Having corrected the lateral shift and the blockage to extension, it is now essential to teach the patient to perform self-correction by side gliding in standing followed by extension in standing. This must be done on the very first day, so that the patient is equipped with a means of reducing the derangement himself at first sign of regression. Failure to teach self-correction will lead to recurrence within hours, ruining the initial reduction, and the patient will return the next day with the same deformity as on his first visit.
I have discarded the technique of self-correction as described previously and instead I now teach patients to respond to pressures applied laterally against shoulder and pelvis. Initially, therapist’ assistance is required. Patient and therapist stand facing each other. The therapist places one hand on the patient’s shoulder on the side to which he deviates, and the other hand on the patient’s opposite iliac crest. The therapist applies pressure by squeezing the patient between his hands, ensuring that the patient’s shoulders remain parallel to the ground. When over correction has been achieved by the therapist, the mobility must be maintained by the patient who is therefore taught to actively respond to the pressures applied by the therapist. After some practise, remembering to keep the shoulders parallel to the ground, the heels on the ground and the knees straight, the patient can correct his own deformity. It is important to make the patient stand for a minute or two in the extreme over corrected position.
Immediately following correction of the lateral deformity full extension must be restored. In the corrected standing position the patient must perform about ten repetitions of extension in standing.
Fig. Self-correct ion of lateral shift.
It must be emphasised that as long as the lordosis is retained there is little chance of recurrence of the derangement. If the patient is unable to maintain the reduction, he must perform self-correction during the day at regular intervals. The patient is advised to perform a series of extension in lying exercises after each session of self-correction.
Effects and points to note:
It must be obvious that the last two procedures mainly influence the disc in derangement situations. In all instances time must be allowed for the reduction of the derangement to take place. Failure to correct the common lateral shift is usually the fault of the therapist, who has not taken enough time to allow a change in the contents of the disc to occur. The lateral shift correction including the restoration of extension must be an unhurried process and may take up to forty-five minutes in difficult patients. Constant repetition of the corrective procedures is necessary.
During the correction period there must be a continual reference to the patient’s symptoms. When there is any suggestion of the production or enhancement of limb pain, treatment must be applied with great caution and a change should be made to the angle of flexion or extension in which the lateral shift is being corrected.
Maintenance of the lordosis following the reduction of the derangement must be emphasised from the first day, and we must ensure that the patient has adequate knowledge to retain his lordosis while sitting. The most common cause of regression or recurrence of symptoms within a few hours of reduction is a poor sitting posture. For example, after a successful reduction a patient may drive home for twenty to thirty minutes and on leaving the car full derangement has recurred. This occurs commonly and must be anticipated. In order to cope with this problem the patient should be provided with a lumbar support — for example, a rolled towel or something similar — to accentuate and support the lordosis in sitting.
In acute cases patients should go home (and not back to work) after reduction has been achieved. On arrival home they should move directly to a mirror and check if derangement has recurred. If so, they should perform the self-correction procedures before it becomes too difficult to reduce the lateral shift without outside help. Then they must lie prone for a few minutes on a bed or on the floor prior to performing a series of extension in lying exercises. This pattern should be repeated each hour or whenever possible throughout the day, and between exercise sessions the patient must be lying and not sitting. On retiring for bed the patient must lie supine in the over corrected position, with a lumbar support in the small of the back to maintain the lordosis, for about thirty minutes before going to sleep. The next morning there is usually a significant reduction in the deformity and pain after the correction procedure has been performed once or twice, although when first awaking the pain may be quite noticeable on movement.