One of the most common pathologies encountered in the health care field is low back pain. It is almost guaranteed that someday in your career as a physical therapist, you will encounter a patient with this diagnosis. With the prevalence of low back pain in our society, there is a large financial drain on the health care system that could be decreased with proper management.
The diagnosis of disc herniation as the source of back pain is a controversial issue. There is a large proportion of the population that is asymptomatic and shows disc herniation in MRIs, which leads to the issue of the disc being incorrectly labeled as the source of the patient's complaints sometimes. With the appearance of a herniating disc, some surgeons and patients jump to the conclusion that a surgical procedure is necessary for correction without considering conservative treatment. While surgery can be effective for some individuals, it may represent an expensive overreaction to the patient's symptoms.
The study we looked at this week was a systematic review of conservative treatment for lumbar disc herniation with radiculopathy. Studies were only included if the patients were over 18 years old and referred with leg pain (with or without low back pain). 75% of the patients had to have a confirmed lumbar disc herniation through MRI or CT as well. Participants with discs that were only "bulging" were not included. Studies were also excluded if surgery was performed or an injection was used; accupuncture, along with other physical therapy interventions, was labeled as conservative therapy.
The review found that advice had poorer short and intermediate outcomes for back pain and leg pain compared to surgical microdiscectomy, but there was no difference in the long term. Those who pursued surgery had better function compared to the advice group at short-term follow-up, but no difference was noted at intermediate and long-term outcomes. Manipulation was found to be effective as long as the annulus was still intact. No difference was found between traction, Low Level Laser Therapy, and ultrasound, but traction had good results when combined with electrotherapy and medications in the short term. The review found moderately strong evidence that stabilization exercises were better than no treatment at all. It should be noted that there are possible adverse effects linked between ibuprofen use and traction.
While this article offers some information on the effectiveness of various conservative treatment methods in treating lumbar disc herniation radiculopathy, it does not sufficiently examine the entire scope of physical therapy interventions, such as repeated motions, extension based exercises, neuromuscular education of the core, etc. While there are plenty of studies out there that look at the effectiveness of interventions like repeated motions, neuromuscular education, and core stabilization, there weren't many studies looking at those treatment methods that fit the specific inclusion criteria of this systematic review. It does not mean they are not effective, but it points out an excellent research opportunity for anyone interested. Be sure to keep an eye out for some posts coming out in the near future for treating low back pain.
Hahne AJ, Ford JJ, McMeeken JM. "Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review." Spine (Phila Pa 1976). 2010 May 15;35(11):E488-504. Web. 09/15/2012.
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