Chapter I

INTRODUCTION
Disc herniation is fundamentally a release of the nuclear material from the
confinement of the enveloping annulus fibrosus capsule. Herniation of the nuclear material
may result from excessive forces, repeated stresses, but any combination of the above may be
involved. The term herniation, or rupture, is more explainable and understandable in a
mechanical sense than the term slipped. Bulging of the disc is also an accepted term. 1
Herniated discs are common source of back pain. 2 Low back pain (LBP) is a common
musculoskeletal disorder causing huge humanitarian and economical costs (Andersson,
1999). It is often classified, according to duration of pain, as acute (short term), sub-acute
(intermediate) and chronic (long term) and is typically referred to as being specific or nonspecific (Anderson, 1999; Merskey and Bogduk, 1994).3
Herniated nucleus pulposus most commonly happens at 30 40 years of age. A higher
prevalence occurs for the lumbar region at the L4-L5 or L5-S1 discs followed by the C5-C6.
Approximately of these injuries will resolve with conservative care in 6 month to 1 year.4
Pain and other symptoms from a herniated disc can vary widely from one person to
the next. Complaints range from local pain to radiating pain. One of the most common set of
symptoms associated with a herniated disc is sciatica. 2 Sciatica is generally understood to
mean referred pain or hyperaesthesia-paresthesia down the course of the involved nerve root.
The patient may describe this discomfort as burning, aching, sharp, dull, or tender.
The sensation may be localized by the patient as being across the low back, into the buttocks,
along the posterior-lateral thigh, along the calf, or even into the ankle or toes.1
The purpose of the management of low back pain are reduce pain, increase trunk and
pelvic muscles strength, increase lumbar stability, reduce lumbar muscle spasm. 5 The
management of low back pain comprises a range of different intervention strategies including
surgery, drug therapy, and non-medical interventions. The objective of the present study is to
determine the effectiveness of physical and rehabilitation interventions (i.e. exercise therapy,
transcutaneus electrical nerve stimulation (TENS), education, massage, traction, lumbar
support, and heat/cold therapy) for low back pain.

Chapter II
1

CASE REPORT
I.

Identity

Name

: Mr. IT

Gender / Age

: Male / 63 years old

Address

: Malalayang II, Manado

Religion

: Christian

Occupational

: University-level instructor

Medical Record

: 144314

Examination date : March 20, 2013

II.

Anamnes (History)
Referred from Neurology Department Prof. dr. R. D. Kandou Manado with Lumbal

spondylosis and act of ousting at L3-4.

Chief complain:
Pain in the low back.
History of present illness:
Pain in the low back has felt for about 2 month. This pain arising after the patient with
a history of heavy lifting that water gallon (Aqua). According to patient the pain feels like
electric shock radiating from the lower back to the buttocks and back of the left thigh. The
pain will be felt when getting-up from lying position or waking position from sitting to
standing. The pain will also be felt when patient sneeze / cough or straining during bowel
movements. Pain will be reduced if the patient in a sitting or lying position. For now, this
pain, patient currently taking medication obtained from Neurology Department
(Meloxicam 15 mg twice a day, Ultracet three times a day, Myonal twice a day, Kalmeco
once daily). There is no weakness in the limbs. There is no history of sorted-sequence at
the site of pain. Severe pain at night is never felt by the patient. There was no history of
weight loss in the past three months. There was no history of fever. There is no morning
stiffness.
Because of this pain patient feel disturbed in his daily life activities such as bending while
dressing or wearing shoes or bathing, toileting (there is pain when straining), or such a
long standing in work place (approximately 1 hour). Patient had never experienced a
history of trauma or impact around the back. Defecate and urinate normally.
History of past illness:
2

Hypertension for about 3 years, but not consumed medicine regularly.

Have no history for diabetes.
Have no history for any operation.
Have no history for tumor in the body.

History of psycologic:
Patients are open, communicative, and wise character. Patient was worried for the
disease.
History of habitual:
When sleep using a spring bed and one head pillow. In connection with his job, patient in
work place always standing for about 1 hour, sometimes walking and sometimes just
standing, when sitting sometimes not use seat back and body potition sometimes slight
bending when writing on the desk, have a class in the second floor so if at work place
must take for about 15 stairs. Sometimes take some work to house and using a laptop but
when sitting not using a seat back. When walking never in a hurry. Patient using a driver
for to go to work place, home to work place distance of about 25 kilometers (ManadoTondano), there are 3 - 4 times a week to teach at the college schedule.
Patient do not smoke cigarette or drink alcohol.
History of socioeconomic:
Living with wife and one female grandchild 12 years old, wife as a housewife, has
two children and is married. Type permanent home, 1 floor, tiled floor, power source is
the State Electricity Company (Perusahaan Listrik Negara), the source of water from the
Water Company (Perusahaan Air Minum), there are no stairs in the house, using the type
water closet squatting and sitting. The monthly fee for a family is felt still quite enough.
The cost of treatment using Askes (Asuransi Kesehatan / health insurance). Patient
routinely go to church once a week and once a week of activities in the environment.

III.

Physical Examination (March 20, 2013)

Karnofsky Performance Scale (KPS): 80 (normal activity with efforts; some signs or
symptoms of disease).
Level of Consciousness

: compos mentis

Glasgow Coma Scale

: Eye 4 Verbal 5 Motoric 6

Vital sign:
-

Blood pressure
Pulse
Respiratory rate
Body temperature

: 140/80 mmHg
: 80 pulse/minute, regular, full fill.
: 20 times/minute.
: afebrile

Body weight

: 63 Kg

Body height

: 157,5 cm

Body mass index

: 25,4 (overweight)

Visual Analoque Scale:

0 _________________X_____________________________10
4 (dynamic) (march 20, 2013)
General Status:
Head

: normocephal.

Eye

: No anemis on conjunctiva, no icterus on sclera, pupil isochoric.

Neck

: trachea in the midline.

Thorax
Cor;
Inspection

: ictus cordis not seen

Palpation

: ictus cordis not palpable

Percussion

: upper border: ICS III; left border: ICS V left midclavikular line; right
border right sternal line.

Auscultation : first and second heart sound normal, no murmur sound.

Pulmo;
Inspection

: thoracic movement symmetric

Palpation

: stem fremitus left = right

Percussion

: sonor on all lung field

Auscultation : vesicular breath sound, ronchi (-/-), wheezing (-/-)

Abdomen
Inspection

: no spider nevi.
4

Palpation

: normal size of liver and spleen.

Percussion

: tympani in all abdominal surface.

Auscultation : normal intestinal sound.

Locally Status:
Look : Front: simetris on right and left shoulder and on right and left hip;
Side: it seems lordotic lumbal straighten.
Back: no scoliosis.
no swelling and redness on lower back.
No deformity on both knee.
Gait analysis: No antalgic gait.
Feel

: no warmth on lower back.

Prosesus spinosus position in the middle from upper to lower back.
Spasm on paravertebral muscle (right/left) at level L1-L5.
Folding skin test positif on level L1-L5.
Pain on pressure to vertebra lamina (right/left) on level L1-L3.
Schober test: 3,5 cm

Movement: slight pain when bending forward.

Figure 1. Patient look front and back side.

Leg length
Lower Extremity
5

Right
84 cm
79 cm

Apparent leg length

True leg length

Left
84 cm
79 cm

Figure 2. Measurement leg length.

Lower extremity circumference
Lower Extremity
Right
Left
43 cm
43 cm
33 cm
33 cm

Tight circumference
Calf circumference

Figure 3. Measurement leg circumference.

Range of motion
Trunk
Extension-Flexion
Lateral flexion
Rotation

200 0 700
250 0 250
200 0 200
6

Hip
Extension-Flexion
Abduction-Adduction
External rotation - Internal rotation

Right
30 0 - 1250
400 0 200
600 0 400
0

Left
30 0 - 1250
400 0 200
600 0 400
0

Figure 4. Measurement Range of Motion.

Motoric status

Movement
Muscle tone
Physiologic reflex
Pathologic reflex

Lower extremity
Right
Left
normal
normal
normal
normal
normal
normal
negative
negative

Miotome
L2
L3
L4
L5
S1

Right
5
5
5
5
5

Left
5
5
5
5
5

Figure 5. Manual muscle test for lower extremity.

Dermatome
L1
L2
L3
L4
L5
S1

Right
2
2
2
2
2
2

Left
2
2
2
2
2
2

Figure 6. Sensibility test for lower extremity.

Provocation test
Right
Valsava
Laseque
SLR
Braggard
Sicard
Contra Laseque
Patrick
Kontra Patrick
FNST

Left
Positive

Negative
800
Negative
Negative
Negative
Negative
Negative
Negative

Positive
500
Positive
Positive
Positive
Negative
Negative
Negative

Functional Measurement:
Modified LBP disability questionnaire (Modified Oswestry Disability Index = ODI);
Pain Intensity
I can tolerate the pain I have without having to use pain medication.
The pain is bad, but I can manage without having to take pain medication.
Pain medication provides me with complete relief from pain.
Pain medication provides me with moderate relief from pain.
Pain medication provides me with little relief from pain.
Pain medication provides has no effect on my pain.
Personal Care (eg, Washing, Dressing)
I can take care of myself normally without causing increased pain.
I can take care of myself normally, but it increases my pain.
It is painful to take care of myself, and I am slow and careful.
I need help, but I am able to manage most of my personal care.
I need help every day in most aspects of my care.
I do not get dressed, wash with difficulty, and stay in bed.
Lifting
I can lift heavy weights without increased pain.
I can lift heavy weights, but it causes increased pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if the
weights are conveniently positioned (eg, on a table).
Pain prevents me from lifting heavy weights, but I can manage light to medium
weights if they are conveniently positioned.
I can lift only very light weights.
I cannot lift or carry anything at all.
Walking
Pain does not prevent me from walking any distance.
Pain prevents me from walking more than 1 mile.
Pain prevents me from walking more than mile.
Pain prevents me from walking more than mile.
I can only walk with crutches or a cane.
I am in bed most of the time and have to crawl to the toilet.
Sitting
I can sit in any chair as long as I like.
9

 I can only sit in my favorite chair as long as I like.

Pain prevents me from sitting for more than 1 hour.
Pain prevents me from sitting for more than hour.
Pain prevents me from sitting for more than 10 minutes.
Pain prevents me from sitting at all.
Standing
I can stand as long as I want without increased pain.
I can stand as long as I want, but it increases my pain.
Pain prevents me from standing more than 1 hour.
Pain prevents me from standing more than hour.
Pain prevents me from standing more than 10 minutes.
Pain prevents me from standing at all.
Sleeping
Pain does not prevent me from sleeping well.
I can sleep well only by using pain medication.
Even when I take pain medication, I sleep less than 6 hours.
Even when I take pain medication, I sleep less than 4 hours.
Even when I take pain medication, I sleep less than 2 hours.
Pain prevents me from sleeping at all.
Social Life
My social life is normal and does not increase my pain.
My social life is normal, but it increases my level of pain.
Pain prevents me from participating in more energetic activities (eg, sports, dancing).
Pain prevents me from going out very often.
Pain has restricted my social life to my home.
I have hardly any social life because of my pain.
Traveling
I can travel anywhere without increased pain.
I can travel anywhere, but it increases my pain.
My pain restricts my travel over 2 hours.
My pain restricts my travel over 1 hour.
My pain restricts my travel to short necessary journeys under hour.
My pain prevents all travel except for visits to the physician/therapist or hospital.
Employment/Homemaking
10

 My normal homemaking/job activities do not cause pain.

My normal homemaking/job activities increase my pain, but I can still perform all
that is required of me.
I can perform most of my homemaking/job duties, but pain prevents me from
performing more physically stressful activities (eg, lifting, vacuuming).
Pain prevents me from doing anything but light duties.
Pain prevents me from doing even light duties.
Pain prevents me from performing any job or homemaking chores.
Interpretation of scores
0% to 20%: minimal The patient can cope with most living activities. Usually no
disability:

treatment is indicated apart from advice on lifting sitting and

exercise.
21% - 40%: moderate The patient experiences more pain and difficulty with sitting,
disability:

lifting and standing. Travel and social life are more difficult and
they may be disabled from work. Personal care, sexual activity
and sleeping are not grossly affected and the patient can usually

be managed by conservative means.

41% - 60%: severe Pain remains the main problem in this group but activities of
disability:

daily living are affected. These patients require a detailed

61% - 80%: crippled:

investigation.
Back pain impingeson all aspects of the patients life. Positive

81% - 100%:

interpretation is required.
These patients are either bed-bound or exaggerating their
symptoms.

Scoring: 19/50 x 100% = 38%

11

Additional Examination:
MRI Lumbosacral:

12

Figure 7. MRI Lumbosacral.

Expertise:
-

On imaging T1 T2 : bulging minimal on level L3-4, L4-5, L5-S1.

Vertebra alignment: still good.
Lordotik lumbar curve somewhat straightened.
There are osteofit corpus vertebra lumbal.
No listhesis vertebra.
No compression fracture vertebra.
Para vertebra: not sheathed.
13

Soft tissue swelling (-).

Conclusion:
-

Bulging (HNP) on level: L3-4, L4-5, and L5-S1.

Spondylosis lumbal.
No compression fracture / listhesis.

Fergusons Angle: 380

Resume:
A man, 63 years old, with pain in the low back for 2 month, after lifting a heavy object, feel
like an electric to upper left thigh, pain will felt if cough or sneezing or straining in bowel
movement, will decrease with sitting or in lying position. Blood pressure: 140/80 mmHg,
VAS: 4, Spasm on paravertebral muscle at level L1-L5, Folding skin test positif on level L1L5, Pain on pressure to vertebra lamina on level L1-L3. Schober test: 3,5 cm. Limitation
trunk range of motion. Provocation test positive for valsava test, for left leg: Laseque test,
SLR: 50%, Braggard test, Sicard test, Contra Laseque. Dermatome & Miotome are normal.
Modified ODI: 38%. Fergusons angle: 380. MRI: Bulging (HNP) on level L3-4, L4-5, and
L5-S1.
Diagnosis
-

Clinical diagnosis

: Hernia Nucleus Pulposus

Hypertension stage I
Etiological diagnosis : Mechanical subacute
Topic diagnosis
: Bulging L3-4, L4-5, and L5-S1
Functional diagnosis :
Body functions
: sleep function sometimes disturbed by pain,

exercise tolerance function limitation for bending forward activity.

Body structures
: structure of trunk (it seems lordotic lumbal

straighten), abdomen area have a potbellied.

Activities and participation
: changing basic body potition (pain when
getting-up from lying position), lifting and carrying object (cant lift a heavily
object for example water gallon), toileting (felt pain when straining during bowel
movement), dressing (felt pain when wearing trousers or pants), felt pain if want
14

wearing shoes, work as a University-level instructor and 3 4 times in a week to

go to workplace.
Environment factors

: products and technology for employment

(using a laptop), using stairs in workplace, professional (work as a Universitylevel instructor), work place is far from home (Manado-Tondano), in house just
living with wife and a grandchild, health services using ASKES (health

insurance).
Personal factors

: 63 years old, education Strata 1 (S1), man.

Advis: Consult to Internal Department.

Consult to Nutrision Department.
Problems
-

Pain on low back.

Limitation trunk range of motion.
Limitation in activity due to disability (dressing).
Abnormal mobility.
Disturbance in vocational.
Worried about the illness.
Hypertension stage I.
Overweight.

Management:
Medikementosa: (from Neurology department)
-

Meloxicam 15 mg 2x1
Ultracet 3x1
Myonal 2x1
Kalmeco 1x1

Rehabilitation Programs:
-

Physiotherapy
Evaluation:
Pain on low back
Spasm on paravertebral muscle at level L1-L5
Limitation on trunk flexibility.
Program:

Breathing exercise.
Infrared therapy on low back (duration 20 minutes, lamp distance about 40 45
cm, three times in a week. Will control again after six time therapy or if any
complains from patient).
15

Massage on low back (using hand with effleurage technique, on paravertebra

lumbal (L1-L5) muscle, duration 15 minutes).

Mckenzie exercise (gradually).
Orthotic prosthetic:
Evaluation:
It seems lumbal lordotic on back (straightened).
Have a potbellied.
Program:

Lumbosacral orthose (LSO)

Occupational Therapy:
Evaluation:
Limitation on activity due to disability.
No proper back potitioning especially when doing job.
Recreational / leisure become limitation cause of pain on low back.
Limitation in ADL (dressing, take a bath, wearing a shoes).
Program:

Guided for proper back potitioning (i.e how to get up from lying potition, when sit
always use seat back if doing job or when use a laptop, sit on bed if wearing a

trouser / pants).
Assistive device if needed when take a bath (a shower / horse / water dipper with
long handle) or when wear a shoes (shoe lace).

Pshycologic
Evaluation:
Have a good character / charism, communication with the examiner.
Worried about his condition.
Program:

Support mental for patient and family.

Cognitive behavioural therapy.

Sosial medicine
Evaluation:
16

Living in Manado, have a job as a University-level instructor, have a car for come to
hospital, montly cost are enough for family, living in permanen house. Patient go to
church once a week. For medical cost use ASKES.
Program:
Have a good economic and social living.
Education for control for rehabilitation program routinely.
-

Education:
Remember to do proper back positioning.
Reduce body weight.
Sitting on bed if will wearing trousers.
Sitting on chair and take one leg above the other leg if want using a shoes or use a

shoe lace.
Using shower or horse to take a bath or use a water dipper with long handle.
Corset lumbosacral just wear when go to workplace and can taken off if will go to

sleep. Corset can washed using hand and dry out not direct to sunlight.
Time stands: when standing for long periods, interlude with periods of sitting
moment, standing with one foot placed higher than the other leg will reduces
hyperlordotic, when taking something on the ground, do not bend, but the bend in

the knee.
Walking time: walk in an upright position, relax and do not rush.
When sitting: not too soft foam, contour seat backrest has a contour shape S as the
backbone, the seat should not be too high so that when seated knee lower than the
thigh, when sitting all back area should as much as possible contact with the back

seats.
When sleep: back in the average state, may be given one pillow under your knees
fold.

Example for proper back positioning:

17

Prognosis
Ad vitam

: bonam

Ad functionam

: dubia ad bonam

Ad sanationam

: bonam

Follow-up
March 23, 2013

18

Consult answer from Internal Department:

Working diagnose: Hypertension stage I, Low Back Pain ec HNP.
Therapy: Amdixal 5 mg 1x1 (morning), continued another therapy from Neurology
Department and Medical Rehabilitation Department.
Plan: cek routine haematology, blood sugar, 2 hour postprandial, ureum, creatinin, uric acid,
lipid profile, urinalysis.
ECG, Thorax x-ray.
March 26, 2013
ECG: normal
March 28, 2013
S: Pain on low back
O: Blood pressure: 130/80 mmHg
VAS = 3
Spasm on paravertebral muscle at level L1-L5.
Folding skin test positif on level L1-L5.
Pain on pressure to vertebra lamina on level L1-L3.
Schober test: 3,5 cm
Valsava
Lasequ

Right
Left
Positive
Negativ Positive

e
SLR
Bragard

e
800
Negativ

550
Positive

Sicard

e
Negativ

Positive

Contra

e
Negativ

Positive

Lasequ

e
Patrick

Negativ

Negativ

Kontra

e
Negativ

e
Negativ

Patrick
FNST

e
Negativ

e
Negativ
19

e
e
Modified LBP disability questionnaire: 24%.
Laboratory:
Parameter
Leukosit
Erytrosit
Hemoglobin
Hematocrit
Trombosit
Blood sugar
2 hours post prandial
Creatine
Ureum
Uric acid
SGOT
SGPT
Total cholesterol
HDL
LDL
Triglyseride
HbA1C

Resume
7500
5.13
15.2
42.3
255
132
144
0.9
23
6.7
54
60
226
54
149
117
8,4

Normal
4.000 10.000 /mm3
4.25 5.40 x 106/mm3
12.0 16.0 g/dL
37.0 47.0 x 103/mm3
150 450 x 103/mm3
70 125 mg/dL
110 140 mg/dL
0.6 1.1 mg/dL
20 40 mg/dL
2 7 mg/dL
0 33 mg/dL
0 43 mg/dL
160 200 mg/dL
0 40 mg/dL
0 150 mg/dL
30 190 mg/dL
4,5 6,3 %

A: HNP
Hypertension stage I
P:
-

Physiotherapy
Evaluation:
Pain on low back
Spasm on paravertebral muscle at level L1-L5
Limitation on trunk flexibility.

Program:

Breathing exercise.
Infrared therapy on low back (duration 20 minutes, lamp distance about 40 45

cm, three times in a week).

Massage on low back.
Mckenzie exercise.

Occupational Therapy:
20

Evaluation:
Limitation on activity due to disability.
Recreational / leisure become limitation cause of pain on low back.
Program:

Guided for proper back potitioning.

Pshycologic
Evaluation:
Have a good character / charism, communication with the examiner.
A bit worried about his condition.
Program:

Support mental for patient and family

Cognitive behavioural therapy

April 6, 2013
Thorax x-ray: normal
Consult answer from Nutrient Department: Diet diabetic DM 1700 cal, reduce salt intake.
April 23, 2013
S: Slight pain on low back.
O: Blood pressure: 120/80 mmHg
VAS = 1
No spasm on paravertebral muscle.
Folding skin test negative.
No pain on pressure to vertebra lamina.
Schober test: 4 cm.
Valsava
Laseque
SLR
Braggard
Sicard
Contra Laseque
Patrick
Contra Patrick
FNST

Right
Left
Positive
Negative Positive
800
600
Negative Positive
Negative Positive
Negative Negative
Negative Negative
Negative Negative
Negative Negative

Modified LBP disability questionnaire: 16%.

21

A: HNP
Hipertension stage I
P:
-

Physiotherapy
Evaluation:
Slight pain on low back
Program:

Breathing exercise.
Infrared therapy on low back (duration 20 minutes, lamp distance about 40 45

cm, three times in a week).

Mckenzie exercise.

Occupational Therapy:
Evaluation:
Can do most activity.
Program:

Guided for proper back potitioning.

May 23, 2013

S: No pain on low back
O: Blood pressure: 120/80 mmHg
VAS = 0
No spasm on paravertebral muscle.
No pain on pressure to vertebra lamina.
Schober test: 4,5 cm.
Provocation test:
Valsava
Laseque

Right
Left
negative
Negativ Negativ

SLR
Braggar

e
800
Negativ

e
800
Negativ

d
Sicard

e
Negativ

e
Negativ

Contra

e
Negativ

e
Negativ
22

Laseque
Patrick

e
Negativ

e
Negativ

Contra

e
Negativ

e
Negativ

Patrick
FNST

e
Negativ

e
Negativ

Modified LBP disability questionnaire: 0%.

A: HNP
Controled hypertension.
P:
-

Physiotherapy
Evaluation:
No pain on low back.
Program:

Breathing exercise.
Infrared therapy on low back (duration 20 minutes, lamp distance about 40 45

cm).
Mckenzie exercise.
Occupational Therapy:
Evaluation:
Can do all of the activity.
Program:

Guided for proper back potitioning.

November 2, 2013
S: pain on low back (one day ago, patient was lift up his grandchild)
O: blood pressure: 120/80 mmHg
VAS = 3
Spasm on paravertebral muscle.
Pain on pressure to vertebra lamina.
Schober test: 3,5 cm.
Provocation test:
Valsava
Laseque

Right
Left
negative
Negativ Negativ
23

SLR
Braggar

e
800
Negativ

e
800
Negativ

d
Sicard

e
Negativ

e
Negativ

Contra

e
Negativ

e
Negativ

Laseque
Patrick

e
Negativ

e
Negativ

Contra

e
Negativ

e
Negativ

Patrick
FNST

e
Negativ

e
Negativ

Modified LBP disability questionnaire: 24%

A: HNP + controlled hypertension

P:
-

Physiotherapy
Evaluation:
Pain on low back
Spasm on paravertebral muscle at level L1-L5
Program:

Breathing exercise.
Infrared therapy on low back.
Massage on low back.
Mckenzie exercise.

Occupational Therapy:
Evaluation:
No proper back potitioning.
Program:

(remind) Guided for proper back potitioning.

24

Pshycologic
Evaluation:
Worried about his condition.
Program:

Cognitive behavioural therapy.

November 12, 2013

S: no pain on low back
O: blood pressure: 120/80 mmHg
VAS = 0
No spasm on paravertebral muscle.
No pain on pressure to vertebra lamina.
Schober test: 4 cm.

Provocation test:
Right
Valsava
Laseque
SLR
Braggard
Sicard
Contra Laseque
Patrick
Kontra Patrick
FNST

Left

negative
Negative
Negative
0
80
800
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative

Modified LBP disability questionnaire: 0%

A: HNP + controlled hypertension
P:
-

Physiotherapy
Evaluation:
No pain on low back
Program:

Breathing exercise.
Infrared therapy on low back.
Mckenzie exercise.
25

Occupational Therapy:
Evaluation:
Can do all of the activity.
Program:

Guided for proper back potitioning.

Pshycologic
Evaluation:
Not worried about his condition.
Program:

Cognitive behavioural therapy.

Chapter III
DISCUSSION

A man, 63 years old, was referred from Neurology Department Prof. dr. R. D. Kandou
Manado with Lumbal spondylosis and act of ousting at L3-4. After taking anamneses and
physical examination include MRI Lumbosacral, patient was diagnosed with Hernia
Nucleus pulposus and hypertension stage I.
Herniation is defined as a localized displacement of disc material beyond the limits of
the intervertebral disc space.

Figure 8. Schematic bulging HNP.

The disc material may be nucleus, cartilage, fragmented apophyseal bone, anular tissue, or
any combination thereof.6 The term herniation of the intervertebral disk was synonymous
with herniation of the nucleus pulposus (HNP).

7,8

The term herniation, or rupture, is more

explainable and understandable in a mechanical sense than the term slipped. Bulging of
the disc is also an accepted term. 1 Herniated discs are common source of back pain. 2 HNP
is one of the caused Low Back Pain (LBP) as a result from degenerative process. 9 LBP is a
leading cause of disability. It occurs in similar proportions in all cultures, interferes with
26

quality of life and work performance, and is the most common reason for medical
consultations. Few cases of back pain are due to specific causes; most cases are nonspesific. No single treatment is superior to others.10
HNP are most common among men, which the incident tops in fourth and fifth
decade. The incidence is among people age 35-55 (Moschetti, Pearson, Abdu; 2009). 8
Research by group study of pain PERDOSSI in may 2002 showed patients with LBP
amount 18,37% from total patients with pain. In Jakarta, Yogyakarta, and Semarang
hospitals showed incident about 5,4 5,8% and the most frekuent in 45 65 years old.11
HNP more common to an individual which in job frequently to bend or lifting object.
HNP can caused by some situation for example: degenerative of intervertebra disk, minor
trauma to older patient with degenerative process, falling down, and lift or pull a heavy
object.9 Patient in this case report was 63 years old and has a job as a University-level
instructor and when working sometimes make potition on back that unproper like bend
when writing and do not use seat back when using a laptop. Sometimes patient doing his
job in the house, so this unproper potition for back happen either in work office and
house. At home patient sometimes lift a heavy object like water gallon, so it can trigger to
become HNP.
If the load increases on the disc, the annulus fibrosus not hold the nucleus pulposus
(gel) will come out, there will be pain because the gel is in the vertebral canal suppress
root. Buildings that contain receptors sensitive to nociceptive pain are stimulated by a
variety of local stimuli (mechanical / thermal, chemical). This stimulus spending will be
responded with a variety of inflammatory mediators that will lead to the perception of
pain. Pain is a protective mechanism that aims to prevent movement so that the healing
process is possible. One form of protection is a muscle spasm, which in turn can lead to
ischemia. Pain can occur in the form of inflammatory pain in the network with the
involvement of a variety of inflammatory mediators; or neuropathic pain caused by a
primary lesion in the nervous system. Irritation neuropathic nerve fibers can lead to two
possibilities. First, suppression only occurs in the nerve-rich membrane wrapping
nociceptors from nervi nevorum inflammation that causes pain. Pain is felt along the
nerve fibers and nerve fibers increased with stretching, for example due to the
movement. The second possibility, the emphasis of the nerve fibers. In this condition
there is a change biomolecular ion channels which include accumulation of Na and other
ions. This buildup causes the onset of mechano-hotspots are highly sensitive to
mechanical and thermal stimuli. This is the basis of the examination Laseque.9
27

Clinical manifestations can occur depending on the location of the affected lumbar.9
Complaints range from local pain to radiating pain. One of the most common set of
symptoms associated with a herniated disc is sciatica. 2 Both sciatic nerve (nerve
ischiadicus) is the largest and longest nerve in the body. Almost each of the fingers. On
each side of the body, the sciatic nerve runs from the lower spine, behind the hip joint,
down to the buttocks and hamstrings. There sciatic nerve is divided into several branches
and continues to the foot. When the sciatic nerve pinched, inflamed, or damaged, sciatica
pain may spread to the legs along the sciatic nerve. Sciatica is pain felt along the way
ischiadicus till nerve to the leg, usually on one side only. Pain is felt like a pin prick.
Walking, running, climbing stairs, and straighten the legs aggravate the pain, which is
relieved by bending the back or get sit.9 Mechanical low back pain is characterized by
increased pain with motion and decreased pain with rest, whereas the pain of
nonmechanical low back pain generally occurs at rest and is less affected by motion. 12 In
the history of the patient obtained a complaint of pain feels like electric shock radiating
from the lower back to the buttocks and back of the left thigh. The pain will be felt
during sleep or waking position from sitting to standing. The pain will also be felt when
people sneeze / cough or straining during bowel movements. Pain is reduced when in a
sitting position or lying down. There is no weakness in the limbs. There is no disruption
to defecate and urinate. Because the pain elicited by movement so it is included to
mechanical.
In physical examination, the patients spine should be inspected first for abnormal
curvatures, and the gait should be observed. Palpation of the vertebrae should be
performed to elicit localized tenderness. Range of motion, including flexion, extension,
and rotation, should also be assessed. Neurologic examination should include assessment
of muscle strength and tone, assessment of tendon reflexes, and sensory examination. A
straight-leg raise test should be performed in patients with evidence of sciatica or
radicular pain. The straight-leg raise test is specifically aimed at detecting lumbar nerve
root irritation. A positive straight-leg raise sign is identified when sciatica is reproduced
between 30 60 degrees of leg elevation.

28

Figure 9. Straight-leg raise test.

Radicular pain arises from nerve root compression or irritation. Schobers test can be used
to measure the degree of impairment of range of motion. This test is performed by
marking the lumbar spine at 0 cm and at 15 cm; more specifically, a mark is made 10 cm
above S1 and another 5 cm below. The patient is then asked to flex as far forward as
possible, and the degree to which the marks separate is noted. The points normally
separate at least 5 cm.12

Figure 10. Illustration of Schobers test.

From physical examination for this patient found lordotic lumbal straighten, spasm on
paravertebral muscle at level L1-L5, folding skin test positif on level L1-L5, pain on
pressure to vertebra lamina on level L1-L3. Schober test: 3,5 cm, it means trunk
flexibility decreased because there are spasm on muscle at low back. Provocation test
positive for valsava test, for left leg: Laseque test, SLR: 50%, Contra laseque, it means
the possibility for HNP. In gait analysis, there is no antalgic gait. In motoric (muscle
strength and tone) and sensoric examination (protopatic and proprioseptic) was normal.
For reflexes in lower leg, in this case, knee reflex and Achilles reflex are normal.
29

VAS (Visual Analog Scale): measure variation in back pain. The intensity of pain
recorded using a visual analoque scale ranging from no pain to maximum pain.
Rosenberg N, et al (2004) suggest that evaluation of patients according to VAS of pain is
an accurate measurement. Patient was asked the point where they rated his pain. 16 In this
case VAS was used for pain measurement. Evaluation for pain every time patient control.

Figure 11. Visual analog scale.

Functional measurement using modified Oswestry low back pain disability
questionnaire (ODI = Oswestry Disability Index). ODI was originally described in 1980.
The questionnaire consists of 10 items addressing different aspects of function. Each item
is scored from 0 to 5, with higher values representing greater disability.19 If all 10 section
are completed the score is calculated as follows;
Example: 16 (total scored)
50 (total possible score) x 100 = 32%
If one section is missed or not applicable the score is calculated;
16 (total scored)
45 (total possible score) x 100 = 35.5%
Interpretation os scores:20
0%

to

20%: The patient can cope with most living activities. Usually no

minimal disability:

treatment is indicated apart from advice on lifting sitting and

exercise.
40%: The patient experiences more pain and difficulty with sitting,

moderate

lifting and standing. Travel and social life are more difficult and

disability:

they may be disabled from work. Personal care, sexual activity

21%

and sleeping are not grossly affected and the patient can usually
be managed by conservative means.
41% - 60%: severe Pain remains the main problem in this group but activities of
disability:
61%

daily living are affected. These patients require a detailed

investigation.
80%: Back pain impinges on all aspects of the patients life. Positive
30

crippled:
81% - 100%:

interpretation is required.
These patients are either bed-bound or exaggerating their
symptoms.

In this case report the version of the ODI was used modified. Modified ODI was similar
to the modified ODI used by Hudson-Cook et al, who replaced the sex life section with a
question related to fluctuations in pain intensity. Hudson-Cook et al reported levels of
test-retest reliability and internal consistency for the modified version similar to those of
the original ODI. A section regarding employment and home-making ability was
subtitued for the section related to sex life because the sex life item is frequently found to
be left blank. In this case report functional measurement (modified ODI) was taken
everytime patient come for control schedule.
Diagnosed was made from anamneses, physical examination and additional
examination (Magnetic Resonance Imaging), are hernia nucleus pulposus and
hypertension stage I, so for this patient have komorbid disease. There are some problem
for this patient; Pain on low back, Limitation in activity due to disability (dressing, when
get up from lying potition), Abnormal mobility (feel doesnt comfort after walking for
about 100 m), Disturbance in vocational (have past some steps in work place, sometimes
have stand when gived materi in classroom), worried about the illness, Hypertension
stage I, overweight. For hypertension I made a consult to Internal Department, and for
overweight I made consult to Nutrision Department.
The purpose of the management of low back pain are reduce pain, increase trunk and
pelvic muscles strength, increase lumbar stability, reduce lumbar muscle spasm. 5 Physical
fitness and cognitive behavioural therapy may have the most to offer in terms of
treatment. Drug therapy offers temporary relief, especially for acute back pain, but it is
rarely of material benefit in people with chronic back pain. Paracetamol and non-steroidal
anti-inflammatory drugs bring the pain to tolerable level, but they probably should not be
taken for long periods of time (the self-medication direction usually restrict use to 12
days). Moist heat and (sometimes) cold cabinets, may be useful. Cure is the aim, but it
may be difficult to achieve. Ability to live with the pain with minimal restrictions
imposed by the pain is a more realistic goal. For those purposes, understanding the person
and constellation within which the pain occurs is an important first step from which to
derive others. Explanation and education; physical conditioning, maintenance of activities
whenever possible; appropriate physical and mental relaxation; mood improvement and
31

improvements in self-image that lead to greater confidence and social functioning and to
socioeconomic enhancement; and avoidance of relapses are all at least as important mere
prescription-writing.10

Figure 13. Health Care Guideline: Adult acute and Subacute LBP.13

32

33

34

Basic on some problems in medical rehabilitation, the patient are gived program in
physiotherapy, psycologic, occupational therapy, orthotic prostetic, social medicine. For
medication just continued from Neurology department.

35

At physiotherapy have gived program infrared on low back, massage on low back,
and Mckenzie exercise.
Infrared. Superficial heat modalities convey heat by conduction or convection. Superficial
heat elevates the temperature of tissues and provides the greatest effect at 0.5 cm or less from
the surface of the skin. Superficial heat modalities as infrared heat lamps. 14 Therapeutic
effects of local administration of heat, both shallow and deep, occurred by the presence or
production of heat transfer. In general, the physiological reaction that can be accepted as the
basis for the application of heat therapy is that the heat will increase viscoelastic collagen
tissue and reduce joint stiffness. Heat also reduces pain by increasing the pain threshold nerve
fibers. Another effect is to improve muscle spasms, increase blood flow, helping the
resolution of inflammatory infiltrates, edema and exudate. Superficial heat therapy produces
the highest heat on the surface of the body, but its penetration into the tissue just a few
millimeters. Before therapy is important for remember contraindication heat therapy. 22 There
is moderate evidence that heat wrap therapy reduces pain and disability for patients with back
pain that lasts for less than three months (Australasian Cochrane Centre, Monash Institute of
Health Services Research, Monash University Australia, 2005). The addition of exercise to
heat wrap therapy appears to provide additional benefit. Heat treatments include infrared heat
lamps.14 In aplication distance from lamp to skin surface are 60 70 cm ( lamp 750 1000
W), 45 50 cm (for smaller lamp). Duration time is 20 minutes. Therapy will stop if patient
feel hot on skin surface (36 38 0 C slightly hot) (38 410 C hot).15 For this patient was gived
infrared on low back, with lamp distance to skin surface for about 40 45 cm, and duration
time 20 minute. Observation during therapy for control if the heat is comfort for patient.
Infrared therapy was given three times per week for this patient.

Figure 14. Superficial heating with infrared.

36

McKenzie exercise. McKenzie exercises for low back pain are beneficial treatment for
increasing flexibility of spine and improving the pain with better relief. McKenzie exercise
has been reported as the most commonly used method by physiotherapist for the management
of patients with LBP. Helen AC et al (2004) has a systematic review of randomized clinical
trial was conducted to investigate the efficacy of McKenzie therapy in the treatment of spinal
pain. This review shows that for low back pain patients McKenzie therapy does result in a
greater decrease in pain and disability.16
Typical McKenzie Back Extension Exercises:
1. Prone lying. Lie on your stomach with arms along your sides and head turned to one
side. Maintain this potition for 5 to 10 minutes.

2. Prone lying on elbows. Lie on your stomach with your weight on your elbows and
forearms and your hips touching the floor or mat. Relax your lower back. Remain in
this position 5 to 10 minutes. If this causes pain, repeat exercise 1, then try again.

3. Prone press-ups. Lie on your stomach with palms near your shoulders, as if to do a
standard push-up. Slowly push your shoulders up,keeping your hips on the surface
and letting your back and stomach sag. Slowly lower your shoulders. Repeat 10 times.

4. Progressive extension with pillows. Lie on your stomach and place a pillow under
your chest. After several minutes, add a second pillow. If this does not hurt, add a
third pillow after a few more minutes. Stay in this potition up to 10 minutes. Remove
pillows one at a time over several minutes.

5. Standing extension. While standing, place your hands in the small on your back and
lean backward. Hold for 20 seconds and repeat. Use this exercise after normal
activities during the day that place your back in a flexed potition: lifting, forward
bending, sitting, etc.
37

McKenzie exercises were applied for this patient but not all exercise can be done because
patient said feel doesnt comfort on low back when continue to step 3 so in this case patient
only do step 1 and 2 and step 5. This exercise was continued at home and be done twice a day
except step 5. Exercise in hospital be done after infrared application and massage.

Figure 15. McKenzie exercise.

Massage. Massage is mechanic and systematic stimulation for body soft tissue through
giving pressure and stretch with rhythmic for therapeutic goal.15 It can do by using hand or
with mechanical tools. Effects that arise in the administration of massage can be grouped into
two: that is reflektoris effects and mechanical effects are physiological. Effects from
38

reflektoris include: a sense of comfort, relaxation of muscles, reduces mental tension and
soothe (sedation). While the mechanical effects such as: improving blood flow and lymph,
intramuscular movements that stretch the attachment and mobilize liquid deposits.
Indications massage applications are: soft tissue injury with pain, stiffness, spasms and
muscle tension. While contraindications include infection, malignancy process, diseases of
the skin. The techniques of massage can include:
1. Stroking (effleurage)
a. Shallow (superficial)
b. In (deep)
2. Compression (= petrissage)
a. Friction
b. Kneading
3. Percussion and vibration22
Duration time for 15 30 minutes for trunk. In this case, massage was gived by using hand
with effleurage technique for the muscle on the back on paravertebral muscle at level L1 L5
that on exam was found spasm with duration 15 minutes, after infrared aplication and gived
three times per week.
At psychologic, patient was given cognitive behavioural therapy.
Cognitive Behavioural Therapy (CBT) is a method that can help manage problems by
changing the way patient would think and behave. It is not designed to remove any problems
but help manage them in a positive manner. How it used: Negative thoughts (e.g., my back
pain is uncontrollable) --- Negative feelings (e.g., depression, anger) and maladaptive health
behaviuors (e.g., skipping treatment sessions) --- Reinforcing negative cycle. If one negative
thought can be addressed through education and methods to manage symptoms. 17 In this case
patient have worried for this illness so with CBT we give patient education to change his
mind for manage the problems.

At Orthotic Prosthetic, patient was gived lumbosacral orthose.

Spinal orthoses may be used as an adjunctive treatment for various conditions that can cause
low back pain, including degenerative intervertebral discs. Lumbar spine orthoses should be
considered for short-term use as part of a comprehensive rehabilitation program. To prevent
psychological dependence, patients should be weaned from their orthosis rapidly, when
clinically appropriate. Long term use of lumbar orthoses should be discouraged in most cases
39

secondary to potential adverde effects, including possible loss of strength of core body
musculature, psychological dependence, and decreased spinal mobility.18 In this case patient
was given LSO lumbosacral corset type. This orthosis was used especially if go to the work
place and can take off along rest time.

Figure 17. Wearing Lumbosacral corset.

At Occupational therapy, patient give guided for proper back position.
Proper back position. Posture is the position in which you hold your body upright against
gravity while standing, sitting or lying down. Good posture involves training your body to
stand, walk, sit and lie in positions where the least strain is placed on supporting muscles and
ligaments during movement or weight-bearing activities. Proper posture:

Keeps bones and joints in the correct alignment so that muscles are being used
properly.

Decreases the stress on the ligaments holding the joints of the spine together.

Prevents the spine from becoming fixed in abnormal positions.

Prevents fatigue because muscles are being used more efficiently, allowing the body
to use less energy.

Prevents strain or overuse problems.

Prevents backache and muscular pain.

40

Contributes to a good appearance.

In this case report, the patient was gived the most guided for proper back potitioning
including some proper potitioning e.g. how correct potition when getting up from lying
potition, when getting out after drive a car, advise in sit potition when wearing a trousers or
pants and use shower or water dipper with long handle.

Figure 18. Education when getting-up from bed.

Figure 19. Education when getting-out from car.

Figure 20. Education good posture when sitting.

41

At social medice, patient have a good income and using ASKES (Asuransi
Kesehatan), living in Manado and have a vehicle for go to hospital so we give suggestion it
is important to come regularly for rehabilitation program.
Patient Improvement
In an attempt to assess treatment decisions, WHOs (World Health Organisation) low
back pain initiative recommended outcome measures that would standardize evaluations.10

Figure 18. WHO recommended outcome measures for low back pain.
March 20th 2013
History and Physical Examination.
Have found pain on low back, feel like an electric to upper left leg, pain will felt if
cough or sneezing or when standing or walking more than 2 hours, will decrease with rest
like lying. Pain like this first time was feel for about 6 years ago. Spasm on paravertebral
muscle at level L1-L5, Folding skin test positif on level L1-L5, Pain on pressure to vertebra
lamina on level L1-L3, Schober test: 3,5 cm, provocation test positive for Valsava test, for
left leg: Laseque test, SLR: 50%, Braggard test, Sicard test, Contra Laseque.
VAS: 4
Schober test: 3,5 cm
Modified Oswestry Disability index (ODI): 38%.

42

March 28th 2013

History and Physical Examination.
Have clinical sign almost same with the first time exam, Contra Laseque (+) except
SLR 550.
VAS: 3
Schober test: 3,5 cm
Modified Oswestry Disability index (ODI): 24%
April 23rd 2013
History and Physical Examination.
Pain on low back was reduced and have found no spasm on paravertebral muscle,
folding skin test negative, no pain on pressure to vertebra lamina. SLR 60 0,

Contra Laseque

(-).
VAS: 1
Schober test: 4
Modified Oswestry Disability index (ODI): 16%
May 23rd 2013
History and Physical Examination.
No pain on low back and have found no spasm on paravertebral muscle, no pain on
pressure to vertebra lamina. Laseque and contra Lasque (-), SLR: 800.
VAS: 0
Schober test: 4,5
Modified Oswestry Disability index (ODI): 0%
There are improvement for this patient. In history and physical examination at third
control begun showed improvement and then at last control showed maximal improvement.
For VAS showed improvement at second control and continue decreased till the last treatment
the pain was disappear. Trunk flexibility trough Schober test showed improvement at last
control. Modified low back pain disability questionnaire, using modified Oswestry Disability
Index showed more better at third control until last control.
The symptoms can appear again if there are wrong position on the back so it is
important to take care the proper back position.

43

Chapter IV
CONCLUSION
A man with Lumbal Hernia nucleus pulposus and Hypertension stage I, was gived
intervention trough infrared, massage, McKenzie exercise, Lumbosacral corset, Cognitive
behavioural therapy, education in proper back positioning will result improved according to
outcome measure by WHO.
The symptoms can appear again if there are wrong position on the back so it is
important to take care the proper back position.

44

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