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CASE REPORT
Year : 2023  |  Volume : 23  |  Issue : 1  |  Page : 26-30

Effectiveness of therapeutic exercises for lumbar disc herniation in an athlete


1 Department of Physical Therapy, Najran General Hospital, Najran, Kingdom of Saudi Arabia
2 Faculty of Medicine, Helwan University, Helwan, Egypt

Date of Submission07-Jul-2022
Date of Decision03-Oct-2022
Date of Acceptance09-Oct-2022
Date of Web Publication07-Aug-2023

Correspondence Address:
Amal Fehr
Faculty of Medicine, Helwan University, Helwan
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjsm.sjsm_16_22

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  Abstract 


Lumbar Disc Herniation LDH affects athletes more than the majority of the general population worldwide. The standard management of lumber disc herniation is a conservative treatment including non-steroid anti-inflammatory drugs and physical therapy however if conservative management fails to improve patient manifestations, surgery is recommended. The goal of this study was to emphasize that, whether the therapeutic exercise intervention for an athlete patient with a lumbar disc herniation complaining of Low Back Pain (LBP) radiating to the lower limb would be effective in return to sports activities. A 37-year-old athlete weightlifter patient was referred to the physical therapy department with a chief complaint of low back pain radiating to the right lower limb for the last year, patient was using a cane as a walking aid since a sports injury almost a year ago. The patient had been diagnosed via Magnetic resonance imaging with L5-S1 disc herniation. The clinical musculoskeletal examination consisted of; a range of motion, muscle manual test, pain severity scale by visual analogue scale, and lower extremity functional index. The patient was handled by a single physiotherapist who is well-experienced in managing sports injuries, our patient had received 24 sessions in 8 weeks, divided into 4 intensity-increasing phases. In the first phase, the goal was to reduce pain, through gentle stretching, and Range of Motion ROM exercises. The exercises increased in intensity gradually throughout each phase. The last phase's goal was to allow the patient to return safely and effectively to the sport, this phase continued with the same given program before in addition to sport-specific exercises. The patient's initial visual analogue scale was 8\10 and Lower Extremity Functional Index LEFI 18\80. In the last session of the treatment program patient scored by the Visual Analogue Scale VAS 2\10, and lower extremity function index LEFI 72\80. The patient was able to carry out the functional activity in a free pain Range of Motion ROM with appropriate posture and he was capable to return to his usual sports activities. This report describes the treatment program of an athlete patient with Lumbar Disc Herniation LDH that resulted in decreased pain, improve motor function, and the ability to return to sport.

Keywords: Athlete, disc herniation, exercise, low back pain, lumbar, sport


How to cite this article:
Alshahrani F, Alshahrani M, Almurdif H, Alsgoor A, Fehr A. Effectiveness of therapeutic exercises for lumbar disc herniation in an athlete. Saudi J Sports Med 2023;23:26-30

How to cite this URL:
Alshahrani F, Alshahrani M, Almurdif H, Alsgoor A, Fehr A. Effectiveness of therapeutic exercises for lumbar disc herniation in an athlete. Saudi J Sports Med [serial online] 2023 [cited 2023 Sep 22];23:26-30. Available from: https://www.sjosm.org/text.asp?2023/23/1/26/383096






  Introduction Top


Lumbar disc herniation (LDH) is a very common condition in the medical field. These cases can vary from compression of one root to multiple roots with radiating pains known as radiculopathy some conditions combined with sensorimotor deficits. The treatment could be conservative treatment including physical therapy, anti-inflammatory, analgesics, corticosteroids, or surgery.[1]

LDH is highly prevalent among athletes, the reason is repetitive multimicrotrauma and pressure on the spine superadded by faulty practice during sports activities.[2] Prevention consists of proper performance technique, body posture, neck and trunk stability, and flexibility. The assessment includes physical examination and imaging by magnetic reasoning imaging (MRI) or computed tomography.[3] The primary treatment is physical therapy and anti-inflammatory medications, if the conservative treatment fails, surgery could be effective.[4]

The goal is to emphasize that therapeutic exercise intervention for an athlete patient with an LDH is effective in terms of return to sports (RTSs).


  Case presentation Top


A 37-year-old male athlete weightlifter was referred to the physical therapy department with low back pain (LBP) and difficulty walking posttrauma after a deadlift exercise carrying 150 kg on December 9, 2021.

After trauma, the pain started immediately and symptoms aggravated with time, after 3 days, the patient was unable to sit, stand, or walk for a long time without pain. He reported LBP in the central lower lumbar region, radiating to the right buttock, and right lower limb.

During this period, he was given tegretol (carbamazepine) 1 tablet 200 mg once daily.

The patient's goals of treatment were to eliminate pain, return to normal activity, and RTSs.

Examination and assessment

According to the observational assessment, the patient ambulated with cane, during the anterior inspection, the patient was lateral bent toward the left side of the body, mesomorph body type, and sciatic scoliosis gait pattern. There were no red flags.[5]

By self-report measure found pain in the lower lumbar region and extended into the right lower limb, scored 8 \10 on the Visual Analog Scale (VAS).[6],[7] As well as the patient was assessed by the lower extremity functional index (LEFI) is a valid and reliable report to assess the functional status and scored 18\80.[8]

Performance-based measure by palpation, there was tenderness over L4, L5, and S1 vertebrae, and muscle spasm of the paraspinal muscles.

The Range of Motion ROM of the trunk was limited and described in detail in [Table 1], and the Muscle Manual Test MMT is described in [Table 2].[9],[10]
Table 1: Range of motion measurement during the intervention

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Table 2: Manual muscles test measurement during the intervention

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The following special tests were positive in the right side straight leg raising (SLR) and right side slump test.[11],[12]

The patient was tested for myotome S1 and L5 by plantar flexion and dorsiflexion, respectively, and both scored according to MMT 3\5, whereas the dermatome test for L5 and S1 scored 1.[13]

The patient was diagnosed clinically with L5–S1 disc herniation, then he had imaging studies on the lumbosacral region that showed L5–S1 disc herniation, muscle spasm, and straightening of the lumbar curve [Figure 1].
Figure 1: Magnetic resonance imaging view demonstrating the posttrauma L5, S1 disc herniation with marked muscle spasm, and straightening of the lumbar curve

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Physical therapy was initiated by a well-experienced therapist in sports injury management and goals by the physical therapist listed as pain reduction, restoring function, and RTSs activity.

Intervention

The patient was seen for 24 sessions in 8 weeks [Table 3]. For the first 2 weeks, each exercise session included hot moist packs on the lower back for 10 min. The knee to the chest and posterior pelvic tilt exercises are variations of Williams's exercises that lead to decreased disc herniation.[14] Supine lumbar rotation, ankle dorsiflexion, and plantar flexion all exercise were performed in the free pain range of 15 × 3 sets.
Table 3: Intervention from the 1st to 8th week

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In 3rd and 4th week, the exercises therapy goal was to return to normal ROM, each exercise included the same exercises above but combined with pelvic bridging, hip abduction in the supine position, and external rotation in a side-laying position using red TheraBand as 15 × 3 sets, hip extension in quadruped position 15 × 3 sets, and trunk extension from a prone position 15 repetitions hold 10 s.

In the 5th and 6th weeks, to assist the strength of the lower extremity and core muscles of the patient, the following exercises were performed: plank and side plank exercise withhold for 10 s and relax for 10 sets, wall squat exercise withhold for 10 s and relax for 10 s for 10 sets, SLR in bed in flexion, abduction, and extension for 15 × 3 sets with 2 kg ankle weight, single-leg bridging exercises for 15 × 3 sets, reverse crunches for hold 10 s and relax for 10 s for 10 sets, and lunges walking for 15 × 3 sets.

In the 7th and 8th weeks, the given exercises included: plank, side plank, crunches, and reverse crunches on Swiss ball hold for 10 s for 3 sets, single-leg bridging hold for 10-s relax for 10 s for 10 sets, lunges with free weight a 5 kg for 10 × 3 sets, and deadlift a 5 kg for 10 × 3 sets. The patient was educated and supervised to perform the proper technique and instructed to increase the load gradually.


  Results Top


In the first 2 weeks, the goal of physiotherapy was to reduce pain and perform the activity of daily living in as free a pain range as possible. The pain level was scored by VAS 8\10 and the functional level was measured by LEFI was 18\80.

In the 3rd and 4th weeks, pain reduced VAS 5\10 and the patient was able to walk without assistance LEFI 34\80, ROM increased trunk flexion 40 trunk extension 10, and trunk lateral bending right side 10 rotation right side 10.

In the 5th and 6th weeks, the patient performed the full ROM, pain reduced VAS 3\10, was able to walk long distances without pain, able to sit in cross sitting position and standing without pain, LEFI 72\80, SLR, and slump tests bilaterally were negative, in this phase, the goal was to increase muscle strength and core stability.

At the end of the intervention sessions, i.e., at the 7th and 8th weeks, the patient and physiotherapist reached their goals level of function and mobility, the patient had a follow-up MRI requested by the physician and showed no significant changes [Figure 2]. In this phase, the goal was to enable the patient to RTSs activity. The given exercises included plank, side plank, crunches, and reverse crunches on Swiss ball hold 10 s 3 sets, single-leg bridging hold 10-s, relax 10-s, and 10 sets, lunges with free weight 5 kg 10 × 3, and deadlift 5 kg 10 × 3. The patient was educated to perform the proper technique and instructed to increase the load gradually.
Figure 2: Magnetic resonance imaging at the end of the intervention program showed no significant changes

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At the final session, the pain scale was VAS 2\10, and LEFI 72\80.

The patient was able to carry out the functional activity in a free pain range with appropriate posture and return to normal sports activity.


  Discussion Top


A systemic review by Pourahmadi in 2016 reported that pain and neurological deficits associated with symptomatic LDH are often treated by physical therapy.[15] Another study by Fors in 2019 found that patients who are candidates for surgical treatment and have several physical impairments as a result of degenerative lumber spine disorders can get benefit from physiotherapy interventions.[16]

According to a systematic review and meta-analysis study by Reiman in 2016, there is no significant difference in RTS rate for athletes treated surgically and conservatively which were nearly 84%–76%, respectively. The percentage of athletes who RTS activity postsurgical discectomy dramatically decreased from around 38%–65%.[17]

In comparison to Sedrak, 2021, the time and rate outcomes of conservative treatment were similar in terms of return to play approximately 4.11 months with the surgical intervention that range from 5.19 months.[18]

The study by Trompeter in 2017 suggested that factors including repetitive motions and high-volume training (e.g., forward flexion of the trunk) might be responsible for increased rates of sports players' LDH. Howell reported a high correlation between excessive lumbar flexion and the incidence of LBP.[19]

Heat wrap therapy evidenced by French, 2006 that the patient with back pain in acute or subacute stages treated with a hot moist pack to relieve pain has shown a short time reduction of pain, but the effectiveness was slight. Furthermore, the therapeutic exercises to heat wrap therapy show additional benefits.[20]

The common intervention prescribed for patients with symptomatic LDH is stabilization or core stability exercises and motor control exercises.[15]

Exercises for lumbar stabilization and core strengthening can improve mobility, functional disability endurance, and extension strength. However, no specific exercise has superior effusiveness.[21]

In the young male, LDH patients who suffer from pain radiating to their legs and managed by lumber spine stabilization exercises and general exercises appear to be effective to reduce pain and improve functional capacity. Besides, in long term, lumbar stabilization strengthening exercises are more effective than general exercises as reported by Ye in 2015.[22]

Limitation

There were enormous outside factors such as lifestyle or exercises performed outside the clinic. The patient attempted to be treated with an alternative intervention which is cupping therapy.


  Conclusion Top


This report describes the treatment program of an athlete patient with LDH that resulted in decreased pain and improve motor function, and the ability to RTS was achieved.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Corniola MV, Tessitore E, Schaller K, Gautschi OP. Lumbar disc herniation – Diagnosis and treatment. Rev Med Suisse 2014;10:2376-82.  Back to cited text no. 1
    
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Lurie JD, Tosteson AN, Tosteson TD, Carragee E, Carrino JA, Kaiser J, et al. Reliability of magnetic resonance imaging readings for lumbar disc herniation in the spine patient outcomes research trial (SPORT). Spine (Phila Pa 1976) 2008;33:991-8.  Back to cited text no. 3
    
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Yamaguchi JT, Hsu WK. Intervertebral disc herniation in elite athletes. Int Orthop 2019;43:833-40.  Back to cited text no. 4
    
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Downie A, Williams CM, Henschke N, Hancock MJ, Ostelo RW, de Vet HC, et al. Red flags to screen for malignancy and fracture in patients with low back pain: Systematic review. BMJ 2013;347:f7095.  Back to cited text no. 5
    
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Mehta SP, Fulton A, Quach C, Thistle M, Toledo C, Evans NA. Measurement properties of the lower extremity functional scale: A systematic review. J Orthop Sports Phys Ther 2016;46:200-16.  Back to cited text no. 8
    
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Littlewood C, May S. Measurement of range of movement in the lumbar spine – What methods are valid? A systematic review. Physiotherapy 2007;93:201-11.  Back to cited text no. 9
    
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Capra F, Vanti C, Donati R, Tombetti S, O'Reilly C, Pillastrini P. Validity of the straight-leg raise test for patients with sciatic pain with or without lumbar pain using magnetic resonance imaging results as a reference standard. J Manipulative Physiol Ther 2011;34:231-8.  Back to cited text no. 11
    
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Trainor K, Pinnington MA. Reliability and diagnostic validity of the slump knee bend neurodynamic test for upper/mid lumbar nerve root compression: A pilot study. Physiotherapy 2011;97:59-64.  Back to cited text no. 12
    
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Kirshblum SC, Biering-Sorensen F, Betz R, Burns S, Donovan W, Graves DE, et al. International standards for neurological classification of spinal cord injury: Cases with classification challenges. J Spinal Cord Med 2014;37:120-7.  Back to cited text no. 13
    
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Dydyk AM, Sapra A. Williams Back Exercises. StatPearls Publishing, Treasure Island (FL); 2019.  Back to cited text no. 14
    
15.
Pourahmadi MR, Taghipour M, Ebrahimi Takamjani I, Sanjari MA, Mohseni-Bandpei MA, Keshtkar AA. Motor control exercise for symptomatic lumbar disc herniation: Protocol for a systematic review and meta-analysis. BMJ Open 2016;6:e012426.  Back to cited text no. 15
    
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Fors M, Enthoven P, Abbott A, Öberg B. Effects of pre-surgery physiotherapy on walking ability and lower extremity strength in patients with degenerative lumbar spine disorder: Secondary outcomes of the PREPARE randomised controlled trial. BMC Musculoskelet Disord 2019;20:468.  Back to cited text no. 16
    
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Reiman MP, Sylvain J, Loudon JK, Goode A. Return to sport after open and microdiscectomy surgery versus conservative treatment for lumbar disc herniation: A systematic review with meta-analysis. Br J Sports Med 2016;50:221-30.  Back to cited text no. 17
    
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Sedrak P, Shahbaz M, Gohal C, Madden K, Aleem I, Khan M. Return to play after symptomatic lumbar disc herniation in elite athletes: A systematic review and meta-analysis of operative versus nonoperative treatment. Sports Health 2021;13:446-53.  Back to cited text no. 18
    
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Trompeter K, Fett D, Platen P. Prevalence of back pain in sports: A systematic review of the literature. Sports Med 2017;47:1183-207.  Back to cited text no. 19
    
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Suh JH, Kim H, Jung GP, Ko JY, Ryu JS. The effect of lumbar stabilization and walking exercises on chronic low back pain: A randomized controlled trial. Medicine (Baltimore) 2019;98:e16173.  Back to cited text no. 21
    
22.
Ye C, Ren J, Zhang J, Wang C, Liu Z, Li F, et al. Comparison of lumbar spine stabilization exercise versus general exercise in young male patients with lumbar disc herniation after 1 year of follow-up. Int J Clin Exp Med 2015;8:9869-75.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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