Functional restoration for a chronic lumbar disk extrusion with associated radiculopathy.

The annual incidence of lumbar disk herniation (LDH) has been estimated to be 1% of the population. (1) When an LDH results in clinical evidence of radiculopathy, and if conservative treatment such as medication and physical therapy fails, diskectomy often is recommended. (1,2) There is no consensus, however, as to the most effective conservative treatment for lumbar disk herniation with associated radiculopathy (LDHR). One systematic review indicated some support for the use of epidural steroids for LDHR, but insufficient evidence to support the use of nonsteroidal anti-inflammatory medication, traction, or intramuscular steroids. (3) The use of bed rest for LDHR appears to be ineffective. (4) A study involving 250 patients with acute radiculopathy showed no difference in outcomes among bed rest, physical therapy, and continuing with daily activities. (5)

The current evidence to support exercise-based rehabilitation of patients with LDHR is limited to nonrandomized outcome studies. A case series of 62 patients with chronic (mean=4.6 months) LDHR who underwent exercise rehabilitation and epidural steroid injections reported a 90% success rate and a 92% return-to-work rate at an average follow-up of 31 months. (6) A subsequent magnetic resonance imaging (MRI) study on 11 of the conservatively managed patients with extruded disks showed that 82% of the disk extrusions had reduced in size at a median follow-up of 25 months, and all of the patients appeared to have reduced neural impingement. (7) Another case series of 22 patients with extruded or sequestered lumbar disks (median duration=4.5 weeks) who received conservative management including active exercise, back school, and epidural steroid injections reported a 77% successful clinical outcome at a mean follow-up of 6.9 months. (8) Other case series and cohort studies have revealed similar clinical or radiological success rates between 70% and 90% for patients with LDH who received various conservative treatments that were often poorly described and not standardized. (9-15)

In contrast to the favorable prognosis described in these studies, other reports of patients with sciatica and potential LDH (without radiological confirmation in all subjects) described less favorable outcomes. Tubach et al (16) followed 622 patients with sciatica and found ongoing leg symptoms in 55% of the patients at a 2-year follow-up and in 53% of the patients at a 4-year follow-up. Similar results were reported by Balague et al, (17) with only 29% of patients reporting a full recovery from sciatica after 12 months, and by Nykvist et al, (18) who reported that 82% of conservatively treated patients still had sciatica after 5 years. Variability in recovery rates among the studies cited may be attributable to differences in outcome measures and definitions of successful outcome (16) as well as to differences in the treatment interventions used in the studies.

Another large cohort study involving 507 patients with sciatica showed that 56% of conservatively treated patients reported reduced leg pain at a 1-year follow-up, (19) 60% reported reduced leg pain after 5 years, (20) and 64% reported a reduction after 10 years. (21) These results suggest that the number of patients improving with conservative management slows over time, with the majority of improvement occurring during the first year. The results of other studies (11,17,22) suggest that the majority of clinical and radiological improvement occurs during the first 3 months after onset of symptoms, with fewer patients recovering after this time frame.

In addition to cohort studies and case series, numerous case reports have been published describing excellent clinical or radiological outcomes in patients with LDHR. Notably, however, patients in these studies typically had acute symptoms, (23-28) and studies involving large cohorts of subjects such as those cited above already confirm that the prognosis is often good in such patients regardless of the intervention. Other case reports on patients with a longer duration of symptoms do not provide convincing clinical or radiological evidence that the patient had LDHR. (29-31)

The scarcity of research into the use of exercise-based interventions such as functional restoration (FR) for LDHR is surprising, given the good evidence demonstrating that such interventions can be effective for the management of nonspecific low back pain (NSLBP). (32,33) In particular, patients with LDHR typically are excluded from randomized controlled trials (RCTs) investigating exercise-based interventions such as FR. Functional restoration has been defined as "a multimodal pain management program that employs a comprehensive cognitive-behavioural treatment orientation to help patients better cope with, and manage, their pain ... while undergoing the sports medicine physical approach to correct functional deficits." (34(p483)) Although there is significant variation in the precise content of different described FR programs, they typically include aerobic and strengthening exercises (for the trunk, upper limbs, and lower limbs) specific to the patient's daily activity and work demands. A cognitive-behavioral approach is utilized in FR to address the psychosocial aspects of chronic injury. Functional restoration programs have been shown to be effective for people with chronic NSLBP (32) and subacute NSLBP (35) when conducted by multidisciplinary teams (32) or when supervised by a sole physical therapist. (33,36) Advantages of single-discipline FR programs may include lower costs and wider accessibility for patients.

The purpose of this case report is to describe the management and outcomes of a patient with clinical and radiological evidence of a chronic L5-S1 disk extrusion with associated S1 radiculopathy who completed an FR program supervised by a physical therapist.

Description

History

The patient was a 26-year-old female child care worker from Melbourne, Victoria, Australia. Although she had worked in this capacity for 7 years, she reported a slow onset of low back pain (LBP) and stiffness, which she attributed to additional vacuuming, cleaning, and lifting required of her during renovations taking place at her workplace. She continued working but commenced periodic chiropractic manipulation, which provided temporary symptom relief.

Eight months following the onset of her symptoms, the patient's LBP had increased in intensity, and a gradual onset of left posterolateral leg pain was noted. An MRI scan was performed that demonstrated significant T2 signal loss involving the T12-L1, L4-5, and L5-S1 disks. In addition, a 5-mm left posterolateral extrusion of the L5-S1 disk was identified, with significant displacement and compression of the left S1 nerve root. The patient's physician certified her as unfit for work and prescribed 15 mg/d of meloxicam (Mobic *), a COX-2-inhibiting nonsteroidal anti-inflammatory drug. She commenced Bowen therapy, an alternative form of massage developed by Tom Bowen (1916-1982) in Geelong, Australia, which consists of "rolling the thumbs and forefingers over a muscle or tendon at precise locations triggering a relaxation response." (37(p32) She also increased her chiropractic treatment to 3 sessions per week. This treatment consisted of application of ice to the lumbar area and massage to the lumbar spine and left leg. She said that she did not receive any manipulative treatment at this time. An exercise regimen of spinal flexion and lateral flexion stretches, hip abduction exercises, and general abdominal bracing without attempting to localize the contraction to a particular muscle group also was prescribed by the chiropractor. This treatment continued for 4 months (ie, 12 months after the initial onset of her LBP). In the final month of this treatment, she noticed a progressive increase in left leg pain and onset of peripheral paresthesia. The patient was examined at that time by a neurosurgeon, who recommended an L5-S1 diskectomy, which she declined because she preferred non-surgical treatment. She then was referred for physical therapy by an occupational rehabilitation provider acting on behalf of the compensable insurer to facilitate recovery and return to work.

Reported Symptoms

The initial physical therapy assessment was 1 year following the onset of LBP (4 months following the onset of her left leg symptoms). Her presenting symptoms are illustrated in the pain drawing completed during the initial assessment (Fig. 1). Questioning revealed increased symptoms each morning for up to 3 hours and waking 3 times per night due to lumbar and leg pain. Some authors (38,39) have suggested that such symptoms may be indicative of a chemical or inflammatory component to the pathology. Her symptoms were aggravated by sitting or standing (limited to a maximum of 20 minutes), walking (limited to 30 minutes), coughing or sneezing, and forward-bending activities such as putting on shoes and socks.

[FIGURE 1 OMITTED]

Examination

Visual estimates of lumbar active range of motion (ROM) revealed flexion and lateral flexion (left and right) limited to reaching two thirds down the length of the thigh and extension limited to 15 degrees. All movements were limited by lumbar and leg pain. Straight leg raise was limited to 60 degrees on the left by leg pain, compared with 90 degrees on the right by hamstring muscle resistance. Moderate-intensity palpation centrally and to the left of the L4-5 and L5-S1 vertebral segments reproduced pain and muscle guarding. Neurological examination of the lower limbs revealed normal sensation, an absent left ankle jerk reflex, and decreased strength (force-generating capacity) of the left gastrocnemius muscle, with the patient unable to perform a left leg heel raise while standing.

The patient's ability to perform a localized contraction of the transversus abdominis muscle was assessed visually with the patient in standing and side-lying positions. Some authors (40,41) have reported that more localized activation of the transversus abdominis muscle relative to superficial abdominal muscles is characterized by an inward movement of the lower abdominal wall. The patient demonstrated a technique of global abdominal wall bracing and was unable to isolate the inward movement to the inferior abdomen. Concurrent palpation bilaterally and immediately adjacent to the L4 and L5 spinous processes revealed a poor ability to actively generate tension in the deep fibers of the lumbar multifidus muscle. (40) Evidence exists that these muscles are involved in normal spinal control and are commonly found to be dysfunctional in individuals with LBP. (40,42,43) Furthermore, retraining these muscles has been shown to be efficacious in patients with acute and chronic LBp. (44,45)

The patient scored 48% on the Oswestry Low Back Pain Disability Questionnaire, indicating a moderate level of perceived pain and disability. This is a valid, reliable, and responsive outcome measure for patients with LBP (46,47) and has been used extensively on patients with sciatica or LDH. (46)

Measures of psychosocial status included a pain drawing, nonorganic signs tests, and the Fear-Avoidance Beliefs Questionnaire (FABQ). The results of the nonorganic signs tests, when scored according to reliable and valid protocols, (48,49) did not reveal evidence of significant psychosocial distress or elevated pain behavior. However, 5 out of a possible 6 symptom descriptors were used when completing the pain drawing (Fig. 1) indicating a possible influence of psychosocial distress on her reported symptoms and prognosis. (50,51) In addition, a score of 46/60 on the FABQ indicated a moderate level of fear-avoidance beliefs, which in previous studies on patients with LBP (52,53) was shown to be predictive of poorer outcomes.

Diagnosis

The patient's symptoms and examination findings were consistent with an L5-S1 disk extrusion with resultant compression and potential inflammation of the left S1 nerve root. Despite 12 months of conservative treatment, deteriorating leg symptoms, and a moderate degree of perceived pain and disability, she expressed a strong preference to avoid surgery. In addition to her physical injury, she had a moderate degree of fear-avoidance beliefs and a pain drawing indicative of some psychosocial distress. After detailed explanation and discussion, the patient agreed to cease chiropractic treatment and commence an FR program supervised by a physical therapist.

Intervention

The physical therapist (AJH) who treated the patient had graduated from La Trobe University, Victoria, Australia, with a Bachelor of Physical Therapy with Honours degree 3 years earlier. He had worked for 3 years in private practice at a clinic specializing in exercise-based management of recalcitrant LBP. He had received approximately 100 hours of clinical mentoring from a senior physical therapist (JJF) with 15 years of experience treating patients with LBP and a master's degree in musculoskeletal physical therapy. A second mentor with 7 years of experience had provided a further 100 hours of training. The mentoring provided training in clinical reasoning, clinical assessment, and management of LBP from a biopsychosocial perspective, including the implementation of basic cognitive-behavioral strategies. The treating therapist also had attended several conferences and short professional development courses relating to LBP, including one by Peter O'Sullivan (45) on assessment and management of lumbopelvic instability using a motor skill learning approach (16 hours).

The exercise component of the patient's program consisted of 3 main phases, which are summarized in

Table 1. The phases of management and time frames of key events in the patient's history are presented in a time line in Figure 2.

[FIGURE 2 OMITTED]

Phase 1

In phase 1, the patient attended 2 sessions per week for 4 weeks. She first was educated regarding her injury. A diagram was drawn to demonstrate her L5-S1 disk extrusion. Her left leg symptoms and neurological findings were described in terms of inflammation and mechanical compression of the left S1 nerve root. Reassurance was provided regarding the potential to improve with appropriate management, given the evidence regarding the importance of a positive patient outlook. (54)

The patient was taught self-management strategies aimed at minimizing therapist dependence and empowering the patient to gain control over symptoms. (55) These strategies included self-application of heat to the lumbar spine using a microwave-heated wheat bag with the aim of producing an analgesic affect and reduction of muscle spasm at the depth of the skin and superficial muscles. It is unlikely that the heat could penetrate to the depth of the disk where inflammation may have been active. (56) Inflammation potentially present in and around the disk and nerve root was controlled by continuing with Mobic medication throughout the program (15 mg/d). Although continuing with daily activity was encouraged, she was advised to minimize activities that have been shown to increase intradiskal pressure such as forward flexion activities and flexed sitting. (57) Such caution may not be necessary for all patients, but given the serious nature of the pathology, the avoidance of potentially provocative postures was justified. This was facilitated initially by the application of rigid strapping tape to the patient's lumbar spine area to discourage excessive lumbar flexion. Following 3 weeks of consistent taping, self-management of symptoms by avoidance of provocative postures had been learned and the taping was no longer required. Lumbar spine taping has received little attention in the literature, but has been briefly described previously. (58,59)

In addition to implementing educational and self-management strategies, retraining of the transversus abdominis, lumbar multifidus, and pelvic-floor muscles commenced during phase 1. After education regarding the importance of these muscles, retraining commenced in side-lying and 4-point-kneeling positions. The patient was instructed to relax all lumbar, abdominal, and pelvic muscle groups and then slowly and gently elevate the anterior aspect of her pelvic floor. To activate the transversus abdominis muscle, a slow and gentle inward movement of the lower abdominal wall muscles was performed, while discouraging any significant movement of the upper abdominal wall, spine, and pelvis. (40,41) A submaximal contraction was sustained for 5 seconds initially, while normal and continuous breathing was maintained: Both therapist observation and palpation of the abdominal wall were used to distinguish optimal transversus abdominis muscle contractions from substitution strategies indicative of excessive activation of other muscle groups. (40) The desired visual appearance of the patient's abdominal wall while performing a pelvic-floor and transversus abdominis muscle contraction is demonstrated in Figure 3.

[FIGURE 3 OMITTED]

The coactivation of the lumbar multifidus muscle was checked via bilateral palpation immediately adjacent to the L4 and L5 spinous processes. (40) Concurrent activation of the pelvic-floor, transversus abdominis, and lumbar multifidus muscles is referred to as the patient's "stabilizing pattern" for the purposes of this case report. Initially, the patient practiced the stabilizing pattern at home 3 times per day in a side-lying or 4-point-kneeling position, performing 5 to 10 repetitions of 5-second holds during each session. The therapist reviewed her 3 times over the first 2 weeks to provide feedback regarding her technique, as well as to implement the other educational and self-management strategies described above. After 2 weeks, the patient could perform the stabilizing pattern precisely in these initial positions and was progressed to a standing position for 1 week (2 review sessions). Visual feedback was provided by standing next to a mirror. Dosage was initially the same as for the side-lying and 4-point-kneeling positions, before progressing to 20 second holds. Finally, the patient began to perform the stabilizing pattern while walking for 1 week, holding for up to 20 to 30 seconds.

Phase 2

The next stage of rehabilitation consisted of integrating the stabilizing pattern into a clinic-based, supervised FR program. The patient attended the clinic 3 times per week for a 5-week period, and she completed 2 additional exercise sessions each week at home. Exercises included walking on a treadmill, step-ups onto a 15-cm-high step, and lifting upper-limb dumbbells (bicep curls, forward raises, and bilateral side raises). The patient was instructed to maintain the stabilizing pattern learned during phase 1 while performing all exercises, and the abdominal wall was observed and palpated periodically by the therapist to ensure that optimal transversus abdominis muscle activation was maintained. Upright cervicothoracic posture also was encouraged. Exercises were separated into 3 sets of short duration activities to avoid excessive fatigue of the stabilizing muscles. Program dosage is outlined in Table 2 for each phase of the FR program. The rate of exercise progression was determined by the therapist at the beginning of each session and was based on multiple factors such as response to the previous exercise session, current status of symptoms, and treatment goals. The patient continued with weekly Bowen therapy during phases 1 and 2 of the program because this therapy appeared to provide short-term symptom relief. She then was encouraged to cease the Bowen therapy in light of her improved ability to control her symptoms via self-management strategies and active exercise.

Phase 3

Following phase 2 of the FR program, the patient was reexamined and had demonstrated substantial improvement (see "Outcomes" section). She then commenced phase 3 of management, consisting of a relatively independent exercise program at a public gymnasium. The program was designed by the physical therapist, who attended the gymnasium with her on the first occasion to orientate her to the facilities, introduce her to staff, and demonstrate the appropriate exercises. The patient then attended the gym 3 or 4 times per week independently and was reviewed in the physical therapy clinic periodically for guidance regarding appropriate increases in exercise intensity and addition of new exercises and to review goals. During the first month of the gym program, the physical therapy review sessions occurred weekly, with the frequency then reduced to fortnightly, then monthly, and then once every 6 weeks prior to discharge. Exercises that were added included lateral pull-downs, triceps push-downs, stepper machine, upright stationary bicycle, squats, and lunges. Intensive erector spinae muscle exercises also were added with the patient lying prone on a Swiss ball and lifting her trunk to horizontal. Strengthening of the erector spinae muscle with such exercises has been shown to be effective for managing chronic LBp. (60,61) Exercises for abdominal muscles more superficial to the transversus abdominis muscle also were added, including straight and oblique crunches, with the patient lifting her head and shoulders from a supine position with knees flexed to 90 degrees and feet flat on the floor. The patient maintained her stabilizing pattern while performing all exercises. As the strength and endurance of the patient's stabilizing pattern improved, increases were made in the duration of aerobic exercise and the weight of resistance exercises (Tab. 2).

Goal Setting

Throughout all phases of management, the patient's personal and lifestyle goals were reviewed, which assisted with exercise progression. Initial goals negotiated with the patient for the first 9 weeks of her program included avoiding surgery, achieving a noticeable relief of leg symptoms, improving the activation technique of her stabilizing function, improving her understanding and self-management of her condition, improving sitting and standing tolerances to 30 minutes, and improving walking tolerance to 60 minutes. Establishing return-to-work goals was delayed until the completion of phase 2 of the program, because this was dependent on her clinical progress. Exercise dosage goals also were established and written in an exercise diary kept by the patient. The initial exercise goals set at the start of intervention had been achieved as planned by the end of phase 2 (Tab. 2).

During phase 3, goal setting targeted remaining functional limitations reported by the patient. For example, she reported unresolved LBP while lifting bowls located in the middle of the dining table. Aiming to address this functional limitation, bicep curls and straight-arm forward raises were commenced in varying degrees of lumbar flexion to improve the activation of the core stabilizing muscles in these positions (3 sets of 10 repetitions with 1-kg dumbbells during each gym session). Two months later, the patient's symptoms when performing such activities had resolved. She also expressed an interest in resuming aerobics classes. After her exercise intensity reached a sufficient level, including 10 minutes on the stepper without discomfort, she was encouraged to recommence a step aerobics class once per week. This resulted in mild left lumbar and left posterior thigh aching for 1 day following the first class, but no such reaction occurred during subsequent classes. She was then guided with regard to safe return to higher-intensity pump aerobics classes. The patient was educated with regard to appropriate pacing of activities as she progressively resumed her household tasks such as vacuuming, mopping, and cleaning bathrooms, and she was fully independent in these activities after 6 months in the gymnasium. By the end of intervention, the patient had achieved all of her exercise and lifestyle goals, but had not yet returned to snow skiing or waterskiing due to the risk of aggravation if a heavy fall should occur. She was advised to attempt these in a further 12 months' time.

Cognitive-Behavioral Strategies

Throughout all phases of the exercise program, cognitive-behavioral strategies were used by the physical therapist. In cases where fear-avoidance beliefs are significant, inclusion of cognitive-behavioral strategies has been found to improve outcomes. (62,63) Cognitive strategies included challenging counterproductive beliefs such as unrealistic expectations regarding recovery time frames and emphasizing the relative benefits of active exercise and self-management as opposed to passive treatment. Behavior modification included positive reinforcement of wellness behaviors such as increasing exercise intensity. Certain social behaviors such as returning to social activity and performing domestic tasks also were positively reinforced. However, given the severity of the pathology, this encouragement was closely balanced with advice regarding appropriate pacing to avoid activity beyond the patient's physical capacity. Examples of specific applications of cognitive-behavioral strategies are presented in Table 3. Systematic application of cognitive-behavioral strategies was documented in the patient's clinical notes by the therapist, along with the patient's response to each technique.

Return to Work

The physical therapist and patient's physician decided at the end of phase 2 that the patient should not return to her child care duties because the high load placed on lumbar disks by frequent lifting and bending posed an unacceptable risk of recurrent injury to the injured disk. The patient's rehabilitation provider and employer negotiated an alternative job as a childhood support worker, consisting of administrative duties and field visits to children, but with no lifting or bending required. The patient commenced her alternative job working 4 hours per day, 2 days per week, and had reached full time (40 hours per week) after 8 months in the gymnasium.

Program Costs

The total cost to the patient's compensable insurer for the FR program was AUD$1,616. This included one initial assessment and 44 standard physical therapy consultations over a 2-year period. In Victoria, Australia, compensable insurers pay significantly below-market rates for physical therapy services, hence the costs of a similar treatment program may be higher in other areas. Treatment was most intensive in the first 9 weeks (23 sessions), and the patient was weaned considerably from treatment during the final year (10 sessions) as she became more independent. Two 12-month gymnasium memberships also were paid by the insurer ($350 each).

Outcomes

The patient was fully reexamined at key stages of management (Tab. 4). Following phases 1 and 2 (9 weeks after commencement), she demonstrated substantial improvement in pain, functional abilities, lumbar ROM, neurological examination findings (including the return of her left ankle jerk reflex), and Oswestry Low Back Pain Disability Questionnaire score. Her reduced waking at night and reduced morning stiffness suggested a reduction in inflammation, and her dosage of Mobic medication was consequently reduced (Tab. 4). The patient reported a high level of adherence to her prescribed medication dosage, and this was monitored by her physician and physical therapist at each review. She continued to improve on each subsequent reassessment and had maintained her improvements 2 years after commencing her FR program.

The patient's adherence to attending physical therapy sessions was excellent, as she missed no scheduled session in the first year. She did forget to attend on 2 occasions during the second year, resulting in an overall attendance rate of 95%. Her adherence to attending the gym appeared to average 3 sessions per week when her gym program card was cited at follow-up physical therapy consultations.

A subsequent MRI scan was performed 14 months after intervention (ie, 18 months following her initial MRI). This MRI scan showed that the L5-S1 disk extrusion had resolved, with no remaining evidence of S1 nerve root compression. Her preintervention and postintervention MRI scans are presented in Figure 4.

[FIGURE 4 OMITTED]

Discussion

This case report has shown how an FR program supervised by a physical therapist was used to rehabilitate a 26-year-old female with a 1-year history of back symptoms and a 4-month history of worsening leg symptoms, with clinical and radiological evidence of an L5-S1 disk extrusion compressing the left S1 nerve root. Functional restoration has been shown to be an efficacious conservative management option for patients with subacute or chronic LBP, (32,33,35) but its effectiveness for LDHR is unclear.

While the principles of the patient's rehabilitation were consistent with a traditional FR approach, some key deviations were considered necessary based on the severity of the pathology. Functional restoration does not typically place a strong emphasis on the diagnosis or management of each patient's specific pathology. (64,65)

Indeed, an assumption often is made that the pathology has largely resolved and that the remaining pain and disability are attributable to psychosocial factors and deconditioning due to inactivity. This traditional approach may explain the large number of FR studies that exclude patients with specific pathologies such as LDHR. Although the patient's improvement may well have been due, in part, to the management of psychosocial factors (Tab. 3) and reversing the effects of deconditioning, appropriate diagnosis and management of the primary pathology using evidence-based principles was an additional focus that may have increased effectiveness. The specific diagnosis was used to provide the patient with accurate education regarding her injury, to justify avoidance of potentially provocative activities and postures, to guide the rate of exercise progression, to encourage adherence to Mobic medication aimed at controlling inflammation, and to place an appropriate emphasis on developing precise activation of her stabilizing pattern.

The therapist considered that optimal function of the transversus abdominis, lumbar multifidus, and pelvic-floor muscles would provide dynamic spinal support for the injured L5-S1 disk. Recent evidence (41) supports the validity of the method of muscular activation used for the patient described in this case report. Some studies (44,45) have demonstrated the physical benefits of specific retraining of these muscle groups in patients with low back injuries. The phases and progression of our program were derived from the motor skill learning approach of retraining these muscles. (40) This approach commences with learning to perform a specific and selective contraction of the transversus abdominis, lumbar multifidus, and pelvic-floor muscles in low-load, static positions (phase 1 of our treatment protocol). This muscular activation is incorporated into progressively more functional positions and exercises (phase 2) and then is regularly integrated into all of the patient's exercise and daily activities (phase 3). The ultimate rehabilitation goal is to reach an autonomous stage whereby the skill of activating the stabilizing muscles becomes automatic without conscious attention. Although most FR programs typically include some form of trunk strengthening exercises, the precise activation of the transversus abdominis, lumbar multifidus, and pelvic-floor muscles followed by a gradual transition of this muscle activation into an FR program has not been commonly described. Gaining optimal control of these muscles before progressing to higher-intensity functional exercises was fundamental to the management of our patient with LDHR and has been shown to be effective in an RCT involving patients with spondylolisthesis. (45)

The patient described in the case report demonstrated marked improvement both clinically and radiologically. This report adds to the existing studies that showed favorable outcomes in patients with LDHR undergoing exercise-based intervention. (6,8) In those studies, however, patients may have also received epidural steroid injections, which have been shown to be effective as a standalone treatment, (3) whereas our patient did not receive such injections. Other case reports have focused on patients with acute LDHR for whom the prognosis was good (23-28) or on patients with chronic conditions without convincing clinical or radiological evidence of LDHR. (29-31) Several studies (11,17,19,20,22) have suggested that the majority of patients undergoing conservative treatment for LDHR demonstrate most improvement during the first 3 months following symptom onset, after which time surgery is often the recommended option. (1,2) Our patient had reported worsening radicular symptoms for 4 months prior to commencing her FR program, but she began to report substantial improvement 4 to 6 weeks after commencing the FR program. It is unlikely that resolution of the patient's disk extrusion commenced until her symptoms began to improve during her FR program, because studies (11,14,66) have shown that morphologic changes in disk herniations seen on imaging typically lag behind improvements in patients' symptoms.

At the time of entry to our treatment program, the patient was a surgical candidate based on descriptions of inclusion criteria for diskectomy. (l,2) Due to the absence of RCTs investigating FR for LDHR or comparing surgery with FR, the relative value of these interventions for such patients is currently unclear. The patient described in this case report chose conservative management primarily due to her preference to avoid surgery. Other patients with LDHR may potentially benefit from a similar FR management approach outlined here prior to surgical intervention, but it is unlikely that all patients with LDHR would attain an outcome similar to that achieved by our patient. Research is needed to determine the proportion of patients with LDHR who would benefit from FR as opposed to surgery, as well as to identify factors that predict a given patient's likely response to each of these respective interventions. Investigations into such questions would require RCTs that involve patients with LDHR.

A limitation of our examination procedures relates to the use of visual measurements of ROM, straight leg raise, and stabilizing muscle function by the therapist. There is presumably a large margin for error in visual estimates, so the reported values should be considered estimates only. Despite large margins for measurement error, it is plausible that improvement did occur in these values throughout the intervention period given the large magnitude of improvement recorded in these variables. In addition, impairment measurements such as ROM were only one of several outcomes followed, with validated measures such as the Oswestry Low Back Pain Disability Questionnaire also demonstrating marked improvement. The changes recorded in the patient's Oswestry scores (Tab. 4) were considerably greater than the 10 percentage points required to be 90% confident that a real change had occurred (minimum detectable change). (47) Other standard clinical and radiological measures such as neurological examination findings, work status, medication dosage, and MRI findings provide further evidence of significant improvement in the patient's status.

Conclusion

Several case series, cohort studies, and case studies suggest that the prognosis for patients with LDHR receiving conservative management is good, although studies focusing on exercise-based management of patients with chronic LDHR are scarce. This case report adds to the current literature by reporting a detailed description of an FR approach to managing a patient with a chronic L5-S1 disk extrusion and associated S1 radiculopathy that was confirmed by clinical and radiological examination. Research is needed to determine the efficacy of FR approaches for managing patients with LDHR.

This article was received November 18, 2005, and was accepted August 7, 2006.

References

(1) McCulloch JA. Focus issue on lumbar disc herniation: macro- and microdiscectomy. Spine. 1996;21(24 suppl):45S-56S.

(2) Gibson JN, Grant IC, Waddell G. The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis. Spine. 1999;24:1820-1832.

(3) Vroomen PC, de Krom MC, Slofstra P, et al. Conservative treatment of sciatica: a systematic review. J Spinal Disord. 2000;13:463-469.

(4) Vroomen PC, de Krom M, Wilmink JT, et al. Lack of effectiveness of bed rest for sciatica. N Engl J Med. 1999;340:418-423.

(5) Hofstee D, Gijtenbeek J, Hoogland P, et al. Weseinde sciatica trial: randomized controlled study of bed rest and physiotherapy for acute sciatica. J Neurosurg. 2002;96:45-49.

(6) Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy: an outcome study. Spine. 1989;14:431-437.

(7) Saal JA, Saal JS, Herzog RJ. The natural history of lumbar intervertebral disc extrusions treated nonoperatively. Spine. 1990;15:683-686.

(8) Ahn S, Park H, Byun W, et al. Comparison of the clinical outcomes and natural morphologic changes between sequestered and large central extruded disc herniation. Yonsei Med J. 2002;43:283-290.

(9) Alaranta H, Hurme M, Einola S, et al. A prospective study of patients with sciatica: a comparison between conservatively treated patients and patients who have undergone operation, part II: results after one year follow-up. Spine. 1990;15:1345-1349.

(10) Ellenberg M, Ross M, Honet J, et al. Prospective evaluation of the course of disc herniations in patients with proven radiculopathy. Arch Phys Med Rehabil. 1993;74:3-8.

(11) Komori H, Shinomiya K, Nakai O, et al. The natural history of herniated nucleus pulposus with radiculopathy. Spine. 1996;21:225-229.

(12) Masui T, Yukawa Y, Nakamura S, et al. Natural history of patients with lumbar disc herniation observed by magnetic resonance imaging for minimum 7 years. J Spinal Disord Tech. 2005;18:121-126.

(13) Shvartzman L, Weingarten E, Sherry H, et al. Cost-effectiveness analysis of extended conservative therapy versus surgical intervention in the management of herniated lumbar intervertebral disc. Spine. 1992;17:176-182.

(14) Takada E, Takahashi M, Shimada K. Natural history of lumbar disc hernia with radicular leg pain: spontaneous MRI changes of the herniated mass and correlation with clinical outcome. J Orthop Surg (Hong Kong). 2001;9:1-7.

(15) Zentner J, Schneider B, Schramm J. Efficacy of conservative treatment of lumbar disc herniation. J Neurosurg Sci. 1997;41:263-268.

(16) Tubach F, Beante J, Leclerc A. Natural history and prognostic indicators of sciatica. J Clin Epiclemiol. 2004;57:174-179.

(17) Balague F, Nordin M, Sheikhzadeh A, et al. Recovery of severe sciatica. Spine. 1999;24:2516-2524.

(18) Nykvist F, Hurme M, Alaranta H, et al. A prospective 5-year follow-up study of 276 patients hospitalized because of suspected lumbar disc herniation. Int Disabil Stud. 1989;11:61-67.

(19) Atlas S, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, part II: 1-year outcomes of surgical and non-surgical management of sciatica. Spine. 1996;21:1777-1768.

(20) Atlas S, Keller R, Chang Y, et al. Surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: five-year outcomes from the Maine Lumbar Spine Study. Spine. 2001;26:1179-1187.

(21) Atlas S, Keller R, Wu Y, et al. Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the Maine Lumbar Spine Study. Spine. 2005;30:927-935.

(22) Webber H. Lumber disc herniation: a controlled, prospective study with ten years of observation. Spine. 1983;8:131-140.

(23) Bergman T, Jogeward B. Manipulative therapy in lower back pain with leg pain and neurological deficit. J Manipulative Physiol Ther. 1998;21:288-294.

(24) Fritz J. Use of a classification approach to the treatment of 3 patients with low back syndrome. Phys Ther. 1998;78:766-777.

(25) Grasland A, Pouchot J, Vinceneux P. Spontaneous regression of disc herniation. J Rheumatol. 2004;31:821.

(26) Morris C. Chiropractic rehabilitation of a patient with S1 radiculopathy associated with a large lumbar disk herniation. J Manipulative Physiol Ther. 1999;22:38-44.

(27) Reyentovich A, Abdu WA. Multiple independent, sequential, and spontaneously resolving lumbar intervertebral disc herniations: a case report. Spine. 2002;27:549-553.

(28) Slavin K, Raja A, Thornton J, et al. Spontaneous regression of a large lumbar disc herniation: report of an illustrative case. Surg Neurol. 2001;56:333-337.

(29) Cox J, Hazen L, Mungovan M. Distraction manipulation reduction of an L5-S1 disk herniation. J Manipulative Physiol Ther. 1993;16: 342-346.

(30) Koury M, Scarpelli E. A manual therapy approach to evaluation and treatment of a patient with a chronic lumbar nerve root irritation. Phys Ther. 1994;74:548-560.

(31) Polkinghorn B, Colloca C. Treatment of symptomatic lumbar disc herniation using activator methods chiropractic technique. J Manipulative Physiol Ther. 1998;21:187-196.

(32) Guzman J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ. 2001;322: 1511-156.

(33) Schonstein E, Kenny D, Keating J, et al. Physical conditioning programs for workers with back and neck pain: a Cochrane systematic review. Spine. 2003;28:E391-E395.

(34) Mayer TG, Gatchel RJ, Kishino N, et al. Objective assessment of spine function following industrial injury; a prospective study with comparison group and one-year follow up. Spine. 1985;10:482-493.

(35) Karjalainen K, Malmivaara A, van Tulder M, et al. Multidisciplinary biopsychosocial rehabilitation for subacute low back pain in working-age adults: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine. 2001;26:262-269.

(36) Liddle S, Baxter G, Gracey J. Exercise and chronic low back pain: what works? Pain. 2004;107:176-190.

(37) Dicker A. Bowen technique: its use in work-related injuries. Aust J Holistic Nurs. 2005;12:31-34.

(38) Deyo RA, Rainville J, Kent D. What can the history and physical examination tell us about low back pain? JAMA. 1992;268:760-765.

(39) Foldes K, Balint P, Gaal M, et al. Nocturnal pain correlates with effusions in diseased hips. J Rheumatol. 1992;19:1756-1758.

(40) Richardson C, Hodges P, Hides J. Therapeutic Exercise for Lumbopelvic Stabilisation: A Motor Control Approach for the Treatment and Prevention of Low Back Pain. 2nd ed. Edinburgh, United Kingdom: Churchill Livingstone; 2004.

(41) Urquhart D, Hodges P, Allen T, et al. Abdominal muscle recruitment during a range of voluntary exercises. Man Ther. 2005;10: 144-153.

(42) Hodges P. Is there a role for transversus abdominis in lumbo-pelvic stability? Man Ther. 1999;4:74-86.

(43) Hodges PW, Richardson CA. Inefficient muscular stabilisation of the lumbar spine associated with low back pain. Spine. 1996;21: 2640-2650.

(44) Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine. 2001;26: E243-E248.

(45) O'Sullivan P, Twomey L, Allison G. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine. 1997;22: 2959-2967.

(46) Roland M, Fairbank J. The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine. 2000;25:3115-3124.

(47) Davidson M, Keating J. A comparison of five low back disability questionnaires: reliability and responsiveness. Phys Ther. 2002;82:8-24.

(48) Werneke M, Harris D, Lichter R. Clinical effectiveness of behavioral signs for screening chronic low-back pain patients in a work-oriented physical rehabilitation program. Spine. 1993;18:2412-2418.

(49) Waddell G, McCulloch J, Kummel E, et al. Nonorganic physical signs in low back pain. Spine. 1979;5:117-125.

(50) Ohlund C, Eek C, Palmblad S, et al. Quantified pain drawing in subacute low back pain: validation in a nonselected outpatient industrial sample. Spine. 1996;21:1021-1031.

(51) Ransford A, Cairns D, Mooney V. The pain drawing as an aid to the psychologic evaluation of patients with low-back pain. Spine. 1976;1: 127-134.

(52) Waddell G, Newton M, Henderson I, et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993;52:157-168.

(53) Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317-332.

(54) Indahl A, Haldorsen E, Holm S, et al. Five-year follow-up study of a controlled clinical trial using light mobilization and an informative approach to low back pain. Spine. 1998;23:2625-2630.

(55) Harding V, Williams A. Extending physiotherapy skills using a psychological approach: cognitive-behavioural management of chronic pain. Physiotherapy. 1995;81:681-688.

(56) Lehmann J, Silvermann D, Baum B, et al. Temperature distribution in the human thigh produced by infrared, hot pack and microwave applications. Arch Phys Med Rehabil. 1966;47:291-299.

(57) Nachemson A. Towards a better understanding of low-back pain: a review of the mechanics of the lumbar disc. Rheumatol Rehabil. 1975; 14:129-143.

(58) Baquie P. Taping: general principles. Aust Fam Physician. 2002;31: 155-157.

(59) Hammill JM. Taping procedures for low back pain. Clinical Management. 1988;8(1):5.

(60) Manniche C, Asmussen K, Lauritsen B, et al. Intensive dynamic back exercises with or without hyperextension in chronic back pain after surgery for lumbar disc protrusion: a clinical trial. Spine. 1993;18: 560-567.

(61) Hansen F, Bendix T, Skov P, et al. Intensive, dynamic back-muscle exercises, conventional physiotherapy, or placebo-control treatment of low-back pain. Spine. 1993;18:98-108.

(62) Morley S, Eccleston C, Williams A. Systematic review and metaanalysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80:1-13.

(63) van Tudler M, Ostelo R, Vlaeyen JW, et al. Behavioral treatment for chronic low back pain: a systematic review within the framework of the Cochrane Back Review Group. Spine. 2000;26:270-281.

(64) Mayer T, Gatchel R, Mayer H, et al. A prospective two-year study of functional restoration in industrial low back injury. JAMA. 1987;258: 1763-1767.

(65) Hazard RG, Fenwick JW, Kalisch SM, et al. Functional restoration with behavioral support: a one-year prospective study of patients with chronic back pain. Spine. 1989;14:157-161.

(66) Benoist M. The natural history of lumbar disc herniation and radiculopathy. Joint Bone Spine. 2002;69:155-160.

* Boehringer Ingelheim Pharmaceuticals Inc, a subsidiary of Boehringer Ingelheim Corp, 900 Ridgebury Rd, PO Box 368, Ridgefield, CT 06877-0368.

AJ Hahne, BPhysio(Hons), is a physical therapist with Spinal Management Clinics, Melbourne, Victoria, Australia. Address all correspondence to Mr Hahne at: [e-mail].

JJ Ford, PhD, MPhysio, BAppSc(Physio), Cred MDT, is General Manager, Spinal Management Clinics of Victoria, and Lecturer, School of Physiotherapy, University of Melbourne, Melbourne, Victoria, Australia.

Both authors provided writing, data analysis, and facilities/equipment. Mr Hahne provided concept/idea/project design, data collection, project management, and the patient. Dr Ford provided institutional liaisons and consultation (including review of manuscript before submission).

Table 1.
The 3 Phases of Management

                 Phase 1                     Phase 2

Duration         4 wk                        5 wk
No. of physical  8 (2 sessions per weeks     15 (3 sessions per week)
  therapy
  consultations
Content          Teaching and practice of    Appropriate stabilizing
                   appropriate stabilizing     pattern incorporated
                   pattern                     into a functional
                 Education regarding injury    restoration program
                   and recovery                supervised in the
                 Implementation of             clinic by a physical
                   self-management             therapist
                   strategies

                 Phase 3

Duration         2 y
No. of physical  21 over 2 y
  therapy
  consultations
Content          Exercise program continued
                   independently at gymnasium
                 Reviews in clinic with
                   physical therapist for
                   goal setting and guidance
                   with exercise progression

Table 2.

Exercise Dosage and Progression at Key Stages of Management

                      Commencement of         End of
                      Phase 2                 Phase 2

Aerobic training
  Treadmill           3 x 2 min @ 2.5 kph     2 x 5 min at 4.5 kph
  Steps               3 x 8                   3 x 30
  Stepper machine
  Stationary bicycle

Resistance training
  Dumbbells
    Bicep curls                               3 sets of 18 (1 kg)
    Forward raises                            3 sets of 10 (1 kg)
    Side raises                               3 sets of 10 (1 kg)
    Lunges
  Lateral pull-down
  Tricep push-down
  Lunges
  Abdominal crunches

  Erector spinae
    muscle exercise
  Swiss ball squats
    against wall
Classes

                      After 4 Months          After 2 Years
                      of Gymnasium            of Gymnasium

Aerobic training
  Treadmill           1 x 10 min at 6.5 kph   1 x 15 min at 6.5 kph
  Steps
  Stepper machine     2 x 5 min               1 x 15 min
  Stationary bicycle  1 x 10 min              1 x 15 min

Resistance training
  Dumbbells
    Bicep curls       3 sets of 15 (2 kg)     2 sets of 15 (5 kg)
    Forward raises    3 sets of 15 (1 kg)     2 sets of 15 (3 kg)
    Side raises       3 sets of 15 (1 kg)     2 sets of 15 (3 kg)
    Lunges            3 sets of 10 (2 kg)     2 sets of 10 (5 kg)
  Lateral pull-down   3 x 10 (10 kg)          3 x 10 (20 kg)
  Tricep push-down    3 x 10 (10 kg)          3 x 10 (15 kg)
  Lunges              3 x 10 (2 kg)           3 x 15 (5 kg)
  Abdominal crunches  3 x 10 (straight)       3 x 15 (straight and
                                                oblique)
  Erector spinae      3 x 10 (unilateral leg  3 x 15 (lifting upper
    muscle exercise     extensions)             torso)
  Swiss ball squats   3 x 10                  3 x 20
    against wall
Classes               Step aerobics           Step aerobics
                                              Pump aerobics

Table 3.
Examples of the Application of Cognitive-Behavioral Strategies

Context                 Strategy Applied        Purpose of Strategy

After 3 treatment       The counterproductive   Assist the patient in
  sessions, the           belief regarding        gaining appropriate
  patient expressed       unrealistic recovery    beliefs regarding
  concern regarding       time frames was         realistic recovery
  ongoing back and leg    challenged leg, "it     time frames and
  pain (the pain had      is too early to         reduce anxiety
  not increased, but      expect improvement      regarding lack of
  had not improved).      yet. For your           improvement to date.
                          injury, it will
                          likely take several
                          weeks of exercise
                          before you will
                          notice much change
                          in your symptoms.

At the beginning of     The patient's positive  Attempt to maintain
  phase 2, the patient    progress to date        focus on
  reported some           with her exercise       rehabilitation and
  depression following    program was             avoid distraction or
  breaking up with her    reinforced, and she     loss of  motivation
  partner. This had       was encouraged to       by a social
  the potential to        maintain her focus      situation.
  distract her from       on the goals set at   Ensure appropriate
  the program and         the beginning of the    management
  reduce motivation       program. The patient    strategies for the
  and adherence.          was encouraged to       normal emotions
                          seek social support     associated with her
                          from family and         relationship
                          friends to assist       breakup. This would
                          with this difficult     ensure that the
                          time.                   patient's
                                                  rehabilitation time
                                                  was used for
                                                  exercise rather than
                                                  regular discussion
                                                  with the physical
                                                  therapist about the
                                                  issue.
During phase 2 of her   The physical therapist  Positively reinforce
  program, the patient    advised, "You are       engagement in
  asked if it was safe    managing well with      appropriate physical
  for her to visit the    your exercise           and social
  beach with friends      program, so you         activities leg,
  on the weekend.         should manage well      going to the beach/,
                          with a trip to the      while maintaining
                          beach. Some walking     appropriate pacing
                          in the water may be     strategies leg,
                          a beneficial            avoiding more
                          exercise for you,       strenuous
                          but I wouldn't          activities).
                          recommend surfing or
                          more strenuous beach
                          games at this
                          stage." When the
                          patient later
                          reported that she
                          had gone to the
                          beach without any
                          increase in
                          symptoms, this was
                          positively
                          reinforced by praise
                          and conversation
                          regarding her
                          enjoyment of this
                          activity.

After 8 weeks of        The patient was fully   Reassessment of the
  intervention, the       re-examined by the      patient's condition
  patient was involved    physical therapist      after a potential
  in a motor car          on the day of her       aggravation provided
  accident and            accident and found      reassurance to the
  demonstrated anxiety    to have sustained no    therapist and
  regarding potential     serious injuries.       patient that the
  exacerbation of her     Her examination         injury had not been
  back injury.            findings in relation    aggravated. This
                          to baseline had         allowed the program
                          actually improved,      to continue without
                          and this was used to    unnecessary
                          reassure the patient    interruption and
                          that no exacerbation    minimized the
                          was apparent to her     patient's anxiety
                          back injury. She was    regarding her
                          advised to continue     accident.
                          with her exercise
                          program the
                          following day, and
                          this wellness
                          behavior was
                          positively
                          re-enforced by
                          praise and social
                          contact during her
                          exercise program.

Table 4.
Assessment Findings at Key Stages of Management (a)

                                              End of Phase 2
                     Initial                  (9 Weeks
                     Assessment               Postassessment)

Symptoms             Constant lumbar and      Reduced lumbar
                       left leg ache            ache
                     "Pins and needles"       Leg ache 2x/wk
                       left foot              No "pins and
                                                needles"
Inflammation
  Waking at night    3x/night                 Nil
  Morning stiffness  3 h                      Nil

Medication
  Mobic              1 x 15 mg/d              1 x 15 mg/d

Function reports
  Sitting time       20 min (P2)              40 min (P2)
  Standing time      20 min (P2)              30 min no pain
  Walking time       30 min (P2)              1 h no pain
  Shoes/socks        Unable to do             Not difficult
  Coughing/sneezing  Maximally painful        Somewhat painful

Range of motion
  Flexion            Reaching two thirds      Reaching one half
                       length of thigh          length of shin

  Extension          15[degrees]              35[degrees]

Neurological
  Reflexes           Absent ankle jerk L      Ankle jerk present
  Myotomes           L heel raise very        L heal raise
                       difficult                normal
  Dermatomes         Normal                   Normal
Straight leg raise   L=60[degrees]            L=75[degrees]
                     R=90[degrees]            R=90[degrees]
Stabilization        Poor                     Good
  pattern
Oswestry             48%                      22%
Work status          Off work                 Commenced
                                                alternative job
FABQ                 46/60                    43/60

                     After 4 Months
                     of Gymnasium/
                     Phase 3                  After 1 Year
                     (6 Months                of Gymnasium
                     Postassessment)

Symptoms             Feels "stronger"         Feels "even
                     General lumbar             stronger"
                       soreness               General lumbar
                     No leg symptoms            soreness
                                              No leg symptoms
Inflammation
  Waking at night    Nil                      Nil
  Morning stiffness  Nil                      Nil

Medication
  Mobic              1 x 7.5 mg/d             1 x 7.5 mg/mo

Function reports
  Sitting time       2 h                      2 h
  Standing time      30+ min                  2-3 h no pain
  Walking time       No limit                 No limit
  Shoes/socks        Not difficult            Not difficult
  Coughing/sneezing  Not painful              Not painful

Range of motion
  Flexion            Reaching two thirds      Reaching two
                       length of shin           thirds length of
                                                shin
  Extension          45[degrees]              45[degrees]

Neurological
  Reflexes           Normal                   Normal
  Myotomes           Normal                   Normal

  Dermatomes         Normal                   Normal
Straight leg raise   L=80[degrees]            L=80[degrees]
                     R=90[degrees]            R=90[degrees]
Stabilization        Excellent                Excellent
  pattern
Oswestry             20%                      18%
Work status          25 h/wk                  40 h/wk

FABQ                 40/60                    31/60

                     After 2 Years
                     of Gymnasium

Symptoms             Feels 80% of
                       normal
                     General lumbar
                       soreness
                     No leg symptoms
Inflammation
  Waking at night    Nil
  Morning stiffness  Nil

Medication
  Mobic              Nil

Function reports
  Sitting time       2.5 h
  Standing time      2-3 h no pain
  Walking time       No limit
  Shoes/socks        Not difficult
  Coughing/sneezing  Not painful

Range of motion
  Flexion            Reaching two
                       thirds length of
                       shin
  Extension          45[degrees]

Neurological
  Reflexes           Normal
  Myotomes           Normal

  Dermatomes         Normal
Straight leg raise   L=80[degrees]
                     R=90[degrees]
Stabilization        Excellent
  pattern
Oswestry             14%
Work status          40 h/wk

FABQ                 31/60

(a) P2=maximum possible due to pain,
L=left, R=right, Oswestry=Oswestry
Low Back Pain Disability Questionnaire,
FABQ=Fear-Avoidance Beliefs Questionnaire.