PIVD-Prolaps inter vertebral disc
It is a discrete clinical entity wherein the posterior longitudinal ligaments gives way and the disc material herniated in to the spinal canal.
Incompetence of the posterior longitudinal ligament can be result of the vertical spine instability or can be a result of an acute stretch related to sudden exertion or bending.
WHAT COUSES OF PIVD- Falling from a singnificant height and landing on your buttocks. This can transmit significant force the spine.
Bending forward ace subtantial stress on the inter vertebral discs.if you bend and attempt to lift an object which is too heavy this force may couse a disc a rupture.
Heavy manual labour
Repetitive lifting and twisting
Postural stress
obesity
Poor and inadequate strength of the trunk
Sitting for long hours
Increasing age (a disc is more likely to develop a weakness with increasing age)
SYMPTOMS
In severe cases, loss of control of bladder and/or bowels, numbness in the genital area, and impotence (in men).
Numbness, pins and needles, or tingling in one or both arms or legs.
Pain behind the shoulder blade(s) or in the buttock(s)Pain running down one or both arms or legs.
Diagnosis of a Herniated Disc-
Bowstring test
Femoral stretch test
A Lasegue test, also known as Straight-leg Raising Test, is performed. The patient lies down, the knee is extended, and the hip is flexed. If pain is aggravated or produced, it is an indication the lower lumbosacral nerve roots are inflamed.
X-rays.
MRI(Magnetic resonance imaging).
TREATMENT OF PIVD-
Conservative management-
Rest: Rest and Anti-inflammatory and analgesics.
b) Reduction: Continue bed rest and traction for 2 weeks may reduce the herniation in over 90% cases. If no improvement with rest and traction, epidural injection of corticosteroid and local anaesthetic are given.
c) Chemonucleolysis: dissolution of the Nucleus Pulposus by percutaneous injection of a proteolytic enzyme (chymopapain). This enzyme has the property of dissolving fibrous and cartilaginous tissue.
Physical therapy treatment in pivd-
Before planning the treatment, determine the position of comfort or symptom reduction i.e FUNCTIONAL POSITION. The patient may have...
a) Extension bias: Patient's symptoms are lessened in position of extension (bending back) and provoked in flexion (bending forwards) e.g PIVD.
b) Flexion bias: Patient's symptoms are lessened in position of spinal flexion (bending forwards) and provoked in spinal extension (bending backwards) e.g spinal stenosis, spondylolisthesis.
Spinal Extension (bending back) is contraindicated if:
i) when no position or movement decreases or centralizes the pain.
ii) when saddle anaesthesia and/or urinary incontinence is present (could indicate spinal cord or cauda equina lesion due to large central disc herniation).
iii) when patient is in such extreme pain that he rigidly holds the body immobile.
Spinal flexion (bending forward) is contraindicated if:
i) when extension relieves the symptoms.
ii) when flexion increases or peripheralises the symptoms.
ACUTE PHASE:Aims:
a) To relieve pain.
b) To promote muscle relaxation.
c) To relieve inflammation and pressure against the pain sensitive or neurologic structures.
d) patient education.
e) prevention.
Physical Therapy Management in Acute Phase of PIVD:
a) CONTROLLED REST- is recommended i.e rest in the form of-
*Posture and activity modification- Avoid flexed postures, sitting for long duraton, bending or lifting activities, asymmetric postures ( flexion and rotation). All these increase the disc pressure.
*Local support in the form of corset (lumbosacral belt), abdominal binder, tape etc. These measures will enhance healing and prevent reinjury to the healing disc. Within 10 days fibrin is laid down. If spine is maintained in lordosis, the annulus will heal in shortened position and nucleus will be retained centrally.
*If symptoms are severe, bed rest (maximum for 2 days) on a hard bed is indicated with short periods of walking at regular intervals ( with corset). Walking promotes lumbar extension and stimulates fluid mechanics to help reduce swelling in the disc/connective tissues.
*If patient presents with inability to straighten up, make the patient lie prone with 2-3 pillows under the abdomen. As the pain subsides, remove the pillows and prop up the trunk by placing pillows under the thorax. By this nucleus pulposus is shifted forwards and relieves pain and gains a lordosis.
b) MODALITIES TO REDUCE PAIN AND SPASM-
*Cryotherapy: reduces muscle spasm and inflammation in acute phase.
*TENS: relieves pain in both acute and chronic phases.
*US: as phonophoresis increases extensibility of connective tissues
*Moist heat: used as an adjunct before applying specialised techniques to decrease muscle spasm.
*SWD- pulsed SWD in acute condition and continuous SWD in chronic cases.
*IFT
*Soft tissue manipulation- to reduce local muscle spasm and induce relaxation.
*Traction- may be beneficial to relieve nerve root compression and radiculopathy or paraesthesias in the acute phase of PIVD. Reduces nuclear protrusion by decreasing the pressure on the disc or by placing tension on the posterior longitudinal ligament. Time of traction should be short in acute phase else there could be an increase in disc pressure leading to increased pain due to fluid imbibition ( less than 15 minutes of intermittent traction and less than 10 minutes of sustained traction).