THE DIAGNOSIS AND CONSERVATIVE

TREATMENT OF THE LUMBAR DISC SYNDROME

BY
FRANKLIN SCHOENHOLTZ, D.C.
Diplomate, American Board of Chiropractic Orthopedists

LECTURE DELIVERED ON
APRIL 29,1977
AT THE
AMERICAN COLLEGE OF CHIROPRACTIC ORTHOPEDISTS CONVENTION
PALM SPRINGS, CALIFORNIA
 THE CLINICAL DIAGNOSIS OF
THE LUMBAR DISC SYNDROME
Discussions of disorders of the spine must begin with separating
lumbar intervertebral disc disease from normal, predictable
sequences of morphological alterations. For the purpose of
this lecture I shall concern myself with the general highlights
of the diagnosis and conservative treatment of the lumbar disc
syndrome.
The lumbar disc syndrome represents one of the most common
causes of back and leg pain. It is a multi-faceted symptom
complex and must be recognized as such if the diagnosis and
treatment are to be correct.
Initially, careful and methodical analysis of the patient’s signs
and symptoms are essential to base the nature of the clinical
manifestations of the affected disc and to determine which disc
and nerve roots are at fault. If the doctor will take his time to hear
what the patient is telling him he can assess the behavior of the
syndrome.
Such an examination should provide significant information
necessary to establish a valid diagnosis. The doctor should weigh
all of the subjective and objective clinical features in order to
correlate the data with the pathophysiological changes of the disc.
It is interesting that at times I have to restrain myself based upon
subjective history, not to lead the patient into the diagnosis of a
lumbar disc lesion.
The clinician sees with disturbing regularity missed diagnoses of
lumbar disc lesions. However, it is also important that he does not
polarize his thinking to the opposite spectrum and then classify
all back and leg pain to abnormalities of the lumbar intervertebral
disc.
There are many approaches to a detailed examination. The plan
that I follow is to critically analyze the subjective factors and
then evaluate the objective manifestations of the clinical picture.
A most important consideration in determining a diagnosis is that
negative findings are of equal importance as positive findings.
SUBJECTIVE COMPLAINTS OF PAIN
Generally speaking patients seek your services because of pain.
Patients will, if given the opportunity to express themselves,
describe all the essential characteristics of their pain.
During an acute attack the pain may be in the lumbar region
with or without radicular involvement. The patient may have a
difficult time in delineating and localizing the exact site of the
pain. However, in the case of leg pain the patient is usually quite
accurate in describing its location.
Intensity, as well as patterns of pain may be influenced by other
considerations of which the patient is keenly aware, such as,
acute unguarded movements. The nerve roots may have become
so irritable that any slight movement may be capable of causing
severe aggravation of the pain. A sudden cough or sneeze may
produce an accentuation of the pain. The patient soon becomes
aware of positional relief. He may assume certain postures in
order to decrease the tension and the pressure on the nerve root.
The patient learns that by decreasing vertical stress he can attain
some relief of pain. This he does by usually assuming the fetal
position with hips and knees fully flexed while laying in bed.
THE DOCTOR-PATIENT
PSYCHOLOGICAL PAIN RELATIONSHIP
Pain is a psychological phenomenon with both physical and
emotional components and the doctor is called upon constantly to
make value judgments.
Due to the difficulty and chronicity of the lumbar disc syndrome
we often find ourselves agonizing with the patient over an
extended period of treatment when improvement is not as we had
expected.
Because of the normal tendency to prefer praise to blame we may
become frustrated and even display subtle hostility towards the
patient. Most of us have had the experience of treating a lumbar
disc patient that should have improved with our therapy, yet, with
considerable regret we find that the patient may be unresponsive.
The patient’s attitude toward us often plays a significant role in
determining the success of our therapy.
When patients feel that you are annoyed with their complaints
they often develop their own hostility and with covert criticism
announce with triumph at each visit, “Your treatment is not
helping.” This statement renders the doctor powerless to retaliate.
At times the doctor, with a sense of punishment, attempts to
“punt” by banishing the patient with a referral to a specialist
when it is not necessary.
All of us want to succeed. We want to provide a valuable service
to the patient, as well as, gain a sense of accomplishment that we
are practicing our profession well.
When doctor-patient hostility develops it is our responsibility
to take time to explain to the patient the complexities involved
in the treatment of lumbar disc disease. The patient needs
reinforcement and reassurance. During the treatment program the
chronic lumbar disc patient has to have confidence that the doctor
understands him and his problems and is kind and gentle in both
word an manner.
SENSORY DISTURBANCES
During the course of root compression the sensory fibers may be
compressed causing paresthesia and later loss of sensation in the
affected detmatome.
This is a most interesting phenomenon, for it appears to provide
the only example of a pathognomonic sensation.
Because of the subjective aspect of sensory testing, an abnormal
sensory pattern is considered of clinical significance only if it can
be correlated with the other radicular signs and symptoms.
It should be remembered that dermatome distributions vary from
individual to individual and considerable overlap may exist.
MOTOR DEFICITS
Abnormalities in motor function are considered objective. Yet,
clinically one of the major concerns of the patient is that he has
a weakness or complete loss of function in a group of muscles.
This may occur with a disc lesion affecting the L-5 nerve root.
In this instance the patient is unable to dorsiflex his foot and he
notices that he “slaps his foot while walking.” This abnormal gait
is caused by either a weakness or paralysis of the anterior tibial or
peroneal muscles. When the S-1 root is affected the patient loses
the ability to stand on his toes because of motor dysfunction. Due
to the overlap of nerve supply this may present confusion to the
examiner because there is no definite rule that may be absolutely
applied in evaluating motor deficits.
REFLEX CHANGES
Deep tendon reflexes in relationship to lumbar disc disease is
usually confined at the levels of L4-L5 and L5-S1.
Generally in progressive disc disease we see far more patients
with symptoms that are attributable to posterior lateral
protrusions and as a result asymmetrical findings are clinically
significant.
Impairment of L5 nerve root is not always associated with reflex
absence at the knee.
A diminution or absence of the ankle jerk is usually
pathognomonic of involvement of S1. When this reflex is lost the
level most involved is usually the L5-S1 disc.
POSTURAL CHANGES
During an acute attack the patient assumes an antalgic position
in which he exhibits a flattened lumbar spine. The entire trunk
appears to be projected forward so that the affected leg is flexed
at the hip and knee. When the nerve root is under tension and
traction the patient develops a lateral list which is referred to as
a “sciatic scoliosis.” The patient attempts to relieve the pain by
involuntarily shifting his trunk to decrease root compression.
Sciatic scoliosis is a variable clinical feature in that the trunk
may shift from side to side in the same patient depending on the
relationship of the nuclear sequestrum.
MUSCLE SPASM
During an acute attack we always have lumbar muscle spasm.
This is a reflex protective mechanism in which the patient has
no control It is apparent to the expert clinician and is always
palpable. The muscles are tense and rigid to the touch and the
spasm is responsible for the flattening of the lumbar spine and the
lateral list to one side.
The difference between palpatory findings in acute, subacute, and
chronic disc lesions are both quantitative and qualitative. With
acute and subacute lesions the differential findings are relatively
few; however, if the lesion persists, the types of findings
gradually change, i.e., the early evidence of over stimulation
gradually gives way to evidence indicating fatigue of the affected
area.
Muscle spasm and pain are usually associated with derangement
of the lumbar disc and may not be associated with nerve root
involvement.
PALPATION AND PERCUSSION
Palpation can produce pertinent information providing it is
accurately interpreted. It is a routine procedure for the doctor
and he can usually determine by eliciting tenderness along the
iliac crest as to what structural protective shift has taken place.
Palpation of the affected sciatic notch will usually confirm
radicular involvement and can be readily explained by the
hypersensitivity of the fibers of an affected root transversing the
sciatic notch.
Percussion may be less informative than palpation but in some
cases fist percussion over the lumbar spin in the mid-line will
produce radiating leg pain. When pleximeter percussion over
the spinous process evokes a positive response you have a
sound index of the sensitivity of the affected tissues and nerve
root. However, when percussion at that level yields no pain or
discomfort, it does not eliminate the possibility of a lumbar disc
involvement.
STRAIGHT LEG RAISING
This test is often confused with the Lasegue Test. It is considered
the most important of all leg tests and is used in all acute and
subacute attacks of lumbar disc lesion. It is performed with the
patient lying supine and the extended leg is flexed on the trunk at
the hip by the examiner.
Generally, a positive straight leg raising test on the affected
side is accompanied by mild restriction of the unaffected leg.
Added consideration of this maneuver on the uninvolved side
may produce pain on the opposite side. The explanation of this
phenomenon is that you raise the normal leg you cause the lower
lumbar nerve roots on the opposite side, especially the L5-S1 root
to move slightly down.
LASEUGE TEST
This test is performed with the patient attempting to extend his
knee from 90 degrees to 180 degrees while he is supine. When
a lumbar disc lesion is present causing root irritation to the
limit to which the knee can be extended is diminished. Pain is
produced in the leg and back beyond this point. Pain can also be
reproduced by this maneuver by sharply dorsiflexing the foot thus
stretching the sciatic nerve and tractioning the nerve root.
 SITTING ROOT TEST
This test is performed with the patient sitting on the examination
table with his legs hanging free. The knee is extended to the
point of resistance and then the clinician places his hand over the
occiput and flexes the cervical spine sharply. The sudden traction
of the sensitive nerve root caused by forward flexion induces pain
along the distribution of the nerve pathway.
RADIOGRAPHIC EXAMINATION
Radiographic study of the lumbar spine is mandatory in the
examination of these patients who exhibit clinical manifestations
of lumbar disc disease. The decision of the relevance of
radiographic abnormalities is beset by many pitfalls. In my view,
in nearly every case the clinical findings take precedence over
x-ray changes. Rarely, the radiograph may show an overriding
lesion that clinical examination did not detect then only is it
diagnostic taken alone.
The radiographs should be of excellent quality and should be
taken in accordance with all details of an established technique.
The series should include anteroposterior, lateral, obliques and a
lateral spot of the L5-S1 joint.
X-rays of the lumbar spine may reveal the following
abnormalities:
1. Diminished intervertebral space
2. Osteophytic production
3. Anterior or posterior subluxation of a vertebra
4. Sacralization of the 5th lumbar vertebra
5. Congenital defects and other pathological processes
CONSERVATIVE TREATMENT AND
MANAGEMENT OF THE LUMBAR DISC SYNDROME
The approach to the treatment of a patient with a disc lesion is a
difficult feat. The proper selection of one method over another
method depends on the specific patient.
After practicing for 15 years I still have not arrived at absolute,
firm guidelines for patient management. The varied clinical
picture of disc injury leads to the dilemma of treatment choice.
The deciding factor in treatment selection is one of the most
difficult to evaluate. At one end of the spectrum is the patient
completely intolerant of any pain and at the other end is the
patient who is completely casual in response to his condition.
The goals to be established in a conservative program should be
threefold:
1. Relief of pain
2. Increase of functional capacity
3. Slowing of the disease progression
The quality of results in patients with lumbar disc lesions
depends upon the criteria that, although manipulation is the crux
of the matter, first and foremost it is only a part of the whole
procedure. Manipulation is our chief modality among the various
physical methods of treatment. However, since this lecture was
designed, mindful of the fact that the following speaker is to
discuss the manipulative approach to lumbar disc syndrome, I
shall offer alternative modes of therapy at this time.
To achieve the maximum benefit from any form of therapy the
doctor must be allowed discretionary latitude not only in choice
of modality but also in the intensity and time of its use. Variations
in treatment must be made in response to the patients reaction
which may change from visit to visit.
It is my intention to present principles of different techniques
and their efficacy in the conservative management of acute and
chronic lumbar disc lesions.
BEDREST
One of the most important factors in the treatment of an acute
disc lesion is an adequate period of bed rest. A firm mattress is
recommended. Bed boards have fallen out of favor and in fact, in
many instances, they will actually increase the level of pain noted
by the patient.
The patient should lie in a position so that his hips and knees are
flexed. The patient is warned against sleeping in a prone position
which will result in extension of the lumbar spine.
Of prime importance is the duration of bed rest. Frequently,
patients are allowed to return to their occupation before the
inflammatory process of the disc lesion has diminished. The
patient should be informed that after an acute disc attack a
minimum of 2 to 3 weeks is required at complete bed rest.
Gradual mobilization is then instituted over a period of 10 to 14
days if the patient has relief of pain and paravertebral muscle
spasm.
It is of great importance to note that any patient with neurological
deficits or with progressive atrophy of the lower extremities
should be referred for surgical consultation. This patient may not
be a candidate for conservative management and a reevaluation
should be considered in order to establish a favorable prognosis.
When you feel your conservative treatment program will be
effective, you should clarify and warn the patient that it is
unrealistic to expect a person with a frank disc protrusion to
return to full activities in less than one month. Compromise on
this point is frequently sought by the patient but in the long run it
will not be to his benefit.
You should be quite candid in explaining to the patient
that surgical procedures may require a prolonged period of
rehabilitation in itself and that the choice of a conservative
program may preclude the necessity of operative intervention.
The modality of bed rest is of great importance so that the
inflammatory reaction may diminish. It is hoped that the edema
and hyperemia of the soft tissue surrounding the protrusion will
subside, allowing the patient to become free of his acute pain
and peripheral neurological involvement. The relief may or
may not be permanent, thus the prognosis would still have to be
considered guarded.
PHYSICAL THERAPY
Physical therapy, historically, is one of the newest and yet one of
the oldest fields. It is one of the newest because only in the past
35 years has it become recognized as an integral part of practice.
It is one of the oldest because the first man who bathed a wound
in a stream instituted the practice of hydrotherapy; and the first
man who rubbed a bruised muscle introduced massage. History
reveals primitive cave paintings of early man lying under the sun
to receive the benefits of its warmth.
I do not feel it is necessary for practitioners to know the physics
of the various modalities used in our practices to be able to
recommend their benefits. However, it is essential for the doctor
to understand the clinical principles of the therapy so that he can
design a treatment program that will provide effective patient
management.
The principles of physical therapy are:
1. Prevention of morbidity
2. Maintenance of a normal physiological state
3. Restoration of functional loss in the anatomical structure
TRACTION
In many instances traction has gained the reputation of being
a specific treatment for a lumbar disc lesion. The supposition
that traction separates the lumbar vertebra and permits the disc
to return to its “container” is without basis and is an untenable
conclusion.
There is a great controversy surrounding home pelvic traction.
Some authorities feel it is a cumbersome apparatus which makes
bed rest less comfortable. They feel that the therapeutic value is
highly dubious and probably nonexistent except for enforcing
a program of bed rest However, other authorities feel home
pelvic traction produces distraction of the vertebra, allowing
the intervertebral foramina to increase in size, thus reducing
inflammatory reaction.
Motorized intermittent traction is supplanting all other methods
of traction and properly applied may provide the following
values:
1. Decreases muscle spasm
2. Has a massage-like effect upon the muscles and
ligamentous structures
3. Diminishes swelling and promotes better circulation in the
tissue thus helping to reduce inflammatory reaction
4. Helps to prevent the formation of adhesions between the
nerve roots and the adjacent capsular structures
THERMAL THERAPY
HEAT: No one as yet has been able to demonstrate clinically the
superior value of any specific thermal therapy. Heat will increase
circulation, aid in muscular relaxation and improve nutritional
status of tissues. In injury it often will alleviate pain and stiffness.
This type of therapy would serve as a prelude to treatment that
will influence the successful management of the condition.
HYDROCOLLATOR PACKS: Hydrocollator packs have a
predominantly superficial thermal effect. The temperature
pattern with hydrocollator packs is, however, not the same as
with infrared, for the rise is far quicker with the hydrocollator
pack, and there is the alternating quick rise and more gradual fall
of temperature, as the hydrocollator pack is ordinarily applied
therapeutically. Furthermore, the intense sensory stimulation with
hydrocollator packs may play a significant role in the apparently
greater relaxation.
MICROWAVE AND SHORT WAVE THERAPY: Broadly
speaking, the therapeutic indications for microwave diathermy
differ little, if at all, from those applicable to short wave
diathermy. Microwave irradiations find their chief value in
bringing about a significant rise in the temperature and a local
increase in blood supply in deeper structures. The obvious
advantage of microwave therapy is that with it, it is possible
to heat the deeper tissues without undue heating of the more
superficial tissues. With the modern equipment now available
it is possible to localize heat to the specific area to be treated
and to control and measure the dosage. The technique of
application is simple and the patient is comfortable and free from
apprehensions.
COLD THERAPY: Ice massage provides surface anesthesia. The
patient usually responds in 4 stages; cold, burning, aching and
numbness. When the skin is cold it becomes extremely red and
a histamine-like reaction occurs during the remaining 3 phases.
The patient may become conscious of a tender mass over the site
of maximum pain that is not palpable to the examining fingers.
When this sensation abates the pain is relieved and the treated
area is numb. Gentle stretching of the muscle can then start,
helping to relieve muscle tension and rigidity. Ice, as well as cold
packs on the skin act as a vasoconstrictor and decrease localized
hemorrhage. It acts as a decongestant to an area that has been
injured, thus reducing swelling and edema. Clinically it decreases
muscle fatigue and helps break the spasm to facilitate gentle
limbering movements.
ETHYL CHLORIDE AND FLURO-METHANE SPRAY: When
localized lumbar paraspinal muscle pain seems to emanate from
a specific site, surface anesthetics, such as ethyl chloride or fluro-
methane spray, occasionally are helpful. When the lumbar region
has been sufficiently cooled it should be possible to stretch the
muscle to its normal resting length. This is probably the most
important part of this therapy.
ULTRASOUND: This modality produces a “micro-massage”
of the cellular tissues, thus producing mechanical vibrations
which increase the blood supply, stimulating the metabolism and
producing an analgesic effect. Further results include breaking
up tissue deposits (such as scar tissue and calcium deposits) and
promotion of their absorption. All of these therapeutic effects
play an important role in improving mobility and relieving pain.
ULTRASOUND IN ASSOCATION WITH MUSCLE
STIMULATION: Ultrasonic sonations combined with muscle
stimulation causes a mechanical pumping by electrical impulse.
By its mechanical action ultrasound helps soften microscopic
fibrous tissues and scars. This therapeutic combination promotes
dissipation of metabolic waste products of the muscle group
being treated, thus helping to restore a normal physiological state.
MUSCLE STIMULATION: This is an alternating current used
for muscle stimulation. The current causes muscles to contract
and helps the patient activate a muscle without using it to move a
joint (similar to an isometric exercise). Consideration should be
given to the fact that this therapy also allows an alienated muscle
to be brought into action in which another muscle has taken over
by substitution.
GALVANISM: Galvanic current is used with the anode active
to relieve pain and to lessen tissue swelling. The latter probably
results in promoting an osmotic effect by ionizing the salts in the
tissue fluids. The pain relieving effect is considered a clinical fact
but the cause remains obscure.
INTERFERENTIAL CURRENT: Recent developments
have shown that this unique modality is quite effective in the
management of musculoskeletal joint disorders.
Interferential currents are generated as an interference
phenomenon which permits higher intensity currents to be used
in the field of muscle stimulation.
It has been my experience that a pronounced effectiveness is
obtained through a combination with vacuum massage which
allows the frequency to rapidly over excite muscles beyond their
capabilities to respond. This produces an anti-spasmotic and
depressant effect, thus relieving muscular rigidity and eliciting a
definite analgesic response.
It has been my clinical judgment that the subacute patient
responds favorably and tolerates this type of therapy well.
MECHANICAL VIBRATION: The physiological effect of
this mode of therapy will increase blood and lymph flow, thus
reducing edema and congestion. This type of deep mechanical
massage is tolerated by the patient as it often reduces pain by
stretching and relaxing rigid muscles.
MASSAGE: This mode of therapy was known in antiquity and
may be helpful in the modern day conservative management of
low back pain. Paraspinal muscle spasm can be relaxed by gentle
massage. This particular therapy provides a mechanical effect in
helping the return of venous blood, lymph and catabolites into the
mainstream of circulation.
LUMBAR IMMOBLIZATION
Anatomical structures can be held in normal or corrective
position which permit only limited movement. The purpose is to
prevent component structures of the joint from exceeding normal
physiological limits and to provide firm support where indicated.
The relief from pain after application of supportive appliances is
often immediate and dramatic.
PRINCIPLES AND OBJECTIVES OF IMMOBOLIZATION
1. To immobilize, support and stabilize
2. To approximated tissue in order to promote healing
3. To reinforce and protect
4. To substitute for defects in fibrous tissue temporarily
LUMBOSACRAL BRACE
When fitting a lumbosacral brace appliance the steels should
be accurately molded to the sacrum and to the lumbar lordsis.
Bending irons are a necessity in any orthopedic practice.
Correction and stabilization should be reevaluated in attaining the
optimal lordotic curve during the patient management. The steels
should have the tendency to hold the thorax slightly backwards;
it should not press it forward. If the curve of the steel is less than
that of the patient’s lordosis as he stands upright, the effect would
then be to force the thorax forward and that posture would then
be contraindicated to good muscular tone. This is a common
failing which makes an otherwise acceptable brace less effective.
PLASTER JACKET
This custom made appliance is utilized with great efficacy by the
chiropractic orthopedist. Patients often get dramatic relief by its
application. The success of this device is that it not only provides
the patient with the essential principles of immobilization
but it can be worn for an indefinite period of time. One of the
advantages is that even though it is plaster, it is so designed that
it may be taken off at night so that excessive muscular fatigue
does not occur.
Over the years of successful employment of this plaster jacket
in my own practice I have felt that if a unilateral hip spica could
be made part of the jacket we would add another dimension that
would insure added immobilization.
Other than a plaster jacket my recommendations are a plastozote,
thermo plastic flexion body jacket, as well as the steel reinforced
chairback brace because of their extreme lightweight durability.
All of the above lumbar devices are fitted to the patient’s own
measurements.
EXERCISE THERAPY
When a patient has a lumbar disc lesion one of this basic
symptoms is a loss of function usually accompanied by pain.
A program of low back exercises should include an understanding
that you are treating the muscle spasm which is a secondary
reflex reaction in addition to attempting to reduce the lumbar
lordosis.

Within our profession there is mild disagreement as to the
benefits of flexion vs. extension exercises. There are those who
feel that the flexion approach only exacerbates symptoms by
added stress on the anterior portion of the disc thus causing the
posterior tear in the annulus to widen.
It is my feeling that when exercises are to be introduced they
should be initiated only at the subacute stage and that is probably
the critical factor in the treatment. As a result, I, personally, prefer
the flexion approach.
A flexion exercise program can accomplish 4 basic goals:
1. Subluxation or overriding facets can be placed in a position
where they are diminished
2. The spine can be placed in a position of stability where the
shearing strains are minimized in the lower lumbar disc
levels.
3. The intervertebral foramina are opened, allowing maximum
room for exit of the nerve roots.
4. Strengthening of the abdominal musculature and flexors of
the spine. Both of these muscle groups have been shown
to be important in supporting the spine and alleviating
gravitational stress of the intervertebral disc.
The goals and reasons for the effectiveness of the lumbar
exercises outlined above are theoretical and open to debate. Their
efficacy is based upon and empirical and clinical basis which has
been clearly shown in practice.
TRANSCUTANEOUS NERVE STIMULATION:
Once again interest has become in vogue with the use of
electrical currents for the relief of chronic pain, particularly, pain
of neurogenic origin.
The prime indication for the use of a dorsal column stimulator is
the long standing and intractable nature of the pain.
Some patients may derive significant improvement from this
modality and will also appreciate some degree of improvement
within the limited anatomical area affected by transcutaneous
stimulation.
The physiological aim is that the treatment will stimulate larger
myelinated afferent fibers to block at the level of the spinal cord,
the passage of pain impulses carried by smaller afferent fibers.
When the patient responds to this type of therapy he can be
supplied with a portable stimulator which can be used when he
feels it is necessary.
BEHAVORIAL CONDITIONING AND BIOFEEDBACK
Modification of behavior has been applied to the clinical sciences.
Specific behavior can be conditioned by positive reinforcement.
In regard to musculo-skeletal pain, conditioning is predicated on
the assumption that chronic pain responses are learned behaviors.
In a clinical atmosphere, positive techniques are carried out by
skilled therapists or informational feedback from a biofeedback
recording machine.
It has to be understood that these techniques are in their infancy
and they are not applicable to all patients. If behavioral patterns
are successfully modified the long term results have yet to be
assessed.
LIFESTYLE ADAPTATION TO THE CONDITION
Every chore the patient does from housekeeping to getting in and
out of a car must be analyzed in terms of body mechanics. The
patient must practice both defensive and protective movements
until they become second nature.
In conservative management a frequent deficiency is that the
doctor does not design a program that will teach the patient how
to cope with daily living habits.
The patient should be instructed to reduce obesity, improve
mobility and avoid excessive muscular stress. We have to help
the patient resume activities that will not create recurrent attacks
of low back pain.
The doctor should take time to stress the advantages of this
program to the patient, reviewing the potential problems of what
may occur in the future if such a regimen is not followed.
SUPPLEMENTS
Stress vitamins (B complex) are effective in order to enhance
neural metabolic integrity, especially in acute conditions.
In the long range management, vitamin C is of extreme value in
all of the collagen diseases. Recommended dosage of 2000 mg.
daily should be considered during the supportive phase of lumbar
disc disease.
TREATMENT PROGRAM
From visit to visit, changes in the patient’s progress and therapy
should be fully explained to him. As the treatment program
proceeds the doctor and the patient will benefit from an
occasional review of their progress. Reexamination during the
course of therapy is of extreme value for it is quite possible for
another disorder to appear. The doctor must never lose sight of
the maximum objective --- restoration, in every way possible ---
of optimum health and function.
EPILOGUE
In the study of disc disease clinical science is still attempting to
establish treatment guidelines. Wide divergence in management
of patients, even within our own profession, causes honest
academic and intellectual differences. When reviewing those
patients who have been exposed to a multi-disciplined approach
it becomes apparent that a large measure of the recovery rate
depends on such factors as: the starting point, body types,
hereditary influences, occupational demands, methodology of
approach, quality of primary care, etc.

It has been my attempt to present a broad overview of the lumbar

disc syndrome. In my opinion, until investigations contain the
multiplicity of total conservative care, end results will continue to
be incomplete.

Copyright Dr Franklin Schoenholtz 2009