A CASE STUDY ON THE MANAGEMENT OF LOW BACK PAIN USING HOT PACK,EXERCISE, MASSAGE AND POSTURAL EDUCATION.   

A CASE STUDY SUBMITTED TO ST. JOHN OF GOD COLLEGE OF HEALTH DUAYAW NKWANTA - BRONG AHAFO AS PARTIAL FULFILLMENT FOR THE AWARD OF DIPLOMA IN PHYSIOTHERAPY

MARCH 2018

BY:ASARE PRINCE, ELLONYE PASCAL, OSEI KONADU BRIDGET, OWUSUA CECILIA, BERNARD ACHEAMPONG   

DECLARATION 

We declare that this work was done by us and has never been done by anybody in this school. All sources used or quoted are duly indicated and acknowledged by means of complete references. 

DEDICATION

We dedicate this work to the Almighty God for the strength and wisdom to do this work, we also dedicate this work to our parents and guardians for trusting us with their support, finances and prayers. We say God bless them. We again dedicate this case study to our supervisor Mr. John Agana Ayamga for their constructive corrections and support throughout our stay in this college.
We say God bless you.   

ACKNOWLEDGEMENT

We thank God for seeing us through and how far He has brought us. We also show gratitude to our client Mr. Daglah Vincent for her permission and cooperation. We acknowledge the tremendous efforts of our supervisor Mr. John Agana Ayamga and the entire administrative staff of the St John of God College of Health. To our families, we say a big thank you for your support and encouragement.   

   CHAPTER ONE

 

                           INTRODUCTION                                           

1.1 Background

Low back pain remains a prevalent health burden according to epidemiological data with an increasing length in years lived with disability (Vos et al,2012) and an increasing financial burden globally (Hoy et al, 2012). Low back pain is defined as “pain that occurs posteriorly in the region between the lower rib margin and the proximal thighs” (Kinkade, 2007). Pain can vary from a dull constant ache to a sudden sharp feeling. According to European Guidelines for Prevention of Low Back Pain (2004), low back pain may be classified by duration as acute (pain lasting less than six weeks), sub-chronic (pain lasting between six to twelve weeks), or chronic (pain lasting more than twelve weeks). The condition may further be classified as either mechanical, non- mechanical or referred pain.

 

Some of the common causes of low back pain include; sprain and strain which account for most acute back pain as a result of overstretching or tearing ligaments, intervertebral disc degeneration which when happens the discs deteriorate and they lose their cushioning ability (Rousselin, 1990), herniated or ruptured discs, radiculopathy, sciatica which is caused by compression of the sciatic nerve, spondylolisthesis, a traumatic injury and spinal stenosis (Grobler, 1993). 

 

In the common presentation of low back pain, pain develops after movement that involves lifting, twisting, or forward bending. The symptom may start soon after the movement or upon waking up the following morning. It may or may not worsen with certain movements such as raising the leg, or positions such as sitting or standing (Casazza, 2012). 

Low back pain can be managed through physical therapy such as exercises, heat therapy, therapeutic massage and back schooling as stated by some literatures (Kumar et al, 2014). A back school is an educational program that teaches practical information about back care, posture, body mechanics, back exercises, and how to prevent long term back problems. Some of the complications of low back pain include; nerve damage as a result of increased pressure on the nerves that run through the spinal canal, weight gain as a result of restricted mobility, and loss of work due to disability (Clifton et a, 1994). Considering the unicity of this case, we find interest in following it to know the outcome of the physiotherapy interventions prescribed.

1.2 MAIN OBJECTIVE

To find out treatment outcome of therapeutic exercises, hot pack, massage and postural education on a low back pain patient.

1.3 Specific Objectives i To reduce pain level from 4/10 to 0/10 on VAS scale within the eight weeks of study.  ii To improve core muscles strength from 3/5 to 4/5 within the eight weeks of study. iii To educate patient on correct sitting postures within the eight weeks of study.

1.4 Problem Statement

Injuries to the lumbar spine are painful, chronic and in most cases non-reversible conditions, and the individuals suffering from them are unable to attend to their social, occupational and other daily activities. Pain in the lumbar spine and systematic drug intake become a part of the daily routine of these persons, and usually they will accompany them from the third decade of their lives onwards (Roupa et al, 2006).

According to the results of studies carried out in the United States, low back pain is the most frequent reason for temporary disability among the population at large in the age group under 45, and in persons age 45-56, it is the third most frequent reason leading to the restriction of physical activity of individuals having suffered heart trouble and rheumatic diseases. It is generally accepted that nursing staff belong to the group of high risk professions with regard to the occurrence of musculoskeletal injuries, especially in the area of the lumbar spine (Hignett, 1996).

  CHAPTER TWO

 LITERATURE REVIEW

2.1 Low Back Pain

 European Guidelines for Prevention of Low Back Pain (2004) defines low back pain as “pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain. Similarly, low back pain can also be defined as pain that occurs posteriorly in the region between the lower rib margin and the proximal thighs (kinkade, 2007). Low back pain is a common problem and a major cause of disability. The 2010 global burden of disease study estimated that low back pain is among the top 10 diseases and injuries that accounts for the highest number of disability adjusted life years worldwide (Lancet, 2012). The life time prevalence of low back pain is estimated at about 50%-70% in the developed countries. In Africa, there is a global assumption that low back pain prevalence is comparatively lower than developed countries. Low back pain is mostly seen in farmers, bankers, drivers, traders, doctors, nurses and weight lifters (Quinette and Karen, 2007). The most common form of low back pain is the one that is called “non-specific low back pain” and is defined as “low back pain not attributed to recognizable, non-specific pathology” (European Guidelines for Prevention of Low Back Pain, 2004).

 2.1.1 Classification of Low Back Pain

According to the European Guidelines for Prevention of Low Back Pain (2004), low back pain may be classified by duration as acute (pain lasting less than six weeks), sub-chronic (pain lasting between six to twelve weeks), or chronic (pain lasting more than twelve weeks).  

2.1.2  Causes

First and foremost, the nerves of the lumbar spine can be irritated by mechanical pressure (impingement) by bone or other tissues, or from disease, anywhere along their paths- from their roots at the spinal cord to the skin surface causing nerve irritation (Clifton et al, 1994). Secondly, the stress that poor posture exerts on the spine can lead to anatomical changes in the spine. This in turn can cause back pain through the constriction of blood vessels and nerves. The stress can also cause problems with the muscles, discs and joints as a result of poor posture. Furthermore, damage to the disc occurs because of degeneration (wear and tear) of the outer ring of the disc, traumatic injury or both. As a result, the central softer portion of the disc can rupture (herniate) through the outer ring of the disc and about the spinal cord or its nerves as they exit the bony spinal column.

This rupture is what causes the commonly recognized “sciatica” pain of herniated disc that shoots from the lower back and buttocks down the leg, this is known as lumbar radiculopathy (Clifton et al, 1994).

In addition, there is bony encroachment where any condition that results in movement or growth of the vertebrae of the lumbar spine can limit the space (encroachment) for the adjacent spinal cord and nerves. Finally, arthritis is also one of the causes of low back pain. Thus, spondyloarthropathies are inflammatory types of arthritis that can affect the lower back and sacroiliac joints. Examples include; reactive arthritis (Reiter’s disease), ankylosing spondylitis, psoriatic arthritis, and arthritis of inflammatory bowel diseases (Clifton et al, 1994).

2.1.3   Pathophysiology

The lower back is made up of five vertebrae (L1-L5), sometimes including the sacrum. In between these vertebrae are fibro-cartilaginous discs (Hughes, 2012). The intervertebral disc is the main joint between two consecutive vertebrae in the vertebral column. Each disc consist of three different structures: an inner gelatinous nucleus pulposus, an outer annulus fibrosis that surrounds the nucleus pulpous and two cartilage endplates that covers the upper and lower surface of the vertebral bodies (Borczuk, 2013).  The disc act as cushion, preventing the vertebrae from rubbing together and protecting the spinal cord. Nerves come from and go to the spinal cord through specific opening between the vertebrae. 

Stability of the spine is provided by the ligaments and muscles of the back and abdomen. Small joints called facet joints limit and direct the movement of the spine (Floyd et al, 2008). Over time, the discs loose flexibility and ability to absorb physical forces (Borczuk, 2013). This decrease the ability to handle physical forces that increases stress on other part of the spine to thicken and bony growth to develop on the vertebrae. As a result, there is less space through which the spinal cord and the nerve roots may pass (Borczuk, 2013). When a disc degenerates as a result of injury or disease, the makeup of the disc changes: blood vessels and nerves may grow into its interior or herniated disc material can push directly on a nerve root. Any of these changes may result in back pain (Hughes, 2012).

2.1.4 Clinical Features of Low Back Pain

Low back pain can cause a wide variety of symptoms and signs depending on the precise cause of the pain. Symptoms that can be associated with low back pain include: numbness or tingling of the lower extremities, incontinence of urine or stool, inability to walk without worsening pain, lower extremities weakness, atrophy (decrease in size) of lower extremities muscles, joint pain and fatigue (Makhsous et al,  2009).   

2.1.5 Complication

Disability is one of the complications of back pain and it is the most common cause of absence from work. It is also the most common reason for disability in working adults resulting in sick leaves. This is because back pain limits mobility and range of motion required for standing, bending and sitting (Clifton et al, 1994). Also, back pain as a result of herniated disc may irritates, compress and damage the spinal nerve as it passes through the nerve canal between the vertebrae, and this is known as nerve irritation. This results in a variety of complications such as weakness and numbness in the leg and severe shooting pain traveling from the back to the leg at one side of the body due to sciatica. This occurs when the sciatic nerve is compressed or damaged causing symptoms in the leg. In severe cases, nerve damage can also cause problems in bladder and bowel function (Clifton et al, 1994). Moreover, chronic back pain can disrupt sleeping, eating patterns and other activities. This loss of mobility can lead to emotional distress and anxiety, this is known as depression. Depression can become severe and impede recovery time as individuals lack energy and motivation to exercise and do other activities. Long term use of medications for back pain can cause dependency and addiction (Clifton et al, 1994). Lastly, back pain causes loss of activity and restricts movement leading to weight gain and obesity. Muscles may also become weaker due to stay in one position for long period and body posture may worsen due to muscles and ligament weakness, resulting in body fat accumulation (Clifton et al, 1994).

2.2 Medical Treatment

The medication typically recommended first are Non-Steroidal Anti-inflammatory Drugs (NSAIDs), though not aspirin or skeletal muscle relaxants and these are enough for most people (Miller, 2012). Benefits with NSAIDs however, is often small. High quality review has found acetaminophen (Paracetamol) to be no more effective than placebo at improving pain, quality of life or function (Machado et al, 2007).

2.3   Physiotherapy Management

 Exercise therapy is the main conservative treatment approach for lumbar spondylosis. The therapy must include aerobic exercise, muscle strengthening and stretching exercises. The exercises and programs has to be of various intensities, duration and frequency. Kumar et al, (2014) has concluded that core muscle strengthening exercises together with strengthening of the gluteus Maximus and flexibility training of the lumbar spine is an effective rehabilitation approach for all patients with chronic low back pain. Another management of low back pain is spine manipulation. This is because the risk of calcification should be taken into consideration. The risk may be high or low but spinal manipulation can be used in the treatment (Ruddock et al, 2016). Moreover, heat application causes increased capillary blood pressure and increased cellular permeability. The effect of heat is to increase blood flow and local metabolic ability with relaxation of muscle spasm (Poka, 2000). Massage appears to have a potential role in beneficial pain relief (Borges et al, 2014). It helps in blood circulation and also helps to improve muscle tone. Example is kneading. In addition, Transcutaneous Electrical Nerve Stimulation (TENS) is a frequently used therapeutic modality which appears to give an immediate reduction in pain symptoms following the therapy (Buchmuller et al, 2012). More importantly, back schooling thus, educating patient on keeping the back straight, plays a role in the management and prevention of low back pain. The educational therapy must include reviews of lumbar anatomy, explanations of the concept of posture, ergonomics and giving appropriate back exercises (Scott, 2012). Finally, Lumbar support also plays a role in the management of low back pain. Patients suffering from chronic low back pain benefit from lumbar support. It occurs to limit spine motion, stabilize, correct deformity and reduce mechanical forces (Makhsous et al, 2009).   

Chapter Three

Assessment

3.1 Client’s Demographic Data

i.       Name *****

ii.     Age:    29 years

iii.   Sex: male

iv.   Town: Duayaw-Nkwanta

v. Date of Admission: 20/ 10/ 17

vi  Religion: Christain

vii. Occupation: Nurse

viii. Marital Status: Single

ix. Nearest Relative: ********

3.2 Vital Signs 

Temperature: 36.6⁰C

Blood Pressure: 120/80mmHg

Height: 175cm

Weight: 68kg

BMI: 22.2kg/m²

3.3 Subjective Assessment

i.     Patient Complaint: Pain has been in the lower back for 5years, he felt pains in the lower back on long standing but sits for comfort. The patient complained of pains in the lower back when he sleeps in supine for longer time but turns to sleep sideways for comfort. 

ii.  History of Patient Complaint

No history of trauma. Patient said he was used to going for fishing in his adolescent age.

iii. Past Medical/ Surgical History

SCD⁰, Asthma⁰, H PT⁰, Surgery⁰

iv. Drug History: Patient is not on any drug.

Family and Social History:

He lives alone. There is no history of alcohol and smoking.

3.4 Observation/ Examination

 A young man, conscious and alert, walks independently. Patient assumed stoop posture and sometimes slouches in sitting. 

3.4.1 Musculoskeletal Assessment

a.   AROM in the lumbar region.

b.  Flexion – Full ROM, No pains

c.   Extension – Full ROM, No pains.

d.  Left rotation –Full ROM with pains in the right para spinal muscles.

e.   Right rotation – Full ROM with pains in the left para spinal muscles.

f.    Left side flexion – Full ROM with pains in the right para spinal muscle.

g.  Right side flexion – Full ROM with pains in the left para spinal muscles

h.  On palpation, pain felt at the lumbar

3.4.2 Neuromuscular Assessment

Sensation in the lower back intact. (Pricking, temperature) Muscle tone (lower back) is normal.

Abdominal muscle is normal.

Vertebral with pain in the Para spinal muscles.

Pains at the lumbar on VAS is 4/10

Pains in the para spinal muscles is 3/10

3.4.3 Functional Assessment

a.       Feels pain in the lower back when sleeps in supine for longer time. Turns to sleep sideways for comfort

b.      Feels pain in the lower back on long standing. 

c.       Can perform all ADLs with minimal pains in the lower back.

3.4.4 Special Test

Slump test – negative

Straight leg raise test – negative 

3.4.5 X-Ray Investigation

X-ray of the anterior-posterior (A/P) and lateral spine showed a slight degenerative changes at the fourth and fifth lumbar vertebrae.

                                                                   CHAPTER FOUR                                                                             

 DATA ANALYSIS

 4.1 Implementation of Treatment

The patient participated in the treatment program of low back pain which focused on pain management and improving muscle strength. The patient attended the facility twice each week (Mondays and Fridays) for treatment. The table below shows the various treatment given to the patient during our period of study.

Table 4.1 various treatment given throughout the eight weeks period of study.

Week	Day	Blood pressure	Treatment	Duration
Two	Monday	130/80	Postural education on proper sitting and sleeping postures. Hot pack to the low back Abdominal curls Massage Back strengthening exercise	20 minutes 10reps, 2 sets 10 minutes 10 reps, 2sets.
	Friday	130/80	Hot pack to the low back Abdominal curls Massage Back strengthening exercise	20 minutes 12reps, 2 sets 10 minutes 10 reps, 2sets.
Four	Monday	120/80	Hot pack to the low back Abdominal curls Massage Back strengthening exercise	20 minutes 13reps, 2 sets 10 minutes 12 reps, 3sets.
	Friday	120/80	Hot pack to the low back Abdominal curls Massage Back strengthening exercise	20 minutes 14reps, 2 sets 10 minutes 13 reps, 3sets.
Six	Monday	120/80	Hot pack to the low back Abdominal curls Massage Back strengthening exercise	20 minutes 15reps, 2 sets 10 minutes 14 reps, 3sets.
	Friday	120/80	Hot pack to the low back Abdominal curls Massage Back strengthening exercise	20 minutes 18reps, 2 sets 10 minutes 10 reps, 4sets.
Eight	Monday	120/80	Hot pack to the low back Abdominal curls Massage Back strengthening exercise	20 minutes 10reps, 3 sets 10 minutes 10 reps, 4sets.
	Friday	120/80	Hot pack to the low back Abdominal curls Massage Back strengthening exercise	20 minutes 10reps, 3 sets 10 minutes 10 reps, 4sets.

 Table 4.2 bi-weekly evaluation of pain after treatment.

Week	Days of Evaluation	Region	Pain Intensity of the Low Back Upon Evaluation
Two	Monday	Low back	4/10
Four	Monday	Low back	2/10
Six	Monday	Low back	1/10
Eight	Monday	Low back	0/10

Table 4.3 changes in muscle strength with respect to treatment.

Week	Muscle Power
Two	3
Four	3
Six	4
Eight	4

4.3.1 Analysis of Results 4.3.2 Response of Pain to Treatment over a Period of Eight Weeks

From figure 4.1 below, the pain decreased by 2 units between week 2 and 4. However, week 4, 6 and 8 showed a unit decrease in pain.

Fig 4.1 changes in pain intensity with respect to weeks From figure 4.2 below, muscle power showed a considerable increase from week 4 and 6. Between week 6 and 8, the muscle power of 4 was maintained.

Fig 4.2 changes in muscle strength throughout the eight weeks of treatment.

CHAPTER FIVE   

DISCUSSION OF RESULTS 

5.1 Boundaries of Low Back Pain

According to European Guidelines for Prevention of Low Back Pain (2004), they defined low back pain as “pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain. We agree with them because our patient had pains below the costsal margin and above the inferior gluteal folds without leg pains.

5.2 Individuals at Risk of Low Back Pain

Our patient is a nurse and his occupation is a risk factor of low back pain, which coincides with what Hignett (1996) said “it is generally accepted that nursing staff belong to the group of high risk professions with regard to the occurrence of musculoskeletal injuries, especially in the area of the lumbar spine.

5.3 Reduction of Pain Throughout the Eight Weeks of Study

Decreased in pain intensity of our patient might be due to the use of hot pack and massage. This finding is in agreement with the study conducted by (Poka, 2000) where heat applied for 20minutes in treatment, light effleurage massage and postural education relieve pain.  

5.4 Strengthening of Muscles 

Core muscle strengthening exercises together and flexibility training of the lumbar spine is an effective rehabilitation approach for all patients with chronic low back pain (Kumar et al, 2014) which we agree with them because at the end of our treatment session, muscle power increased from grade 3 to grade 4.

5.5 Postural Education

Scott (2012) said, educational therapy must include reviews of lumbar anatomy and explanations of the concept of posture. We agree with him because at the end of the study, we were able to correct the sitting posture of our patient through postural education.

CHAPTER SIX 

SUMMARY, CONCLUSION,RECOMMENDATION

6.1 Summary

This study was carried out at the physiotherapy department of St. John of God Hospital DuayawNkwanta, using a patient diagnosed with low back pain. Conservative treatment approach was used in the study. The patient received routine application of hot pack, massage, postural education and exercises. He routinely attended for therapy twice every week (Mondays and Fridays) throughout the eight weeks of study. After the eight weeks, pain reduced from 4 to 0.

Specific objectives set up in the beginning of the study were to reduce lumbar pain, to strengthen the muscles and to educate patient on correct sitting posture. At the end of the eight weeks of treatment, pain was reduced from 4 to 0, muscle strength also increased from 3 to 4, the sitting posture of the patient was corrected through postural education. Based on the results above we were able to achieve our goals.

6.2 Conclusion

The patient showed improvement in muscle strength, a decrease in severity of pain and correction of wrong sitting posture which came as a result of effective implementation of treatment.

6.3 Recommendation

We recommend that, 

A token should be given to the facility in-charge to entice them help students during the period of study.

Periods for follow-ups should be given on the timetable and students must be allowed to use those periods for the assigned duty. 

                                                            

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