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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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...
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 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...
Spinal manipulation techniques There are many differing philosophies and concepts surrounding the practise of spinal manipulation and its effects on the pathologies which may exist in the spine. To satisfy all these philosophies an equal number of institutions has developed, teaching those wishing to learn. No matter what school presents its case or which philosophy is adhered to, all manipulative specialists claim to have a high success rate. They all use techniques which vary in nature, application and intent; they proclaim that their own methods are superior to those used by others; and yet, somehow they all obtain uniformly good results. Self-limitation of low back pain plays, of course, a significant role in this happy situation. Apart from this there are definite benefits which are obtained quickly by using manipulative techniques. Throughout the years I have practised many forms of mobilisation and manipulation, including osteopathic and chiropractic techniques and those taught by Cyriax. I have come to be...
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