Low Back Pain. Contraindications

Although it has been accepted throughout that all patients have received adequate medical screening, occasionally patients with serious pathology or mechanical disorders unsuited to mechanical treatment are encountered during routine examination. If in the examination no position or movement can be found which reduces the presenting pain, the patient is unsuited for mechanical therapy, at least at this time.

The existence of serious pathology should be considered when the history states that there has been no apparent reason for the onset of symptoms; that the symptoms have been present for many weeks or months, and have during that time increased in intensity; and that they are constant; and the patient feels that he is gradually getting worse. On examination the pain remains exactly the same, irrespective of positions assumed or movements performed. Usually there is little loss of function if any, and postural deformity is not often seen. In addition to the examination finding, the patient often looks unwell and may complain of feeling unwell. Mechanical procedures described in this book should never be applied to patients presenting with signs and symptoms of this nature.

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Saddle anaesthesia and bladder weakness are indications of compression of the fourth sacral nerve root. These symptoms occur in major disc herniation and, when present, form a definite contra-indication to manipulative procedures.

Patients who exhibit signs of extreme pain — that is, who become transfixed on movement, and freeze and immobilise the spine when palpation is attempted — are considered unsuitable for mechanical therapy, at least at this stage.

Developmental or acquired anomalies of bone structures which may lead to weakness or instability of mechanical articulations are hazards to manipulative procedures. Architectural faults should be excluded from mechanical therapy. Exceptions are minor grades of spondylolisthesis where symptoms are mild and intermittent. The presence of spondylolisthesis at a certain segment is not necessarily an indication that symptoms are forthcoming from that segment. It is seen very often indeed that pain is the result of disc derangement at a different level.

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A simple clinical test may determine whether spondylolisthesis is responsible for the presenting pain, as it will often reduce or abolish pain in the presence of that condition. Place one hand across the sacrum of the standing patient and the other firmly against the abdomen. By further compressing the abdominal content while at the same time increasing pressure on the sacrum, pain in standing arising from spondylolisthesis is markedly reduced or abolished. On the other hand, pain arising from derangement of any of the lumbar discs will usually be enhanced by this procedure, and postural or dysfunctional pain remains unaffected. Thus, if pain is increased with this test the patient should be treated as for the derangement syndrome, but if pain is reduced the presence of spondylolisthesis must be investigated and the necessary precautions must be taken in the treatment.

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Bed rest

Patients with mechanical low back pain are often advised to rest as much as possible, preferably in bed. In many instances this is inappropriate if not bad advice. The nutrition of the intervertebral discs depends entirely on osmosis, and movements of the spine are essential for the flow of fluids containing nutriments. To rest the joints of patients with mechanical low back pain often only adds to the problems of restoration of function and full rehabilitation. The only patient who should be placed on bed rest is the very acute patient with severe constant low back pain with or without sciatica whose symptoms are considerably worse during weight bearing, and in whom no movement or position can be found to reduce or centralise the pain.

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In order to prevent the development of dysfunction within or about the involved intervertebral joint following derangement, regular assessment of the patient on bed rest is required and treatment must be instituted as early as possible. This is particularly important in the patient who responds very well to bed rest, because without movement this patient will become painfree but may develop a significant loss of function.

Supports

If, following reduction of derangement, all efforts at prevention of immediate recurrence are unsuccessful, it may be desirable to supply the patient with a corset for short term support and stability. Long term use of a corset is undesirable as it merely hastens the development of dysfunction.

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Surgery

The question of surgical intervention inevitably arises in the minds of doctors, therapists and patients alike when progress is slow or non-existent. The decision as to whether one should or should not operate must always concern the orthopaedic surgeon.

It is my experience that, in New Zealand, surgery will be performed only when conservative treatment methods have failed. This does not always include adequate mechanical therapy, but usually it has allowed adequate passage of time. Fortunately, few patients in New Zealand receive surgery for low back pain only, and the procedures of laminectomy and discectomy are reserved for patients suffering significant nerve root compression.

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The difficulties surrounding the diagnostic criteria for surgical intervention are enormous. One study showed a large number of positive myelograms in lumbar spines of patients who were asymptomatic and had been admitted and X-Rayed for conditions other than low back pain.5 Thus the value of the myelogram, the good old standby relied upon by many doctors, has become somewhat suspect.

The results of surgery can also be seen to vary significantly. Randomly selected patients with low back pain, referred pain to one leg, and positive myelograms coupled with clinical signs, were divided into two groups. The patients in the one group received surgery, those in the other group not. It was found that at the end of one year ninety percent of the non-operated patients were better; that the operated patients were only better in the first two months following surgery; and that at the end of one year the results in the group that had received surgery were the same as in the group that had not been operated upon.

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The final result of a disc lesion is not endangered by a three months’ waiting period before surgery is undertaken. However, a longer wait may be prejudicial as it may leave the patient with residual disability.

Fielding states that Nachemson, Rothman and Hirsch have all found that there is a clear correlation between the early return of symptoms following surgery and the formation of scar tissue. Quoting Fielding:

“Early return of symptoms usually means the formation of scarring which cannot be cured by surgery and means that the results will be poor’’.

Rothman examined sixty-eight patients who had undergone two or more unsuccessful spinal surgical interventions. He reports that seventy-five percent of the patients claimed partial or total disability. Half of the failures in multiple surgery are due to scarring or nerve root adherence. Scarring and fibrosis are associated with a high failure rate and dismal results.

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It is appropriate to make clear that scarring causes dysfunction, described earlier in this book. Scarring does not necessarily have to cause problems provided it is discovered early enough and dealt with adequately in the manner suggested in previous chapters. I believe that one procedure is mandatory following surgery for lumbar disc protrusion: that is, the regular performance of one full straight-leg-raising movement at two hourly intervals. This should reduce significantly the complications of fibrosis and nerve root adherence. Just as recent scars can be stretched and lengthened by dysfunction treatment procedures, so should the prevention of inextensible scar formation be feasible by the even earlier use of the same procedures.

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Back pain. The Cause of Pain THE NOCICEPTIVE RECEPTOR SYSTEM Most tissues in the body possess a system of nerve endings which, being particularly sensitive to tissue dysfunction, may be referred to as nociceptive receptors. The free nerve endings of the nociceptive system provide the means by which we are made aware of pain. Wyke describes the distribution of the nociceptive receptor system in the lumbar area: it is found in the skin and subcutaneous tissue; throughout the fibrous capsule of all the synovial apophyseal joints and sacro-iliac joints; in the longitudinal ligaments, the fiaval and interspinous ligaments and sacro-iliac ligaments; in the periosteum covering the vertebral bodies and arches, and in the fascia, aponeuroses and tendons attached thereto; and also in the spinal dura mater, including the dural sleeves surrounding the nerve roots. The nociceptive innervation of the spinal ligaments varies from one ligament to another. The system is found to be most dense in the posterior longitudinal l...
Spine Health. PROCEDURE 5 — SUSTAINED EXTENSION To apply a sustained extension stress to the lumbar spine an adjustable couch, one end of which may be raised, is a necessary piece of equipment. The patient lies prone with his head at the adjustable end of the couch which is gradually raised, about one to two inches at the time over a five to ten minute period. Once the maximum possible degree of extension is reached, the position may be held for two to ten minutes, according to the patient’s tolerance. When lowering the patient the adjustable end of the couch should slowly be returned to the horizontal over a period of two to three minutes. This must not be done rapidly, for acute low back pain may result. Fig. Sustained extension. Effects: The procedure is predominantly used in the treatment of derangement. The effect is similar to that of the third procedure, but a time factor is added with the graduated increase and the sustained nature of the extension. In certain circumstances a sustained extension stress is preferable...
Spine Health. PROCEDURE 13 — FLEXION IN LYING The patient lies supine with the knees and hips flexed to about forty-five degrees and the feet flat on the couch. He bends the knees up towards the chest, firmly clasps the hands about them and applies overpressure to achieve maximum stress. The knees are then released and the feet placed back on the couch. The sequence is repeated about ten times. The first two or three flexion stresses are applied cautiously, but when the procedure is found to be safe the remaining pressures may become successively stronger, the last two or three being applied to the maximum possible. Fig. Flexion in lying. Effects: Flexion in lying causes a stretching of the posterior wall of the annulus, the posterior longitudinal ligament, the capsules of the facet joints, and other soft tissues. As the movement takes place from below upwards the lower lumbar and lumbo-sacral joints are placed on full stretch at the beginning of the exercise as soon as movement is initiated. Thus, the procedure is very i...
Spine Health. PROCEDURE 14 — FLEXION IN STANDING The simple toe touching exercise in standing does not need much elaboration. The patient, standing with the feet about thirty centimeters apart, bends forward sliding the hands down the front of the legs in order to have some support and to measure the degree of flexion achieved. On reaching the maximum flexion allowed by pain or range, the patient returns to the upright position. The sequence is repeated about ten times, should be performed rhythmically, and initially with caution and without vigour. It is important to ensure that in between each movement the patient returns to neutral standing. Fig. Flexion in standing. Effects: Flexion in standing differs from flexion in lying in various ways. Naturally, the gravitational and compressive forces act differently in both situations. In flexion in standing the movement takes place from above downwards, and the lower lumbar and lumbo-sacral joints are placed on full stretch only at the end of the movement. In addition, the lumbo...
Spine Health. PROCEDURE 12 — ROTATION MANIPULATION IN FLEXION The sequence of procedure 11 must be followed completely to perform the required pre-manipulative testing. If the manipulation is indicated a sudden thrust of high velocity and small amplitude is performed, moving the spine into extreme side bending and rotation. Fig. Rotation manipulation in flexion. Effects: There are many techniques devised for rotation manipulation of the lumbar spine. When rotation of the lumbar spine is achieved by using the legs of the patient as a lever or fulcrum of movement, confusion arises as to the direction in which the lumbar spine rotates. This is judged by the movement of the upper vertebrae in relation to the lower — for example, if the patient is lying supine and the legs are taken to the right, then the lumbar spine rotates to the left. It has become widely accepted that rotation manipulation of the spine should be performed by rotation away from the painful side. This has applied to derangement as well as dysfunction, because hitherto n...