nature of this report there is little literature with which this can be compared. However, a case series of 6 patients who were treated with slump stretching has been reported, 4 of who reported long duration of symptoms, from 6 months to 4 years, and who had some similar criteria to this patient (George, 2002). ANR is a syndrome diagnosis and its validity has not been compared to any reference standard. Critics may suggest that this patient recovered in spite of, rather than as a result of, the pain provoking exercises. However, the clinical relevance of this case report is that patients with prolapsed discs and neurological decits may not have to strictly avoid end range exion loading even though it produces pain temporarily. Since the ANR classication is relatively seldom, randomized controlled trials of the exercise treatment are difcult to conduct and it is suggested that clinicians publish case studies or randomized controlled trial (N-of-1 trial) on this type of patient.

Fig. 2. Neural stretches.

ensure that exercises affect the involved tissue (McKenzie and May, 2003). The patient was instructed to continue with 68 repetitions of exion exercises in lying followed by left leg neural stretches 68 repetitions, 56 times each day (Fig. 2). Also the patient was instructed to perform 10 repetitions of lumbar extension exercises in lying, to reduce the risk of recurrence (Larsen et al., 2002). For the same reason posture correction in sitting was enforced with the use of a lumbar roll (Snook et al., 1998; Snook et al., 2002; Pynt et al., 2008). On follow up at 4 weeks the patient had been exercising 34 times each day. Maximum pain intensity over the last 48 h had reduced from 7 to 3 on the 11-point numeric pain rating scale and the skin sensation on the lateral aspect of the left foot was normal. Straight Leg Raise now produced symptoms at 45 degrees of elevation.

4. Fourth to fth visit 6 weeks to 3 months References At the fourth visit the patients compliance with the exercise programme had been poor as he had been exercising 01 times per day, because he did not feel the exercises affected his symptoms. The diagnosis and prognosis was discussed and exercises progressed to repeated exion in sitting with the left knee straight, which produced concordant symptoms in the left leg. He was encouraged to perform 8 repetitions, 56 times daily. At visit number 5 the exercise was progressed to repeated exion in standing 68 repetitions, performed 56 times per day and still the patient was instructed to also perform 10 repeated extension exercises in lying or standing.
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5. Sixth visit 5 months At the nal visit the patient reported freedom of symptoms for 4 weeks, he had not taken any analgesics for a month, walking was normal and pain free, sitting and bending over was pain free and the patient felt he had regained condence in all functional activities including bending his spine. Improvement in lumbar exion range of movement was documented by a Schober measure of 10/ 14 cm and nger-to-oor-distance of 0 cm. A change of at least 1 cm in Schober measure is required before a true improvement in range of motion can be concluded (Tousignant et al., 2005). Neurological examination revealed sustained normal sensation at the lateral aspect of the left foot and left straight leg raise to 80 degrees with no symptoms but tightening in the hamstring. However, the left Achilles reex was still decreased.

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