Evaluation of an effective conservative therapy for lumbar disc herniation.

Low back pain is one the most common medical conditions.1 Twenty-six percent of men and 30% of women over 18 years old in the United States suffer from low back pain; for adults over 45 years old, the percentage is 32.1%.2 In Canada, a survey from Saskatchewan found that in a 6-month period, 5 in 10 Canadians suffer from low back pain; up to 85% of working people can expect to experience low back pain during their lifetime.3

Many different problems can cause low back pain, however, lumbar disc herniation (aka, slipped or ruptured disc) is one of the most common causes and most challenging diseases to treat. The treatment of lumbar disc herniation is controversial, with recommendations ranging from conservative approaches—bed rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and manipulation—to more invasive approaches—physiotherapy, epidural steroid injection, and surgery. Conservative treatment generally is considered accessible, safe, and economical, but its long-term effectiveness remains unproven.

In a systematic review, Vroomen et al examined the effectiveness of conservative treatment for sciatica (often caused by disc herniation). The authors concluded that the majority of the conservative therapies “were not superior to placebo, except epidural steroid injection and manipulation.”4

In Western countries, conservative therapy does not include acupressure,4-7 but in Eastern countries such as China, most patients with lumbar disc herniation have been treated by this method and have received excellent clinical results, especially for new-onset injuries. A review of 4 studies found that a high percentage of patients treated with acupressure (70%-80%) had relief of lower back pain and sciatica and were able to return to work and activities of daily living.8-11

We have worked as osteopaths and acupressurists in Canada for 19 years. We have observed many patients with lumbar disc herniation who have experienced unsuccessful conservative treatments but received pain relief from acupressure. Thus, the main objective of this article is to discuss the methodology and results of combining osteopathic medicine and acupressure therapy to treat lumbar disc herniation.

Make-up of Patients

We evaluated 35 patients treated in our clinic over a 12-year period. All 35 patients were diagnosed with lumbar disc herniation by an orthopedist or neurologist and had lower back pain and sciatica that they described as increasing pain or an electrical feeling when coughing and sneezing. Twenty-one out of the 35 patients had magnetic resonance imaging (MRI) or CT scans that confirmed the diagnosis of lumbar disc herniation (15 before therapy, 6 during therapy).

Among the 21 patients that have undergone MRI or CT, 10 patients were diagnosed as having disc herniation with spondyloarthropathy, 4 patients were diagnosed as having disc herniation with spinal stenosis, and 7 patients were diagnosed with disc herniation only.

The 35 patients in the study were divided into 2 subgroups: those with first-onset pain (25 patients) and those with recurrent disc pain (10 patients) (Table 1).

A control group consisting of 22 patients who had previously been treated with conservative therapy other than osteopathy plus acupressure were used for comparison. These other conservative therapies included bed rest for at least 2 days (11/22 patients), analgesics or NSAIDs (20/22) (most commonly used: acetaminophen, ibuprofen, naproxen, and aspirin), physiotherapy (9/22), acupuncture (6/22), and epidural steroid injections (3/22).

Among these 22 patients, 21 patients did not achieve any optimal clinical outcome. Only 1 patient who received a steroid injection experienced temporary relief of sciatica but had recurrence of pain after 2 months.

Study Design

All 35 patients received the authors’ treatments twice a week for 1 to 4 months depending on the patient’s condition. The authors’ treatments combine acupressure and osteopath manipulation as well as massage.

Treatments consisted of the following:

Massage of the lower back and hip for 5 to 10 minutes to warm up the body and make it more flexible.

Acupressure to specific points based on the area of herniated disc for 10 to 20 minutes until the pain was lessened or completely gone.

Acupressure to specific points to improve local circulation.

Manipulation including: Bilateral body side twisting (Not applicable to posterocentral disk herniation) Traction of the leg and body with the patient lying on his back, followed by flexing of the legs Rolling (Figure 1), knocking, and shaking of the lower back with the patient lying on his stomach Traction of the leg and body, alternating with low-back rolling and knocking (Figure 2), with the patient lying on his stomach

Rest in the same prone position for 2 to 5 minutes following the termination of above manipulation.

After the manipulation, the patient stood up and immediately attached a corset (Figure 3) to the lower back, ending the session. Patients were instructed to wear the corset continuously throughout the treatment period (except when bathing and sleeping). In addition, patients were instructed to apply a hot water bottle or heated bag to the lower back in the evening following each treatment session.

Study Results

Study results were calculated using the “X2 of correction in 2x2 table” to determine the significance of the results between the osteopathy plus acupressure group (experimental group) and other conservative treatment group (control group).

In subgroup 1, 22 out of 25 patients (88%) achieved significant clinical benefit, based on self-reported complete disappearance of low back pain and sciatica pain as well as loss of electrical feeling when coughing and sneezing. Three out of 25 patients (12%) experienced some, but not complete, pain relief.

In subgroup 2, 4 out of 10 patients (40%) reported a significant clinical result, 5 out of 10 patients (50%) felt less pain, and 1 patient (10%) reported feeling no change.

In all, 26 patients (74%) had an excellent clinical result (P<0.001). They were all able to return to work and resume activities of daily living. The 26 patients were interviewed by telephone 1 to 6 months after stopping treatment, and reported continued benefits from the treatment at that time (Table 2).

The clinical criterion for the efficacy of osteopathy plus acupressure adopted for the study was 100% remission of low back pain and sciatica symptoms. The vast majority of patients (26 out of 35 patients) reached this criterion. Of the 9 patients who failed therapy, 8 patients felt less pain and 1 patient reported feeling no change.

Discussion

In cases of disc herniation (both contained and non-contained), the primary pathologic change is disc displacement; the secondary pathologic effects include chemical inflammation of the nerve root and changes in local circulation. Herniated discs compressing the inflamed nerve root and decreasing circulation are the most common causes of sciatica.12-14

If conservative therapy can correct disc displacement, relieve inflammation, and improve circulation locally, then it should yield favorable clinical outcomes. However in Western countries, the reported success rate of conservative therapy for sciatica caused by nerve root compression varies from 35% to 97% in various case series and trials.15,16 A systematic review of the literature related to conservative treatment of sciatica (often caused by disc herniation) concluded that except for epidural steroid injection and manipulation, which had some positive effects, most conservative therapies are not superior to the placebo.4

The common conservative therapies used in Western countries such as bed rest, analgesics, NSAIDs, steroid injection, physiotherapy, even acupuncture, are only intended to relieve local inflammation, not to correct disc displacement.17-21

Manipulation, such as traction, side-posture manipulation, and body rolling, has been reported to have some good results.4,22,23 Manipulation should result in some disc displacement correction, but manipulation alone can not significantly reduce local inflammation and improve local circulation. Thus, we recommend a combination of acupressure and osteopath manipulation.

Our study showed this approach could correct disc displacement, relieve inflammation of the sciatic nerve as well as the area around the herniation, and improve local circulation.

Few Western doctors and patients are aware of, or understand, this treatment. This may help explain why conservative treatment in Western countries often fails. In light of the above discussion, an argument can be made for further study of this new conservative therapy.

Conclusion

Combined osteopathy and acupressure can be considered as one of the best conservative treatments for patients with lumbar disc herniation. Osteopathy and acupressure manipulation may be thought of as the first choice, especially for those patients with an initial onset of back pain. Exceptions to this rule would be in cases of acute, severe pain, progressive motor weakness, or cauda equina syndrome.

Last updated on: February 9, 2016

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