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Background

    Nowadays, chronic-degenerative diseases of the spinal cord constitute a multi-factorial syndrome with very alarming economic impact, not mentioning the emotional aspect, which can even sideline economically active individuals from social/ labour activities. Causes can be mechanical, degenerative, rheumatic, traumatic, infectious and psychogenic (HENNEMANN, 1994; NACHEMSON, 1982).

    Lumbago is the most symptomatic of such these diseases in developed countries like USA, Canada, UK, Sweden, Belgium, where there is an uniformity of annual incidence: every group of 1,000 active workers, 50 suffers from such disease (SKOVRON et al., 1994).

    Generally, it is admitted that 80% of the adult population have or will have lumbago, from 30% to 40% of such population have lumbar disk hernia in an asymptomatic way (ORTIZ, 2000) and, from 2% to 3% are already suffering from such disease, whose incidence in individuals older than 35 years old is of 4.8% in males and 2.5% in females. The average age for the first pain crisis is 37 and, in 76% of the cases, an early case of lumbar pain happened on the previous decade (NEGRELLI, 2001; NACHEMSON, 1983; CECIN, 1991).

    In Brazil, the economic repercussion of such data made lumbago to become the first cause for the payment of temporary leave and the third cause in compulsory retirement (FERNANDES, 1994). Despite epidemiologic data reach the various social extracts, just a few have access to evasive surgical treatments or minimally evasive ones (WETLER & BARROS, 2004).

    In the other hand, it is observed that 260.000 diagnosed lumbar pulposus disk hernia operations are made in the United States every year, what means a proportion of 170 cases to every group of 100.000 adults, which is one of the world´s biggest indexes of surgical indicative if compared to Washington State index of 11.5 operations per 100.000 (15 times less). An 8-12-week period must be observed, with tests and physiotherapy tests, before an operation. Currently, it is known that disk hernia is responsible for a minimal percentage of patients with lumbar chronic pain irradiating to the sciatic nerve (LEBKOWSKI et al., 2002).

    Besides its low cost, conservative treatment has been showing good results in approximately 80% to 90% of the individuals with lumbar disk hernia. It should be applied for a minimal period of 4 to 6 weeks. In case the individual does not get a small and progressive improvement, surgical treatment should be considered, what means 10% of the cases (ORTIZ, 2000).

    Surgery should be avoided because it is proved that hernia may retrocede with physiotherapy and clinical treatments, use of jackets, medicines, infiltration procedures, etc. It is believed that lumbar disk hernia surgery should not be made before 6 months of clinical treatment, even including the use of an antidepressive medicine, because the surgery has a high index of failure, i.e., more than 40% of the cases (KRAATS et al., 2004).

    Coortes studies show that results in operated & non-operated patients are quite the same after ten years, and that the operated ones had significant improvement in the first year post-surgery (WEBER, 1983). FRASER (1995) re-endorsed this data re-evaluating 56 patients with examinations of Magnetic Resonance Imaging (MRI) and Computerised Tomography (CT), ten years after evasive & non-evasive interventions, aiming to study long-term morphologic changes. His findings were consistent and similar to WEBER´s ones (1983).

    Conservative treatment can be divided into three phases: acute phase (a physician should work in this part), post-acute phase (part of the physiotherapist) and late phase (HENNEMANN, 1994). The Physical Education Professional should work in this last stage; in order to proportionate the individual who suffers from hernia to keep active, avoiding the return of an acute crisis of pain (WETLER & BARROS, 2004).

    The problem that carried us to develop such research is characterised as follows: Which could be the effects of a conservative treatment through a Programme of Postural Gymnastics for a period of 6 months, in individuals with lumbar disk hernia of both sexes?

General target

    The goal of such study is to check the effects of a Programme of Postural Gymnastics during a period of 6 months in individuals with lumbar disk hernia of both sexes, from 29 to 70 yrs old.

Material & methods

Study outlining

    Experimental Study of analytic purpose like: Randomised Clinic Essay (PEREIRA, 1997).

Sample of the Study

    The current study selected 30 individuals with lumbar disk hernia of both sexes, obtained from a sample of volunteers. In this study, such individuals will be introduced to a conservative treatment of postural gymnastics (GP) during a period of 6 months, and they will be subdivided in two groups, varying the exposition degree: 14 individuals in a Group of Study (79 classes) and 16 in a Group of Control (52 sessions).

Data treatment

    Pain scores reduced after 6 months of postural gymnastics: ANOVA was used, as well as "t"-Student, Wilcoxon and Mann-Witney tests comparing paired samples to know if any significant difference was perceived among the groups. Chi-Square test evaluated the influence of GP at the decrease of pain level.

    MRI Examination positively changed the spontaneous re-absorption of the lumbar disk hernia: a 95% confidence level was used to know if there was significance in the reports of spontaneous re-absorption of lumbar disk hernia (p < 0,05). In case the p-value obtained by the Chi-Square test is greater than 0,05, the initial hypothesis is accepted and, if smaller than 0,05, the alternate hypothesis is accepted as true.

Results and discussion

Hypothesis # 1 - Pain scores reduced after 6 months of Postural Gymnastics;

Chart # 1 - Evolution in the levels of pain

    Through a qualitative analysis of the pain scores, it may be checked that only "light" and "moderate" levels could be seen out of all ones. While the "before" proportion of individuals with moderate level used to be more than 55%, this proportion reduced to only 20% after Postural Gymnastics. Simultaneously, the share of people with "light" pain increased to 80% from 43,33%.

    From this Study, it may be concluded that "level score diminished after 6 months of Postural Gymnastics". In the "late stage" of the conservative treatment, pain scores were in an acceptable level or, in other words, moderate and light according with "Oswestry Questionnaire of Incapacity by Lumbago" (WETLER & BARROS, 2004; HENNEMANN, 1994).

    Chart 1 shows in qualitative terms how notorious the evolution of pain levels before & after Postural Gymnastics were. In other words, there were a significant migration from moderate level to the light one, with moderate scores going from 56,67% (before) to 20,00% (after), while light (before) used to be 43,33%, jumping to 80,00% (after) (p-value = 0,0035).

Hypothesis # 2 - There is spontaneous re-absorption of the lumbar disk hernia, through the use of the conservative treatment during the gap period of MRI Examinations (before & after).

Chart # 2 - Result of MRI Examinations

    Remark: None = no changes during the gap period between examinations; Positive = total or partial spontaneous absorption of the hernia; Negative = growth in hernia´s size.

    Comparing the results of IRM examinations, approximately before and after the period of conservative treatment, it may be checked out an improvement in approximately 22% of the cases of hernia and, in two situations, the total and complete re-absorption of it.

    In this study, it is affirmed that "there is spontaneous re-absorption of the lumbar disk hernia through the use of the conservative treatment during the gap period of MRI Examinations (before and after)".

    In Chart 2, it is perceived that the number of hernias totalled 36, despite the only 30 participants of the sample. It was also revealed that 8 individuals, or 22.22%, obtained positive results with total or partial spontaneous re-absorption, while only one (2,78%) had an increase at the size of the lumbar disk hernia. In the remaining part of the sample (75%), no kind of change was identified during the gap period between the examinations.

    With a 95% confidence degree, such results have shown that the positive result was significant (8,64 - 35,80, p < 0,05), confirming the second hypothesis and also corroborating other studies showing there is an spontaneous re-absorption in the natural history of the lumbar disk hernia, only using the conservative treatment (KAWAJI, et al., 2001; SAAL, 1999; YUKAWA, 1996; HARO et al., 1996; IKEDA et al., 1996, VIRRI et al., 1996, MATSUBARA et al., 1995, FRASER, 1995, HENNEMANN, 1994; TEPLICK, 1992).

    Almost the totality of the reports of MRI Examinations was issued in a qualitative form, with or without adjectives like: small, moderate, big or bulky hernia. In our research, only one report was described in a quantitative form, (subject 1/ before) "in L4/ L5, there is a posterior left para-median hernia, with approximate 12-mm caudal migration" and (subject 1/ after) "there are no evidences of lumbar disk hernia". However, we had the necessity to include a radiologist physician in our staff to issue a final report, once it was not clear when a partial re-absorption happened. In several Japanese studies, measurements were quantitative, even with the use of units in cubic centimetres (three-dimensional characteristic of some imaging examinations). It would be highly relevant if the equipments available in Brazil could reach such technology (KAWAJI, et al., 2001; YUKAWA, 1996; HARO et al., 1996; IKEDA et al., 1996, MATSUBARA et al., 1995).

Conclusions

    The percentage of pain level before Postural Gymnastics Programme was of 56,67% (moderate, for 17 individuals) and 43,33% (light, for 13 individuals). After the Programme, it was checked a substantial growth in "light pain" level, being 20% (moderate, in 6 individuals) and 80% (light, in 24 individuals), with p-value = 0,0035 (p< 0,05). A significant difference was perceived between the Group of Study and the Group of Control, with p-value = 0,0099 (p< 0,05).

    In the 30-individual-sample, it was observed that 36 disks were with lumbar disk hernia. Through the conservative treatment, a significant spontaneous re-absorption happened in 22,22% of the sample with lumbar disk hernia (p< 0,05), with an average gap period of 13,03 months between the first and the second Magnetic Resonance Imaging Examination.

Bibliographic references

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revista digital · Año 10 · N° 81 | Buenos Aires, Febrero 2005   © 1997-2005 Derechos reservados