The comprehensive exercise programme on the regression of the herniated lumbar disc The effect of the comprehensive exercise programme on the regression of the herniated lumbar disc: A case report Dimitrije Kovac 1 1 Fitness medico, Rehab center, Belgrade, Serbia Lumbar disk | Exercise | Case study Headline I t has been reported that the lumbar herniated discs have the potential for spontaneous regression following conserva- tive treatments that involve various forms of physical therapy. [1] Aim The aim of this report is to demonstrate positive results for the treatment of a disc herniation with a comprehensive home exercise programme. Case report A 40-year-old male recreational tennis player came to our prac- tice with complaints of low back and left leg pain for the pre- vious two weeks after playing tennis. He rated the pain on the visual analogue scale (VAS) as a 6-7/10 and reported the presence of numbness in the left leg. He reported no previous surgeries, spinal traumas or chronic medical conditions except occasional moderate low back pain that was associated with long sitting at work. His symptoms aggravated by forward bending and sitting longer than 15 minutes. The low back extension and walking were found to provide temporary relief from symptoms. He has been initially treated by a physician with nonsteroidal anti-inflammatory drugs (NSAID), bed rest and cortisone injections with good response. Upon his physi- cal examination the straight leg raise (SLR) test was positive at 40 degrees on the left side. The contralateral SLR test was negative. He also had a positive Slump test for the sciatic nerve and reduced flexion of the lumbar spine. The patel- lar and Achilles tendon reflexes were normal as well as gait and toe/heel walking. Manual muscle testing for the plantar, dorsal flexors, knee and hip extensors showed no decrease in strength. MRI of the lumbar spine revealed a herniated L5 disc with compression of the left S1 root (Figure 1). After the examination, a comprehensive intervention based on the active exercises was applied (Table 1). The patient was instructed to perform exercises at home. The first phase of the intervention included side-lying and sitting neural mobi- lization exercises (’nerve flossing’) for the left sciatic nerve and the McKenzie exercise protocol with emphasis on the lumbar extension in prone and standing position.[2,3] The nerve floss- ing was performed 5 times per day with 10 repetitions in both seated and side-lying position. The McKenzie exercises were also performed 5 times per day and included 10-12 repetitions with 10 seconds holding into extension. The patient was also advised to avoid movements that aggravate his symptoms, to reduce sitting longer than 20 minutes to use low back support while sitting and to sleep on the side with a pillow between his legs. No manual therapy or spinal traction was applied. Three weeks after the initial exercise programme, the reassessment showed a negative SLR test and improvement in the Slump test, lumbar flexion range of motion (ROM) and reduction of pain (VAS 4/10). The numbness was present occasionally. He was then introduced with the 12-weeks intervention pro- gramme with the focus on maintaining the lumbar spine in a neutral position. The programme included abdominal bracing, diaphragmatic breathing, hip abductor and extensor strength- ening, spine stabilization exercises and proper lifting mechan- ics (’hip hinging’) during daily tasks. Each exercise was done in 3 sets of 10 repetitions, once a day.[4,6] Results On the third visit, following the 12-week intervention period, a significant improvement in terms of pain reduction (VAS 0/10), negative SLR and Slump test, and increased lumbar flexion ROM was found. The Patient also reported a signifi- cant reduction in numbness and better seating tolerance. Af- ter the post-intervention assessment, the patient gradually re- turned to his fitness regimen which included cycling, jogging, and 3 tennis sessions per week. He also continued to perform the exercises from the intervention programme three times per week. Ten months later, a control MRI showed a significant regression of the herniated L5/S1 disc (Figure 2). Discussion The spontaneous regression of the herniated disc can occur probably due to the combination of dehydration, retraction, and inflammation-related resorption.[5] However, it is still un- clear which type of conservative treatment has the most fa- vorable effect on resorption of the protruded disc. The active neural sciatic nerve mobilization applied in the first phase had a positive effect on reducing pain and numbness and resulted in improved ipsilateral SLR test after three weeks. It has been proposed that neural mobilization improves nerve gliding and reduces nerve adherence to the herniated disc thus reducing the symptoms.[2] It is known that intradiscal pressure in the lumbar spine increases with prolonged flexion, which can fur- ther aggravate symptoms in people with disc herniation. A combination of repeated flexion and rotation of the lumbar spine, which is a common pattern in tennis, may lead to disc bulging or protrusion. Repeated extension movements, which were also part of the first phase of the exercise programme, can cause anterior migration of nucleus pulposus, thus reduc- ing forces on the posterior annulus. Furthermore, the ’hip hinge’ mechanics that involve the dissociation of hip flexion from flexion of the lumbar spine during daily activities, seems to havemaint positive effect on maintaining a neutral spine.[6] The lumbar stabilization exercise programme that also empha- sizes maintaining a neutral spine position decreases the load on the posterior part of the lumbar discs which may create the conditions for its spontaneous regression. [4,6] sportperfsci.com 1 SPSR - 2020 | Mar. | 83 | v1
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The comprehensive exercise programme on the regression of the herniated lumbar disc
The effect of the comprehensive exerciseprogramme on the regression of the herniatedlumbar disc: A case reportDimitrije Kovac 1
1Fitness medico, Rehab center, Belgrade, Serbia
Lumbar disk | Exercise | Case study
Headline
It has been reported that the lumbar herniated discs havethe potential for spontaneous regression following conserva-
tive treatments that involve various forms of physical therapy.[1]
AimThe aim of this report is to demonstrate positive results forthe treatment of a disc herniation with a comprehensive homeexercise programme.
Case reportA 40-year-old male recreational tennis player came to our prac-tice with complaints of low back and left leg pain for the pre-vious two weeks after playing tennis. He rated the pain onthe visual analogue scale (VAS) as a 6-7/10 and reported thepresence of numbness in the left leg. He reported no previoussurgeries, spinal traumas or chronic medical conditions exceptoccasional moderate low back pain that was associated withlong sitting at work. His symptoms aggravated by forwardbending and sitting longer than 15 minutes. The low backextension and walking were found to provide temporary relieffrom symptoms. He has been initially treated by a physicianwith nonsteroidal anti-inflammatory drugs (NSAID), bed restand cortisone injections with good response. Upon his physi-cal examination the straight leg raise (SLR) test was positiveat 40 degrees on the left side. The contralateral SLR test wasnegative. He also had a positive Slump test for the sciaticnerve and reduced flexion of the lumbar spine. The patel-lar and Achilles tendon reflexes were normal as well as gaitand toe/heel walking. Manual muscle testing for the plantar,dorsal flexors, knee and hip extensors showed no decrease instrength. MRI of the lumbar spine revealed a herniated L5disc with compression of the left S1 root (Figure 1).
After the examination, a comprehensive intervention basedon the active exercises was applied (Table 1). The patient wasinstructed to perform exercises at home. The first phase ofthe intervention included side-lying and sitting neural mobi-lization exercises (’nerve flossing’) for the left sciatic nerve andthe McKenzie exercise protocol with emphasis on the lumbarextension in prone and standing position.[2,3] The nerve floss-ing was performed 5 times per day with 10 repetitions in bothseated and side-lying position. The McKenzie exercises werealso performed 5 times per day and included 10-12 repetitionswith 10 seconds holding into extension. The patient was alsoadvised to avoid movements that aggravate his symptoms, toreduce sitting longer than 20 minutes to use low back supportwhile sitting and to sleep on the side with a pillow between hislegs. No manual therapy or spinal traction was applied. Threeweeks after the initial exercise programme, the reassessmentshowed a negative SLR test and improvement in the Slump
test, lumbar flexion range of motion (ROM) and reductionof pain (VAS 4/10). The numbness was present occasionally.He was then introduced with the 12-weeks intervention pro-gramme with the focus on maintaining the lumbar spine in aneutral position. The programme included abdominal bracing,diaphragmatic breathing, hip abductor and extensor strength-ening, spine stabilization exercises and proper lifting mechan-ics (’hip hinging’) during daily tasks. Each exercise was donein 3 sets of 10 repetitions, once a day.[4,6]
ResultsOn the third visit, following the 12-week intervention period,a significant improvement in terms of pain reduction (VAS0/10), negative SLR and Slump test, and increased lumbarflexion ROM was found. The Patient also reported a signifi-cant reduction in numbness and better seating tolerance. Af-ter the post-intervention assessment, the patient gradually re-turned to his fitness regimen which included cycling, jogging,and 3 tennis sessions per week. He also continued to performthe exercises from the intervention programme three times perweek. Ten months later, a control MRI showed a significantregression of the herniated L5/S1 disc (Figure 2).
DiscussionThe spontaneous regression of the herniated disc can occurprobably due to the combination of dehydration, retraction,and inflammation-related resorption.[5] However, it is still un-clear which type of conservative treatment has the most fa-vorable effect on resorption of the protruded disc. The activeneural sciatic nerve mobilization applied in the first phase hada positive effect on reducing pain and numbness and resultedin improved ipsilateral SLR test after three weeks. It has beenproposed that neural mobilization improves nerve gliding andreduces nerve adherence to the herniated disc thus reducingthe symptoms.[2] It is known that intradiscal pressure in thelumbar spine increases with prolonged flexion, which can fur-ther aggravate symptoms in people with disc herniation. Acombination of repeated flexion and rotation of the lumbarspine, which is a common pattern in tennis, may lead to discbulging or protrusion. Repeated extension movements, whichwere also part of the first phase of the exercise programme,can cause anterior migration of nucleus pulposus, thus reduc-ing forces on the posterior annulus. Furthermore, the ’hiphinge’ mechanics that involve the dissociation of hip flexionfrom flexion of the lumbar spine during daily activities, seemsto havemaint positive effect on maintaining a neutral spine.[6]The lumbar stabilization exercise programme that also empha-sizes maintaining a neutral spine position decreases the loadon the posterior part of the lumbar discs which may create theconditions for its spontaneous regression. [4,6]
sportperfsci.com 1 SPSR - 2020 | Mar. | 83 | v1
The comprehensive exercise programme on the regression of the herniated lumbar disc
Fig. 1. Axial and sagittal T2-weighted imaging of the initial MRI obtained 2 weeks after the first presentation for the symptoms.
Fig. 2. Axial and sagittal T2-weighted imaging of the control MRI obtained 10 months after the initial MRI.
Table 1. Intervention programmePhase one - 3 weeks long Phase two – 12 weeks long
McKenzie – prone lumbar extension (5 times per day, 10-12 repetitions with 10seconds into extension)McKenzie - standing lumbar extension (5 times per day, 10-12 repetitions with 10seconds into extension)Sciatic nerve flossing - side lying (5 times per day with 10 repetitions)Sciatic nerve flossing – seated 5 (times per day with 10 repetitions)
Quadruped hollowingDiaphragmatic breathing - supine, “90-90”hip abductor strengthening - side lyingCurl-up - abdominal muscles strengtheningSide plank – knees bentDead lift patterning - hip hinge with the stickBird dogFront plankEach exercise was done in 3 sets of 10 repetitions, once a day.
Practical ApplicationsMany studies have demonstrated the ability of the lumbar discto spontaneously regress after the conservative treatments.However, different treatments within physical therapy requiresignificant financial burdens and often time-consuming. Thiscase report supports the hypothesis that comprehensive, indi-vidually based, cost-effective, home exercise programmes canhave a positive effect on the spontaneous regression of the her-niated disc as well as on the clinical signs and symptoms.
References1. Chiu C-C, Chuang T-Y, Chang K-H, Wu C-H, Lin, P-W, Hsu W-Y. The probability of sponta-neous regression of lumbar herniated disc: a system-atic review. Clinical Rehabilitation 2015;29(2):184–195.[https://doi.org/10.1177/0269215514540919]
2. Anikwe EE, Tella BA, Aiyegbusi AI, Chukwu SC. Influ-ence of Nerve Flossing Technique on acute sciatica and hiprange of motion. Int J Med Biomed Res 2015;4(2):91-99.[http://dx.doi.org/10.14194/ijmbr.4.2.5]3. Liebenson, C. McKenzie self-treatments for sciatica.Journal of Bodywork and Movement Therapies 2005;9:40–42.[doi:10.1016/j.jbmt.2004.10.005]4. McGill SM, Karpowicz A. Exercises for spine stabiliza-tion: motion/motor patterns, stability progressions, and clin-ical technique. Arch Phys Med Rehabil. 2009;90(1):118-26.[doi: 10.1016/j.apmr.2008.06.026]5. Turk O, Antar V, Yaldiz C. Spontaneous re-gression of herniated nucleus pulposus: The clinicalfindings of 76 patients. Medicine 2019;98(8):e14667.[doi:10.1097/MD.0000000000014667]6. Vangelder LH, Hoogenboom BJ, Vaughn DW. (2013). Aphased rehabilitation protocol for athletes with lumbar inter-vertebral disc herniation. International journal of sports phys-ical therapy 2013; 8(4):482–516.
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