Early rehabilitation of athletes using hydrotherapy after surgical treatment of lumbar disc herniation: preliminary report of three cases

Abstracts

Os autores avaliaram três atletas do sexo masculino, submetidos a tratamento cirúrgico de hérnia discal lombar, com o objetivo de avaliar os resultados, após serem submetidos a um protocolo de reabilitação com base em hidroterapia. Este método permitiu a reabilitação precoce dos atletas, iniciando-se na primeira semana após a cirurgia. Os atletas foram avaliados em 5 ocasiões: pré-operatório e nos 4 meses seguintes. Houve melhora completa da dor em dois atletas. O terceiro caso apresentou no 4º mês 1,3% da intensidade máxima. As atividades de vida diária no período pré-operatório em média apresentaram-se com 21,6% da freqüência máxima, chegando a 99,3% no 4º mês. A freqüência de prática esportiva teve em média 10% da intensidade no pré-operatório, no 4º mês os atletas já praticavam a atividade esportiva com uma freqüência de 84,6% do normal. O nível de atividade esportiva foi relatado em média como 10% daquele estabelecido pelos atletas antes do início dos sintomas, atingindo 88,3% no 4º mês. Concluímos que os atletas apresentaram melhora evolutiva em todos os parâmetros analisados, especialmente em relação a dor. Portanto, a hidroterapia mostrou-se um método eficaz e bem tolerado na reabilitação precoce da cirurgia de hérnia discal em atletas.

hidroterapia; hérnia discal; atletas

RELATO DE CASO

Early rehabilitation of athletes using hydrotherapy after surgical treatment of lumbar disc herniation: preliminary report of three cases

Marcelo Wajchemberg^I; Leonardo Pires^II; Reynaldo C. Rodrigues^II; Karina S. Mano^II; Morgana de Sá Sottomaior^II; Moisés Cohen^III; Rene J. Abdalla^IV; Eduardo B. Puertas^V

^IAssistant Doctor

^IIPhysiotherapist

^IIIHead of Center

^IVScientific Coordinator

^VHead, Vertebral Column Pathology Group - UNIFESP - EPM

^{Correspondence}

SUMMARY

Three male athletes submitted to surgical treatment of lumbar disc herniation were assessed aiming to evaluate the results of a rehabilitation protocol based on aquatic therapy. This method allowed early rehabilitation of the athletes, within a week after surgery.

The athletes were evaluated in 5 occasions: pre-operatively and in the 4 following months. Complete improvement of pain was observed in two athletes. The third case had 1.3% of the maximum intensity in the 4^th month. The daily life activities during the pre-operative period presented 21.6% of the maximum frequency on average, reaching 99.3% in the 4^th month. The frequency of practicing sports was on average 10% the pre-operative intensity; in the 4^th month the athletes already played sports with a frequency 84.6% of the normal. The level of sporting activities was reported as 10% on average of the one established by the athletes before the symptoms had started, reaching 88.3% in the 4^th month.

We conclude that the athletes had an evolutionary improvement in all the analyzed parameters, especially as regards pain. Thus, hydrotherapy was an effective and well tolerated method in the early rehabilitation of athletes after disc herniation surgery.

Key Words: hydrotherapy, disc herniation, athletes.

INTRODUCTION

In the practice of sports, the lumbar vertebral column is frequent localization of lesions when compared to other body segments. In spite of that, this region often does not call medical attention, and consequently the number of studies is limited. Lumbar pain is very representative among the sports, since it is a condition which impairs performance; in order to understand it good knowledge of the column anatomy and biomechanics is necessary to make adequate diagnosis and treatment.

It was established⁽¹⁴⁾ that students who did not play sports had higher risk of back pain as compared to the ones who practiced sports. In spite of that, 15% of all sport lesions occur in the vertebral column⁽¹²⁾, and there are no studies detailing the incidence of specific lesions and their relationship with different sports. In 1986, a study with 17 modalities of sports, in a period of 10 years, has shown that 80% of the column lesions occurred during training, 6% in competitions, and 14% in the pre-season phase. Besides that, 59% of the cases were acute, 12% overuse lesions, and 29% were due to pre-existing conditions⁽¹⁹⁾.

Reviewing the literature, there are few studies related to post-surgical treatment of lumbar discectomy. The aim of this study was to evaluate the results of the application of an accelerated protocol based in hydrotherapy to the post-surgical rehabilitation of athletes submitted to surgical treatment of lumbar disc herniation.

MATERIAL AND METHODS

Three athletes, participants of national competitions, were evaluated using analogical visual scales by orthopedists and physiotherapists of the Sports Trauma-Orthopedics Center (CETE), Department of Orthopedics and Trauma, "Escola Paulista de Medicina" — Federal University of São Paulo, within October, 1999 and May, 2000 in the city of São Paulo, after being submitted to surgical treatment of lumbar disc herniation and after receiving early physiotherapeutic treatment based in hydrotherapy^(5,27).

They were 17 to 38 year-old males. Mean age was 26.6 years. One was a basketball player, 1 practiced athletism and 1 played football.

DIAGNOSIS

The athletes complained of back pain irradiating to the lower limbs with complete disability to practice sports, the symptomatology varying from 3 to 8 months (mean 5.5 months). During the physical examination, the Lasègue sign was positive in 2 of the 3 athletes. Only one presented decreased patellar reflex and athrophy of the quadriceps muscles. None of the athletes presented sphincter alterations. Diagnosis was confirmed by magnetic ressonance (RM) and left central lateral disc herniation was found in 2 patients and left foramen disc herniation in 1 patient (Figure 1), always at the L4-L5 level. All the patients had been clinically treated with analgesics and anti-inflammatory medication and physiotherapy showing partial improvement; they were not allowed to resume their competitive activities.

SURGICAL TECHNIQUE

All the patients were operated on through the posterior via (Figure 2) with longitudinal incision between the L4 and L5 spinal processes, with incision and delicate avertion of the unilateral paravertebral muscles until approaching the respective lamina. Partial unilateral laminotomy was effected, preserving the articular facet, and afterwards an incision was made in the yellow ligament, revealing the dural sac and isolating the nerve root. Carefully averting the nerve root, it was possible to identify the disc herniation and proceed to ressection. After this, foraminectomy was carried out.

PHYSIOTHERAPEUTIC TREATMENT

All the athletes were submitted to the same protocol of physiotherapeutic treatment ^(5,27) (^{Appendix 1}). The predominant protocol was hydrotherapy, the athletes beginning rehabilitation in the water with an impermeable adhesive tape covering the surgical suture. Treatment was daily effected with sessions of 90 minutes on average. Sports were resumed gradatively after the 9^th week, and totally after 13 weeks.

EVOLUTION OF THE ATHLETES

Evaluation was carried out using analogical visual scales⁽³⁾ (from 0 to 10, that is, 0% to 100%, the maximum value equivalent to normal, except for pain intensity), observing 4 parameters: frequency of practice, sports activity level, daily life activities (AVD) and pain intensity. The athletes were evaluated in 5 moments: before surgery and during the 4 subsequent months. The results were considered good when all the parameters at the end of the 4^th month reached proportions similar or equal to those before the lesion occurrence. The bad results were considered those parameters that after 4 months showed great deficit as concerns the parameters reported in the period preceding the lesion.

RESULTS

Analyzing the cases as a whole, the daily life activities (chart 1) that in the pre-operative period presented on average 21.6% of the maximum frequency, reached 43.3% in the 1^st month, 84% in the 3^rd month, and 99.3% in the 4^th month after surgery. Pain (chart 2), according to the athletes, presented a 83% intensity in the pre-operative period. This symptom was totally resolved in two cases, in the 2^nd month and in the 3^rd month, respectively. The third case presented 1.3% of the maximum intensity during the 4^th month evaluation. Frequency of sport practice (chart 3) presented on average 10% of the pre-operative intensity, 40.6% in the 1^st month. In the 4^th month the athletes were able to practice sports with a frequency 84.6% of the normal. The sports activity level (chart 4) was reported as on average 10% of the one established by the athletes before the appearance of the symptoms, reaching 50% in the 3^rd month and 88.3% in the 4^th month.

Considering the cases individually it was found that:

Athlete I

A seventeen year-old male athlete practicing basketball for 8 years. In the pre-operative evaluation he practiced sports with only 10% of the maximum frequency. AVDs were practiced with 85% limitation. Besides that, sports were played with only 10% of maximum intensity and, according to the athlete, pain was near 100%. After surgery, gradual improvement was observed in the parameters, in the 1^st month with 2% pain intensity reported before surgery. In the 2^nd month, all AVDs were carried out without any pain. Frequency of sports practice and sports activity level at the 3^rd month presented only 15% deficit and at the 4^th month they were complete.

Athlete II

A thirty-eight year-old male athlete, practicing athletism for 17 years. In the pre-operative period he played sports with 20% maximum frequency. AVDs were practiced 45%, and sports with 20% of maximum intensity. Pain was 82% of the maximum reported by the athlete. Ind the 1^st month, pain presented 55% intensity. In the 4^th month, AVDs were normally carried out in 98% of the cases, the frequency of practice being 60% and the activity level reaching 98% of the maximum intensity. Pain represented only 4% of the initial intensity.

Athlete III

A twenty-five year-old male athlete, practicing football for 12 years. In the period before surgery, the athlete was not practicing any sports activity and carried out only 5% of his AVDs. Pain represented 67% of the maximum intensity. In the 1^st month, the frequency of sports practice was 67%, however with 20% of the maximum intensity. Pain represented 20% and AVDs were carried out in 57% of the cases. Pain was totally absent in the 3^rd month. In the 4^th month, the athlete practiced sports with 94% of the frequency previous to the lesion, 67% of the maximum intensity and all AVDs were carried out with no complaints.

DISCUSSION

The surgical treatment of the lumbar disc herniation is described since 1934^(15-25). In Germany, about 20,000⁽¹⁰⁾ and in the United States of America 200,000 discectomy procedures are effected during one year⁽³³⁾. The patients submitted to this procedure in general are older than 40 years, however 1-3% of the surgeries are carried out in individuals below the age of 21^(9-30). In this study, the patients submitted to surgical treatment are elite athletes, and this characteristic limitates the number of studies since the subject is scarce in the scientific literature.

There are 2 distinct forms of treatment for the lumbar disc herniation: (1) the conservative treatment submits the patient to rest, uses anti-inflammatory drugs, manipulations and several other modalities of physiotherapy; and (2) surgical treatment followed by rehabilitation.

Rehabilitation, after surgical treatment, is differently considered in different studies. In 1993⁽²³⁾ two models were used. The first model recommended a high intensity program with abdominal exercises and column extension, according to the patient's limit of pain. The second, traditional, aimed to increase the amplitude of movements with light and progressive exercises, according to the patient's development. Both ought to start in the 5^th week after surgery and were maintained during 6 weeks. In 1996⁽⁷⁾ early mobilization was instituted, the patient progressively exerting the activities, according to his possibilities (without restrictions). In a recent study⁽⁸⁾, early rehabilitation was suggested beginning 4 weeks after surgery. The exercises are exclusively active aiming to strengthen the column muscles, the abdominal muscles and the lower limb muscles. In 1999⁽³⁴⁾ elite athletes participated of a conservative protocol based in modification of activities, physiotherapy (ice, ultrasound, electric stimulation, etc.) lumbar orthesis, non-hormonal anti-inflammatory drugs (AINH), and a postural orientation program. In our study, we present a protocol based in hydrotherapy with early rehabilitation^(5,27). In the 1^st week, stretching, loosening, and isometric exercises for the lower limbs and abdominal muscles are carried out inside the water and, after the 9^th week, the athlete resumed the sports activities. The main objective is to maintain the sports activity characteristics and promote muscular and proprioceptive equilibrium, providing early resuming of sports at an activity level close to that established before the lesion occurrence.

Some factors can influence the surgical treatment results. The kind of rehabilitation offered during the post-operative period favors good results but can also deteriorate them⁽¹⁷⁾. In a study within 1988 and 1991, it was shown that intensive exercises for the column were primordial not only to reduce lumbar pain but also to produce satisfactory results to the treatment⁽²³⁾. It is suggested⁽⁷⁾ that restrictions during the post-operative period are not necessary since the patients submitted to this conduct stay far from the activities longer and when they return they do not present complications. So, the protocol used in this study focuses early rehabilitation through hydrotherapy in which physical properties as floating reduce the compressive and shearing forces on the column, allowing early realization of exercises in a safe environment without overload^(6-4). Aquatic exercises begin in the 1^st week post-surgery (Figure 3) aiming postural orientation and improved flexibility (Figure 4), strength, resistance and muscular function, emphasizing the abdominal (Figure 5) and paravertebral^(6,28,4) muscles. At the beginning of the rehabilitation, rotation movements are avoided due to the paravertebral muscles deficiency that in this moment provides little stabilization to the column^(35,3). This early rehabilitation without any impact aims to avoid the deleterious effects of rest as alteration of the composition of the lumbar column muscle fibers⁽¹⁸⁾ and, mainly, provides the athlete a treatment inside the standards found in his sports activity. During the protocol, the activities are somehow functional, simulating the sports activities previously performed. For instance, in basketball, the baskets are adapted to the swimming pool margins and the athlete, before returning to his practice on the ground, exercises the basic movements of that modality as jumps, running, displacements (Figure 6) and throwing. In athletism, the athlete runs inside the swimming-pool and then he resumes training on the ground.

The surgical treatment in general presents good results. In 1991⁽¹⁾, it was established that the results obtained after discectomy were satisfactory in 80% of the cases. Other authors⁽¹¹⁾ established about 96% good and excellent results. Analyzing the surgical treatment in patients below 21 years, 77% improvement of pain and 85% satisfaction on the part of the patients were found⁽³¹⁾. Considering the athletes treatment, it was concluded⁽³⁴⁾ that 90% of them resumed high level competitions. The conservative treatment presents 90% of good and excellent results⁽²⁹⁾. In 1983⁽³⁶⁾, 280 patients with disc herniation were prospectively analyzed, and the surgical and the conservative treatments were compared. After one-year follow-up, the patients treated conservatively presented 61% of satisfactory results; the ones treated with surgery had a greater proportion of satisfactory results (80%). After 10 years, the results were similar for the conservative and surgical groups. The results of the surgical treatment seem to deteriorate with evolution, causing recurrence of pain and symptoms in the column^(11,16). However, several studies demonstrate that the results obtained in evaluations with short follow-up are similar to those reported for long periods. In 1987⁽²²⁾, it was concluded that the results obtained with a one-year follow-up were as satisfactory as those obtained with 5-10 years follow-up. It was established⁽³¹⁾ that the results deteriorate as time passes, however the mean for good results reveals a high rate of success. Thus, in spite of the good results found in this study, definitive conclusions cannot be presented since follow-up is still short and a higher number of cases is necessary to represent a more significant sample.

Literature shows better results for the surgical option at the short-term and similar results at the long-term. In this study, the option⁽³⁶⁾ was the surgical treatment providing improvement of the symptoms and consequent possibility to resume the sports activities in a short period. The 3 analyzed patients (athletes) presented good results concerning improvement of symptoms and resumption of daily life and sports activities. Pain in the 1^st month was already 1/3 the intensity reported in the period before surgery. In the 2^nd month, the AVDs were practiced 50% more intensely as before the lesion. In the 3^rd month, the sports were practiced with about 50-60% intensity as compared to before the lesion. In the 4^th month, 99.3% were performed with no intercurrences. The results are consistent with the literature, since all the athletes resumed their sports activities and attained on average 80-88% intensity in the 4^th month, with no complaints about pain. One must consider that the three athletes were operated on in only one level. In 1999⁽³⁴⁾, athletes surgically treated in two levels presented worse recovery results.

CONCLUSIONS

The data suggest good results in the physiotherapeutic treatment with hydrotherapy in patients submitted to surgical treatment of lumbar disc herniation. This study is the preliminary result of a permanent follow-up which will be maintained aiming to reach a more significant sample and then to clarify aspects related to rehabilitation of athletes with lumbar disc herniation. One must emphasize that the rehabilitation of athletes, whenever possible, demands interaction between treatment and sport, aiming maintenance of the sport characteristics and early recovery in an environment somehow adapted to the sports activities. The literature shows controversies as concerns the more adequate rehabilitation for the patients, in particular athletes submitted to surgical treatment, mainly as concerns the moment to start with rehabilitation exercises. Thus, studies about that matter must be stimulated, since a uniform conduct for the post-operative rehabilitation of athletes submitted to discectomy does not exist.

The focusing of the surgical treatment for athletes and non-sport practicing patients must be different since some symptoms related to disc herniation are tolerated in the performance of the daily life activities, however, at the same time disables the athlete to the practice of sports, that is, pain can cause great difficulties to practice sports not interfering so intensely in the daily life activities. Criteria and limits to indicate surgical or conservative treatments are not very clear and it is necessary to approach the individual conditions of each athlete.

REFERÊNCIAS BIBILIOGRÁFICAS

Trabalho recebido em 20/03/2001. Aprovado em 28/03/2002

*Work performed at the Sports Trauma-Orthopedics Center (CETE) and Vertebral Column Pathology Group - UNIFESP - EPM

^{Appendix 1}

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Appendix 1

Correspondence to

Av. Lineu de Paula Machado, 660

CEP 05601-000 - São Paulo - SP

Publication Dates

• Publication in this collection
  02 Sept 2005
• Date of issue
  June 2002

History

• Received
  20 Mar 2001
• Accepted
  28 Mar 2002