the outcome of an extension oriented exercise program on a

The Outcome of an Extension Oriented Exercise Program on a 55-year-old Male with

Low Back Pain, Unilateral Foot Drop, and Urinary Incontinence: a Retrospective

Case Study.

A Capstone Project for PTY 768

Presented to the Faculty of the Department of Physical Therapy

Sage Graduate School

In Partial Fulfillment

of the Requirements for the Degree of

Doctor of Physical Therapy

Daniel Mark Perry, SPT

May, 2010

Approved:

_________________________________

Gabriele Moriello PT, PhD, MS, GCS

Research Advisor

_________________________________

Marjane Selleck, PT, DPT, MS, PCS

Program Director, Doctor of Physical Therapy Program

SAGE GRADUATE SCHOOL

I hereby give permission to Sage Graduate School to use my work,



Case Study.

For the following purposes:

- Place in the Sage Colleges Library collection and reproduce for Interlibrary Loan.

- Keep in the Program office or library for use by students, faculty,

or staff.

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or licensing agencies, as an example of student work.

- Use as a resource for professional or academic work by faculty or staff.

Daniel Perry 2/28/10

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Case Study.

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Case Study.

By Daniel Mark Perry, SPT 2010

Abstract

Background: There are many studies available pertaining to the relationship between

extension oriented exercise and discogenic low back pain, but there is limited published

literature about the effect of these exercises on discogenic low back pain presenting with foot

drop and bladder dysfunction. Purpose: To observe the outcomes of an extension oriented

exercise program with discogenic low back pain presenting with foot drop and bladder

dysfunction in a participant at an outpatient physical therapy clinic. Case Description: The

participant was a 55 year old male with low back pain, foot drop and bladder dysfunction

resulting from an acute lumbar disc herniation. Methods: A physical therapist certified in the

McKenzie method evaluated the participant with the McKenzie Institute’s Lumbar Spine

Assessment. Other tools and measures included a gait assessment, manual muscle testing,

self reported level of function questionnaire, an 11-point pain rating scale, and a subjective

report of bladder function. The therapist designed an intervention program based on

extension exercises, which were administered over 3 treatment sessions. Outcomes: The

participant abolished his back pain, foot drop and bladder dysfunction. He also improved his

strength and gait allowing him to return to his normal activities at work and at home at full

functional capacity. Discussion: This case study demonstrates the benefit of conservative

physical therapy treatment, such as extension oriented exercise, for managing discogenic low

back pain with foot drop and bladder dysfunction. Abolishment of symptoms may be a result

of a dynamic internal disc model, where posterior disc loading with extension exercise,

allows the disc contents to migrate away from the neural structures to reduce pressure on

these structures and relieve symptoms of back pain, foot drop and bladder dysfunction.

3

Background and Purpose

Low back pain is the second leading cause of doctor’s office visits in the United

States (U. S.).1 Seventy-five percent of the adult U. S. population has already reported some

type of low back pain in the past 3 months and close to 33% of the adult workforce will be

affected by low back pain each year.1,2

The direct and indirect costs associated with back

pain have been steadily increasing despite our education and advances in medical treatment.3

Direct costs include doctor and hospital fees, travel to and from healthcare offices, imaging,

pain medication, and rehabilitation after surgical intervention. Indirect costs include the

economic burden of lost wages and decreased productivity at work and at home.4 Ambrossi

et al5 reported that average total costs for lumbar disc herniation including diagnostic testing

and surgery is $23,915 compared to conservative treatment which costs $2,315 on average.

Costs for surgical intervention of a herniated lumbar disc may be high but the rate for

complete recovery from symptoms may not follow suit. Girardi et al6 reported that full

motor recovery from a disc herniation was only 71% in patients with preoperative ankle

dorsiflexor strength grades 2/5 or better, while Ghahreman et al7 found the rate of complete

recovery in patients with preoperative foot drop (grade 0, 1, 2/5 ) was only 27%. If the

debilitating back pain associated with disc herniation can be alleviated with swift

conservative management, the burden on the healthcare system may be reduced.

Herniation of an intervertebral disc in the lumbar spine is a common cause of low

back pain.1 An intervertebral disc is a structure found between two vertebrae which is made

up of an outer fibrous shell called the annulus which surrounds an inner softer center called

the nucleus. The entire structure is designed to provide cushioning between two vertebrae

when forces are applied. As the disc ages, years of repetitive stress, twisting, and

4

compression can cause microtrauma to the annulus allowing the softer nucleus to push out

against or even through the annulus forming what is commonly called a herniated disc.

Direct pressure on the surrounding spinal structures and nerve roots or irritation and

inflammation around a nerve root can result in paresthesias or motor dysfunction in the

associated nerve distribution. Symptoms vary from patient to patient. Twenty percent of

individuals who have a positive disc herniation on MRI are asymptomatic8 while others

report intense pain, tingling, numbness, or even muscle weakness within the effected

myotome.

The L4-L5 and L5-S1 regions account for approximately 95% of all diagnosed spinal

disc herniations.1

A herniated disc in the lumbar spine can result in pain and paresthesias in

the low back and lower extremities, muscle weakness in the lower extremities, or bladder

dysfunction due to the proximity to the cauda equina and pressure on these nerve roots that

influence bladder control.9,10

Reports of compression of the nerve roots controlling the ankle dorsiflexor and

causing foot drop has been recorded.6,7

Compression of the L4 or L5 nerve roots in the

lumbosacral plexus by a disc herniation can cause a disabling weakness of the innervated

ankle dorsiflexors, particularly the anterior tibialis muscle. Compression of the L5 nerve root

prevents descending transmission of neural impulses to the alpha motor neuron leading to the

deep peroneal nerve that supplies the anterior tibialis muscle. Weakness of the anterior

tibialis muscle (grades < 2+/5) can result in a foot drop. Foot drop can interfere with

ambulation due to difficulties clearing the toes during the swing phase of gait. People often

compensate for this with excessive hip flexion or a Trendelemburg gait pattern. An ankle–

foot orthosis may be needed to assist a person with this deficit to prevent complications with

5

balance, coordination, and biomechanical compensation injuries during gait that can reduce

the patient’s activities of daily living and quality of life.6

Mixter and Barr11

observed that lumbar intervertebral disk protrusion may cause

neurological disorders resulting in bladder and voiding dysfunction. The motor and sensory

nerves of the urinary system are extensions of the cauda equina originating from the conus

medullaris and account for both sympathetic and parasympathetic bladder control. All of the

sacral nerves controlling the urinary system run posterior to the lumbar vertebral bodies and

discs until reaching their sacral exit, thus a disc protrusion anywhere in the lumbar spine may

compress the cauda equina and sacral nerve roots leading to urinary dysfunction.10

Researchers have suggested conservative methods for treating urinary incontinence through

bladder and pelvic floor muscle training, but not for incontinence of a discogenic nature.10-14

Extension oriented exercises like prone press-ups have been a popular and effective

physical therapy treatment strategy for patients with low back pain associated with a

protruding lumbar disc.15-18

Powers et al19

reported a significant reduction in the average

pain score and increase in range of motion in the lumbar spine after a single treatment

session. The McKenzie method of treatment for low back pain utilizes similar patient-

generated extension oriented exercises and is a gaining acceptance and popularity for treating

patients with discogenic pain.19-24

The McKenzie approach to low back pain is often referred

to as “mechanical diagnosis and therapy (MDT)” because it contains both comprehensive

patient assessment and treatment components.20

McKenzie identifies a disc protrusion and

associated signs and symptoms as a derangement syndrome and pain can often be centralized

or moved back to point of origin with self generated exercises.22-26

The theory behind

extension exercise and resolution of symptoms is based on the assumption that when the

6

spine is flexed into the pain free direction of preference, the vertebrae above and below the

involved disc opens anteriorly and closes posteriorly allowing the disc to migrate back to its

normal anatomical position relieving pressure on the nerve roots. Many studies have

reported the effectiveness of the McKenzie extension exercises for treatment of low back

pain,19,21-26

but there is little evidence to support the effectiveness of these extension

exercises for the treatment of a patient presenting with unilateral foot drop and bladder

dysfunction. Alleviation of bladder symptoms and foot drop with extension exercises but

may be beneficial due to the theory surrounding the mechanism of his symptoms and relief of

pressure on the controlling nerve roots.

In many cases, surgical intervention is warranted but for others, the less costly

conservative treatment may be beneficial and require less time out of work and with post

operative rehabilitation. There is extensive research regarding the effectiveness of extension

oriented lumbar exercises on back pain but little research has been composed for

effectiveness on foot drop and bladder control. The purpose of this case study was to

examine the outcome of a conservative treatment approach of extension oriented exercise on

a 55 year old man with low back pain, unilateral foot drop, and bladder dysfunction

associated with a lumbar disc herniation. The hypothesis is this participant will show signs

of relief of his symptoms stated above according to the theory of the intervention.

Methods

Case Description

The participant was a 55 year old male respiratory therapist in generally good health

with a 6 week history of acute low back pain after bending forward in his garden. His pain

symptoms were constant and initially started in his low back and progressed to his left

buttocks, thigh, leg, and then foot. He developed left lower extremity weakness that evolved

7

into a foot drop and reported episodes of urinary incontinence since the onset of low back

pain. Symptoms were aggravated by bending or flexing forward, sitting cross-legged, or

standing for long periods of time. Symptoms were less aggravating when sitting, standing,

walking or “on the move”, and at night while laying supine on a firm bed or on his right side.

He reported no sleep disturbances or night pain. The participant was diagnosed by his

primary physician with a lumbar disc protrusion with radiculopathy on his left side.

A routine magnetic resonance imaging (MRI) study of this participant’s lumbar spine

was obtained by his primary physician and results were made available to the physical

therapist. Images were described as sagital T1, T2 and fat-suppressed T2 STIR. Axial T1

and T2-weighted images were also obtained. In addition, axial and sagital fat-suppressed T1-

weighted images were obtained after gadolinium enhancement. A summary of reported

impressions from the MRI can be found in Table 1.

On a brief self reported medical questionnaire, the participant reported he had never

received Physical, Occupational, or Speech Therapies for any reason in the past. His past

medical history was unremarkable. He used corrective lenses for vision. He was a social

smoker and limited his alcohol consumption to about 4 drinks per week. He listed his only

medical concern as “resolution of back injury,” and his expectation for treatment was to

“improve left leg function.” The participant reported having prescriptions for Crestor and

prednisone that was being weaned down. He denied any use of over-the-counter NSAIDs.

Approval for working with human subjects during this study was granted after

application and extensive review by the Sage College’s Institutional Review Board

(Appendix A). No humans were harmed by intent or inadvertently during the course of this

study.

8

Examination

The physical therapist performing the examination was certified in MDT for more

than 4 years at the time of this examination. The examination consisted of tests and

measures from The McKenzie Institute Lumbar Spine Assessment (Appendix B), a reliable

instrument used to classify patients into the specific categories of syndromes.25,27-30

The

assessment form consisted of a basic medical history and physical examination where the

participant’s responses to movement allowed the therapist to make a provisional

classification of his condition of either a derangement, dysfunction, or postural syndrome.

Results from the movement exam are summarized in Table 2. The participant in this study

was classified by the therapist as having a derangement syndrome in his lumbar spine as

defined by McKenzie.23

The participant’s gait pattern was observed as he exited the clinic’s waiting room and

entered the treatment area to sit, a distance of about 15 meters. Observation of his gait

revealed a left foot drop during the swing phase and terminal extension resulting in a

compensating hip-hike on the ipsilateral side to clear his toes from dragging on the floor. He

reported his pain as a range from 2/10 to 10/10 on an 11 point numeric pain rating scale

(NPRS) since onset. He denied numbness or tingling in his back, buttocks, and lower

extremities.

A manual muscle test (MMT) of the participant’s lower extremities was performed

by the therapist according to procedures outlined by Hislop and Montgomery.31

His muscle

strength was normal (5/5) except for his left ankle dorsiflexor strength (3/5) that resulted in

left calf muscle tightness from a lack of voluntary dorsiflexion movements. Visual

inspection and palpation in standing revealed a reduced lumbar lordosis. He had a forward

9

head and rounded shoulders. No lateral shift or scoliosis was observed in the standing or

sitting position. While sitting on a flat plinth he was observed to be fidgety to get into a

comfortable seated position. He reported his low back pain improved with correction of

sitting posture. A seated slump test revealed negative dural signs bilaterally. The slump test

is a common clinical examination of low back related leg pain.32

The slump test (sensitivity

= 0. 84) was designed to place the sciatic nerve roots under tension to reproduce radicular

pain in patients with lumbar disk herniation and detect nerve root compression.33

The

procedure for this test was followed according to a protocol described by Magee.34

The use

of the McKenzie lumbar spine assessment allowed the therapist to make a rapid and gross

observation of the participant’s lumbar range of motion (ROM) and affect on function

without the need for extensive and time consuming goniometric measurements. See Table 3

for lumbar ROM limitations.

The participant completed a self reported assessment of his level of function and

activities of daily living during his initial visit while sitting in the waiting room at the clinic.

On the assessment form, the participant was instructed to circle one of 6 choices that he

determined to be an accurate representation of his level of function with different daily tasks.

The results for this self assessment (except for self-care, eating, and manipulative skills

which the participant reported having no problem with) are represented in Table 4. The

participant was able to ambulate community distances without an assistive device

independently.

Outcome Measures

The participant’s back pain intensity in this study was measure by a NPRS. The

NPRS has been reported to be a sensitive, accurate, and reliable instrument for measuring

10

changes in pain intensity.35-38

The 11-point NPRS is recommended as a core outcome

measure in clinical trials of chronic pain treatments, because it is less abstract and easier to

understand than other clinical pain measures.39

The NPRS was an eleven point scale

represented by a horizontal line on a wall in the clinic. The number zero was located at the

far left of the line and 10 at the far right. Zero represented no pain and 10 represented the

most pain imaginable. Vertical marks representing numbers 1 through 9 were evenly spaced

on the line between the 0 and 10. When measuring pain during this study, the participant

was asked to verbally state his number corresponding to his back pain intensity during his

examination and treatment session. Paice and Cohen38

found the verbal administration of the

NPRS a valid test for changes in acute pain with a statistically significant correlation with the

visual analog scale (VAS) (r = 0. 847, p < 0. 0001). Childs, Piva, and Fritz37

reported the

minimum clinically significant difference in the NPRS after treating patients with low back

pain as a change of 2.2 and 1.5 points after 1 and 4 weeks of treatment, respectively.

The McKenzie Institute Lumbar Spine Assessment was used to identify the

participant’s baseline musculoskeletal impairments during the initial evaluation and to

determine the effectiveness of the interventions. This instrument, when performed by

therapists with training in the McKenzie method, allows for reliable classification and

baseline for progress in patients with lumbar pain.25-30

Interexaminer reliability of the

McKenzie lumbar spine assessment in performing clinical tests and classifying patients with

low back pain into syndromes were good and statistically significant (Kappa 0.6 – 0.7, 95%

confidence interval) when the examiners had been trained in the McKenzie method.40

The

proportion of patients who could be classified into one of the syndrome categories defined by

McKenzie using the assessment form has been generally high, with a mean of 87%.21

Clare,

11

Adams, and Maher25,26

reported the reliability of syndrome classification was k = 0.56 (95%

confidence interval 0. 46–0. 66) with a percentage agreement of 91%.

The participant’s gross lower extremity muscle strength was measured by the MMT

described in the text by Hislop and Montgomery.31

In literature review of more than 100

published studies, evidence suggests good reliability, external, and internal validity in the use

of MMT for patients with neuromusculoskeletal dysfunction.41

A strong correlation (r =

0.768; P < 0.001) has been found between MMT and hand held dynamometry, often

considered to be the gold standard of muscle strength testing.

The participant’s bladder function was measured subjectively by self reporting more,

less, or no change in micturition frequency. Abrams, Artibani, Gajewski et al43

recommended that subjective measures should be the standard tool for assessment and

treatment of patients with bladder dysfunction because objective measurements do not

clearly represent the patients personal lifestyle priorities or quality of life.

Evaluation/Prognosis

From the examination, the participant was observed as having functional limitations

in duties required by his occupation, difficulty with leisure activities, and activities of daily

living. These limitations are a result of his impairments of low back pain, muscle weakness,

and ROM. He was able to centralize his pain out of his left lower extremity and abolish his

pain in his low back after 10 repeated lumbar extensions in lying position, identifying him as

good candidate to respond favorably to an extension oriented exercise program. The

therapist determined he had a posterior lumbar derangement with left unilateral asymmetrical

symptoms below the knee and classification of derangement syndrome which was consistent

12

with his medical diagnosis of lumbar disc protrusion and unilateral lower extremity

radiculopathy.

According to the American Physical Therapy Association’s Guide to Physical

Therapy Practice,44

this participant fell into a Preferred Practice Pattern of 4F with impaired

joint mobility, motor function, muscle performance, range of motion, and reflex integrity

associated with spinal disorders, ICD-9 code 722. The participant presented a physician

signed prescription for physical therapy for 3 times a week for 10 weeks. The guide

recommended the expected number of physical therapy treatments to be in the range of 8 to

24 visits within 1 to 6 months time and stated that he would demonstrate full return of

impairments and return to work and leisure activities within that time frame. Judging by the

participant’s functional status and responses to the examination, and through previous

experience with patients with low back pain, the therapist estimated his needed number of

treatments to be between 8 and 12 forty-five minute visits.

Goals

The goals for this participant were designed by the therapist with intention to be met

within the anticipated number of treatment sessions. Short-term goals were to abolish or

centralize the participant’s leg and back pain, to resolve his foot drop, and restore his lumbar

range of motion to within his normal limits. Restoration of the participant’s bladder control

was not identified as an anticipated goal through his immediate plan of care secondary to a

lack of available evidence associating lumbar exercise with bladder control. Long-term goals

for this participant were for him to return to full functional capacity at work and at home,

with his leisure activities and activities of daily living.

13

Plan of Care

The participant’s plan of care was designed by the therapist based on his directional

preference and symptom response (decrease, abolition, or centralization of pain) from the

lumbar assessment form during the evaluation. Extension oriented interventions

recommended by McKenzie23,24

for treating derangement syndrome were implemented. The

frequencies of these skilled interventions during visits are summarized in Table 5. In

repeated extension in lying (REIL), the patient was prone on a plinth with his elbows bent

and hands flat with palms down at about chest level. Then the participant pushed up on his

hands to lift his chest off the plinth keeping his hips down and then returned to starting

position. One repetition was up and back down. In REIL with patient over-pressure, the

participant started in the elbows extended position and pushed into maximal lumbar

extension while keeping his hip on the plinth. REIL with therapist overpressure allowed the

therapist to apply a vertical force down onto the participant’s lumbosacral region during

maximal lumbar extension. Grade 3-4 posterior - anterior (PA) oscillatory mobilizations

were applied to the participant’s L3-L5 vertebrae in a fashion described by Maitland.45

The participant was instructed in a standing stair calf stretch where he put one foot in

maximal dorsiflexed position on a bottom stair and leaned into it for 20 seconds. He did this

for both legs. To address his head forward and rounded shoulders, he was also instructed on

a seated slouch exercise where he would allow gravity to lower his head and shoulders and

flex his spine, and then instructed to correct his posture by contracting his back muscles with

spinal extension and scapular retraction. The therapist’s hands were lightly placed on the

skin over the participant’s rhomboids and mid-trapezius muscles to facilitate the correct

action and contraction.

14

The participant was educated on correct static and dynamic posture that included

keeping his ears in a vertical line with his hips and ankles, as described in detail by Magee,34

and the proper body mechanics of lifting to reduce stress on his low back. Home exercises

are summarized in Table 6. The participant was instructed to do prone press-ups at home on

his floor as well as standing back bends with his hands on his hips. He was also instructed on

the use of a pillow or rolled towel for lumbar support while sitting or driving.

Outcomes

The participant was evaluated by the therapist at the initial visit according to the

McKenzie lumbar form. As stated above, the outcomes of the initial evaluation are

documented in Table 2. The entire initial session lasted no longer than 45 minutes. At the

end of the session the participant was instructed in his home exercise program. He

demonstrated normal cognition and willingly complied with all his interventions. He was

able to demonstrate all his exercises correctly and independently before leaving the clinic.

He did not show up for his next 2 visits (2 and 5 days post evaluation) for reasons unknown.

During the next treatment session (5 days post evaluation), the participant reported

much less leg and thigh pain after clinical intervention and fully complying with his home

exercise program. He still reported only minor pain in his lumbo-sacral region before that

treatment session. This second session lasted no more than 35 minutes and was still able to

demonstrate his home exercises independently and completely. At his third and final session

(7days post evaluation), the participant reported complete abolishment of his leg, thigh, and

back pain, a 0/10 in the NPS. The therapist also observed an absence of foot drop and

Trendelenburg during his gait as he ambulated from the waiting room to the exercise room.

The participant reported gaining complete control over his bladder function.

15

The third and final treatment session lasted no more than 17 minutes including

interventions and education about maintaining his home exercise program for prevention of

future reoccurrence. The participant was able to return to his previous level of function and

activities of daily living at home and at work without symptoms after this third session. The

participant was scheduled for a formal follow-up and discharge on his fourth visit so ROM

and MMT were not performed at this third visit. This data was not available due to

participant’s absence at fourth visit.

Discussion

Low back pain is second leading cause of doctor’s office visits in the US.1

A large

percentage of these cases are discogenic in nature. The economic burden may be reduced if

injuries can be alleviated with swift conservative management. Extension oriented exercises,

like the ones used with the McKenzie Method of treatment, is a form of conservative

management. The participant mentioned here had a history of back pain, bladder dysfunction

and foot drop associated with multiple level lumbar disc bulges. He was provided a simple

treatment program of extension oriented exercises and after only three sessions of physical

therapy, the participant reported complete abolishment of his pain, foot drop, and bladder

dysfunction and all short term and long term goals were met.

The McKenzie method is a comprehensive system of both patient assessment and

exercise for chronic low back pain. The assessment portion attempts to classify back pain

into causation, movement limitation, directional preference and symptom centralization

which is then used to formulate a treatment strategy. Typically, the directional preference

becomes the treatment principle,24

like in this participant who favored low back extension

rather than flexion to minimize and centralize pain symptoms. According to Werneke et al,46

16

centralization is a good prognostic indicator. They reported that patients whose symptoms

centralize improve faster and have better outcomes than those patients whose symptoms do

not centralize, which may explain why the participant in this study demonstrated

improvement after so few visits to therapy.

Wetzel and Donelson47

described the anatomical mechanism of discogenic radicular

symptoms and the treatment strategy for centralization. They describe a dynamic internal

disc model based on cadaveric, disco-graphic, and MRI studies. This model shows posterior

migration of inner disc contents in response to anterior disc loading during lumbar flexion,

and anterior migration in response to posterior disc loading with extension. Because of this

loading phenomenon, extension exercise, or directional preference of extension, allows the

disc contents to migrate forward and away from the neural structures reducing pressure on

these structures and relieving radicular symptoms. The same phenomenon is responsible in

this participant whom presented with multiple level posterior lumbar disc bulges, exacerbated

by bending forward to pick up sticks in his garden.

As we can see, numerous studies have been published discussing how exercises are

effective with back pain,1,16-22,25

but as previously mentioned, the effectiveness of extension

oriented exercises for the treatment of discogenic bladder dysfunction and deep peroneal

neuropathy has not been fully investigated.

Relief of bladder dysfunction and foot drop in this participant may be accredited to

Wetzel and Donelson’s47

dynamic internal disc model as well. Repetitive spinal flexion or

bending forward allows the softer nucleus to push out posteriorly against the annulus forming

a bulge.20,23,24

This bulge applies pressure to the surrounding spinal structures and nerve

roots causing irritation and inflammation to the nerve root or spinal cord running adjacent to

17

the disc.1,5-9,11,19,20-25

Pressure on the spinal cord or nerve roots may interfere with normal

nerve conduction to its associated structures within that particular nerve distribution.

O’Flynn, Murphy, and Thomas48

suggested that bladder dysfunction may be a direct result of

pressure to the cauda equina in patients with a disc protrusion occurring within the lumbar

and sacral regions of the spinal column, as seen in our participant here. The sensation of

fullness or the neural mechanisms for urine retention may be compromised resulting in

uncontrolled micturition. Extending the vertebrae above and below the involved disc spaces

allows the discs to migrate back to their normal anatomical position relieving pressure on the

cauda equina promoting normal bladder control.

The same can be said for relief of his foot drop. Extension allows the disc to migrate

forward relieving pressure from the sciatic nerve roots. These roots form the trunk of the

sciatic nerve that bifurcates in the popliteal fossa forming the superficial and deep peroneal

nerves, the latter being responsible for motor function of the tibialis anterior muscle needed

for dorsiflexion of the ankle during gait.6,7

One limitation to this study is the lack of objective measures for gait analysis and

bladder control. Although subjective reporting can be good tools for measuring the level of

impairments and functional limitations, it is in the best interest of the participant and

therapist to record accurate objective measures for recording improvements and for insurance

reimbursement and documentation. Abrams, Artibani, Gajewski et al43

suggest self reported

subjective measures are an accurate measure of bladder control but a detailed patient log of

urine output and frequency of uncontrolled micturition may have been useful for determining

the true effectiveness the program on bladder dysfunction.

http://en.wikipedia.org/wiki/Tibialis_anterior

18

Detailed lumbar ranges of motion may have also been useful to measure range of

motion progress throughout the course of treatment. Clare26

suggests four approaches that

would be helpful to measure lumbar range of motion in a clinical setting including

inclinometer methods, fingertip to floor method, and the use of a tape measure to determine

the distance from the sternal notch to the supporting surface in a prone-press-up position. All

of these tools are described in detail in that article.

A third objective measurable that would have been valuable would be active range of

motion of the participant’s ankle dorsiflexors. Gait observation for foot drop and

compensation patterns were used for determining progress of his ankle function but

measuring active ranges of motion over time in conjunction with muscle testing his

dorsiflexors would have been a more useful outcome measure.

A quality of life questionnaire, such as the Oswestry Disability Index may have been

a valuable tool for measuring effectiveness of interventions and progress. This self-reported

questionnaire has been reported as reliable and valid for measuring responsiveness to

treatment in people with low back pain and sciatica.48,49

Lastly, the most accurate measure to determine the level of effectiveness of the

intervention program would be electromyogram (EMG), nerve conduction studies, and an

MRI. EMG and nerve conduction studies may determine the rate of conduction of

neurotransmitters from the spinal level to the target tissues and give an accurate

representation of the severity of disc bulge pre and post treatment.50

MRI studies can give a

detailed image of the location of the disc in relation to the nerve structure and show progress

of the disc migration after intervention.8

19

This case report may be useful for future research determining the effectiveness of

lumbar extension oriented exercises or the value of the McKenzie method of treatment as a

conservative intervention for patients with discogenic related bladder dysfunction and foot

drop.

20

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Table 1: MRI Findings

Mild anterior wedge compression fracture at

L3 of older finding

L3-L4 broad-based disc bulge osteophyte

complex mildly deforming the thecal sac

5 mm of retrolisthesis of L4 on L5 L4-L5 broad-based disc bulge with moderate

thecal sac deformity and moderate spinal

stenosis

Rudimentary disc S1-S2 L5-S1 broad-based disposing osteophyte

complex.

25

Table 2: Results reported on lumbar assessment form.

Symptoms During

Testing

Symptoms After

Testing

Mechanical Response

↑ROM ↓ROM No

Effect

Pretest symptoms standing: In Standing (IS) = 2-3/10 leg pain

to foot

FIS NE NE X

Rep FIS ↑L Shin Pain , ↑L

Buttock Pain

W X

EIS NE NE X

Rep EIS NE NE X

Pretest symptoms in lying: In Lying (IL) = 2-3/10 L leg to foot

FIL NE NE X

Rep FIL NE NE X

EIL NE NE X

Rep EIL NE Centralization of L

Lower Extremity;

0/10 low back pain

Key: FIS = Flexion in Standing, EIS = Extension in Standing, FIL = Flexion in Lying, EIL =

Extension in Lying, Rep = Repeated, NE = No Effect, W = Worse.

26

Table 3: Observed lumbar range of motion limitations.

Maj Mod Min Nil Pain

Standing

Lumbar Flexion

(F)

X No Pain

Standing

Lumbar

Extension (E)

X No Pain

Side Gliding R X No Pain

Side Gliding L X No Pain

27

Table 4: Participant reported functional limitations.

DD 0 1 2 3 4

Managing Household

Cooking/Washing Dishes X

Laundry X

Houskeeping X

Shopping X

Yard work X

Maintaining a Position

Lying Down/Sleeping X

Prolonged Sitting/Standing X

Squatting/Kneeling X

Activities

Driving/Traveling X

Lifting/Bending/Carrying X

Reaching X

Twisting X

Pushing/Pullin X

Recreation and Leisure

Sports(baseball, running,

golf)

X

Social gatherings, out to eat X

Art (painting, drawing, etc.

)

X

Performing Arts X

Hobbies (gardening) X

Movement

Moving your arms and leg X

Moving your neck and back X

Getting into/out of bed/chair X

Walking X

Climbing stairs X

Employment

Work regular schedule X

Perform regular tasks X

Key: DD = Normally don’t do, never have to, want to, or plan to do; 0 = No problem at all,

can do when and how you want, and without pain; 1 = Minor problem, can do without help,

but with pain or minor annoyance; 2 = Moderate problem, need some help or can’t do the

way you’d like to do it; 3 = Major problem. Need a lot of help, very hard to complete, or

cannot do safely; 4 = Can’t do at all, would like to do again.

28

Table 5: Therapy interventions in outpatient clinic

Day 1 Day 2

Intervention Repetitions Sets Repetitions Sets

Rep EIL 10 1 5 2

Rep EIL with Participant Overpressure 10 1 5 1

L3-L5 Mobilization in Prone 0 0 10 2

Seated Slouch and Correct 10 2 10 2

Rep EIL with Therapist Overpressure 0 0 5 1

Bilateral Calf Stretch on Stairs 0 3 X 20 Sec Hold

Key: Rep = Repeated, EIL = Extension in Lying

29

Table 6: Home exercises

Home Exercise Sets Reps Times Per

Day

Hold Added

Pound

s

Lumbar Extension (Prone Press Ups) 1 10 8 0 0

Lumbar Extension

(Standing Back Bend with Hands on Hips)

1 10 8 0 0

30

Appendix A

Copy of IRB Approval Letter.

31

Appendix B

the outcome of an extension oriented exercise program on a

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