Dyskopatie w części lędźwiowo-krzyżowej kręgosłupa – analiza postępowania fizykalnego

Introduction

Spinal pain is one of the most common medical conditions of the 21st century [1–7]. Recent studies have shown that sacral pain occurs in as many as 80% of adults and 39.5% of adolescents. Sacral pain usually develops in occupationally active persons aged 35–55 years and constitutes the second most common cause of absence from work of the patients.

Etiopathogenesis

Aging is associated with changes concerning intervertebral disc nutrition and hydration, resulting in disc damage and, consequently, pain. Other factors contributing to the development of this problem include obesity, no/limited physical activity, spending long hours in a sitting position at work, and overload of the lumbosacral section of the spine [8, 9]. The intervertebral disc structures (annulus fibrosus and nucleus pulposus) are well hydrated in young people, but later dehydrate as the patients age.
Some specialists believe that damage to the annulus fibrosus marks the beginning of the process of disc degeneration, leading to disintegration of proteoglycans and collagen degradation in the intervertebral disc. At the same time, the cellular activity in the process of matrix reproduction decreases and the activity of proteolytic enzymes increases. The nucleus pulposus undergoes fragmentation and dehydration while clefts develop in the annulus fibrosus.
The development of this intervertebral disc disorder may be associated with abnormal statics of the spine. Gradual limitation of intervertebral disc function results from spinal diseases, congenital spine deformities, spinal overload and accumulating microtrauma, post-traumatic changes, and the process of aging [2–5].

Clinical presentation

Lumbosacral discopathy results in characteristic clinical symptoms, such as limited spinal mobility and severe pain, gait disturbances, decreased lumbar lordosis, and a positive Lasègue’s sign and Patrick’s test.

Physiotherapy and rehabilitation

Physical therapy and rehabilitation conducted in lumbosacral disc disease are aimed at eliminating pain and inflammation and lowering the tension in the paraspinal muscles. The most common procedu­res include electrotherapy, laser therapy, cryotherapy, magnetic field therapy, ultrasound, and rehabilitation [10–20].

Aim of the research

The aim of the research was to analyse physical therapy and rehabilitation of patients suffering from lumbosacral discopathy.
Main research problem and hypotheses: assessment of a change in spinal mobility and pain as a result of rehabilitation in patients with discopathy of the lumbosacral spine.
Research hypotheses:
1. The rehabilitation resulted in decreased pain intensity.
2. The rehabilitation resulted in a lower frequency of pain episodes.
3. The rehabilitation resulted in a lower frequency of taking analgesics.
4. The rehabilitation resulted in a decreased degree of physical activity limitation.
5. The rehabilitation resulted in an improved lumbosacral spine mobility when bending forwards in Schober’s test.
6. The rehabilitation resulted in an improved lumbosacral spine mobility when bending backwards in Schober’s test.

Material and methods

The study was conducted in a group of 54 patients aged 20–60 years, who suffered from lumbosacral disc disease involving the L4–L5 and L5–S1 levels. There were 32 (59.3%) women and 22 (40.7%) men. The patients underwent physical therapy and rehabilitation:
– diadynamic currents (CP, LP), time: 15 min, 10 procedures,
– laser therapy (He-IR) at a dose of 4–6 J/cm², time: 15 min, 10 procedures,
– ultrasound therapy, 0.6 W/cm², 6 min, 10 procedures.
When the pain was eliminated, kinesiotherapy was introduced in the form of exercise aimed at restoring spinal mobility in the sagittal plane, exercise improving deep spinal stabilisation, and then general keep-fit exercise focused on everyday activity of a given patient
The patients were examined before and after a 2-week rehabilitation programme conducted in January-April 2016 in two out-patient rehabilitation clinics in Radom.

Study methods

The research tool consisted of a questionnaire prepared by the authors. This survey included 17 closed questions and five open ones. Part I focused on basic demographics, type of work, physical activity, frequency and type of pain, the time of diagnosis, and the presence of concomitant diseases of the spine.
Part II of the questionnaire assessed pain intensity before and after the rehabilitation programme based on two subjective scales used to evaluate pain severity: a VAS scale and the Laitinen scale. Moreover, Schober’s test was used to assess the level of improvement of lumbosacral spine mobility after the rehabilitation. The patients also assessed the efficacy of the rehabilitation and answered whether they would decide to undergo this treatment again.

Statistical analysis

Statistical analysis used the following tests:
– Wilcoxon matched pairs test to check for significant differences between pre- and post-rehabilitation measurement values,
– Mann-Whitney’s U test for two groups to check for intergroup differences in the selected quantitative parameters (between two groups),
– Kruskal-Wallis test to check for intergroup differences in the selected quantitative parameters (between more than two groups),
– Fisher’s exact test to check for statistically significant relationships between qualitative variables.

Results

The results were statistically analysed and are presented in Tables 1–30.
The study group was heterogeneous with respect to gender: 59.3% of the patients were female and the other 40.7% were male. The majority of the study patients were aged 51–60 years (57.4%). Half of the respondents had normal body mass index (BMI) values, 42.6% of the patients were overweight, and 7.4% had class I obesity.
Mean body mass of the study participants was M = 75.63 kg and the median value was Me = 73.5 kg, which means that half of the patients weighted no more than 73.5 kg.
The height of the study patients varied from 160 cm to 190 cm. The height of almost half of the patients (48.1%) was below 170 cm. Mean height was M = 173.04 cm, while the median value was slightly lower at Me = 171.50 cm.
The study patients had secondary (37%) and higher (35.2%) education. One in three study patients was a pensioner or was drawing a disability pension (33.3% of the group). 18.5% of the respondents did hard physical work.
More than a third of the study patients stated they engaged in physical activity several times a week (35.2%) and 20.4% of the respondents said they practised physical activity once a week.
The study patients had usually been diagnosed with discopathy approximately 5 to 10 years before the study. 31.5% of the respondents had been diagnosed with the diseases 1 to 5 years before the study. 48.1% of the study patients with discopathy suffered from other diseases.
More than a half of the study patients experienced pain every day (53.7%), and 29.6% of the patients suffered from pain several times a week.
40.7% of the study patients suffered from radiating pain, 33.3% of the patients experienced chronic pain, and 25.9% reported acute pain. The patients usually felt pain in the lumbosacral (L-S) section of the spine (64.8%). Half of the patients usually experienced pain during physical activity. 25.9% of the patients suffered from pain at rest, and in 24.1% pain occurred usually after physical activity.
Table 17 presents changes in measurements according to the Laitinen scale. Table 18 presents the results of measurements of spinal mobility. Table 19 presents the results of measurements of lumbosacral spine mobility.
The majority of the study patients (85.2%) underwent physical therapy (procedures). Kinesiotherapy was conducted in 68.5% of the study patients, and 42.6% of the patients underwent massage.
The treatment included: magnetic fields (85.4% of the patients), laser therapy (70.8%), ultrasound (62.5%), TENS current (54.2%), cryotherapy (41.7%), and interference current (31.3%).
Before rehabilitation, the medium VAS scale assessment was 6.33 and the median was Me = 7. After rehabilitation the mean value was M = 4.54 and the median was Me = 5.
When asked about the assessment of the rehabilitation, 40.7% of the study patients stated they felt better. A significant improvement and restored function were observed in 16.7%.
A vast majority of the patients (92.6%) declared that they would again undergo the rehabilitation procedures if their symptoms worsened.

Hypothesis: The rehabilitation resulted in decreased pain intensity

The variable of pain intensity was analysed at two measurement points: before rehabilitation and after rehabilitation (a significance level of 0.05). It can be concluded that there are statistically significant differences in pain intensity between the two measurements, and the hypothesis: “The rehabilitation resulted in decreased pain intensity” was confirmed.

Hypothesis: The rehabilitation resulted in a lower frequency of pain episodes

The variable of pain frequency was analysed at two measurement points: before rehabilitation and after rehabilitation. There are statistically significant differences in pain frequency between the two measurements, and the hypothesis: “The rehabilitation resulted in a decreased frequency of pain” was confirmed.

Hypothesis: The rehabilitation resulted in a lower frequency of taking analgesics

It can be concluded that there are statistically significant differences in the frequency of taking analgesics between the two measurements, and the hypothesis was confirmed.

Hypothesis: The rehabilitation resulted in a decreased degree of physical activity limitation

The variable of physical activity limitation was analysed at two measurement points: before rehabilitation and after rehabilitation. It can be concluded that there are statistically significant differences in the physical activity limitation between the two measurements.

Hypothesis: The rehabilitation resulted in an improved lumbosacral spine mobility when bending forwards in Schober’s test

The variable of spinal mobility when bending forwards was analysed at two measurement points: before rehabilitation and after rehabilitation. It can be concluded that there are statistically significant differences in this variable between the two measurements, and the hypothesis was confirmed.

Hypothesis: The rehabilitation resulted in an improved lumbosacral spine mobility when bending backwards in Schober’s test

The variable of spinal mobility when bending backwards was analysed at two measurement points: before rehabilitation and after rehabilitation. It can be concluded that there are statistically significant differences in this variable between the two measurements; the hypothesis was confirmed.

Discussion

Spinal pain syndromes constitute a major clinical and social problem. This condition is present in approximately 18% to 30% of all patients admitted to physiotherapy clinics. The chronic and recurrent character of this syndrome causing long-term inability to work is also a major social problem. Physical therapy and rehabilitation constitute the basis of the treatment. The aim of this study was to analyse physical therapy and rehabilitation in a group of 54 patients with disc disease affecting the lumbosacral section of the spine. The majority of the patients were aged 51–60 years (57.4%). Half of the respondents were people with normal body mass while the other patients were overweight or had class I obesity. The study confirmed a positive influence of the treatment on the patients’ health status measured in an objective and subjective assessment. The pain intensity in the VAS scale decreased, as did pain intensity and frequency, the frequency of taking analgesics, and limitation of physical activity in the Laitinen scale; mobility of the lumbosacral section of the spine improved. Similar results were obtained by Szulkowska et al. They assessed the effects of ultrasound therapy and interference currents in patients with lumbosacral pain syndromes. The patients who were treated with interference currents showed an approximately 50% decrease in pain, while the effects of ultrasound therapy were small. Korabiewska et al., who compared the analgesic effects of diadynamic currents and magnetic field therapy in patients with lumbosacral pain syndromes, found a decreased level of pain and stress.
The statistically significant influence of the rehabilitation on improved lumbosacral spine mobility shown in this study is consistent with the results achieved by Zdrodowska et al. [15], who found that both magnetic field therapy and low-energy laser therapy have a beneficial effect on improving spinal mobility and relieving pain in patients with discopathy. A study by Gworys et al. [17] revealed that the use of physical therapy and kinesiotherapy helps decrease pain in lumbosacral pain syndromes. Appropriate treatment of low back pain syndromes consists of a comprehensive therapy combining physiotherapeutic procedures and kinesiotherapy. It is very important to educate the patients and their families with respect to the ergonomics of work and rest. To sum up, the results of this study are consistent with the observations made by the above-mentioned authors. The physical therapy procedures used in the patients reduced the pain and improved lumbosacral mobility. Physical therapy and rehabilitation constitute the basis of the treatment in this group of patients.

Conclusions

Lumbosacral pain syndromes constitute a difficult clinical and social problem. The rehabilitation contributed to a reduction in pain as measured in a VAS scale. The treatment resulted in pain relief, a lower frequency of pain episodes, a lower frequency of taking analgesics, and less physical activity limitations according to the Laitinen scale. The management contributed to a better mobility of the lumbosacral spine.

Conflict of interest

The authors declare no conflict of interest.

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Address for correspondence:

Włodzisław Kuliński MD, PhD, Prof. UJK
Department of Physical Medicine
Institute of Physiotherapy
Faculty of Medicine and Health Science
Jan Kochanowski University
al. IX Wieków Kielc 19, 25-317 Kielce, Poland
E-mail: wkulinski52@hotmail.com