Spine Health. PROCEDURE 16 — CORRECTION OF LATERAL SHIFT

This procedure has two parts: first the deformity in scoliosis is corrected; then, if present, the deformity in kyphosis is reduced and full extension is restored. The patient, standing with the feet about thirty centimeters apart, is asked to clearly define the areas where pain is being felt at present. The therapist stands on the side to which the patient is deviating and places the patient’s near elbow at a right angle by his side. The elbow will be used to increase the lateral pressure against the patient’s rib cage.

The therapist’s arms encircle the patient’s trunk, clasping the hands about the rim of the pelvis. Now the therapist presses his shoulder against the patient’s elbow, pushing the patient’s rib cage, thoracic and upper lumbar spine away while at the same time drawing the patient’s pelvis towards himself. In this manner the deformity in scoliosis is reduced and, if possible slightly overcorrected.

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Initially, there will be significant resistance to the procedure, which may actually cause an increase in pain. It is quite safe to continue with correction as long as centralisation of pain takes place, and therefore the patient must be questioned continually about the behaviour of his pain. Relaxation of the patient during the procedure is very important and we should always try to get the patient to ‘let it all go’. The first pressure in the series should be a gentle gradual squeeze which is held momentarily and then released. After this an accurate assessment of the patient’s reactions must be made. Experience has taught me that too much pressure or too fast a correction in the initial stages may result in fainting and collapse of the patient. If well tolerated the pressure is applied a little further each time. As correction progresses over ten to fifteen rhythmically applied pressures, the patient usually describes that the pain moves from a unilateral to a central position, and by the time over correction is achieved there will be a significant reduction in intensity of the pain or the pain may have moved slightly to the opposite side. If after a few rhythmical pressures no progress is made in the correction, it may be necessary to apply a longer and more sustained pressure.

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Sometimes reduction may be felt clearly by the therapist and the patient’s trunk is felt to move slowly but surely from its previously held position. In lightly-built or tall and slender patients shift correction may occur quite easily, and only a few minutes of ten to fifteen pressures are required to reduce the derangement. On the other hand, some acute lateral shifts are extremely difficult to reduce and one may have to perform five or six series of corrective pressures.

Assuming that correction of the deformity in scoliosis has been achieved, we must now proceed with restoring the lumbar lordosis. This is preferably commenced in the standing position. The patient no longer exhibits a lumbar scoliosis but may still have a kyphosis. The therapist, holding the patient as for correction of the scoliosis, must maintain slight over correction while moving the low back of the patient into the beginning of extension. A few movements will indicate the ease with which the lordosis will be restored. If the extension range improves rapidly it is usually belter to recover as much extension as possible in the standing position. If extension does not increase rapidly, then it is better to change to extension in lying. This procedure should produce a steady and continuing reduction of central pain, and it should automatically follow for all patients with a postero-lateral derangement once the scoliosis has been corrected and the symptoms have centralised.

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Fig. Correction of lateral shift.

Effects:

These will be discussed following the next procedure.

The Intervertebral Disc STRUCTURE In the lumbar spine the intervertebral discs are constructed similarly to those in other parts of the vertebral column. The disc has two distinct components: the annulus fibrosus forming the retaining wall for the nucleus pulposus. The annulus fibrosus is constructed of concentric layers of collagen fibres. Each layer lies at an angle to its neighbour and the whole forms a laminated band which holds the two adjacent vertebrae together and retains the nuclear gel. The annulus is attached firmly to the vertebral end plates above and below, except posteriorly where the peripheral attachment of the annulus is not so firm. Moreover, the posterior longitudinal ligament with which the posterior annulus blends is a relatively weak structure, whereas anteriorly the annulus blends intimately with the powerful anterior longitudinal ligament. The posterior part of the annulus is the weakest part: the anterior and lateral portions are approximately twice as thick as the posterior port...
Examination of Back Pain Having digested the information supplied by the referring doctor, extracted as much relevant information as possible from the patient, and checked the radiologist’s report, we may proceed to the examination proper. If the patient is able to do so, we should make him sit on a straight backed chair while taking his history. During this lime he will reveal the true nature of his sitting posture. When the patient rises to undress after the interrogation we should observe the way he rises from sitting, his gait, the way he moves, and any deformity that may be obvious. We will record the following: I. POSTURE SITTING If the patient has been sitting during history taking, we already have a good impression of his posture. We now ask him to sit on the edge of the examination table with his back unsupported. In the majority of cases the patient will sit slouched with a flexed lumbar spine. Some patients are more aware of the relationship between their posture and pain. They have discover...
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 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...
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