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.

READ:   Spine Health. PROCEDURE 1 — LYING PRONE

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.

READ:   Spine Health. PROCEDURE 14 — FLEXION IN STANDING

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.

READ:   ASSESSMENT OF PAIN

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.

READ:   Spine Health. PROCEDURE 12 — ROTATION MANIPULATION IN FLEXION

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.

READ:   Spine Health. PROCEDURE 5 — SUSTAINED EXTENSION

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.

READ:   The Derangements and Their Treatment

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.

READ:   Spine Health. PROCEDURE 3 — EXTENSION IN LYING

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...
TREATMENT OF THE POSTURAL SYNDROME Every patient must be examined and analysed individually, and educated for his own particular postural stress. Education is probably the most important part of the treatment for low back pain of postural origin. The patient must have a clear and unambiguous explanation of the mechanism that produces his pain. He must realise that, when he assumes the positions of stress causing pain, he is in fact pulling the ligaments apart; and all that is required to stop his postural pain, is to stop stressing the ligaments for about ten days. I also explain to the patient that once he commences the correction regime, he will and should develop some new pains which are commonly felt higher in the back. This is merely the consequence of adjustment to a new postural habit. The more often pain is triggered, the more readily it will occur. And the less often pain is triggered, the more difficult it is to be produced. Thus, poor sitting positions maintained regularly will cause pain after the passage...
Spine Health. PROCEDURE 3 — EXTENSION IN LYING The patient, already lying prone, places the hands (palms down) near the shoulders as for the traditional press-up exercise. He now presses the top half of his body up by straightening the arms, while the bottom half, from the pelvis down is allowed to sag with gravity. The top half of the body is then lowered and the exercise is repeated about ten times. The first two or three movements should be carried out with some caution, but once these are found to be safe the remaining extension stresses may become successively stronger until the last movement is made to the maximum possible extension range. If the first series of exercises appears beneficial, then a second series may be indicated. More vigour can be applied and a better effect will be obtained if the last two or three extension stresses are sustained for a few seconds. It is essential to obtain the maximum elevation by the tenth excursion and once obtained the lumbar spine should be permitted to relax into the most extreme ...
The Derangement Syndrome Of all mechanical low back problems that are encountered in general medical practise, mechanical derangement of the intervertebral disc is potentially the most disabling. It is my belief that in the lumbar spine, if in no other area, disturbance of the intervertebral disc mechanism is responsible for the production of symptoms in as many as ninety-five percent of our patients. Twenty-five years of clinical observation and treatment of lumbar conditions have convinced me that certain phenomena and the various movements which affect them, can occur only because of the hydrostatic properties invested in the intervertebral disc. For thirty years Cyriax has attributed lumbar pain to internal derangement of the intervertebral disc mechanism. He has outlined the cause of lumbago, and proposed that pain of a slow onset is likely to be produced by a nuclear protrusion while that of a sudden onset is caused by a displaced annular fragment. Although at present we are unable to prove either of ...
WHAT IS PAIN? Definition of Pain In dictionaries, pain (ICD-9: 780.96) is defined as a sensation of hurting or of strong discomfort in some part of the body, caused by an injury, a disease, or a functional disorder and transmitted through the nervous system. A nurse, Margo McCaffery, who worked for years with clients in pain and conducted extensive research in the field of pain, defines pain as whatever the experiencing person says it is, existing when he or she says it does. This definition is perhaps the most useful because it acknowledges the client’s complaint, recognizes the subjective nature of pain, and implicitly suggests that diverse measures may be undertaken to relieve pain. The IASP and the American Pain Society (APS) define pain as an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. Again, this definition further confirms the multiple components of pain in a person’s psychological and physiological exist...