A case of a 16-year-old Indian adolescent with discal herniation in L4 – L5 region with classical sign of ‘foot drop’ was successfully managed by conservative, non-surgical approach following principles of yoga intervention. Patients practised yoga under supervision of yoga expert, four times a day for first two weeks followed by once a day for consecutive two years. Yoga protocol included gentle yoga based loosening practices, simple asanas, yogic breathing techniques and yogic guided relaxation,
Disc herniation is a serious condition that may lead to significant disability. If it is untreated, eventually it leads to spinal cord compression and serious neurological deficits such as foot drop, difficulties related to bowel and bladder evacuation and walking. In the present day’s long hours of desk work and long driving has increased the risk and prevalence of disc herniation (
Yoga is one among the popular alternative and therapies. Yoga intervention found to be useful in various chronic conditions including chronic low back pain (CLBP). It is a safe and effective intervention for CLBP (
The present case report is on teenager with adolescent disc herniation followed by foot drop and severe disability and recovery of the disease with yoga intervention and avoiding the surgery.
A 16-year-old male patient, height 6-foot, weight 118 kg, Mumbai, India reported with the chief complaint of severe pain in the left calf region extending up to the toes. The debilitating pain made it very difficult for the patient to even walk or sit or lie down in supine position. He was unable to even perform his daily chores such as passing his motions. He was not able to straighten up his leg and was dragging it while walking as he was unable to lift it. There was a tingling sensation along with numbness in the left leg. The big toe of the leg foot could not pronate equally as much as the right leg big toe as shown in
Pre-treatment Left Leg Big Toe Drop is seen.
Patient parents consulted an orthopaedic surgeon who advised a Magnetic Resonance Imaging (MRI) scan and advised immediate hospitalisation for complete bed rest and further observation. MRI revealed disc herniation in L4–L5 region of the vertebral column.
Patient visited a neurologist who diagnosed the left leg foot drop and sensation loss at calf level. He advised pain killer and further consultation with a spine specialist.
A second opinion was sought with a spine specialist who examined the patient and the MRI and advised complete bed rest for 10 days followed by surgical intervention if the symptoms persist after 10 days. Considering the patient’s age, the parents were not so keen to do an immediate surgical approach.
The Patient was so much in pain that he was prescribed multiple pain killers by the doctors (
Showing prescription treatment with multiple pain killers
Medications | Dose | Duration | |
1.
|
Chymoral Forte
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2 Tablets T.D.S
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1st week when pain started |
4. | Gabapentin 100 mg | 1 Tablet | 2nd week onwards |
5. | Lycra 50 Ultracet | 1 Tablet | 3rd week onwards |
Conservative treatment approach was sought. The mother contacted Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA) University, Bengaluru, After examining the reports, the physicians at S-VYASA also felt that surgical approach was the only option but could try the conservative intervention and a non-surgical plan was adopted under physician’s guidance. As the patient was in Mumbai and unable to travel to Bengaluru, a yoga therapist and expert was appointed to the patient.
The therapist after understanding the chief complaints of the patient, went and examined the toilet commode and immediately advised to change the toilet seat to a higher-level seat so that the patients discomfort and pain due to impinging of the nerve in the lower back region would be minimal. The rationale behind this decision comes from the fact that the oblique muscles of the back and the vertebral column face maximum amount of force in seated position. This force is further increased when the seat is has its base lower than the thigh. So, increasing the height of the toilet seat lead to change in the angulation between the resting position of the patient’s thighs and the toilet seat subsequently leading to lesser force being exerted on the vertebral column, decreasing the pain felt due to the nerve impingement.
The treatment regimen was as follows: For four continuous days, only passive therapy was given four times a day, followed by Pranayama and Deep Relaxation Technique (DRT). In addition to this, mind sound resonance techniques (MSRT) – a mindfulness-based relaxation technique is also given. After four days of passive therapy, the patients are advised to move on to active movements mentioned in the list below (
Duration of procedure | Frequency | Duration of intervention | ||
1. | Loosening of fingers | 1 minute | 2 times a day | 2 weeks |
2. | Loosening of Wrist | 1 minute | 2 times a day | 2 weeks |
3. | Shoulder Rotation | 1 minute | 2 times a day | 2 weeks |
For Foot Drop | ||||
4. | Toe Bending | 1 minute | 2 times a day | 2 weeks |
5. | Ankle Bending | 1 minute | 2 times a day | 2 weeks |
6. | Ankle Rotation | 1 minute | 2 times a day | 2 weeks |
For Improvement in Walking | ||||
7. | Toe Walking | 1 minute | 2 times a day | 2 weeks |
8. | Heel Walking | 1 minute | 2 times a day | 2 weeks |
9. | Line Walking | 1 minute | 2 times a day | 2 weeks |
10. | Cross Walking | 1 minute | 2 times a day | 2 weeks |
11. | Drill Walking | 1 minute | 2 times a day | 2 weeks |
12. | 1 minute | 2 times a day | 2 weeks |
Breathing practices
Breathing practices | Duration of procedure | Frequency | Duration of intervention | |
Hand Stretch Breathing | 2 minutes | 5 Rounds for 2 times day
|
2 weeks
|
|
Hands In and Out Breathing | 2 minutes | 5 Rounds for 2 times day
|
2 weeks
|
|
Ankle stretch Breathing | 2 minutes | 5 Rounds for 2 times day
|
2 weeks
|
|
Tiger Breathing | 2 minutes | 5 Rounds for 2 times day
|
2 weeks
|
The frequency and duration of the exercises were maintained keeping in mind the comfort of the patient.
After seven days, the patient was able to walk longer distances with less discomfort. A small walk of about 500 meters was introduced in his daily regimen once a day.
By 10th day, Yogasanas (
Showing various Yoga asanas
Duration of procedure | Frequency | Duration of intervention | ||
1. | 2 minutes | 3 Rounds two times a day
|
2 weeks
|
|
2. | 2 minutes | 3 Rounds two times a day
|
2 weeks
|
|
3. | 2 minutes | 3 Rounds two times a day
|
2 weeks
|
|
4. | 2 minutes | 3 Rounds two times a day
|
2 weeks
|
|
5. | 2 minutes | 3 Rounds two times a day
|
2 weeks
|
|
6. | 2 minutes | 3 Rounds two times a day
|
2 weeks
|
Once the Yoga Intervention started, the dose of allopathic medicines reduced gradually (
Showing the reduction of medications in the prescription
Medications | Dose | Duration | |
1. | Flexon MR | 1 Tablet B.D | First 2 weeks of Yoga Intervention |
2. | Gabapentin | 1 Tablet | 1 month of Yoga Intervention |
After a month of yoga intervention all allopathic medications were stopped. Forward bending asanas were strictly contraindicated at this stage of recovery. Patient also took up to himself to reduce his weight by weight training exercises and strict dietary control under the controlled supervision of a personal trainer and a dietician respectively.
Reduction in pain was achieved gradually from the start of the yoga therapy. The patient started to perform his daily chores comfortably by the second week. The patient could appear for his board Exams which were a month later.
The patient was initially taking high doses of neuropathic pain killer like Gabapentin. As the Yoga Therapy progressed, the dosage gradually reduced to nil by the end of the month.
Patient became totally ambulatory by the end of one month. Foot drag recovery was much gradual and it took almost six months to get above 95% recovery. The toes of the left foot which had lost their ability to pronate recovered to full normalcy (as compared to the unaffected contra lateral toe) in about 10 months. The patient had to be careful many a times while walking as he would tend to lose some body balance because of the inadequate toe control.
Both feet simultaneously pronating post treatment.
In the left calf region, the numbness and tingling reduced significantly in one week which completely healed by over four months. There was a drastic loss of muscle mass in the left calf leading to circumferential loss of approximately five cm as compared to the right calf in the same region. There was improvement of four cm over next two years with aid of intensive ipsilateral training using resistance bands and calf raises.
The MRI reports did not show much difference in the discal herniation in L4-5 level of clinical significance. There is additional disc protrusion seen in L5-S1 level. But since the patient was absolutely sign and symptom free of foot drop, pain in lower back, numbness and tingling sensation in left leg, decision was taken to ignore the changes.
This was a tailor-made treatment protocol of yoga and may not be effective in all the individuals.
A case of a herniated disc in L4 L5 region in a teenager patient was conservatively managed using principles of yoga therapy as proposed by the SVYASA institute at Bengaluru, India. Foot drop, a sign which most clinicians advise to be treated by surgical intervention, was successfully corrected by non-invasive yoga therapy. All other symptoms like pain, numbness, and tingling were also effectively treated in the adolescent patient whose parent was not keen to take the high risk of surgical intervention at such a young age. Strengthening of back muscles using relevant
We are thankful to the members of SVYASA University for helping in preparing yoga therapy module.
SR and KGM: has contributed to the writing of the manuscript
NR and AS: has planned the treatment protocol
JL: is the yoga therapist
The authors declare no source of funding received for this study.
Yes.
Authors declare no conflict of interest.