Prolapsed Intervertebral Disc (PID) & Sciatica

1. Created By : Hayati Zaihan
PID & SCIATICA

2. DefinitionPID&
Sciatica
Prolapsed Intervertebral Disc
A herniated disc in the spine causes back pain, often
described as burning or stinging, and can extend into
the leg. Weakness or changes in sensation may occur.
The gel-like center of the disc is displaced,
compressing nerves or the spinal cord.
Most cases heal within a few weeks.
MRI imaging is usually not needed until six weeks of
persistent symptoms.

3. DefinitionPID&
Sciatica
Sciatica
Sciatica is characterized by excruciating pain and
paresthesias in the sciatic nerve distribution or
associated lumbosacral nerve root and can severely
impact the quality of life of those affected.

4. Anatomy

5. Anatomy

6. - Intervertebral discs consist of a collagenous ring (annulus fibrosus)
around a gel-like center (nucleus pulposus).
- Disc herniation happens when the nucleus pulposus bulges through the
annulus fibrosus.
- Aging and trauma are common causes of disc herniation.
- Lumbar spine is most affected, followed by the cervical spine.
- Herniation compresses nerves and increases local inflammation.
- Posterolateral herniation is common and can compress nerve roots.
- Large midline herniation can compress the spinal cord.
- Back pain results from disc pressure and inflammation.
Aetiology
Aetiology
Aetiology
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Pathophy
Pathophy
Pathophy
siology
siology
siology
Aetiology

7. The intervertebral disc comprises the annulus fibrosus and nucleus
pulposus.
The vertebral canal is formed by vertebral bodies, discs, and ligaments,
housing the spinal cord.
Herniated discs result from mechanical nerve compression by the
bulging nucleus pulposus and local inflammation.
Tears in the annulus fibrosus can allow nucleus pulposus material to
impinge neural structures.
Changes in herniated discs include nuclear degeneration, displacement,
and fibrosis.
Aetiology
Aetiology
Aetiology
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&
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Pathophy
Pathophy
Pathophy
siology
siology
siology
Pathophysiology

8. Causes,
Sign&Symptom
Causes:
Natural,age-relatedwearandtearonthespine,knownasdisk
degeneration
Traumaticevents,suchasfalls
RiskFactors:
Gender:Menbetweenages20and50aremostsusceptible
Improperliftingtechniques,especiallyusingbackmuscles
insteadoflegs
Beingoverweight,whichaddsstresstolowerbackdisks
Repetitiveactivitiesthatstrainthespine
Prolongedsitting,especiallywhiledriving
Sedentarylifestylelackingregularexercise
Smoking,whichmayacceleratediskdegenerationbyreducing
oxygensupply

9. Causes,
Sign&Symptom
Sign&Symptom
Radicularpain
Lowbackpain
Sensory abnormalities at the lumbosacral nerve
rootsdistribution
Weakness at the lumbosacral nerve roots
distribution
Limitedtrunkflexion
Pain exacerbation with straining, coughing, and
sneezing
Painintensifiedinaseatedposition,asthepressure
applied to the nerve root is increased by
approximately40%

10. Conservative Treatments:
- NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
- Physical therapy (initiated after at least three weeks of symptoms)
- Muscle relaxers (limited evidence for effectiveness)
- Oral corticosteroids (limited evidence for effectiveness)
- Opioid analgesics for severe pain (prescribed for shortest duration possible)
- Translaminar epidural injections and selective nerve root blocks (second-line modalities for unresponsive cases)
Surgical Treatments:
- Laminectomies with discectomies (for cervical or lumbar herniated discs)
- Anterior cervical decompression and fusion (for cervical herniated discs)
- Artificial disk replacement
- Lateral or anterior approach with complete discectomy and fusion (for lumbar herniated discs)
Doc&
PhysioMx
DocMx

11. Pain mx
Back pain exercise program
Lumbar stabilization exercise
Home education program
Patient education
Doc&
PhysioMx
PhysioMx

12. Pt c/o: Pain at Rt side of back when
in prolong upright position,
radiating to Rt hip down to
hamstring.
Pt aim: To reduce pain at Rt
lowerback area and able to work
with less pain.
Pain scale:
VAS:
Ease: 0/10
Current: 3/10
Agg: 6/10
Subjective AX
Pt's details
Name: Mr R
Age: 50 y/o
Gender: Male
Race: Indian
D/O Ax: 04/03/2024
Dr Diagnosis: PID & Sciatica
Dr Mx: Conservative (painkiller injection &
prescribed medication), refer to
physiotherapy
Investigation:
XRay - NAD
MRI - Swelling near L4/L5

13. Nature of pain: Dull aching pain
Area of pain: Rt lowerback
radiating to Rt hamstring.
Agg: Prolong trunk upright
position & sudden movement after
immobilization
Ease: Lying & consume painkiller
24h symptoms:
am: pain when wake up
pm: pain when prolong trunk
upright position (walking, st. &
sitt) & sudden movement after
immobilization.
night: pain doesn't disturb
sleep
Irritability: High
Cont.
Body chart:
Dull aching pain
VAS ease: 0/10
VAS current: 3/10
VAS agg : 6/10

14. Pt had cervical spondylosis
(unable to spesifically remember
& clarify the chronology of the
condition)
Sudden onset of pain at Rt side of
lowerback since beginnig of this
January at workplace while walking. Pt
decide to go for checkup at Poliklinik
Tasek on the same day. There
conservative mx was taken; pt was
given painkiller and nerve medication
with diagnosis of having PID. Pt was
referred to PCHS and went there 4
days later. Pt undergoes XRay (NAD)
and MRI after 2 days being admitted
to ward. Result of MRI shows swelling
at L4/L5 level to the Rt side of the
disc. With the same diagnosis, pt was
referred to GSRC on 21/02/2024 for
further mx.
Current Hx
Past Hx
Cont.

15. PMHX:HPT, DM Cervical spondylosis
Drug hx: HPT meds, DM meds,
cerebrex, painkiller
Family hx: His father had cervical
spondylosis
Surgical hx: NIL
General Health: Healthy
SOCIAL HX
Occupation: Manufacturer Executive
Nature of job: Prolong walking >14,000
steps to observe colleagues
Marital status: Married with 2 child
Allergic background: NKDA/NKFA
Dominant hand/leg: Rt
Hobby: NIL
Cont.
Home environment: Double-storey house,
seated toilet
Alcoholic/smoking: Stopped smoking,
occasionally drink alcohol
Prev physio mx: Mx for cervical
spondylosis
Functional activity limitation:
Difficulty to climb to second stair at
home
Limited working ability as pt needs to
walk to observe his colleagues

16. Local Observation
(Rt lowerback)
No swelling, redness, bony deformity,
scar & wound seen. Pt skin integrity
was also normal.
Palpation
Tenderness : Grade I
Oedema: No
Temperature: Normal
Ms spasm: Medial Rt hamstring, Rt gluts
OBJ
AX
General Observation
A mesomorph Indian man came into
GSRC accompanied by his son. He
present with slight limping gait and
rounded shoulder with Lt sh seems
higher compared to RT sh.

17. Movement Start End Difference
Flex 51.0 56.5 5.5
Ext 51.0 47.0 4.0
Rt lat flex 65.0 51.0 14.0
Lt lat flex 67.5 54.0 13.5
Rt rot 72.5 80.0 7.5
Lt rot 72.0 79.0 7.0
Trunk
ROM
INTERPRETATION:
REDUCE TRUNK ROM DUE TO PAIN
AND TIGHTNESS

18. Trunk
Ms Grade
Flex
3/5
Ext
Rt lat flex
Lt lat flex
Rt rot
Lt rot
MMT
INTERPRETATION:
REDUCE TRUNK MS POWER DUE TO
REDUCE MS ACTIVITY AND PAIN

19. Back Rt Lt
SLR 0-60 FROM
Neurodynamic test
Cont.
Interpretation: Limited Rt SLR d/t sciatic nerve compression &
hamstring tightness.
Sensation test
Pinprick test: Intact

20. Hip
ROM
INTERPRETATION:
REDUCE HIP ROM DUE TO
TIGHTNESS
Move
ment
Rt Lt
Normal range
A P A P
Flex 0-40
0-
60
FROM
0-120
Ext
FROM
0-10
Abd 0-45
Add 0
Int
rot
0-10 0-15 0-45
Ext
rot
FROM 0-45

21. Hip
Ms Rt Lt
Flex 3/5
5/5
Ext
4/5
Abd
Add
Int rot
Ext rot
MMT
INTERPRETATION:
REDUCE HIP MS POWER DUE TO
REDUCE MS ACTIVITY AND PAIN

22. Move
ment
Rt Lt
Normal range
A P A P
Flex
FROM FROM
0-180
Ext
0-60
Abd 0-180
Add 0
Int
rot
0-70
Ext
rot
0-90
Shoulder
ROM
INTERPRETATION:
NORMAL ROM FOR BOTH SH

23. Shoulder
Ms Rt Lt
Flex
5/5 5/5
Ext
Abd
Add
Int rot
Ext rot
MMT
INTERPRETATION:
NORMAL MS POWER OF BOTH SH

24. 1. Pain at Rt lowerback due to
degenerative process.
2. Reduce trunk ROM due to
reduce pain and tightness.
3. Reduce trunk ms power due to
reduce ms activity and pain
4. Reduce hip ROM due to
tightness.
5. Reduce hip ms power due to
reduce ms activity and pain
6. Limited ADL function in
climbing stairs and working
activity due to reduce trunk
function.
Analysis

25. STG
1. To reduce pain at Rt lowerback in 1/7
2. To improve trunk ROM due to reduce
1/52
3. To improve trunk ms power 2/52
4. Reduce hip ROM in 1/52
5. To improve hip ms power due 2/52
LTG
1. To regain ADL function in climbing
stairs and working activity and prevent
secondary complication such as fall,
operative mx & etc
Analysis

26. Pain mx
Therapeutic exs
HEP
Pt edu
Plan of
Tx &
Intervention
Pt in prn ly, therapist perform trigger point
release at Rt gluteus medius 15 secs, 5 reps
Pt in prn ly, apply combined machine
(TENS&U/S) at back of Rt buttock and prox
to dist Rt hamstring for 5 mins at each area
Pt in prn ly, apply ice pack at RT hamstring
and at back for 10 mins
Pt in prn ly, apply dry cup at medial Rt
hamstring for 10 mins
Pain mx

27. Ask pt to perform as taught in
therapeutic exs 3 times a day at home
Ask pt to apply icepack at pain
area when pain arise
Educate pt to correct posture to
prevent from worsening the
postural abnormality
Pt in sup ly, perform lower trunk rotation exs, 15 secs
hold, 5 reps, 3 sets
Pt in sup ly, perform hamstring stretch, 15 secs hold, 5
reps, 3 sets
Pt in sup ly, perform SLR strengthening exs, 10 secs
hold, 10 reps, 3 sets
Therapeutic exercise
Cont.
Home Exercise Program
Pt education

28. Evaluation
1. Pt is able to understand and follow therapist command.
2. Pt claim pain reduce to 2/10
Review
1. To continue appoinment on 11/03/2024
2. To review on pain scale, trunk ROM & MMT, hip ROM & MMT and
functional activity limitation
Cont.

29. FOLLOW
UP
D/O AX: 17/03/2024

30. Follow Up
SUBJ AX
Pt's details
Name: Mr R
Age: 50 y/o
Gender: Male
Race: Indian
D/O Ax: 17/03/2024
Pt c/o: Pain at Rt lowerback with no more radiating to Rt lower limb
Pt aim: To reduce pain at Rt lowerback and able to work with less pain
Pain scale:
Ease: 0/10
Current: 3/10
Agg: 5/10

31. CONT.
Follow Up
Nature of pain: Dull aching pain
Area of pain: Rt lowerback
Agg: Prolong trunk upright position & sudden
movement after immobilization
Ease: Lying & consume painkiller
24h symptoms:
am: pain when wake up
pm: pain when prolong trunk upright position
(walking, st. & sitt) & sudden movement after
immobilization.
night: pain doesn't disturb sleep
Irritability: Medium
Body chart:
Ease: 0/10
Current: 3/10
Agg: 5/10

32. Follow Up
OBJ AX
General observation: A mesomorph Indian man came into GSRC independently
with normal gait and rounded shoulder with Lt sh seems higher compared to RT sh.
Local observation
(Rt lowerback)
No swelling, redness, bony deformity, scar & wound seen.
Pt skin integrity was also normal.
Palpation
(Rt lowerback)
Tenderness : Grade I
Oedema: No
Temperature: Normal
Ms spasm: Rt gluts

33. TRUNK
Follow
Up
Movement Start End Difference
Flex 51.0 58.0 7.0
Ext 51.0 44.0 7.0
Rt lat flex 65.5 49.0 16.5
Lt lat flex 67.0 50.0 17.0
Rt rot 72.0 80.0 8.0
Lt rot 73.0 82.0 9.0
Movement Start End Difference
Flex 51.0 56.5 5.5
Ext 51.0 47.0 4.0
Rt lat flex 65.0 51.0 14.0
Lt lat flex 67.5 54.0 13.5
Rt rot 72.5 80.0 7.5
Lt rot 72.0 79.0 7.0
BEFORE
AFTER
INTERPRETATION:
REDUCE TRUNK ROM DUE TO TIGHTNESS (WITH IMPROVEMENT)

34. TRUNK
Follow
Up
BEFORE
AFTER
Ms Grade
Flex
3/5
Ext
Rt lat flex
Lt lat flex
Rt rot
Lt rot
Ms Grade
Flex
3/5
Ext
Rt lat flex
Lt lat flex
Rt rot
Lt rot
INTERPRETATION:
REDUCE TRUNK MS POWER DUE TO LACK OF MS ACTIVITY

35. Follow Up
CONT.
Neurodynamic test
SLR (Rt FROM)
Interpretation :
SLR - d/t hamstring tightness
Sensation test
Pinprick - Intact

36. Follow
Up
HIP
BEFORE
AFTER
Move
ment
Rt Lt
Normal range
A P A P
Flex 0-40 0-60
FROM
0-120
Ext
FROM
0-10
Abd 0-45
Add 0
Int rot 0-10 0-15 0-45
Ext
rot
FROM 0-45
Move
ment
Rt Lt
Normal range
A P A P
Flex 0-60 0-95
FROM
0-120
Ext
FROM
0-10
Abd 0-45
Add 0
Int rot 0-20 0-30 0-45
Ext
rot
FROM 0-45
INTERPRETATION:
REDUCE HIP ROM DUE TO TIGHTNESS (WITH IMPROVEMENT)

37. Follow
Up
HIP
BEFORE
AFTER
Ms Rt Lt
Flex 3/5
5/5
Ext
4/5
Abd
Add
Int rot
Ext rot
Ms Rt Lt
Flex 3/5
5/5
Ext
4/5
Abd
Add
Int rot
Ext rot
INTERPRETATION:
REDUCE HIP MS POWER DUE TO REDUCE MS ACTIVITY

38. Follow Up
ANALYSIS
1. Pain at Rt lowerback d/t degenerative process
2.Reduce trunk rom due to tightness (with improvement)
3. Reduce trunk ms power due to lack of ms activity
4. Reduce hip ROM due to tightness (with improvement)
5. Reduce hip ms power due to reduce ms activity
6. Limited ADL function in climbing stairs and working activity due to reduce
trunk function.

39. Follow Up
ANALYSIS
STG
1. To reduce pain at Rt lowerback in 1/7
2. To improve trunk ROM due to reduce 1/52
3. To improve trunk ms power 2/52
4. Reduce hip ROM in 1/52
5. To improve hip ms power due 2/52
LTG
1. To regain ADL function in climbing stairs and working activity and prevent
secondary complication such as fall, operative mx & etc

40. PLAN OF TX & INTERVENTION
Plan of tx
Pain mx
Therapeutic exs
Home exercise programme
Pt education
Follow
Up
Pain Mx
Pt in prn ly, apply hotpack at Rt
lowerback for 10 mins
Pt in prn ly, apply U/S at Rt
lowerback for 10 mins
Therapeutic exercise
Pt in sup ly, perform Rt single knee to chest, 15 secs hold, 8 reps, 2 sets
Pt in sup ly, perform lower trunk rot, 15 secs hold, 8 reps, 2 sets
Pt on all four, perform bird dog exercise, 10 reps, 3 sets
Pt in st, perform active resisted hip flexion, 10 reps, 3 sets

41. PLAN OF TX & INTERVENTION
Plan of tx
Pain mx
Therapeutic exs
Home exercise programme
Pt education
Follow
Up
HEP
Ask pt to perform as taught in
therapeutic exercise 3 times a day
at home
Pt education
Ask pt to apply icepack at pain area
when pain arise
Educate pt about the condition &
possible complications

42. EVALUATION & REVIEW
Follow Up
1. Pt is able to understand and follow
therapist command.
2. Pt claim pain reduce to 1/10
Evaluation Review
1. To continue appoinment on 27/03/2024
2. Plan to review on pain scale, trunk ROM &
MMT, hip ROM & MMT and functional
activity limitation

43. Conclusion
In simple terms, physiotherapy helps reduce pain and
improve movement by fixing problems in the spine.
It can realign displaced discs, create more space for
nerves, and decrease the size of herniated discs.
By doing this, physiotherapy makes it easier for the
spine to move properly, leading to less pain and
better mobility.

44. Thank you for
your attention

45. Reference
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Singh V, Malik M, Kaur J, Kulandaivelan S, Punia S. A systematic review and meta-analysis on the efficacy of
physiotherapy intervention in management of lumbar prolapsed intervertebral disc. Int J Health Sci (Qassim).
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Mitchell, U. H., Helgeson, K., & Mintken, P. (2017). Physiological effects of physical therapy interventions on
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