Home Archive Vol 36, No.3, 2010 Original Papers Remedial Assessment Of Patients With Lumbosacral Pains Caused By Physical Effort

Remedial Assessment Of Patients With Lumbosacral Pains Caused By Physical Effort

T.Miserlis(1), V.Cîrlig(2), C.I.Taisescu(3)

(1)University Clinical Hospital, Ioannine, Greece; (2)Department of Pharmacology, University of Medicine and Pharmacy of Craiova; (3)Normal and Pathological Physiology, University of Medicine and Pharmacy of Craiova

Abstract: This study presents a simple scale for assessing and monitoring the benefic results of the rehabilitation therapy applied and particularly suggests the treatment of patients with lumbo-sacro-pelvic muscle and ligaments pains in a stages program of medical rehabilitation with physical support. The classification on degrees of severity shows that 79.4% of patients suffered from severe pains (between 7 and 10 points) and the remaining 20.6% suffered from average pains. The initial anti - inflammatory and decontracturant treatment supported by thermal electro – kinetic and massotherapy procedures was applied daily for three weeks. Being well known that lumbosacral muscle and ligaments algofunctional syndromes are affections that relapse frequently, we consider that it is necessary to monitor and treat them by periodic recovery, without waiting for the relapses or for any complications to appear, as they are more difficult to treat.

Keywords: lumbo-sacral, anti - inflammatory, recovery


Introduction

Being well known that lumbosacral muscle and ligaments algofunctional syndromes are affections that relapse frequently, we consider that it is necessary to monitor and treat them by periodic recovery; we suggest a simple scale for assessing and monitoring the benefic results of the rehabilitation therapy applied and particularly we suggest the classification of patients with lumbar degenerative pains in a stages program of medical rehabilitation with physical support.

This program should include a more complex first phase of initial treatment, followed one month later by a consolidation therapy, that, if lacking, increases the risk of immediate relapse; it is very important for the patients to attend regular maintenance cures, every almost 3 months, cures that aim to prevent ingravescence, to increase the patients’ effort capacity and to introduce little by little the kinetic maintenance programme in daily activities.

Materials and methods

For the remedial assessment, we have studied a group of 34 young patients who addressed our service for a lumbo – sacral pain caused by physical effort. Clinical and laboratory examinations excluded other causes of disease - discogenous, vertebrogenous or otherwise. We have found instead, the presence of static disorders of lumbosacral segments, sometimes pelvian segments, neglected, developed in sagittal and / or frontal plane. (table 1).

The clinical manifestations of the pain have been quantified since the very beginning, depending on their intensity:

·  lumbosacral pain

·  gluteal and  / or posterior crural referred pain

·  painful limitation of mobility on all movement axes

·  pain upon palpation

·  muscle contracture

Table No. 1 – Characteristics of the group  

Number of cases studied

34 patients

Age

33 - 47 years

Distribution on genders ♀

                                      ♂

24 women

10 men

Types of static troubles:

Kyphosis + loss of lumbar lordosis  

 

14 cases

Loss of kyphrosis + lumbar hyperlordosis 

8 cases

Lumbar hyperlordosis 

9 cases

Lumbar kyphoscoliosis

3 cases

By summing the quantified parameters we have obtained an overall clinical score that we have monitored all over the study. (table 2).

The initial treatment consisted of combined administration of Diclofenac / Aflamil (1 capsule x 3 / day) – antialgic and anti - inflammatory associated with Clorzoxazona (2 capsules x 3 / day) - decontracturant for three weeks. The drug therapy was supported by a complex physical rehabilitation, consisting of thermal therapy, followed by electroanalgesia (diadynamic currents (DDC) + interferential currents), kinetotherapy  for paravertebral asuplisation  and abdominal tonification and massage.

After one month, patients were retested on the same rating scale, and we implemented the IInd phase of the treatment, consisting of Diclofenac (1 capsule x 3 / day) for two weeks, supported by a programme of thermal – kinetic and massotherapy procedures. To see the after – effect of the treatment applied on this type of pains, we reassessed the cases 3 - 6 months after the initiation of the remedial treatment, when new accustisations appeared, of lower intensities. After the assessment of the IIIrd stage we have only applied the physical and therapeutic tripod, thermal – kinetic and massotherapy procedures without medical treatment for two weeks.

Table No. 2 - Clinical manifestations of the pain and their assessment

Lumbosacral pain

Detains activity

Restrains activity  

Normal activity  

 

3 points

2 points

1 point

Referred pain (gluteal / crural)

Present

Absent

 

1 point

0 points

Painful limitation of mobility

Flexion

present

absent

Extension

present

absent

Side inflexions

present

absent

Rotation

present

absent

 

 

1 point

0 points

 

1 point

0 points

 

1 point

0 points

 

1 point

0 points

Pain upon palpation

present

absent

 

1 point

0 points

Contracture

present

absent

 

1 point

0 points

Overall clinical score = 0 – 10 points

We shall therefore mention that, the testing of the patients was done based on the same rating scale, considering the same clinical parameters, and by summing those parameters we have obtained the overall clinical score. An initial and final assessment was done for each stage of treatment - the initial stage, the IInd stage (one month after) and the IIIrd stage (3 to 6 months after). We shall also mention that, depending on the overall clinical score, for a more exact assessment of the severity of the cases we considered three levels of severity:

·  severe clinical forms of disease - clinical score between 7 and 10 points

·  forms of medium severity - between 4 and 6 points

·  forms of low severity (mild disease) – between 0 and 3 points.

We were thus able to highlight, before and after each stage of treatment, the distribution of cases on forms of severity and how patients evolve from severe forms to mild forms of disease.

Results

Our initial evaluation showed the presence of parameters at high levels of intensity, leading to a group high average clinical score of 7.53 points. Distribution on severity shows that initially, 79.4% of patients had severe forms of pain (between 7 and 10 points) and the remaining 20.6% suffered from average forms.

The initial anti – inflammatory and decontracturant treatment, supported by a programme of thermal – kinetic and massotherapy procedures was applied daily for three weeks. The results obtained after this initial treatment were good:

·  lumbosacral pain and referred pain have disappeared in proportion of 70.6%

·  the pain upon palpation and the muscle contracture have completely disappeared 

·  painful limitation of mobility has improved up to almost 70% on all axes of movement 

·  average clinical score decreased to only 1.35 points, the distribution of the classes of severity has changed significantly, full recovery being recorded in 67.6% of cases and mild pain in 23.5% of the cases.

Fig. No. 1 – Gluteal and / or posterior crural referred pain evolution

We have monitored the after – effect in time of these procedures and found that at the one month after assessment the clinical phenomena relapse in most cases, but with a lower intensity, the average clinical score was 4.62 points and the distribution on severity showed that 52.9% of cases were average intensity forms and only 17.6% of the patients presented severe forms.

We considered necessary to apply the second phase of the treatment consisting of anti - inflammatory and antialgic treatment supported by a complex of thermal – kinetic and massotherapy procedures, applied daily for two weeks.

The results were better than after the first stage of treatment:

·  lumbosacral pain disappeared in 85.3% of cases

·  referred / irradiated pain disappeared in 94.1% of patients

·  improve mobility was recorded at a rate of 88% on all axes of movement

·  average movement score at clinical at the level of the group decreased 0.62 points and the distribution in severity showed that only 14.7% of the patients presented mild pain, the remaining 85.3% have fully recovered.

Patients returned to consultation after 3 to 6 months for symptoms similar to the first consultations, but in most cases of moderate intensity. Average clinical score of the third consultation was 5.44 points and the distribution of severity showed 88.2% of average and mild forms of disease.

Fig. Nr. 2 – Painful limitation of mobility

The IIIrd stage treatment consisted of the same thermal – kinetic and massotherapy procedures applied for two weeks, after which all clinical parameters had improved between 90 and 100%, reaching the lowest average clinical score of only 0.41 points.

Painful limitation of mobility has a positive upward trend:

• flexion – improved from 67 to 88 % and then over 90%

• extension - improved from 76 to 85% and then over 94% (Fig. 4)

• side inflections started to improve from the second phase of treatment, and continued in the third phase, over 94%

• rotation - improvement upwards to over 90%.

Conclusions

We therefore notice the limited after – effect in time of the effects of the first phase of therapeutic treatment and the need to consolidate these effects in a second phase, almost one month after, with higher clinical results.

 We have noticed an even better response in the third phase of treatment, with a quasi-complete improvement of the clinical table, even if this phase occurs at a longer interval. Longitudinal study of the evolution of clinical parameters shows the gradual upward improvement and the after – effect at higher levels from the second phase to the third phase of the treatment. Full recovery was obtained at a rate of 91.1%, the rest of the cases being mild cases. 

In conclusion, well known that lumbosacral muscle and ligaments algofunctional syndromes are affections that relapse frequently we consider that it is necessary to monitor and treat them by periodic recovery, without waiting for the relapses or for any complications to appear, which are more difficult to treat.

This study presents a simple scale for assessing and monitoring the benefic results of the rehabilitation therapy applied and particularly suggests the treatment of patients with lumbo-sacro-pelvic muscle and ligaments pains in a stages program of medical rehabilitation with physical support.

In our opinion, this program should include a more complex first phase of initial treatment, followed one month later by a consolidation therapy, which, if lacking, increases the risk of immediate relapse. After these two phases, it is very important for the patients to attend regular maintenance cures, every almost 3 months, cures that aim to prevent ingravescence, to increase the patients’ effort capacity and to introduce little by little the kinetic maintenance programme in daily activities. We must not forget that by neglecting these pains which may seem trivial at first sight, they can result in vertebrogenous and discogenous complications, difficult to treat, involving prolonged rehabilitation, with limited effectiveness and after - effect on the functionality of the lumbosacral segment.

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Correspondence Adress: T.Miserlis MD, PhD student; University Clinical Hospital, Ioannine, Greece miserlistheofanis@yahoo.gr


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