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PHYSIOTHERAPY MANAGEMENT IN LUMBAR FACET JOINT SYNDROME: A

SINGLE CASE STUDY

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 PHYSIOTHERAPY MANAGEMENT IN LUMBAR FACET JOINT SYNDROME: A SINGLE CASE STUDY
Dr. Deepak B Anap (PhD)1, Dr. Subhash M Khatri (PhD)2

Received: 2017
Revised: 2017
Accepted: 2017
ABSTRACT
Author details:
1Professor
and HOD, Dept. of Low back pain is a major cause of disability affecting performance at work.
Musculoskeletal Physiotherapy, DVVPF, One of the hidden and less studied culprit of chronic low back pain is facet
COPT, A.Nagar( M.S.)
2Professor and Principal, Dr. APJ Abdul joint syndrome. Currently, there is paucity in the literature regarding the
Kalam COPT, PIMS, Loni ( M.S.) effectiveness of physiotherapy techniques in treating facet joint syndrome.
Hence this case study was undertaken to find out the effectiveness of
Corresponding author: Deepak B Anap conservative treatment protocol including therapeutic ultrasound and
Email: deepak.anap@hotmail.com
endurance exercise in a diagnosed case of lumbar facet syndrome. A 42 years
Access this article online old, Male Case diagnosed with lumbar facet syndrome was treated with
Web site: www.ijbahr.com Therapeutic ultrasound and back endurance exercise protocol for 2 weeks.
This is an open access article distributed under the Follow up was taken at 3rd week. Pain intensity, Back disability (MODQ) and
terms of the Creative Commons Attribution-Non back endurance was measured at baseline, 2nd week and at follow-up (3rd
Commercial-Share Alike 3.0 License, which allows
others to remix, tweak, and build upon the work
week). From the results of case study we conclude that therapeutic
non-commercially, as long as the author is ultrasound and back endurance exercise protocol can exhibit reduction in
credited and the new creations are licensed under
the identical terms.
pain intensity, back disability and improvement in back muscle endurance in
For reprints contact: a case diagnosed with lumbar facet syndrome.
deepak.anap@hotmail.com
Cite this article as:
Dr. Deepak B. Anap, Dr.
Subhash M. Khatri
Physiotherapy management in lumbar facet KEYWORDS: Lumbar facet joint syndrome, Low Back pain, Physiotherapy
joint syndrome: A single case study. IJBAHR.
2017;1(1):24-25
management

INTRODUCTION syndrome”, which he defined as lumbosacral pain with

Our human society has been haunted by low back pain
since ages. The problem has been so prolific that a
mention of this is even found on papyrus the oldest
surviving text written about 1500 B.C [1]. Although
various attempts have been made in the past to treat this
ailment of mankind, there is poor evidence that low back
pain has changed. Despite the high prevalence of back
pain, based on clinical examination alone; the specific
etiology can be diagnosed in only about 15% of patients
with certainty [2]. Additionally it has to be remembered
well that pain originating from various structures of the
spine is a major cause of chronic back pain problems [3].
There are many structures in the lumbar spine which can
individually or in combination serve as major cause of
pain. After being described as a potential pain generator
by Joel Goldthwait in 1911 [4], the facet joint has been
increasingly recognized as an important cause of low
back pain in 1933, Ghormley [5] first used the term “facet
© 2017 IJBAHR
or without sciatic pain, particularly occurring suddenly
after a twisting or rotary strain of the lumbosacral region.
Non-pharmacological methods including a variety of
physical agents are the cornerstone for the management
of chronic LBP. Therapeutic ultrasound (US) is amongst
the commonly used physical modalities for treating soft
tissue injuries in physiotherapy practice [6].
Effectiveness of ultrasound is already proved in various
types of musculoskeletal pain. Effect of high frequency
currents on deep seated pain and resolution of
inflammation by pro inflammatory effect is already been
documented.
Some authorities [7] suggest that muscle is a potential
source of low back pain. They argued that failure of
muscles to protect passive structures (i. e facet joint,
intervertebral discs) from excessive loading may result in
damage to these pain-sensitive structures and produce
pain [8]. Enhancing muscle endurance, therefore, may
22
International Journal of Biomedical and Allied Health Research
 Anap, et al.: Physiotherapy management in lumbar facet joint syndrome
help to reduce low back pain. To investigate the
effectiveness of a physiotherapy program with specific
exercises in a group of patients with chronic low back
pain diagnosed on MRI imaging and clinical assessment
to be of lumbar facet joint origin; a detailed treatment
protocol was developed. Hence this case study was
conducted to find out the effectiveness of conservative
treatment protocol including therapeutic ultrasound and
endurance exercise in a diagnosed case of lumbar facet
syndrome.
METHOD
A 42 years old, Male, diagnosed case of lumbar facet
syndrome, referred to physiotherapy outpatient
department was screened for the eligibility criteria in this
case. Participant satisfied the inclusion criteria i.e
Participants diagnosed with facetal arthropathy on MRI,
localised unilateral lumbar pain, replication or
aggravation of pain by unilateral pressure over the facet
joint, Pain eased in flexion, Pain in extension, lateral
flexion or rotation to the ipsilateral side. Exclusion
criteria for the study was history of Spinal Surgery,
trauma to the spine, and manipulation under
anaesthesia, Metabolic Disorders – Osteoporosis and
Spinal Tumours. This study was approved by the
Institutional Ethical Committee of PIMS, Loni. Each
subject signed written informed consent before
intervention.
Outcome Measures:
Modified Oswestry Low Back Disability: Questionnaire:
The questionnaire consists of 10 items addressing
different aspects of function. Each item is scored from 0
to 5. Total Score was converted in percentage, scores
range from 0-100% with lower scores meaning less
disability.
Pain :The pain VAS consisted of a 10 cm horizontal line
anchored at one end by the words ‘no pain' and at the
other end by the words 'worst pain'.
Back Endurance Testing: Sorensen Test: Biering-
Sorensen described this method of testing isometric back
endurance; it measures how long (to a maximum of 240
seconds) the subject can keep the unsupported trunk
(from the upper border of the iliac crest) horizontal while
Table 1: Pre & Post comparsion of VAS, MODQ, Soresens Test score
Outcome Baseline 2nd Week
Pain Intensity (VAS) 6.6 5.5
Back Disability (MODQ) 26 24
Back endurance (sec) 44 46
prone on an examination table. Published studies
demonstrate that the test assesses the endurance of all
the Muscles involved in extension of the trunk, which
include not only the paraspinal muscles, but notably the
multifidus muscle.
Intervention: Therapeutic Ultrasound:
Sonopuls – 492 equipment was used with the frequency
set at 1 MHz and the intensity of 1.5 w/cm2 [9]. The
average duration for ultrasound application to each
participant was six minutes.
Exercise Protocol: All exercises were performed 4 days
per week, for 2 consecutive weeks. All participants
performed warm-up, stretching exercises for 15 minutes
before and cool down exercises for 10 minutes after each
session.
Endurance exercises: For all exercises with an isometric
contraction: Participant was asked to hold the muscle
contraction/posture for 10 seconds and repeat 10 times
with a short rest (3-4 seconds) between each
contraction. A 60-second rest interval was given
between each exercise
Exercise 1: Supine abdominal draw exercise with
simultaneous upper and lower extremity flexion.
Exercise 2: Bilateral shoulder lifts
Exercise 3: Contralateral arm and leg lift
Exercise 4: Bilateral shoulder lifts with hands behind the
head
Exercise 5: Bilateral shoulder lifts with arms in full
elevation
Exercise 6: Quadruped position with co-contraction and
simultaneous upper and lower extremity extension.
Exercise 7: Side bridge exercise while maintaining
abdominal draw.
Follow-up Measurements: Participant completed the
MODQ, VAS, Soren’s test Score and Flexion – Extension
range of motion at 3rd weeks (Follow up visit) after the
initial examination.
Analysis: Pre-and post-treatment scores was converted
to a change score by formula: Change
score= Pretreatment score-Post treatment score × 100 /
Pretreatment score.
Follow up ( 3rd Week) % change
3.9 40.90
20 23.07
49 11.36
IJBAHR | 2017 July | Vol 1 | Issue 1:22-25 23
 Anap, et al.: Physiotherapy management in lumbar facet joint syndrome
DISCUSSION
This single case study was undertaken to find out the
effectiveness of conservative treatment protocol
including therapeutic ultrasound and endurance exercise
in a diagnosed case of lumbar facet syndrome.
Result analysis showed 40.90 % improvement in Pain
intensity at the end of followup. Pain relief which was
seen is contributed by addition of therapeutic ultrasound
to the treatment protocol. Results are supported by a
randomized control trial by N.N. Ansari [10] in which the
effect of continuous ultrasound was studied in chronic
low back participants showed improvement in functional
ability because of a significant reduction in pain level.
Dyson M [11] explained that continuous movement of
the ultrasound applicator may increase the temperature
of the area under treatment and stimulates the skin
receptors activating the gate control mechanism.
Mirsad Muftic et al [12] in their study on the effect of
continuous ultrasound on pain caused by degenerative
diseases of the musculoskeletal system found that that
application of continuous ultrasound on chronic pain,
caused by degenerative changes in the musculoskeletal
system, led to a significant reduction in pain.
Morrisette et al [13] stated that the temperature
elevation by ultrasound treatment with intensity either
1.5 w/cm2 or 2w/cm2 is at a level thought to be sufficient
to produce the therapeutic effects proposed with an
elevation in temperature, such as reduction in pain,
spasm and alteration of nerve conduction velocity. It was
found that 10 minutes of ultrasound given at 1.5 w/cm2
applied to an area twice the size of the transducer,
produced a mean temperature increase of 1.9°C, in the
region of the L4-L5 zygapophyseal joint.
Back endurance improved slightly i.e. 11.36 %. The
reason for steady increase in endurance may be due to
short duration of treatment protocol in our case study.
The reduction in pain in the manual therapy groups may
be due to the gain in the endurance of the back extensor
muscles following training, as it has been suggested that
poor endurance of trunk muscles may induce strain on
the passive structures of the lumbar spine like facet
joints, leading to low back pain. These muscles help the
body to maintain a natural posture and control the body
while flexing and extending. Hence based on this theory,
we conclude that reduction of trunk muscle endurance
leads to muscle fatigue and increased pressure on the
soft tissues and facet joints in the spine lead to injuries
of these structures [14].
Back disability level reduced in facet syndrome case by
23.07 % when compared with baseline. Exercise had a
beneficial effect on the emotional and cognitive aspects
of the pain experience. The subject’s pain perception
may have influenced their perception of disability as a
result of their back pain. This argument is supported by
the strong positive correlation between pain and
disability as measured by the MODQ. As the pain scores
decreased, the MODQ scores also decreased. The
reduction of pain may have enabled the participants to
carry on with their activities of daily living, and thus they
reported reduced disability.
Limitations: Limitations of this report are inherent to its
case study design. Without a comparison group, we
cannot determine if similar improvements would have
occurred had these patients received a different
treatment approach or no treatment at all. Future
research in the form of randomized clinical trials should
be conducted to investigate the effectiveness of this
treatment approach in lumbar facet syndrome patients
[15].
CONCLUSION
From the results of case study we conclude that
therapeutic ultrasound and back endurance exercise
protocol can exhibit reduction in pain intensity, back
disability and improvement in back muscle endurance in
a case diagnosed with lumbar facet syndrome.
CONFLICT OF INTREST: None
FUNDING: None
REFERENCES
1. Van Middendorp JJ, Sanchez GM, Burridge AL.
The Edwin Smith papyrus: a clinical reappraisal
of the oldest known document on spinal
injuries. European Spine Journal.
2010;19(11):1815-1823.
2. Deyo RA, Rainville J, Kent DL. What can the
history and physical examination tell us about
low back pain?. JAMA. 1992;268(6):760-765.
3. Lawrence RC, Helmick CG, Arnett FC, Deyo RA,
Felson DT, Giannini EH, et al. Estimates of the
prevalence of arthritis and selected
musculoskeletal disorders in the United States.
Arthritis & Rheumatism. 1998;41(5):778–99.
IJBAHR | 2017 July | Vol 1 | Issue 1:22-25 24
 Anap, et al.: Physiotherapy management in lumbar facet joint syndrome

4. Goldthwait JE. The lumbosacral articulation: An 15. Park S-D, Yu S-H. The effects of abdominal draw-
explanation of many cases of lumbago, sciatica, in maneuver and core exercise on abdominal
and paraplegia. Boston Med and Surg J . muscle thickness and Oswestry disability index in
1911;164(11):365-72. subjects with chronic low back pain. Journal of
5. Ghormley RK. Low back pain. With special Exercise Rehabilitation. 2013;9(2):286-291.
reference to the articular facets, with
presentation of an operative procedure. JAMA.
1933; 101(23):1773-1777.
6. Grazio S, Markulinèiæ B, Nemèiæ T, Grubisic F,
Matijeviæ V, Skala H, Kasun B, Koprivnjak V.
Trgovec, Effect of intereferential current and
therapeutic ultrasound on lumbar spine range of
motion in patients with chronic low back pain.
Proceedings of the 7th Mediterranean Congress
of Physical and Rehabilitation Medicine: 18–21
September. 2008. Portoro (Slovenia)
7. Cady LD, Bischoff D, O’Connell E. Strength and
fitness and subsequent back injuries in
firefighters. J Occup Med. 1979;21(4):269 –272.
8. Seidel H, Beyer H, Brauer D. Electromyographic
evaluation of back muscle fatigue with repeated
sustained contractions of different strengths.
Eur J Appl Physiol. 1987;56(5):592– 602.
9. Durmus D, Durmaz Y, Canturk F. Effects of
therapeutic ultrasound and electrical
stimulation program on pain, trunk muscle
strength, disability, walking performance,
quality of life, and depression in patients with
low back pain: a randomized-controlled trial.
Rheumatol Int. 2009;30(7):901–910.
10. Ansari NN, Ebadi S, Talebian S, Naghdi S,
Mazaheri H, Olyaei G, Jalaie S. A randomized,
single blind placebo controlled clinical trial on
the effect of continuous ultrasound on low back
pain. Electromyogr Clin Neurophysiol. 2006
Nov;46(6):329-36.
11. Dyson M. Mechanism involved in Therapeutic
ultrasound. Physiotherapy. 1987;73(3):116-120.
12. Mirsad Muftic, Ksenija Miladinovic. Therapeutic
Ultrasound and Pain in Degenerative Diseases of
Musculoskeletal System, Acta Inform Med. 2013;
21(3): 170–172.
13. Morrisette DC, Brown D, Saladin ME.
Temperature change in lumbar periarticular
tissue with continuous ultrasound. J Orthop
Sports Phys Ther. 2004 Dec; 34(12):754-60.
14. Arab AM, Ebrahimi E. Clinical trunk muscle
endurance tests in subjects with and without low
back pain. MJIRI. 2005;(2): 95-101.

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