{"id":988,"date":"2020-07-19T14:05:06","date_gmt":"2020-07-19T14:05:06","guid":{"rendered":"https:\/\/brhc.com.sa\/Events\/backstreet-boys-concert-2\/"},"modified":"2020-08-19T10:39:50","modified_gmt":"2020-08-19T10:39:50","slug":"backstreet-boys-concert-2","status":"publish","type":"events","link":"https:\/\/brhc.com.sa\/ar\/Events\/backstreet-boys-concert-2\/","title":{"rendered":"Electrodiagnosis-based management of patients with radiculopathy"},"content":{"rendered":"
\n

The concept and application involving a patient with a large lumbosacral disc herniation<\/h2>\n
\n
Mohamed A. Sabbahi<\/a>a,<\/sup>b,<\/sup>\u204e<\/sup>\u00a0and\u00a0Fikriye Ovak-Bittar<\/a>a<\/sup><\/div>\n<\/div>\n
\n
Author information<\/a>\u00a0Article notes<\/a>\u00a0Copyright and License information<\/a>\u00a0Disclaimer<\/a><\/div>\n<\/div>\n<\/div>\n
<\/div>\n
\n
Go to:<\/a><\/span><\/div>\n

Abstract<\/h2>\n
\n
\n

Objectives<\/h3>\n

The evaluation of patients with lower back pain (LBP) is based mainly on clinical examinations and imaging procedures that are subjective or anatomic in nature. The treatments, either physical therapy or osteopathy, lack evidence-based protocol and may be disruptive to the spine. Therefore, a neurophysiologic-based approach to managing such patients is necessary.<\/p>\n<\/div>\n

\n

Methods<\/h3>\n

A 40-year-old female complained of LBP and radiculopathy for more than 12\u202fyears, a condition that was accompanied by numbness, tingling and weakness in the left leg. This study examined the effectiveness of using an innovative concept and method on a patient with a 19-mm disc herniation. An electro diagnosis-based evaluation and treatment approach testing tool, Soleus H-reflexes, was applied during unloading (with the patient lying down), loading (with the patient standing or sitting), and various trunk position protocols. A structured treatment was based on the results of H-reflex, including direction-sensitive exercises and manipulation, progressing from unloading to full loading. A custom-based home program was developed for sleeping and sitting positions, with all being directed at non-invasively decompressing the compromised nerve root. Data was analyzed using descriptive statistics.<\/p>\n<\/div>\n

\n

Intervention and results<\/h3>\n

Stepwise application of the developed procedures resulted in complete resolution of the radicular and spinal symptoms, with a reduction in the size of the herniated disc from 19\u202fmm to 4\u202fmm and recovery of the H-amplitude by the end of the treatment. Functional recovery was also complete by the end of the program. A follow-up after 12\u202fmonths showed maintained results.<\/p>\n<\/div>\n

\n

Conclusions<\/h3>\n

The discussed concept and method exhibited their effectiveness in this case study, and the results obtained are due to the consistency and maintenance of the neural decompression using a direction sensitive therapy protocol.<\/p>\n<\/div>\n

\n

Significance<\/h3>\n

Direction sensitive exercise therapy based on H-reflex testing is effective in treating large herniated lumbar discs.<\/p>\n<\/div>\n<\/div>\n

Keywords:\u00a0<\/strong>Herniated lumbar disc, Lower back pain, H-reflex, Non-surgical therapy, Direction sensitive exercise, Spinal rehabilitation<\/span><\/div>\n<\/div>\n
\n
Go to:<\/a><\/div>\n

1.\u2003Introduction<\/h2>\n

Lower back pain (LBP) management is based on clinical, imaging and electromyographic (EMG) studies. EMG and magnetic resonance imaging (MRI) are generally performed on a patient who is in a resting position. An objective electrophysiological method that is sensitive to nerve root pathologies can be tested on patients while they are lying down or standing up. These tests relate information that can lead to effective treatment strategies (Abdulwahab and Sabbahi, 2000<\/a>,\u00a0Ali Ashraf and Sabbahi, 2001<\/a>,\u00a0Ali and Sabbahi, 2000<\/a>,\u00a0Bronfort et al., 2008<\/a>). This procedure has been under development in our laboratory for several years, with many successful studies that were reported in abstract forms. The procedure is based on testing the amplitudes of H-reflex of patients in static positions (lying and free standing) and during eight different trunk postures (Abdulwahab and Sabbahi, 2000<\/a>,\u00a0Ali Ashraf and Sabbahi, 2001<\/a>,\u00a0Ali and Sabbahi, 2000<\/a>). The H-reflex latency has been used to detect the delayed signal due to neural\/root\u2019s degeneration while ignoring the amplitude that detects axonal dysfunction (Ali and Sabbahi, 2000<\/a>,\u00a0Alrowayeh and Sabbahi, 2011<\/a>). This report presents a single case of a patient with a large (19\u202fmm) herniated disc, with the purpose of discussing the techniques (testing and treatment) and their effect on saving the patient from spinal surgery. A cross-sectional study is currently being prepared for future publication.<\/p>\n

H-reflexes have long been used to test nerve root pathologies (Abdulwahab and Sabbahi, 2000<\/a>,\u00a0Ali Ashraf and Sabbahi, 2001<\/a>). The \u03b1-moto neurons are activated by electrical stimulation of the afferent nerve fibers with the signal passing centrally to the spinal cord; this results in reflex muscle contraction (Fisher, 2002<\/a>). Testing soleus H-reflexes while the patient is standing has resulted in increasing the possibility of detecting minimal neural impingement (Ali Ashraf and Sabbahi, 2001<\/a>). Nerve root impingement might be contained while the patient is lying down, causing an increased H-amplitude. An increased trunk load while a patient is standing may provoke an increased disc protrusion with pressure on the nerve root, resulting in small H-reflex amplitude. Although some studies have tested H-reflexes before and after manipulation therapy, a test on the dynamical changes of H-reflex and its effect on neural pressure are lacking (Sabbahi, 1997<\/a>,\u00a0Suter et al., 2005<\/a>).<\/p>\n

In this study, H-reflex amplitude was measured to evaluate the degree of on-line axonal compression\/decompression during trunk static and dynamic procedures (Abdulwahab and Sabbahi, 2000<\/a>,\u00a0Ali Ashraf and Sabbahi, 2001<\/a>,\u00a0Ali and Sabbahi, 2000<\/a>). Test-retest reliability of H-reflexes on a patient in different positions has been previously reported (Ali and Sabbahi, 2000<\/a>).<\/sup>\u00a0Furthermore, soleus H-reflex amplitude was reported to be 100% specific for lumbosacral radiculopathy (Sabbahi et al., 1990<\/a>).<\/p>\n

\n

1.1. The concept<\/h3>\n

Radiculopathy is a neuro-mechanical disorder caused by compression of the nerve root associated with foraminal narrowing (Fig. 1<\/a>). This compression is mainly direction-sensitive. Decompressing the nerve root can be achieved by direction-sensitive exercise (DSE) therapy (Table 1<\/a>). Identifying the direction of neural compression\/decompression can be accomplished by testing the H-reflexes in \u201cstatic\u201d and \u201cdynamic\u201d protocol. The decompression posture is called the optimum spinal posture (OSP) and the compression posture is called the unwanted spinal posture (USP), (Fig. 2<\/a>), (Sabbahi et al., 2015b<\/a>).\u00a0Fig. 2<\/a>\u00a0shows the reflex amplitude modulations in different trunk positions in an optimal patient presenting both the OSP and the USP.<\/p>\n

\n
\"An<\/div>\n
\n
Fig. 1<\/a><\/div>\n
\n

A spinal segment with disc herniation bulge (left) and a spinal segment with an illustration of possible direction of nerve root impingement in advanced arthritis.<\/p>\n<\/div>\n<\/div>\n<\/div>\n

\n

Table 1<\/h3>\n
\n

Exercise types with loading level. Mobilization (Mob), manipulation (Manip) and strengthening (Strength) protocol during an 8-week period of treatment.<\/p>\n<\/div>\n

\n\n\n\n
\"An<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<\/div>\n
\n
\n
<\/div>\n

\"An<\/a><\/p>\n<\/div>\n

\n
Fig. 2<\/a><\/div>\n
\n

A:<\/strong>\u00a0Dynamic testing of soleus H-reflex in a patient with radiculopathy showing the reflex amplitude in the neutral stand and in different movement directions with the USP (decreased signal) and OSP (recovered) signal amplitudes.\u00a0B<\/strong>; Location of the stimulus electrodes,\u00a0S<\/strong>: stimulus electrode,\u00a0R<\/strong>: recording electrode,\u00a0G<\/strong>: ground electrode.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n

\n
Go to:<\/a><\/div>\n

2.\u2003Case presentation<\/h2>\n

A 40-year old female complained of LBP for 12\u202fyears. Although spine surgery was recommended, the patient rejected it.<\/p>\n

\n

2.1. Clinical examination<\/h3>\n

The patient reported severe pain in the lumbosacral region radiating to the left lower limb, accompanied by a burning sensation on the bottom of the foot and numbness\/tingling and weakness in the leg. A Straight Leg Raise (SLR: a nerve tension test) was limited to 30\u00b0, Achilles tendon reflex was absent in the left foot, and sensory loss in L4-L5 dermatome in the left leg was present.<\/p>\n<\/div>\n

\n

2.2. Functional evaluation<\/h3>\n

The Oswestry LBP disability questionnaire (OD), Visual Analogue Scale (VAS) for pain, gait evaluation (symmetry), tiptoes\/heels walking and self-reported functions were evaluated before and at the end of the program (Table 2<\/a>).<\/p>\n

\n

Table 2<\/h3>\n
\n

Soleus H-reflex amp, MRI, pain intensity, and functional data; before and at the end of the treatment program.<\/p>\n<\/div>\n

\n\n\n\n\n\n\n\n\n\n\n
Limb<\/th>\nEvaluation<\/th>\nSoleus H-reflex amp; mv<\/p>\n
\n<\/th>\n		SLR<\/th>\nVAS<\/th>\nODS<\/th>\nMRI disc herniation size<\/th>\n<\/tr>\n
Prone<\/th>\nStanding<\/th>\n<\/tr>\n<\/thead>\n
Right<\/td>\nBefore<\/td>\n4<\/td>\n4.5<\/td>\n90\u00b0<\/td>\n0<\/td>\n<\/td>\n<\/td>\n<\/tr>\n
After<\/td>\n1.5<\/td>\n2<\/td>\n90\u00b0<\/td>\n0<\/td>\n<\/td>\n<\/td>\n<\/tr>\n
<\/td>\n<\/tr>\n
Left<\/td>\nBefore<\/td>\n0.01<\/td>\n0.01<\/td>\n30\u00b0<\/td>\n7\/10<\/td>\n96%<\/td>\n19\u202fmm<\/td>\n<\/tr>\n
After<\/td>\n3.25<\/td>\n2.75<\/td>\n90\u00b0<\/td>\n1\/10<\/td>\n10%<\/td>\n4\u202fmm<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n
\n
\n

*SLR:<\/strong>\u00a0Straight Leg Raise,\u00a0VAS<\/strong>: Visual analogue scale,\u00a0ODS:<\/strong>\u00a0Oswestry Disability Scale,\u00a0mv<\/strong>: millivolts.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n

\n

2.3. MRI reports<\/h3>\n

\u201cL4-5: large extruded central to left paracentral disc herniation measuring 19\u202fmm in craniocaudal dimension by 11\u202fmm in AP, with marked compression of bilateral L5 nerve root\u201d (Fig. 3<\/a>).<\/p>\n

\n
\n
<\/div>\n

\"An<\/a><\/p>\n<\/div>\n

\n
Fig. 3<\/a><\/div>\n
\n

MRI scan before and at the end of the treatment program.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n

\n

2.4. The electro diagnostic testing\/procedures<\/h3>\n

The patient signed a consent form prior to an EMG\/NCV testing routine using Cadwell Sierra unit (Kennewick, WA). This was followed by a static and dynamic H-reflex test. Although routine EMG\/NCV studies were completed, this report discusses the H-reflex data to represent nerve root function\/dysfunction. The tibial nerve was electrically stimulated in the popliteal fossa using 1\u202fmsec pulses at 0.2\u202fHz, and the signal was recorded using a 1000\u20135000 gain and 10\u202fHz\u201310\u202fK\u202fHz filter. All tests were performed while the patient was prone (Sabbahi et al., 1990<\/a>) as well as while she was standing. The peak to peak amplitudes of the soleus muscle\u2019s H-reflex was measured to identify the degree of reflex asymmetry or lack thereof between both legs (Ali Ashraf and Sabbahi, 2001<\/a>). Five representative traces were recorded in each limb at different phases (lying and standing) of the test. The results identified the left leg with the smaller H-amplitude in both lying and standing positions, indicating the severity of the neural pressure (Sabbahi et al., 2015a<\/a>,\u00a0Sabbahi et al., 2015b<\/a>). Soleus H-reflex of the symptomatic leg was recorded at the end of each trunk direction in order to structure the treatment protocol. Five representative traces were recorded in the following trunk positions; right-side bend (RSB), left-side bend (LSB), backward bend (BB), forward bend (FB), right rotation (RR), left rotation (LR), right-side bend and left rotation (RSB\u202f+\u202fLR), and left-side bend and right rotation (LSB\u202f+\u202fRR). The H-reflexes were measured at the same level of motor-neuron excitability in different movement direction. This was carried out by adjusting the stimulus amplitude to keep the M-response constant during these dynamic tests. These descriptive movement directions were selected to direct the patient to her OSP and a home exercise regime (Fig. 4<\/a>). This dynamic test was carried out at the beginning of the program to structure the treatment protocol, i.e., identify the optimum spinal posture (OSP) and the unwanted spinal posture (USP). Repeatability and H-amplitude stability were maintained by recording the five traces in the static phase at the final range of movements in OSP and USP. This study aims to discuss not only the electrodiagnostic technique and its application to a patient with a 19\u202fmm herniated disc but also the process of physical therapy protocol and its outcome.<\/p>\n

\n
\n
<\/div>\n

\"An<\/a><\/p>\n<\/div>\n