Spine Health. PROCEDURE 1 — LYING PRONE

The patient adopts the prone lying position with the arms alongside the trunk and the head turned to one side. In this position the lumbar spine falls automatically into some degree of lordosis.

Fig. Lying prone.

Effects

In derangement with some degree of posterior displacement of the nuclear content of the disc the adoption of procedure 1 may cause, or contribute to, the reduction of the derangement provided enough time is allowed for the fluid nucleus to alter its position anteriorly. A period of five to ten minutes of relaxed prone lying is usually sufficient. This procedure is essential and the first step to be taken in the treatment and self-treatment of derangement.

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In patients with a major derangement, such as those presenting with an acute lumbar kyphosis, the natural lordosis of prone lying is unobtainable. These patients cannot tolerate the prone position unless they are lying over a few pillows, supporting their deformity in kyphosis.

In minor derangement situations the degree of posterior movement of the nucleus is relatively small. Prone lying may actually reduce the derangement without any other procedures being required in the treatment, provided sufficient time is allowed for the fluid mechanism to alter to a more anterior position. In these situations the prone position, though obtainable, may initially be painful. This does not indicate that the procedure is undesirable. The increase of pain in this position is nearly always felt centrally and is in fact desirable. If pain is produced or enhanced peripherally, the prone position must be considered harmful and should not be maintained.

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A basic requirement for the self-treatment of derangement is that the prone position can be obtained and maintained. In this position the patient will commence the self-manipulative procedures, based on the extension principle.

In dysfunction there is a loss of extension movement or a reduced lordosis. In some patients with extension dysfunction the loss of movement may be enough to prevent lying prone for more than a few minutes. For these people lying prone in bed or while sunbathing has become impossible, because soft tissue shortening has reduced the available range of movement and prolonged extension stress produces pain.

The prone lying procedure by itself is not sufficient to resolve extension dysfunction. However, when adopted regularly and in conjunction with other procedures, prone lying should become painless as lengthening of shortened tissues takes place.

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The prone lying position should be obtained by all patients attending for treatment of low back pain. It has been suggested that this position can be harmful because it increases and accentuates the lumbar lordosis. This applies only in a few situations: when we have failed to correct a relevant lateral shift prior to assuming the prone lying position; when extension produces or increases the compression on the sciatic nerve root; and in those rare derangements where nuclear material has accumulated anteriorly or antero-laterally, and prone lying increases the derangement. In all other instances the prone lying position is highly beneficial.

Patients with posterior derangement should after reduction be careful when arising from the prone position to standing. Every effort must be made to maintain the restored lordosis while moving from lying to standing in order to maintain the reduction of the derangement.

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The Derangements and Their Treatment DERANGEMENT ONE Central or symmetrical pain across L4/5. Rarely buttock or thigh pain No deformity In Derangement One the disturbance within the disc is at a comparatively embryonic stage. Due to minor posterior migration of the nucleus and its invasion of a small radial fissure in the inner annulus, there is a minimal disturbance of disc material. This causes mechanical deformation of structures posteriorly within and about the disc, resulting in central or symmetrical low back pain. The accumulation of disc material also leads to a minor blockage in the affected joint preventing full extension, but the blockage is not enough to force the deformity of kyphosis upon the joint. In patients with Derangement One the history, symptoms and signs are usually typical of the syndrome, and the test movements confirm the diagnosis of derangement. Because the disturbance within the joint is relatively small it responds well to the patients’ own movements, and the majority of pati...
Spine Health. PROCEDURE 4 — EXTENSION IN LYING WITH BELT FIXATION The patient’s position and the exercise are the same as in the third procedure, but now a fixating belt is placed at or just below the segments to be extended. The safety belt is the first simple external aid, used to enhance maximum extension. It does so by preventing the pelvis and lumbar spine lifting from the couch. Other methods of restraint may be used effectively, for example the body weight of a young son or daughter when exercising at home. Fig. Extension in lying with belt fixation. Effects: This procedure creates a greater and more localised passive extension stress than the previous ones. It is particularly suitable for stretching in the case of extension dysfunction, and is more often required in dysfunction than in derangement. In dysfunction some pain will be experienced in the small of the back while exercising, because contracted tissues are being stretched. In derangement the rules pertaining to the centralisation phenomenon must be observed, and the proce...
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 6 — EXTENSION IN STANDING The patient stands with the feet well apart and places the hands (fingers pointing backwards) in the small of the back across the belt line. He leans backwards as far as possible, using the hands as a fulcrum, and then returns to neutral standing. The exercise is repeated about ten times. As with extension in lying it is necessary to move to the very maximum to obtain the desired result. Fig. Extension in standing. Effects: Extension in standing produces similar effects on derangement and dysfunction as extension in lying, but it is less effective in the earlier treatment stages of both syndromes. Whenever extension in lying is prevented by circumstances, an extension stress can be given by extension in standing. In derangement, extension in standing is designed to reduce accumulation of nuclear material in the posterior compartment of the intervertebral joint, provided this accumulation is not gross. In the latter case extension in lying will have to be performed first. Th...
The Postural Syndrome DEFINITION I would define the postural syndrome as mechanical deformation of postural origin causing pain of a strictly intermittent nature, which appears when the soft tissues surrounding the lumbar segments are placed under prolonged stress. This occurs when a person performs activities which keep the lumbar spine in a relatively static position (as in vacuuming, gardening) or when they maintain end positions for any length of time (as in prolonged sitting). History Patients with postural pain are usually aged thirty or under. Frequently they have a sedentary occupation and in general they lack physical fitness. In addition to low back pain they often describe pains in the mid-thoracic and cervical areas. They state that the pain is produced by positions and not by movement, is intermittent and may sometimes disappear for two to three days at a time. It is often found that, when patients are more active at weekends — playing tennis and dancing — they have relatively little or no t...