Chiropractic management of a 47-year–old firefighter with lumbar disk extrusion

Abstract

Objective

This case report describes the effect of exercise-based chiropractic treatment on chronic and intractable low back pain complicated by lumbar disk extrusion.

Clinical Features

A 47-year–old male firefighter experienced chronic, unresponsive low back pain. Pre- and posttreatment outcome analysis was performed on numeric (0-10) pain scale, functional rating index, and the low back pain Oswestry data. Secondary outcome assessments included a 1-rep maximum leg press, balancing times, push-ups and sit-ups the patient performed in 60 seconds, and radiographic analysis.

Intervention and Outcome

The patient was treated with Pettibon manipulative and rehabilitative techniques. At 4 weeks, spinal decompression therapy was incorporated. After 12 weeks of treatment, the patient's self-reported numeric pain scale had reduced from 6 to 1. There was also overall improvement in muscular strength, balance times, self-rated functional status, low back Oswestry scores, and lumbar lordosis using pre- and posttreatment radiographic information.

Conclusion

Comprehensive, exercise-based chiropractic management may contribute to an improvement of physical fitness and to restoration of function, and may be a protective factor for low back injury. This case suggests promising interventions with otherwise intractable low back pain using a multimodal chiropractic approach that includes isometric strengthening, neuromuscular reeducation, and lumbar spinal decompression therapy.

Introduction

Occupation-related low back injury has a tremendous impact on the economy of the United States. Work-related low back injuries and illnesses are responsible for the highest dollar amount of compensation in US industry and are the most common causes of lost-time injury.¹ Supervised exercise therapy has been recommended as a first line of treatment of chronic low back pain (CLBP) as well as spinal manipulative therapy (SMT).² Multidisciplinary treatment emphasizing function-centered rehabilitation has also recently been shown to reduce lost work days when compared with patient-centered treatment.³ Recent literature discusses the safety and efficacy of conservative and surgical treatment of sudden-onset low back pain.4, 5, 6 Most (80%-90%) of the patients experiencing acute low back pain typically recover function and become pain-free, as a result of treatment or the passage of time, within 6 to 8 weeks.⁷

For treatment of CLBP, however, the prognosis is not as promising.⁸ Educational programs such as back schools have shown effectiveness with patients with recurrent and CLBP in various occupational settings.⁹ Exercise therapy has also been indicated as an effective method of treatment, but it is unclear which therapeutic option offers the most cost-effective outcome.10, 11 There is also no conclusive evidence to support a specific type of exercise recommendation in cases of CLBP.¹² Chronic low back pain often presents with one or more underlying factors, and each must be discovered and considered in the treatment plan.

Lumbar stabilization exercise programs have recently gained interest in the biomedical literature. Structural changes in disks, altered neuromuscular recruitment patterns, and/or decreased muscular endurance has been implicated as potential risk factors in patients with CLBP. A superior manual method to test potential risk factors such as decreased strength, coordination, and a neutral spinal position remains unclear in the literature.¹³ In this case, initial testing involved the application of an external head and shoulder weight to provide a beginning reference point with respect to a neutral spinal position and initial spinal stability. This testing process has been previously outlined in the literature.14, 15 The patient also presented with several complicating factors, including a postsurgical procedure and lumbar transitional segment. Although the use of spinal decompression therapy (SDT) is controversial,16, 17, 18 the benefits for certain subgroups of patients with low back pain remain undetermined.¹⁷ Subgroups with lumbosacral transitional segments, for example, have been reported in 2% to 11.5% of the presenting cases of CLBP.19, 20, 21, 22 No conclusive evidence has been reported that associates transitional segments as a cause of low back pain; but such a comorbidity may present clinical complications regarding chiropractic techniques used and require change, for example, in line of drive and force applied.²³ There also has been an increased risk of disk protrusion or disk extrusion above the transitional L5 vertebra in patients with low back pain.²⁴

This case report discusses the treatment and results with a patient who had experienced a failed trial of SMT with CLBP, right extremity pain, and transitional segment in an occupation requiring elevated physical fitness standards.