The Outcome of an Extension Oriented Exercise Program on a 55-year-old Male with
Low Back Pain, Unilateral Foot Drop, and Urinary Incontinence: a Retrospective
Case Study.
A Capstone Project for PTY 768
Presented to the Faculty of the Department of Physical Therapy
Sage Graduate School
In Partial Fulfillment
of the Requirements for the Degree of
Doctor of Physical Therapy
Daniel Mark Perry, SPT
May, 2010
Approved:
_________________________________
Gabriele Moriello PT, PhD, MS, GCS
Research Advisor
_________________________________
Marjane Selleck, PT, DPT, MS, PCS
Program Director, Doctor of Physical Therapy Program
SAGE GRADUATE SCHOOL
I hereby give permission to Sage Graduate School to use my work,
The Outcome of an Extension Oriented Exercise Program on a 55-year-old Male with
Low Back Pain, Unilateral Foot Drop, and Urinary Incontinence: a Retrospective
Case Study.
For the following purposes:
- Place in the Sage Colleges Library collection and reproduce for Interlibrary Loan.
- Keep in the Program office or library for use by students, faculty,
or staff.
- Reproduce for distribution to other students, faculty, or staff.
- Show to other students, faculty or outside individuals, such as accreditors
or licensing agencies, as an example of student work.
- Use as a resource for professional or academic work by faculty or staff.
Daniel Perry 2/28/10
[Type your name(s) - repeat this line for each student] Date
I represent to The Sage Colleges that this project and abstract are the original work of the
author, and do not infringe on the copyright or other rights of others.
The Outcome of an Extension Oriented Exercise Program on a 55-year-old Male with
Low Back Pain, Unilateral Foot Drop, and Urinary Incontinence: a Retrospective
Case Study.
Daniel_Perry_______________________________________________________2/28/10
[Type your name(s) - repeat this line for each student] Date
The Outcome of an Extension Oriented Exercise Program on a 55-year-old Male with
Low Back Pain, Unilateral Foot Drop, and Urinary Incontinence: a Retrospective
Case Study.
By Daniel Mark Perry, SPT 2010
Abstract
Background: There are many studies available pertaining to the relationship between
extension oriented exercise and discogenic low back pain, but there is limited published
literature about the effect of these exercises on discogenic low back pain presenting with foot
drop and bladder dysfunction. Purpose: To observe the outcomes of an extension oriented
exercise program with discogenic low back pain presenting with foot drop and bladder
dysfunction in a participant at an outpatient physical therapy clinic. Case Description: The
participant was a 55 year old male with low back pain, foot drop and bladder dysfunction
resulting from an acute lumbar disc herniation. Methods: A physical therapist certified in the
McKenzie method evaluated the participant with the McKenzie Institute’s Lumbar Spine
Assessment. Other tools and measures included a gait assessment, manual muscle testing,
self reported level of function questionnaire, an 11-point pain rating scale, and a subjective
report of bladder function. The therapist designed an intervention program based on
extension exercises, which were administered over 3 treatment sessions. Outcomes: The
participant abolished his back pain, foot drop and bladder dysfunction. He also improved his
strength and gait allowing him to return to his normal activities at work and at home at full
functional capacity. Discussion: This case study demonstrates the benefit of conservative
physical therapy treatment, such as extension oriented exercise, for managing discogenic low
back pain with foot drop and bladder dysfunction. Abolishment of symptoms may be a result
of a dynamic internal disc model, where posterior disc loading with extension exercise,
allows the disc contents to migrate away from the neural structures to reduce pressure on
these structures and relieve symptoms of back pain, foot drop and bladder dysfunction.
3
Background and Purpose
Low back pain is the second leading cause of doctor’s office visits in the United
States (U. S.).1 Seventy-five percent of the adult U. S. population has already reported some
type of low back pain in the past 3 months and close to 33% of the adult workforce will be
affected by low back pain each year.1,2
The direct and indirect costs associated with back
pain have been steadily increasing despite our education and advances in medical treatment.3
Direct costs include doctor and hospital fees, travel to and from healthcare offices, imaging,
pain medication, and rehabilitation after surgical intervention. Indirect costs include the
economic burden of lost wages and decreased productivity at work and at home.4 Ambrossi
et al5 reported that average total costs for lumbar disc herniation including diagnostic testing
and surgery is $23,915 compared to conservative treatment which costs $2,315 on average.
Costs for surgical intervention of a herniated lumbar disc may be high but the rate for
complete recovery from symptoms may not follow suit. Girardi et al6 reported that full
motor recovery from a disc herniation was only 71% in patients with preoperative ankle
dorsiflexor strength grades 2/5 or better, while Ghahreman et al7 found the rate of complete
recovery in patients with preoperative foot drop (grade 0, 1, 2/5 ) was only 27%. If the
debilitating back pain associated with disc herniation can be alleviated with swift
conservative management, the burden on the healthcare system may be reduced.
Herniation of an intervertebral disc in the lumbar spine is a common cause of low
back pain.1 An intervertebral disc is a structure found between two vertebrae which is made
up of an outer fibrous shell called the annulus which surrounds an inner softer center called
the nucleus. The entire structure is designed to provide cushioning between two vertebrae
when forces are applied. As the disc ages, years of repetitive stress, twisting, and
4
compression can cause microtrauma to the annulus allowing the softer nucleus to push out
against or even through the annulus forming what is commonly called a herniated disc.
Direct pressure on the surrounding spinal structures and nerve roots or irritation and
inflammation around a nerve root can result in paresthesias or motor dysfunction in the
associated nerve distribution. Symptoms vary from patient to patient. Twenty percent of
individuals who have a positive disc herniation on MRI are asymptomatic8 while others
report intense pain, tingling, numbness, or even muscle weakness within the effected
myotome.
The L4-L5 and L5-S1 regions account for approximately 95% of all diagnosed spinal
disc herniations.1
A herniated disc in the lumbar spine can result in pain and paresthesias in
the low back and lower extremities, muscle weakness in the lower extremities, or bladder
dysfunction due to the proximity to the cauda equina and pressure on these nerve roots that
influence bladder control.9,10
Reports of compression of the nerve roots controlling the ankle dorsiflexor and
causing foot drop has been recorded.6,7
Compression of the L4 or L5 nerve roots in the
lumbosacral plexus by a disc herniation can cause a disabling weakness of the innervated
ankle dorsiflexors, particularly the anterior tibialis muscle. Compression of the L5 nerve root
prevents descending transmission of neural impulses to the alpha motor neuron leading to the
deep peroneal nerve that supplies the anterior tibialis muscle. Weakness of the anterior
tibialis muscle (grades < 2+/5) can result in a foot drop. Foot drop can interfere with
ambulation due to difficulties clearing the toes during the swing phase of gait. People often
compensate for this with excessive hip flexion or a Trendelemburg gait pattern. An ankle–
foot orthosis may be needed to assist a person with this deficit to prevent complications with
5
balance, coordination, and biomechanical compensation injuries during gait that can reduce
the patient’s activities of daily living and quality of life.6
Mixter and Barr11
observed that lumbar intervertebral disk protrusion may cause
neurological disorders resulting in bladder and voiding dysfunction. The motor and sensory
nerves of the urinary system are extensions of the cauda equina originating from the conus
medullaris and account for both sympathetic and parasympathetic bladder control. All of the
sacral nerves controlling the urinary system run posterior to the lumbar vertebral bodies and
discs until reaching their sacral exit, thus a disc protrusion anywhere in the lumbar spine may
compress the cauda equina and sacral nerve roots leading to urinary dysfunction.10
Researchers have suggested conservative methods for treating urinary incontinence through
bladder and pelvic floor muscle training, but not for incontinence of a discogenic nature.10-14
Extension oriented exercises like prone press-ups have been a popular and effective
physical therapy treatment strategy for patients with low back pain associated with a
protruding lumbar disc.15-18
Powers et al19
reported a significant reduction in the average
pain score and increase in range of motion in the lumbar spine after a single treatment
session. The McKenzie method of treatment for low back pain utilizes similar patient-
generated extension oriented exercises and is a gaining acceptance and popularity for treating
patients with discogenic pain.19-24
The McKenzie approach to low back pain is often referred
to as “mechanical diagnosis and therapy (MDT)” because it contains both comprehensive
patient assessment and treatment components.20
McKenzie identifies a disc protrusion and
associated signs and symptoms as a derangement syndrome and pain can often be centralized
or moved back to point of origin with self generated exercises.22-26
The theory behind
extension exercise and resolution of symptoms is based on the assumption that when the
6
spine is flexed into the pain free direction of preference, the vertebrae above and below the
involved disc opens anteriorly and closes posteriorly allowing the disc to migrate back to its
normal anatomical position relieving pressure on the nerve roots. Many studies have
reported the effectiveness of the McKenzie extension exercises for treatment of low back
pain,19,21-26
but there is little evidence to support the effectiveness of these extension
exercises for the treatment of a patient presenting with unilateral foot drop and bladder
dysfunction. Alleviation of bladder symptoms and foot drop with extension exercises but
may be beneficial due to the theory surrounding the mechanism of his symptoms and relief of
pressure on the controlling nerve roots.
In many cases, surgical intervention is warranted but for others, the less costly
conservative treatment may be beneficial and require less time out of work and with post
operative rehabilitation. There is extensive research regarding the effectiveness of extension
oriented lumbar exercises on back pain but little research has been composed for
effectiveness on foot drop and bladder control. The purpose of this case study was to
examine the outcome of a conservative treatment approach of extension oriented exercise on
a 55 year old man with low back pain, unilateral foot drop, and bladder dysfunction
associated with a lumbar disc herniation. The hypothesis is this participant will show signs
of relief of his symptoms stated above according to the theory of the intervention.
Methods
Case Description
The participant was a 55 year old male respiratory therapist in generally good health
with a 6 week history of acute low back pain after bending forward in his garden. His pain
symptoms were constant and initially started in his low back and progressed to his left
buttocks, thigh, leg, and then foot. He developed left lower extremity weakness that evolved
7
into a foot drop and reported episodes of urinary incontinence since the onset of low back
pain. Symptoms were aggravated by bending or flexing forward, sitting cross-legged, or
standing for long periods of time. Symptoms were less aggravating when sitting, standing,
walking or “on the move”, and at night while laying supine on a firm bed or on his right side.
He reported no sleep disturbances or night pain. The participant was diagnosed by his
primary physician with a lumbar disc protrusion with radiculopathy on his left side.
A routine magnetic resonance imaging (MRI) study of this participant’s lumbar spine
was obtained by his primary physician and results were made available to the physical
therapist. Images were described as sagital T1, T2 and fat-suppressed T2 STIR. Axial T1
and T2-weighted images were also obtained. In addition, axial and sagital fat-suppressed T1-
weighted images were obtained after gadolinium enhancement. A summary of reported
impressions from the MRI can be found in Table 1.
On a brief self reported medical questionnaire, the participant reported he had never
received Physical, Occupational, or Speech Therapies for any reason in the past. His past
medical history was unremarkable. He used corrective lenses for vision. He was a social
smoker and limited his alcohol consumption to about 4 drinks per week. He listed his only
medical concern as “resolution of back injury,” and his expectation for treatment was to
“improve left leg function.” The participant reported having prescriptions for Crestor and
prednisone that was being weaned down. He denied any use of over-the-counter NSAIDs.
Approval for working with human subjects during this study was granted after
application and extensive review by the Sage College’s Institutional Review Board
(Appendix A). No humans were harmed by intent or inadvertently during the course of this
study.
8
Examination
The physical therapist performing the examination was certified in MDT for more
than 4 years at the time of this examination. The examination consisted of tests and
measures from The McKenzie Institute Lumbar Spine Assessment (Appendix B), a reliable
instrument used to classify patients into the specific categories of syndromes.25,27-30
The
assessment form consisted of a basic medical history and physical examination where the
participant’s responses to movement allowed the therapist to make a provisional
classification of his condition of either a derangement, dysfunction, or postural syndrome.
Results from the movement exam are summarized in Table 2. The participant in this study
was classified by the therapist as having a derangement syndrome in his lumbar spine as
defined by McKenzie.23
The participant’s gait pattern was observed as he exited the clinic’s waiting room and
entered the treatment area to sit, a distance of about 15 meters. Observation of his gait
revealed a left foot drop during the swing phase and terminal extension resulting in a
compensating hip-hike on the ipsilateral side to clear his toes from dragging on the floor. He
reported his pain as a range from 2/10 to 10/10 on an 11 point numeric pain rating scale
(NPRS) since onset. He denied numbness or tingling in his back, buttocks, and lower
extremities.
A manual muscle test (MMT) of the participant’s lower extremities was performed
by the therapist according to procedures outlined by Hislop and Montgomery.31
His muscle
strength was normal (5/5) except for his left ankle dorsiflexor strength (3/5) that resulted in
left calf muscle tightness from a lack of voluntary dorsiflexion movements. Visual
inspection and palpation in standing revealed a reduced lumbar lordosis. He had a forward
9
head and rounded shoulders. No lateral shift or scoliosis was observed in the standing or
sitting position. While sitting on a flat plinth he was observed to be fidgety to get into a
comfortable seated position. He reported his low back pain improved with correction of
sitting posture. A seated slump test revealed negative dural signs bilaterally. The slump test
is a common clinical examination of low back related leg pain.32
The slump test (sensitivity
= 0. 84) was designed to place the sciatic nerve roots under tension to reproduce radicular
pain in patients with lumbar disk herniation and detect nerve root compression.33
The
procedure for this test was followed according to a protocol described by Magee.34
The use
of the McKenzie lumbar spine assessment allowed the therapist to make a rapid and gross
observation of the participant’s lumbar range of motion (ROM) and affect on function
without the need for extensive and time consuming goniometric measurements. See Table 3
for lumbar ROM limitations.
The participant completed a self reported assessment of his level of function and
activities of daily living during his initial visit while sitting in the waiting room at the clinic.
On the assessment form, the participant was instructed to circle one of 6 choices that he
determined to be an accurate representation of his level of function with different daily tasks.
The results for this self assessment (except for self-care, eating, and manipulative skills
which the participant reported having no problem with) are represented in Table 4. The
participant was able to ambulate community distances without an assistive device
independently.
Outcome Measures
The participant’s back pain intensity in this study was measure by a NPRS. The
NPRS has been reported to be a sensitive, accurate, and reliable instrument for measuring
10
changes in pain intensity.35-38
The 11-point NPRS is recommended as a core outcome
measure in clinical trials of chronic pain treatments, because it is less abstract and easier to
understand than other clinical pain measures.39
The NPRS was an eleven point scale
represented by a horizontal line on a wall in the clinic. The number zero was located at the
far left of the line and 10 at the far right. Zero represented no pain and 10 represented the
most pain imaginable. Vertical marks representing numbers 1 through 9 were evenly spaced
on the line between the 0 and 10. When measuring pain during this study, the participant
was asked to verbally state his number corresponding to his back pain intensity during his
examination and treatment session. Paice and Cohen38
found the verbal administration of the
NPRS a valid test for changes in acute pain with a statistically significant correlation with the
visual analog scale (VAS) (r = 0. 847, p < 0. 0001). Childs, Piva, and Fritz37
reported the
minimum clinically significant difference in the NPRS after treating patients with low back
pain as a change of 2.2 and 1.5 points after 1 and 4 weeks of treatment, respectively.
The McKenzie Institute Lumbar Spine Assessment was used to identify the
participant’s baseline musculoskeletal impairments during the initial evaluation and to
determine the effectiveness of the interventions. This instrument, when performed by
therapists with training in the McKenzie method, allows for reliable classification and
baseline for progress in patients with lumbar pain.25-30
Interexaminer reliability of the
McKenzie lumbar spine assessment in performing clinical tests and classifying patients with
low back pain into syndromes were good and statistically significant (Kappa 0.6 – 0.7, 95%
confidence interval) when the examiners had been trained in the McKenzie method.40
The
proportion of patients who could be classified into one of the syndrome categories defined by
McKenzie using the assessment form has been generally high, with a mean of 87%.21
Clare,
11
Adams, and Maher25,26
reported the reliability of syndrome classification was k = 0.56 (95%
confidence interval 0. 46–0. 66) with a percentage agreement of 91%.
The participant’s gross lower extremity muscle strength was measured by the MMT
described in the text by Hislop and Montgomery.31
In literature review of more than 100
published studies, evidence suggests good reliability, external, and internal validity in the use
of MMT for patients with neuromusculoskeletal dysfunction.41
A strong correlation (r =
0.768; P < 0.001) has been found between MMT and hand held dynamometry, often
considered to be the gold standard of muscle strength testing.
The participant’s bladder function was measured subjectively by self reporting more,
less, or no change in micturition frequency. Abrams, Artibani, Gajewski et al43
recommended that subjective measures should be the standard tool for assessment and
treatment of patients with bladder dysfunction because objective measurements do not
clearly represent the patients personal lifestyle priorities or quality of life.
Evaluation/Prognosis
From the examination, the participant was observed as having functional limitations
in duties required by his occupation, difficulty with leisure activities, and activities of daily
living. These limitations are a result of his impairments of low back pain, muscle weakness,
and ROM. He was able to centralize his pain out of his left lower extremity and abolish his
pain in his low back after 10 repeated lumbar extensions in lying position, identifying him as
good candidate to respond favorably to an extension oriented exercise program. The
therapist determined he had a posterior lumbar derangement with left unilateral asymmetrical
symptoms below the knee and classification of derangement syndrome which was consistent
12
with his medical diagnosis of lumbar disc protrusion and unilateral lower extremity
radiculopathy.
According to the American Physical Therapy Association’s Guide to Physical
Therapy Practice,44
this participant fell into a Preferred Practice Pattern of 4F with impaired
joint mobility, motor function, muscle performance, range of motion, and reflex integrity
associated with spinal disorders, ICD-9 code 722. The participant presented a physician
signed prescription for physical therapy for 3 times a week for 10 weeks. The guide
recommended the expected number of physical therapy treatments to be in the range of 8 to
24 visits within 1 to 6 months time and stated that he would demonstrate full return of
impairments and return to work and leisure activities within that time frame. Judging by the
participant’s functional status and responses to the examination, and through previous
experience with patients with low back pain, the therapist estimated his needed number of
treatments to be between 8 and 12 forty-five minute visits.
Goals
The goals for this participant were designed by the therapist with intention to be met
within the anticipated number of treatment sessions. Short-term goals were to abolish or
centralize the participant’s leg and back pain, to resolve his foot drop, and restore his lumbar
range of motion to within his normal limits. Restoration of the participant’s bladder control
was not identified as an anticipated goal through his immediate plan of care secondary to a
lack of available evidence associating lumbar exercise with bladder control. Long-term goals
for this participant were for him to return to full functional capacity at work and at home,
with his leisure activities and activities of daily living.
13
Plan of Care
The participant’s plan of care was designed by the therapist based on his directional
preference and symptom response (decrease, abolition, or centralization of pain) from the
lumbar assessment form during the evaluation. Extension oriented interventions
recommended by McKenzie23,24
for treating derangement syndrome were implemented. The
frequencies of these skilled interventions during visits are summarized in Table 5. In
repeated extension in lying (REIL), the patient was prone on a plinth with his elbows bent
and hands flat with palms down at about chest level. Then the participant pushed up on his
hands to lift his chest off the plinth keeping his hips down and then returned to starting
position. One repetition was up and back down. In REIL with patient over-pressure, the
participant started in the elbows extended position and pushed into maximal lumbar
extension while keeping his hip on the plinth. REIL with therapist overpressure allowed the
therapist to apply a vertical force down onto the participant’s lumbosacral region during
maximal lumbar extension. Grade 3-4 posterior - anterior (PA) oscillatory mobilizations
were applied to the participant’s L3-L5 vertebrae in a fashion described by Maitland.45
The participant was instructed in a standing stair calf stretch where he put one foot in
maximal dorsiflexed position on a bottom stair and leaned into it for 20 seconds. He did this
for both legs. To address his head forward and rounded shoulders, he was also instructed on
a seated slouch exercise where he would allow gravity to lower his head and shoulders and
flex his spine, and then instructed to correct his posture by contracting his back muscles with
spinal extension and scapular retraction. The therapist’s hands were lightly placed on the
skin over the participant’s rhomboids and mid-trapezius muscles to facilitate the correct
action and contraction.
14
The participant was educated on correct static and dynamic posture that included
keeping his ears in a vertical line with his hips and ankles, as described in detail by Magee,34
and the proper body mechanics of lifting to reduce stress on his low back. Home exercises
are summarized in Table 6. The participant was instructed to do prone press-ups at home on
his floor as well as standing back bends with his hands on his hips. He was also instructed on
the use of a pillow or rolled towel for lumbar support while sitting or driving.
Outcomes
The participant was evaluated by the therapist at the initial visit according to the
McKenzie lumbar form. As stated above, the outcomes of the initial evaluation are
documented in Table 2. The entire initial session lasted no longer than 45 minutes. At the
end of the session the participant was instructed in his home exercise program. He
demonstrated normal cognition and willingly complied with all his interventions. He was
able to demonstrate all his exercises correctly and independently before leaving the clinic.
He did not show up for his next 2 visits (2 and 5 days post evaluation) for reasons unknown.
During the next treatment session (5 days post evaluation), the participant reported
much less leg and thigh pain after clinical intervention and fully complying with his home
exercise program. He still reported only minor pain in his lumbo-sacral region before that
treatment session. This second session lasted no more than 35 minutes and was still able to
demonstrate his home exercises independently and completely. At his third and final session
(7days post evaluation), the participant reported complete abolishment of his leg, thigh, and
back pain, a 0/10 in the NPS. The therapist also observed an absence of foot drop and
Trendelenburg during his gait as he ambulated from the waiting room to the exercise room.
The participant reported gaining complete control over his bladder function.
15
The third and final treatment session lasted no more than 17 minutes including
interventions and education about maintaining his home exercise program for prevention of
future reoccurrence. The participant was able to return to his previous level of function and
activities of daily living at home and at work without symptoms after this third session. The
participant was scheduled for a formal follow-up and discharge on his fourth visit so ROM
and MMT were not performed at this third visit. This data was not available due to
participant’s absence at fourth visit.
Discussion
Low back pain is second leading cause of doctor’s office visits in the US.1
A large
percentage of these cases are discogenic in nature. The economic burden may be reduced if
injuries can be alleviated with swift conservative management. Extension oriented exercises,
like the ones used with the McKenzie Method of treatment, is a form of conservative
management. The participant mentioned here had a history of back pain, bladder dysfunction
and foot drop associated with multiple level lumbar disc bulges. He was provided a simple
treatment program of extension oriented exercises and after only three sessions of physical
therapy, the participant reported complete abolishment of his pain, foot drop, and bladder
dysfunction and all short term and long term goals were met.
The McKenzie method is a comprehensive system of both patient assessment and
exercise for chronic low back pain. The assessment portion attempts to classify back pain
into causation, movement limitation, directional preference and symptom centralization
which is then used to formulate a treatment strategy. Typically, the directional preference
becomes the treatment principle,24
like in this participant who favored low back extension
rather than flexion to minimize and centralize pain symptoms. According to Werneke et al,46
16
centralization is a good prognostic indicator. They reported that patients whose symptoms
centralize improve faster and have better outcomes than those patients whose symptoms do
not centralize, which may explain why the participant in this study demonstrated
improvement after so few visits to therapy.
Wetzel and Donelson47
described the anatomical mechanism of discogenic radicular
symptoms and the treatment strategy for centralization. They describe a dynamic internal
disc model based on cadaveric, disco-graphic, and MRI studies. This model shows posterior
migration of inner disc contents in response to anterior disc loading during lumbar flexion,
and anterior migration in response to posterior disc loading with extension. Because of this
loading phenomenon, extension exercise, or directional preference of extension, allows the
disc contents to migrate forward and away from the neural structures reducing pressure on
these structures and relieving radicular symptoms. The same phenomenon is responsible in
this participant whom presented with multiple level posterior lumbar disc bulges, exacerbated
by bending forward to pick up sticks in his garden.
As we can see, numerous studies have been published discussing how exercises are
effective with back pain,1,16-22,25
but as previously mentioned, the effectiveness of extension
oriented exercises for the treatment of discogenic bladder dysfunction and deep peroneal
neuropathy has not been fully investigated.
Relief of bladder dysfunction and foot drop in this participant may be accredited to
Wetzel and Donelson’s47
dynamic internal disc model as well. Repetitive spinal flexion or
bending forward allows the softer nucleus to push out posteriorly against the annulus forming
a bulge.20,23,24
This bulge applies pressure to the surrounding spinal structures and nerve
roots causing irritation and inflammation to the nerve root or spinal cord running adjacent to
17
the disc.1,5-9,11,19,20-25
Pressure on the spinal cord or nerve roots may interfere with normal
nerve conduction to its associated structures within that particular nerve distribution.
O’Flynn, Murphy, and Thomas48
suggested that bladder dysfunction may be a direct result of
pressure to the cauda equina in patients with a disc protrusion occurring within the lumbar
and sacral regions of the spinal column, as seen in our participant here. The sensation of
fullness or the neural mechanisms for urine retention may be compromised resulting in
uncontrolled micturition. Extending the vertebrae above and below the involved disc spaces
allows the discs to migrate back to their normal anatomical position relieving pressure on the
cauda equina promoting normal bladder control.
The same can be said for relief of his foot drop. Extension allows the disc to migrate
forward relieving pressure from the sciatic nerve roots. These roots form the trunk of the
sciatic nerve that bifurcates in the popliteal fossa forming the superficial and deep peroneal
nerves, the latter being responsible for motor function of the tibialis anterior muscle needed
for dorsiflexion of the ankle during gait.6,7
One limitation to this study is the lack of objective measures for gait analysis and
bladder control. Although subjective reporting can be good tools for measuring the level of
impairments and functional limitations, it is in the best interest of the participant and
therapist to record accurate objective measures for recording improvements and for insurance
reimbursement and documentation. Abrams, Artibani, Gajewski et al43
suggest self reported
subjective measures are an accurate measure of bladder control but a detailed patient log of
urine output and frequency of uncontrolled micturition may have been useful for determining
the true effectiveness the program on bladder dysfunction.
18
Detailed lumbar ranges of motion may have also been useful to measure range of
motion progress throughout the course of treatment. Clare26
suggests four approaches that
would be helpful to measure lumbar range of motion in a clinical setting including
inclinometer methods, fingertip to floor method, and the use of a tape measure to determine
the distance from the sternal notch to the supporting surface in a prone-press-up position. All
of these tools are described in detail in that article.
A third objective measurable that would have been valuable would be active range of
motion of the participant’s ankle dorsiflexors. Gait observation for foot drop and
compensation patterns were used for determining progress of his ankle function but
measuring active ranges of motion over time in conjunction with muscle testing his
dorsiflexors would have been a more useful outcome measure.
A quality of life questionnaire, such as the Oswestry Disability Index may have been
a valuable tool for measuring effectiveness of interventions and progress. This self-reported
questionnaire has been reported as reliable and valid for measuring responsiveness to
treatment in people with low back pain and sciatica.48,49
Lastly, the most accurate measure to determine the level of effectiveness of the
intervention program would be electromyogram (EMG), nerve conduction studies, and an
MRI. EMG and nerve conduction studies may determine the rate of conduction of
neurotransmitters from the spinal level to the target tissues and give an accurate
representation of the severity of disc bulge pre and post treatment.50
MRI studies can give a
detailed image of the location of the disc in relation to the nerve structure and show progress
of the disc migration after intervention.8
19
This case report may be useful for future research determining the effectiveness of
lumbar extension oriented exercises or the value of the McKenzie method of treatment as a
conservative intervention for patients with discogenic related bladder dysfunction and foot
drop.
20
References
1. Shahbandar L, Press J. Diagnosis and nonoperative management of lumbar disk
herniation. Oper Techn Sport Med. 2005;13(2):114-121.
2. Walker B. The prevalence of low back pain: a systematic review of the literature
from 1966 to 1998. J Spinal Disord. 2000;13(3):205-217.
3. Dagenais S, Caro J, Hadman S. A systematic review of low back pain cost of illness
studies in the United States and internationally. Spine. 2008;8(1):8-20.
4. Deyo R, Mirza S, Martin B. Back pain prevalence and visit rates: estimates from
U. S. national surveys, 2002. Spine. 2006;31(23):2724-2727.
5. Ambrossi G, McGirt M, Sciubba D, et al. Recurrent lumbar disc herniation after
single-level lumbar discectomy: incidence and health care costs analysis.
Neurosurgery. 2009;65(3):574-578.
6. Girardi F, Cammisa Jr F, Huang R. Improvement of preoperative foot drop after
lumbar surgery. J Spine Disord Tech. 2002;15(6):490-494.
7. Ghahreman A, Ferch R, Rao P, Chandran N, Shadbolt B. Recovery of ankle
dorsiflexion weakness following lumbar decompressive surgery. J Clin Neurosci.
2009;16(8):1024-1027.
8. Boden S, Davis D, Dina T, Patronas N, Wiesel S. Abnormal magnetic-resonance
scans of the lumbar spine in asymptomatic subjects. a prospective investigation. J
Bone Joint Surg Am. 1990;72(3):403-408.
9. Bartolin Z, Gilja I, Bedalov G, Savic I. Bladder function in patients with lumbar
intervertebral disk protrusion. J Urology. 1998;159(3):969-971.
10. Appell R. Voiding Dysfunctions: Diagnosis and Treatment. New York, NY:
Springer-Verlag; 2000.
11. Mixter W, Barr J. Rupture of the intervertebral disc with involvement of the spinal
canal. New Engl J Med. 1934;211:210-214.
12. Yoon H, Song H, Ro Y. A comparison of the effectiveness of bladder training and
pelvic muscle exercise on female urinary incontinence. Int J Nurs Stud.
2003;40(1):45-50.
13. Clemens J, Nadler R, Schaeffer A, Belani J, Albaugh J, Bushman W. Biofeedback,
pelvic floor re-education, and bladder training for male chronic pelvic pain syndrome.
Urology. 2000;56(6):951-955.
21
14. Wang A, Wang Y, Chen M. Single-blind, randomized trial of pelvic floor muscle
training, biofeedback-assisted pelvic floor muscle training, and electrical stimulation
in the management of overactive bladder. Urology. 2004;63(1):61-66.
15. Mattiasson A. Discussion: bladder and pelvic floor muscle training for overactive
bladder. Urology 2000;55(5A):12-13.
16. Browder D, Childs J, Cleland J, Fritz J. Effectiveness of an extension-oriented
treatment approach in a subgroup of subjects with low back pain: a randomized
clinical trial. Phys Ther. 2007;87(12):1608-1618.
17. Slade S, Keating J. Unloaded movement facilitation exercise compared to no
exercise or alternative therapy on outcomes for people with nonspecific chronic low
back pain: a systematic review. J Manipulative Physiol Ther. 2007;30(4):301-311
18. Mayer J, Mooney V, Dagenais S. Evidence-informed management of chronic low
back pain with lumbar extensor strengthening exercises. Spine J. 2008;8(1):96-113.
19. Powers C, Beneck G, Kulig K, Landel R, Fredricson M. Effects of a single session of
posteror-to-anterior spinal mobilization and press-up exercise on pain response and
lumbar spine extension in people with nonspecific low back pain. Phys Ther.
2008;88(4):485-493.
20. Clare H, Adams R, Maher C. Construct validity of lumbar extension measures in
McKenzie’s derangement syndrome. Man Ther. 2007;12(4):328-334.
21. May S, Donelson R. Evidence-informed management of chronic low back pain.
Spine J. 2008;8(1):134-141.
22. Busanich B, Verscheure S. Does McKenzie therapy improve outcome for back pain?
J Athl Train. 2006;41(1)117-119.
23. McKenzie RA. The Lumbar Spine. Mechanical Diagnosis and Therapy. Waikanae,
Wellington, New Zealand: Spinal Publications New Zealand Limited;1981.
24. McKenzie R, May S. The Lumbar Spine: Mechanical Diagnosis and Therapy. 2nd
ed. Waikanae, NZ: Spinal Publications New Zealand Ltd., 2003.
25. Clare H, Adams R, Maher C. A systematic review of efficacy of McKenzie therapy
for spinal pain. Aust J Physiother. 2004;50(4):209-216.
26. Clare H, Adams R, Maher C. Reliability of McKenzie classification of patients with
cervical or lumbar pain. J Manipulative Physiol Ther. 2005;28(2):122-127.
22
27. Hefford C. McKenzie classification of mechanical spinal pain: profile of syndromes
and directions of preference. Man Ther. 2008;13(1):75-81.
28. Kilby J, Stigant M, Roberts A. The reliability of back pain assessment by
physiotherapists, using a “McKenzie algorithm”. Physiotherapy. 1990;76:579-583.
29. Riddle D, Rothstein J. Intertester reliability of McKenzie’s classifications of the
syndrome types present in patients with low back pain. Spine. 1993;18(10):1333–
1344.
30. Razmjou H, Kramer JF, Yamada R. Intertester reliability of the McKenzie evaluation
in assessing patients with mechanical low-back pain. J Orthop Sports Phys Ther.
2000;30(7):368–83.
31. Hislop H, Montgomery J. Daniels and Worthington’s Muscle Testing: Techniques of
Manual Examination. 8th
ed. St. Louis, MO: Saunders; 2007.
32. Walsh J, Hall T. Agreement and correlation between the straight leg raise and slump
tests in subjects with leg pain. J Manipulative Physiol Ther. 2009;32(3):184-192.
33. Majlesi J, Togay H, Unalan H, Toprak S. The sensitivity and specificity of the slump
and the straight leg raising tests in patients with lumbar disc herniation. J Clin
Rheumatol. 2008;14(2):87-91.
34. Magee DJ. Orthopedic Physical Assessment. 5th ed. St. Louis, MO: Elsevier
Health Sciences; 2007:559-561.
35. Farrar J, Young J, LaMoreaux L, Werth J, Poole R. Clinical importance of changes
in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain.
2001;94(2):149-158.
36. Kendrick D, Strout T. The minimum clinically significant difference in patient
assigned-numeric scores for pain. Am J Emerg Med. 2005;23(7):828-832.
37. Childs J, Piva S, Fritz J. Responsiveness of the numeric pain rating scale in patients
with low back pain. Spine. 2005;30(11):1331-1334.
38. Paice J, Cohen F. Validity of a verbally administered numeric rating scale to measure
cancer pain intensity. Cancer Nurs. 1997;20(2):88-93.
39. Dworkin R, Turk D, Farrar J, et al. Core outcome measures for chronic pain clinical
trial: impact recommendations. Pain. 2005;113(1-2):9-19.
23
40. Kilpikoski S, Airaksinen O, Kankaanpaa M, Leminen P, Videman T, Alen M.
Interexaminer reliability of low back pain assessment using the McKenzie method.
Spine. 2002;27(8):207-214.
41. Cuthbert S, Goodheart G. On the reliability of manual muscle testing: a literature
review. Chiropr Osteopat. 2007;15(4).
42. Bohannon R. Measuring knee extensor muscle strength. J Phys Med Rehabil.
2001;80(1):13-18.
43. Abrams P, Artibani W, Gajewski J, Hussain I. Assessment of treatment outcomes in
patients with overactive bladder: importance of objective and subjective measures.
Urology. 2006;68(2):17-28.
44. Guide to Physical Therapist Practice. 2nd ed. Alexandria, VA. American Physical
Therapy Association; 2003.
45. Maitland G, Hengeveld E, Banks K, English K. Maitland’s Vertebral Manipulation.
7th ed. Woburn, MA: Butterworth-Heinemann; 2005.
46. Werneke M, Hart DL, Cook D. A descriptive study of the centralization phenomenon,
a prospective analysis. Spine. 1999;24(7):676–683.
47. Wetzel FT, Donelson R. The role of repeated end-range/pain response assessment in
the management of symptomatic lumbar discs. Spine J. 2003;3(2):146–54.
48. Roland M, Fairbank J. The Roland-Morris Disability Questionnaire and the Oswestry
Disability Questionnaire. Spine. 2000;25(24):3115–3124.
49. Davidson M, Keating J. A comparison of five low back disability questionnaires:
reliability and responsiveness. Phys Ther. 2002;82(1):8–24.
50. Fisher M. Electrophysiology of radiculopathies. Clin Neurophysiol. 2002;13(3):317-
335.
24
Table 1: MRI Findings
Mild anterior wedge compression fracture at
L3 of older finding
L3-L4 broad-based disc bulge osteophyte
complex mildly deforming the thecal sac
5 mm of retrolisthesis of L4 on L5 L4-L5 broad-based disc bulge with moderate
thecal sac deformity and moderate spinal
stenosis
Rudimentary disc S1-S2 L5-S1 broad-based disposing osteophyte
complex.
25
Table 2: Results reported on lumbar assessment form.
Symptoms During
Testing
Symptoms After
Testing
Mechanical Response
↑ROM ↓ROM No
Effect
Pretest symptoms standing: In Standing (IS) = 2-3/10 leg pain
to foot
FIS NE NE X
Rep FIS ↑L Shin Pain , ↑L
Buttock Pain
W X
EIS NE NE X
Rep EIS NE NE X
Pretest symptoms in lying: In Lying (IL) = 2-3/10 L leg to foot
FIL NE NE X
Rep FIL NE NE X
EIL NE NE X
Rep EIL NE Centralization of L
Lower Extremity;
0/10 low back pain
Key: FIS = Flexion in Standing, EIS = Extension in Standing, FIL = Flexion in Lying, EIL =
Extension in Lying, Rep = Repeated, NE = No Effect, W = Worse.
26
Table 3: Observed lumbar range of motion limitations.
Maj Mod Min Nil Pain
Standing
Lumbar Flexion
(F)
X No Pain
Standing
Lumbar
Extension (E)
X No Pain
Side Gliding R X No Pain
Side Gliding L X No Pain
27
Table 4: Participant reported functional limitations.
DD 0 1 2 3 4
Managing Household
Cooking/Washing Dishes X
Laundry X
Houskeeping X
Shopping X
Yard work X
Maintaining a Position
Lying Down/Sleeping X
Prolonged Sitting/Standing X
Squatting/Kneeling X
Activities
Driving/Traveling X
Lifting/Bending/Carrying X
Reaching X
Twisting X
Pushing/Pullin X
Recreation and Leisure
Sports(baseball, running,
golf)
X
Social gatherings, out to eat X
Art (painting, drawing, etc.
)
X
Performing Arts X
Hobbies (gardening) X
Movement
Moving your arms and leg X
Moving your neck and back X
Getting into/out of bed/chair X
Walking X
Climbing stairs X
Employment
Work regular schedule X
Perform regular tasks X
Key: DD = Normally don’t do, never have to, want to, or plan to do; 0 = No problem at all,
can do when and how you want, and without pain; 1 = Minor problem, can do without help,
but with pain or minor annoyance; 2 = Moderate problem, need some help or can’t do the
way you’d like to do it; 3 = Major problem. Need a lot of help, very hard to complete, or
cannot do safely; 4 = Can’t do at all, would like to do again.
28
Table 5: Therapy interventions in outpatient clinic
Day 1 Day 2
Intervention Repetitions Sets Repetitions Sets
Rep EIL 10 1 5 2
Rep EIL with Participant Overpressure 10 1 5 1
L3-L5 Mobilization in Prone 0 0 10 2
Seated Slouch and Correct 10 2 10 2
Rep EIL with Therapist Overpressure 0 0 5 1
Bilateral Calf Stretch on Stairs 0 3 X 20 Sec Hold
Key: Rep = Repeated, EIL = Extension in Lying
29
Table 6: Home exercises
Home Exercise Sets Reps Times Per
Day
Hold Added
Pound
s
Lumbar Extension (Prone Press Ups) 1 10 8 0 0
Lumbar Extension
(Standing Back Bend with Hands on Hips)
1 10 8 0 0
30
Appendix A
Copy of IRB Approval Letter.
31
Appendix B
32