- 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 patients are able to reduce the derangement themselves by applying self-mobilising procedures. It is vitally important that all patients realise and experience the extent to which their own efforts of self-treatment contribute to the reduction of Derangement One. Therefore, it is undesirable to use therapist-technique in the first twenty-four hours of treatment.
Reduction of derangement
The patient with Derangement One will require the application of the extension principle. He should start lying prone (Proc. 1) for about five minutes, followed by lying prone in extension (Proc. 2) for another five minutes. He must then lie relaxed for a short while before commencing extension in lying (Proc. 3). This exercise, a modified press-up, should be done in groups of ten, and during the treatment session the groups are to be repeated five or six times with a rest period of about two minutes in between. During this time the patient should be questioned repeatedly to ensure that reduction of the derangement is taking place. At the completion of thirty or forty press-ups the range of extension should have improved significantly and the pain, if previously felt across the low back, should be localised more centrally. If before exercising the pain was already felt centrally, it should now be reduced in intensity. When reduction is almost complete patients often state that the original pain is gone but a strain pain or stiffness is felt instead. This can be achieved even during the first treatment session. No other procedure should be used if extension in lying (Proc. 3) culminates in centralisation or decrease in intensity of the presenting pain. If this occurs we can assume that there is a reduction in the magnitude of the derangement, and steps should now be taken to ensure that the reduction is maintained.
Maintenance of reduction
In order to maintain reduction of posterior derangement it is essential that the lordosis is maintained at all times. The patient should be instructed that at no time should he allow the lumbar spine to become flattened or convex. We must point out that if he is painfree in the prone lying position with the lumbar spine in extension, there is no reason why pain should arise in other positions such as sitting and standing or during movements and walking, provided that the same degree of extension is retained. If, with the lumbar spine in lordosis, the angle at which the affected joint is held prevents mechanical deformation, no pain will occur providing that angle is maintained.
Successful reduction of derangement will be shortlived if the patient subsequently sits without a lordosis. Sitting is usually the most troublesome position for patients with Derangement One. Bad sitting positions may cause and will definitely prolong symptoms of derangement. However, by maintaining the joints in the position of near maximum lordosis while sitting, the patient ensures that the fluid nucleus is held anteriorly. Of all the sitting positions the intradiscal pressure is at its lowest when sitting with a lordosis. Mechanical deformation will be minimal and the pain level will be greatly reduced in this position.
At this stage the patient should be shown how to maintain the lordosis in sitting. The slouch-overcorrect procedure should not be introduced as yet as it allows the patient to lose his lordosis. This procedure can be added once reduction of the derangement proves stable and the patient is ready for flexion procedures. In the early stages of treatment of Derangment One the patient is instructed to maintain the lordosis with his own muscular effort or with the use of a lumbar support. All patients with this type of derangement are advised to sit with a lumbar support, especially when driving the car or sitting in an easy chair.
Besides maintaining the lordosis the patient must be instructed to repeat the exercises every waking hour for the next twenty-four hours. Hourly repetition of the passively performed extension in lying (Proc. 3) ensures that no significant accumulation of nuclear material recurs in the posterior compartment of the joint. One group of ten repetitions of extension in lying (Proc. 3) is sufficient and it requires less than one minute to complete this. If circumstances prevent the performance of extension in lying (Proc. 3) it must be replaced by extension in standing (Proc. 6).
If following successful reduction, pain returns or increases to its former level at some time later in the day, it is likely that the patient has permitted some flexion to occur and has consequently lost the lordosis. He must take immediate steps to recover it, and usually one group of ten repetitions of extension in lying (Proc. 3) is sufficient but sometimes more may be required. Again, if circumstances prevent the performance of extension in lying (Proc. 3), extension in standing (Proc. 6) must be substituted.
Following reduction of posterior derangement patients should be very careful when rising from the lying and sitting position to standing. Normally, the spine is momentarily flexed when standing up and this must now be prevented. Patients must be shown how to lordose when rising from lying and sitting, because without help they will not easily master this. Again, we must emphasise that even a momentary loss of lordosis may cause recurrence of the derangement.
If patients are uncomfortable while lying in bed, it may be advisable to sleep with a lumbar supportive roll around the waist. This helps to maintain the lordosis when lying supine, and prevents the spine from sagging when lying on the side. On awaking the next morning the patient may feel stiff and painful, but after about an hour he will loosen up and find himself much improved compared with the previous day.
The second treatment should be given twenty-four hours after the first session. Only after this time may we confirm that we have made the correct diagnosis and have chosen the correct principle of treatment. If on returning the patient reports improvement, there is usually a definite change in the symptoms — that is, the pain has centralised or decreased in intensity; or its frequency is reduced; or both. Examination of the range of extension reveals improvement and the patient is better indeed. Our diagnosis is confirmed and we should continue with extension principle procedures. It is a basic rule of treatment, applicable to all syndromes, that technique presently resulting in improvement should not be added to, modified or replaced in any way until all improvement ceases. Thus, the same procedures can be continued safely over a number of days, provided the symptoms continue to improve. When the patient no longer has constant pain he may discontinue lying prone and lying prone in extension (Proc. 1 and 2). His intermittent pain is now most likely caused by loss of the lordosis, especially in slouched sitting, and we must emphasise the importance of the correct sitting posture once more. At this stage the introduction of the slouch overcorrect procedure is desirable in order that the patient may fully appreciate that slouched sitting will produce low back pain whereas correct sitting abolishes it. As further improvement becomes apparent, extension in lying (Proe. 3) may be reduced to two or three times per day — preferably morning, noon and evening, and may be replaced during the day by extension in standing (Proc. 6) whenever it is felt necessary.
We must warn the patient that after having started the treatment programme he is likely to experience ‘new pains’. These may be felt higher in the back, between the shoulder blades, and possibly in the arms. They are different from the original pain for which treatment was sought, and are the result of adjustment by the body to new positions and movements. New pains should be expected and will wear off in a few days to a week, provided the exercises are continued.
All patients should be instructed that, if they have severe pain which worsens or peripheralises at the time of exercising, they should stop the exercises and ask further advice. We must make sure it is well understood that, to be guilty of aggravation of symptoms, the exercises must actually increase the pain at the time of performance and not two hours afterwards. Pain felt immediately after exercising can be a result of the exercise. Pain appearing two hours afterwards is commonly fell because of the position occupied at that time — for example, sitting slouched while watching television.
I have outlined this far the routine that should apply in most Derangement One patients and which should result in the rapid and uneventful resolution of the symptoms. However symptoms and signs do not always respond as we would wish. Where reduction of posterior derangement proves difficult it becomes necessary to apply progressively increasing stresses in order to achieve reduction, and there is a certain order in which these progressions should be made.
Let us assume that the patient already described as an example does not continue to improve, that after the first twenty-four hours improvement ceases. Either the self applied reduction stresses are not adequate to fully reduce the derangement or our diagnosis may be incorrect or the patient may have inadvertently or unwittingly caused recurrence of the derangement. Re-examination is necessary to exclude incorrect diagnosis and re-instruction necessary to ensure the patient understands the self treatment procedures especially those regarding posture, and reduction. Having excluded other possible causes for non-improvement we must conclude that therapist technique should be applied before self treatment procedures will again become effective. Under normal circumstances repeated extension will result in a progressive reduction of pain and or centralisation will occur, but in this instance such a result is not forthcoming. Pain is not continuing to reduce and is still present at the maximum point of extension in lying (Proc. 3). Whenever difficulty arises in obtaining reduction of Derangement One the following progressions should be applied.
The first progression should be the application of extension mobilisation combined at intervals with rotation mobilisation in extension (Proc. 7 and 9) so that eight to ten of each is applied in succession to each segment indicated. As well as the affected segment, the segment above and below should be mobilised. This should immediately be followed by extension in lying (Proc. 3) which now will be increasing in range with concommitant reduction of or centralisation of pain. The effects of mobilisation will be apparent following twenty-four hours and if improvement has resulted the progression should be repeated.
The second progression should be applied only if the first progression has failed to reduce derangement. Again apply the technique of extension mobilisation (Proc. 7). After ten pressures to each of the appropriate segments maintain a continuous pressure at the level affected and ask the patient to perform about ten extension in lying movements (Proc. 3) against the pressure of your hands. Ensure your pressure is moderate but sufficient to prevent the pelvis moving from the treatment table. This increased stress surprisingly, (in derangement) permits freer painless movement rather than more difficult painful movement. This progression will frequently but not always remove the last obstruction to full extension. It may be necessary to apply these sequences on two or three successive days. Should reduction still be elusive a further progression may be required.
The third progression is the extension thrust manipulation (Proc. 8) and should only be applied if the preceding progressions have failed. Prior to manipulation, extension mobilisation (Proc. 7) and rotation mobilisation in extension (Proc. 9) should be applied in order to relax the patient and to provide the therapist with the necessary pre-manipulative information. Remember that repeating the mobilisation should be centralising or reducing pain as the derangement reduces. Providing this is occuring the manipulation can be administered. Should peripheralisation or increasing pain appear then the manipulation is inappropriate. This information can only be acquired by pre-testing. If the manipulation is successful it is usually evident immediately, and further treatment at this session is inadvisable. The patient should proceed with the self treatment programme as instructed on the first visit.
Following each progression the patient should continue through the following twenty-four hours with all advice and exercises initially prescribed. It should be emphasised again here that the progressions should only be initiated when all improvement utilising the patients own movements and abilities have been exhausted. Do not touch the patient unless you are certain that reduction cannot be achieved by any other means.
It can safely be assumed that reduction of Derangement One has been accomplished when full maximum extension in lying is painless even though the patient may describe and be aware of a ‘strain pain’ in this position. It is my experience that patients are well able to differentiate the ‘strain pain’ from the pain that caused consultation. It is necessary always to ask them to make the differentiation, for when asked, ‘in maximum extension do you have pain?’, the answer in invariably ‘yes’ indicating to the unwary that the derangement is not reduced. However if you further ask ‘is it pain, or strain’ the answer is usually ‘strain’. A very subjective line of questioning I know, but very important for I have seen therapists abandon the extension principle of treatment merely because the patient described a pain at the extreme of extension, that occurs commonly as end range strain in any normal joint.
Reduction of the derangement can be assumed when extension is painless. The patient may still describe a pain that appears when he sits and also a pain that appears when he flexes the lumbar spine past a certain point. This description can also be misleading and creates the impression that the derangement is still present. Posterior derangement cannot exist when extension is full and free and painless. The pain the patient is now describing appears in sitting and in flexion because the collagen laid down in the healing structures is now under stress as the posterior vertebral margins are separated by the action of slouching or flexing. These are not the pains of derangement, although derangement could perhaps develop if the positions are maintained for too long. These pains are the pains that arise from dysfunction and are now the sole cause of the remaining symptoms. If left untreated they can remain for years and cause end range pain whenever the patient moves to the extreme of flexion.
It appears that the first collagen fibres appear at about the fifth day after tissue damage occurs and these are the first foundations of scar tissue. Without movement this collagen will be laid down in a haphazard and disorderly fashion and as this disorderly structured tissue contracts with time an inelastic scar forms within the elastic annulus.
It is important that we recognise the signs that indicate when it is appropriate to commence the procedures that when applied enhance the quality of the developing collagen. By applying the appropriate stress, we can influence the direction in which the newly formed collagen fibres will lie so enhancing the strength and quality of the new tissue. At the same time we ensure that the scar that forms is an extensible scar and will not interfere with the adjacent still healthy annular structures. Function must always be restored following posterior derangement.
Recovery of full function
When commencing with flexion procedures initially only flexion in lying (Proc. 13) should be considered. Because of its additional gravitational stress flexion in standing (Proc. 14) should not be applied yet. To ensure that flexion in lying (Proc. 13) may be started safely reassessment of the test movement of flexion in lying is essential. The first time flexion in lying is performed it may cause pain as already some adaptive shortening has taken place in the posterior joint structures due to the maintenance of lordosis. Flexion becoming more painful on repetition indicates that it is too early to perform stretching in flexion; if continued, derangement is likely to recur or shortened structures may be damaged as a result of premature stretching. But flexion becoming less painful on repetition indicates that adaptively shortened structures are gradually being lengthened without further damage; flexion procedures may now be started.
In order to recover flexion the patient must commence with flexion in lying (Proc. 13). Because of the risks involved when performing flexion exercises following recent derangement, he should initially be careful and the following precautions must be taken:
- When starting flexion in lying (Proc. 13) the patient should reduce the number of exercises performed at each session, as well as the frequency of the sessions per day — for example, five or six repetitions of the exercise should be done five or six times per day. Once the condition proves stable, he may gradually work towards a full programme of ten repetitions performed each hour or hour and a half.
- Flexion in lying (Proc. 13) must always be followed by extension in lying (Proc. 3) to ensure that after exercising, the fluid nucleus is restored to the optimal position within the disc, thus removing the risk of recurrence. If due to circumstances the performance of extension in lying (Proc. 3) is impossible, extension in standing (Proc. 6) must be performed instead. Flexion in lying (Proc. 13) should not be done during the first few hours of the day. In this time period the risk of incurring derangement is increased due to an increase in the volume of nuclear fluid as a result of reabsorption and imbibition properties of the disc. This has previously been discussed.
When no further flexion can be gained with flexion in lying (Proc. 13) the patient should progress to flexion in standing (Proc. 14). The same precautions must be taken as for flexion in lying (Proc. 13). Thus, flexion in standing (Proc. 14) should be started on a reduced scale, should always be followed by extension in lying (Proc. 3) or extension in standing (Proc. 6) as a second choice, and should never be performed first thing in the morning. Once full flexion is recovered flexion in standing (Proc. 14) can be discontinued.
Recovery of flexion is considered to be complete when on performance of flexion in lying or standing full range of movement is achieved without pain, though a strain may be felt.
Prevention of Recurrence
Once recovery of function is achieved, the patient is advised to continue for at least six weeks, possibly longer, with extension in lying (Proc. 8:3) twice per day — early in the morning and late at night — flexion in lying (Proc. 13) once per day — late at night; extension in standing (Proc. 6) whenever necessary during the day; and the slouch-correct exercise whenever becoming negligent regarding the correct sitting posture.
Very few patients require to reduce or discontinue activities following derangement of the lumbar spine. We must explain to the patient that he may resume all the activities he is used to and enjoys doing — for example, sports activities, gardening, concreting, activities involving lifting — provided he follows the advice and instructions given to prevent recurrence of derangement.
I believe that failure to prevent recurrence is often the result of our failure to restore full function following derangement or trauma; our failure to ensure the patient has adequate knowledge and full understanding of the prophylactic measures; and, not less often, the patient’s failure to adhere to the prophylactic measures and to apply self-treatment procedures when these are called for.
TYPICAL TREATMENT PROGRESSION — DERANGEMENT ONE
- Assessment and conclusion/diagnosis.
- Explanation of cause of derangement and treatment approach.
- Reduction of derangement: commence with lying prone, lying prone in extension, extension in lying.
- Instruct to maintain lordosis at all times, must sit with lordosis and insert lumbar support. May benefit from supportive roll in bed.
- Repeat extension procedures each hour to maintain reduction and prevent recurrence.
- If extension in lying is not possible, it must be replaced by extension in standing.
- On recurrence of symptoms watch maintenance of lordosis even more, and immediately perform extension in lying.
- Demonstrate the use of lumbar supports in sitting and lying.
- Confirm diagnosis.
- Check sitting posture and exercises.
- If improving then change nothing other than reducing extension in lying to once every two hours; replace extension in lying with extension in standing when necessary.
- If no improvement at all then check vhat exercises are performed far enough into extension, often enough during the day, and that the lordosis is well kept.
- Add extension mobilisation, possibly rotation mobilisation in extension.
- Warn for ‘new pains’.
- Check sitting posture and exercises.
- If improving, continue with procedures as directed.
- Once constant pain has changed to intermittent pain, stop lying prone and lying prone in extension; start the slouch-over correct exercise.
- If no improvement, concentrate on mobilisation techniques and add extension manipulation.
- Check exercises and progress.
- If progress is satisfactory, reduce treatment to three times per week.
- Continue with same programme until painfree for three days at least.
- If progress is unsatisfactory, repeat mobilisation and manipulation techniques.
Day five and seven:
- Check exercises and progress.
- Once painfree for three days reduce extension in lying to three times per day and replace it by extension in standing whenever necessary during the day.
- Commencing flexion in lying; take all necessary precautions.
- Flexion in lying must be followed by extension in lying.
- 1 prefer to see patients with derangement every day until the reduction is stable and patients are in control. This may take up to five days. Then the treatment may be reduced to alternate days.
- Once reduction of derangement proves stable and the patient has been painfree for at least three days, flexion exercises may be started to recover function.
- All flexion exercises must be followed by extension in lying; if this is not possible extension in standing must be performed.
- When no further flexion can be gained with flexion in lying, the patient must start flexion in standing.
- When function is recovered flexion in standing may cease.
- The patient is advised to continue with the exercises for another six weeks to prevent recurrence: he will do extension in lying in the morning; flexion in lying followed by extension in lying in the evening; extension in standing whenever necessary during the day; and possibly the slouch-overcorrect exercise, whenever becoming negligent regarding sitting.
- Before discharge prophylaxis and self-treatment must be discussed in detail. We must emphasise that self-treatment is infinitely preferable to dependence on therapy.
- Central or symmetrical pain across L4/5.
- With or without buttock and/or thigh pain.
- With deformity of lumbar kyphosis.
This acute disturbance within the disc is a progression of Derangement One and, if handled incorrectly, can easily be converted into an acute lateral shift with predominence of unilateral pain (Derangement Four). Any applied torsion will cause this derangement to increase laterally and must therefore be avoided. Derangement Two gives us the clearest clinical picture, reflecting the phenomena occurring within the disc during derangement. There is excessive posterior accumulation of the nucleus with a major blockage of extension accompanying the deformity of acute lumbar kyphosis. Not only is extension prohibited, the vertebrae are also forced apart and their posterior margins cannot approximate. Any attempt to do so results in severe pain, the patient being forced to return to the flexed position where he finds some temporary relief.
Fig. Treatment of Derangement Two from start to finish. Commence reduction by allowing the patient to lie in slight flexion. Two pillows support the spine. Now one pillow supports lumbar flexion. With no support the lordosis is beginning to appear.
Fig. The spine moves towards more extension. As the couch is raised…
Fig. …extension increases until the… lordosis is fully restored.
Fig. After resting flat for a minute or two, the patient should… then apply the extension…
Fig. …movements himself…
Fig. … and remember that the lumbar… spine must sag into full relaxation in order to obtain the maximum effect.
The management of the patient with Derangement Two must be meticulous in the first treatment session. Due to the blockage of extension the patient is normally unable to lie prone, and this is a major obstacle to reduction. The self-treatment procedures of the derangement syndrome can only be commenced when the patient can comfortably lie prone.
In order to effectively treat the kyphotic derangement we must gradually reduce the kyphosis until the prone position is attained. Only then will the patient be able to start the procedures recommended in the treatment of Derangement One. Place the patient prone, ensuring the lumbar spine remains in flexion by placing pillows under the abdomen. The pillows are then gradually withdrawn, one at a time at five minute intervals or as tolerated, until the patient reaches the prone position. To facilitate a slow and gradual reduction it is wise to use several small pillows rather than one or two big ones. An adjustable treatment couch is extremely valuable and much preferred to the use of pillows. Time, the important factor so often overlooked, is essential in the reduction of Derangement Two. To reduce the deformity of kyphosis up to 45 minutes must be allowed for the fluid nucleus to alter its silhouette and its position within the disc. If reduction pressures are applied gradually, allowing intervals between each progression towards extension, a slow but observable recovery of movement will occur. Too rapid increases in the extension range will cause severe pain and may provoke immediate regression.
Once the patient is able to lie horizontally without severe pain and providing the centralisation phenomenon is occuring an attempt should be made to develop the treatment along the lines recommended for Derangement One. Should the level of pain produced by extension in lying (Proc. 3) be still so severe as to prevent its use we must utilise sustained extension procedures. (Proc. 5) The progressions should be small and gradual, the patients shoulders being lifted perhaps four to five centimetres at a time.
On first raising the couch the patient will experience an increase in symptoms and providing these are consistent with the criteria applying to centralisation it is safe to proceed. After a few minutes in the higher position the pain should start to reduce in the thigh or buttock, and although it may increase centrally near the lumbar four five area this should not last for more than a minute or so. Once the pain has subsided to its former level, then and only then can progression to the next higher level be made. Should the centralised pain fail to subside, return the patient for a few minutes to the horizontal position and allow him to recover from the stresses, which can be rather trying. Once recovered, repeat the extension progressions (Proc. 5) which second time around are normally much easier to tolerate. Each progressive increase in extension will initiate the cycle of pain increase, followed by centralisation of pain, followed by a gradual reduction in the central or near central intensity.
It may be necessary from time to time during the course of the reduction to allow the patient a few minutes in the prone relaxed position to permit recovery from the stress of the sustained position. Following the recovery period it will now be possible to raise the patient rapidly to the former maximum extended position from which he has just rested. The impediment to obtaining extension is beginning to diminish.
Following the recovery of extension by this method (Proc. 5) we have reversed Derangement Two to One. The deformity and the pain referred to the buttocks and thigh should no longer be present. Treatment can proceed either immediately or on the following day as for Derangement One.
Pain and deformity of acute lumbar kyphosis can be significantly reduced in the first treatment session. If complete reduction is not possible, at least reduction to Derangement One is usually achieved. It is of vital importance to instruct the patient in the steps required to reduce the derangement himself in case of recurrence. If after returning home lying prone is too painful, the patient must repeat the sequence of lying over pillows and then gradually lowering himself until the prone position is obtained. This can be done on the floor over cushions or in bed over pillows. If reduction of derangement is maintained, the patient will usually be able to commence the extension principle procedures as for Derangement One the next day.
It may take up to twenty-four hours, occassionally longer, to reduce Derangement Two to Derangement One. Once this is accomplished treatment should progress on a daily basis exactly as described for Derangement One, and the recovery time will be the same as for patients with Derangement One.
- Unilateral or asymmetrical pain across L4/5.
- With or without buttock and/or thigh pain.
- No deformity.
In Derangement Three the disturbance within the disc is located more postero-laterally rather than the postero-central position of Derangement One. This may be a progression of Derangement One, but it can also be the primary site of derangement.
Initially the treatment should be the same as for Derangement One. The first twenty-four hours of treatment will determine whether the procedures for reduction of Derangement One can successfully be applied to Derangement Three. Very often the application of the extension principle for Derangement Three reduces the disturbance to Derangement One within twenty-four hours. If on the second visit the patient is improving and the unilateral pain is reducing or centralising, or has moved evenly across the back, self-reduction is progressing and the extension principle as laid out for Derangement One must be continued.
On the second visit, should the patient show no improvement, reexamination and or re-instruction may be necessary; or, as was the case in the reduction of Derangement One the pressures may be inadequate. Should the applied reductive pressures prove inadequate it will again be necessary to progressively increase these and additionally alter the direction in which they may have to be applied.
The first progression in Derangement Three should be precisely the same as that applied as the first progression in the treatment of Derangement One. This progression should be given on the second day.
The second progression should be applied if the patient returns on the third day and is unimproved. With the patient in the prone position a lateral shift is formed by the therapist laterally gliding the patients pelvis away from the painful side. (This in effect creates a lateral shift towards the painful side.) With the pelvis in this off centre position the patient should be asked to perform a sequence of extension in lying (Proc. 3). There is often an initial centralisation of pain as the extensions are commenced. Should the pain subsequently move laterally or peripherally it may be necessary for the therapist to maintain the off centre position passively as the extensions are performed.
Once the repetition of extension results in reduction of pain, or pain felt consistently in the mid line, the therapist can release the passive maintenance of the shifted pelvis. Providing the pains are now reduced or remaining centrally, treatment can progress as for the reduction of Derangement One. It is important to teach the patient how to place the pelvis laterally on his own, for he may have to make this lateral correction at home, in order for extension in lying to be effective.
(An early indication that this progression may be necessary is often obtained during the course of examination of the test movements. Where lateral gliding in standing increases or decreases the patients symptoms or where these movements cause the initiation of centralisation it can be assumed that progression two in Derangement Three is likely to succeed.)
The patient should apply the second progression during the performance of the self treatment procedure of extension in lying (Proc. 3) whenever he does these during the next twenty-four hours.
The third, fourth and fifth progressions should be applied if on the fourth day there is still no improvement.
The third progression sustained rotation, (Proc. 11) should be applied and its effects recorded. The patients legs should be moved towards the painful side as the first rotation is applied. (My records indicate that pressure applied in this direction is most consistently followed by rapid improvement. The centralisation phenomenon is the ultimate guide however.) The position should be held for up to two minutes depending on the patients tolerance and centralisation.
The fourth progression should be rotation manipulation in extension (Proc. 10).
The fifth progression should be rotation manipulation in flexion (Proc. 12). Centralisation or reduction of pain must always be our guide regarding the side to which the technique should be performed or pressure applied. It is my experience that manipulation has a rapid effect and if there is no change in the symptoms after two manipulations in one direction, performed on successive days, the technique should be applied in the opposite direction provided centralisation and reduction of pain occur.
Once full centralisation is achieved Derangement Three is reversed to Derangement One. The treatment should now be continued and progressed exactly as for Derangement One.
- Unilateral or asymmetrical pain across L4/5.
- With or without buttock and/or thigh pain.
- With deformity of lumbar scoliosis.
In 1956 I was fortunate enough to observe an acute lumbar scoliosis in a patient friend, who had more than the average faith in my ability as well as an intense fear of remaining deformed for life. The lateral shift with which he presented was more generous than usually seen, and the poor fellow was in great trouble indeed. At that time I did not know of any treatment method which would restore him rapidly to normal, and there did not appear to be any such reference in the literature either. My friend’s desire to become painfree, his intense fear of remaining deformed for life coupled with my own curiosity regarding the mechanism causing the scoliosis led me to an abortive attempt to rectify the problem and correct the lateral shift. Needless to say, my friend was no better as a result but he was no worse either. He had to retire to his bed for ten days, and four weeks later he was painfree.
I tell this story for a specific reason. The fact that my friend left me neither better nor worse was of little concern to me at the time. However, the fact that his right sided pain had become left sided and the tilt of his trunk to the left had changed to the right, caused great consternation. I wondered what possible pathology could behave in this manner. In the only book available at that time to assist in the treatment of spinal disorders, Cyriax provided the clue that the intervertebral disc is the most likely structure to be responsible for the lateral shift phenomenon.
From then on, bearing the disc in mind, I closely observed every lateral shift that presented and attempted to reduce the derangement. For two years I was unsuccessful, regularly bringing patients to the upright position only to hopelessly watch them fall back into scoliosis. It was not until the significance of facet apposition in extension occurred to me, that I applied the extension principle following lateral shift correction to ensure maintenance of the erect posture.
In the past ten years I have had ample opportunity to treat patients in many parts of the world. On such occasions I am always provided with lateral shift patients who failed to respond to other treatment methods. Apart from the patients whose lateral shift had been present for too long, most responded rapidly and well to my correction techniques. In general, no more than four days are required to reduce the deformity of scoliosis. The procedure of lateral shift correction has now been adopted by doctors and therapists in many parts of the world.
Many theories have been put forward to explain the symptoms and peculiar behaviour of the derangement presented. These theories involve either disc, facet joint, ligaments and muscles, or combinations of any of these structures. Because in its most extreme form the lateral shift co-exists with a prolapsed intervertebral disc exhibiting an accomplished protrusion, we can assume that the disc is heavily involved in the production of this deformity. It is my opinion that Derangement Four is a lateral progression of the posterior disc disturbance of Derangement Two, and a simple progression of Derangement Three.
There is evidence that the incidence of deformity of scoliosis is higher in men than in women. My own statistics show that of all the patients presenting with a lateral shift in a certain time period seventy percent were male and thirty percent female. The results of a similar study reports a proportion of ninety percent male to only ten percent female patients.
Although the literature reports an even distribution of back pain among the sexes, I would dispute this, in patients with the derangement syndrome. Does the rather more accentuated lordosis of the female have anything to do with a lower incidence of lumbar scoliosis?
The majority of patients are seen to develop a lateral shift away from the painful side. My statistics show that ninety percent behave in this fashion, whereas the remaining ten percent deviate towards the painful side. In the latter group reduction is much more difficult to achieve and recovery may take up to three times longer than in patients of the first group.
A small number of patients exhibit an alternating scoliosis. I believe that when a minor disc bulge exists close to the midline very little movement can under certain circumstances cause the bulging to move to the opposite side, again occupying a postero-lateral position. As the disc bulge changes position the lateral shift deformity resulting from the bulge will also change sides. The patient under examination can sometimes create the alternating deformity at will, once he has observed its nature and the mechanism effecting it.
The incidence of a relevant lateral shift in patients with low back pain is very high. My statistics show that fifty-two percent of patients with low back pain have a relevant lateral shift that is, alteration of the lateral shift causes a change in intensity or site of pain or both.
The significance of derangement with deformity of scoliosis is much greater than is generally recognised. In the presence of a lateral shift either flexion or extension in the lumbar spine may be impaired, and sometimes both are affected. Lateral flexion to one side is similarly reduced. The loss of movement is always visible, sometimes markedly so. Furthermore, patients with even a minor lumbar scoliosis who are extended by exercises, mobilisation or manipulation, will become significantly worse with enhancement and peripheralisation of pain. The application of an extension thrust manipulation to a patient with a barely discemable lateral shift may precipitate a disc prolapse. Many patients with an undetected minor lateral shift have entered a clinic for treatment of their back pain only to walk out with sciatica. Again, I must emphasise that it is necessary to test all patients with low back pain for evidence of a relevant lateral shift.
I believe that, to a large extent, the disrepute surrounding the application of extension exercises has developed because of failure to detect minor lumbar scolioses and determine their relevance to symptoms. Indeed, many extension procedures are not successful due to lack of understanding of the nature of the condition to be treated. Usually extension fails because:
- not enough time is allowed for reversal of nuclear fluids to take place;
- it is done actively instead of passively;
- a lateral shift is present;
- or it is applied in the presence of extension dysfunction which results in the production of pain and the abandonment of the exercise.
Fig. Treatment of Derangement Four from start to finish. a – Examination of standing posture — primary lateral shift. b – Examination of movement — flexion in standing. c – Examination of movement — extension in standing.
Fig. d – Examination of movement — deviation in flexion.
Fig. Correction of primary lateral shift.
Fig. Teaching of self-correction of primary lateral shift.
Fig. Selfcorrection of primary lateral shift.
Fig. Recovery of extension. Overcorrection of primary lateral shift — lying prone. Assisting maximum extension.
Fig. Recovery of extension. Overcorrection of primary lateral shift in maximum extension.
The acute lumbar scoliosis is a fascinating condition to treat. In general, the derangement is easily corrected when treated in the early stages, but becomes more difficult to reduce as time passes. After twelve weeks reduction becomes virtually impossible and if at this time marked deformity is still present it is usually permanent unless the affected disc is surgically removed. Even then a minor residual lateral shift often remains visible.
The techniques 1 developed in the late 1950’s for the correction of lumbar scoliosis and first described in 1972 are still the most effective in the treatment of patients with Derangement Four. Despite many efforts to improve the basic procedure this has not been altered in any significant way. I have made some minor changes in the method of achieving correction and these have been included in the discussion of the procedure (Proc. 16).
In a patient with Derangement Four the lateral shift must be corrected first (Proc. 16). Once correction or, if possible, slight overcorrection is achieved the extension loss must be restored (Proc. 3) and the lordosis maintained to prevent recurrence. Facet apposition makes lateral deviation impossible.
Therefore, if the lordosis is maintained neither the lateral shift nor the pain will reappear.
It is of vital importance that the patient is shown on the very first visit how to maintain the lordosis and how to perform self-correction of his lateral shift (Proc. 17) in case of recurrence.
If the lateral shift has been corrected, but after a few days full centralisation is not yet achieved, the application of unilateral techniques may be indicated as outlined before (Derangement Three).
Once the lateral shift has been corrected and full centralisation is achieved as well Derangement Four is reversed to Derangement One. From now on the treatment must be continued and progressed exactly as described for Derangement One.
Effects of lateral shift correction on the disc
Farfan has considered at length the possible effects on the vertebral structures that may result from spinal manipulation. He states that roto-scoliosis — or lateral shift — is caused by rotation usually occurring at the fourth and fifth lumbar vertebrae. He believes that the McKenzie technique of lateral shift correction is effective because firstly it opens the intervertebral space laterally in association with a slight flexion movement which is then followed by an extension movement in the lumbar spine. This produces reduction of the disc disturbance in a manner similar to squeezing a melon seed.
In my experience correction of many hundreds of lateral shifts has only on a few occasions caused a ‘pop’-like effect. When perceivable the correction appears to be a slow flowing process rather than the effects one would associate with squeezing the melon seed. Whatever the true mechanics eventually prove to be, correction of lumbar scoliosis usually leads to a rapid reduction of deformity and symptoms with a corresponding restoration of function. Straight-leg-raising, if reduced before correction, is frequently dramatically restored to normal. I believe that the side bending deformity occurring with lumbar scoliosis is responsible for the reduction in straight-leg-raising on the painful side when the lateral shift is away from the painful side. In this case the elongation caused by the side bending deformity towards the painfree side will reduce the available root length range in straight-leg-raising. Thus, it is not necessarily a bulge in the annulus which limits straight-leg-raising. If the nucleus is disturbed enough to lead to the deformity of lumbar scoliosis without causing the outer annulus to bulge, the deformity by itself will be responsible for the nerve root tension.
Farfan has stated that the procedure of straight-leg-raising does not necessarily have to stretch the sciatic nerve. There is enough evidence to suggest that reduced straight-leg-raising can be caused by a tight nerve root due to the rotation deformity as in sciatic or, as he prefers to call it, roto-scoliosis. This would partially explain why straight-leg-raising can quickly and simply be increased and reduced merely by laterally altering the patient’s position in supine prior to performing the test. Under these circumstances the objectivity of straight-leg-raising is suspect, and the test is therefore irrelevant in judging progress.
It should be pointed out that testing of straight-leg-raising can be very misleading and is only reliable as an objective guide when the patient has constant sciatic pain. Constant sciatic pain is caused by constant mechanical deformation. When a disc protrusion is of sufficient magnitude to cause constant compression of the nerve root, alteration of the lateral shift while lying supine will not allow a better range of straight-leg-raising. If there is constant sciatic pain and straight-leg-raising improves as a result of some manoeuvre, a reduction in the magnitude of the protrusion must have occurred following this manoeuvre. Under these circumstances the objectivity of straight-leg-raising remains constant and therefore the test is useful in assessing the value of a certain procedure and judging progress.
If there is intermittent sciatic pain, the pressure on the nerve root is intermittent. In this case a minor annular bulge may be influenced by movements and the patient’s symptoms can be created or abolished at will without significant alteration in his condition.
- Unilateral or asymmetrical pain across L4/5.
- With or without buttock and/or thigh pain.
- With leg pain extending below the knee.
- No deformity.
Derangement Five is a straight progression of Derangement Three. In Derangement Five the magnitude and location of the disc disturbance are such that impingement of the nerve root and dural sleeve occurs, but is not sufficient to force deformity. If the history is of recent onset, the patient must be treated with great care. It is essential to determine whether the sciatica is constant or intermittent, because the treatment will be different accordingly. If the sciatica has been present for several weeks or months, as sometimes occurs, constant leg pain may have altered to intermittent pain. Generally, if the patient presents with a deformity of scoliosis, sciatica is likely to be constant, and if there is no deformity, sciatica is usually intermittent. Thus, Derangement Five patients are more likely to have intermittent sciatica though exceptions occur, expecially in acute stages of derangement.
Usually, the patient with Derangement Five presents without a deformity in the lumbar spine and the sciatica will be intermittent — that is, there are times in the day when the sciatica is not present. Neurological deficit is infrequently encountered in these patients as even short periods without root compression allow physiological recovery to some extent. Straight-leg-raising may or may not be limited.
If the root irritation is indeed intermittent, the patient can be treated with some caution using mechanical therapy. In the treatment we must make use of those positions and movements which are found to reduce or abolish the sciatica. It must be emphasised that any position or movement which produces or enhances sciatica should not be further developed. When neurological deficit is present the chances of success are greatly reduced.
Intermittent sciatica may be caused by a small disc bulge which is, depending on the patient’s activities, alternately protruding into the canal and retreating into the disc substance, but is not large enough to force deformity upon the joint.
Intermittent sciatica may also be caused by an adherent nerve root or entrapment which is placed under increased tension when certain movements are performed and positions are adopted. For example, a patient with sciatica may have recovered recently from an acute disc prolapse and his symptoms are now becoming intermittent; we must determine whether his sciatica is caused by an increase of disc bulging or by an increased nerve root tension due to entrapment, adherence or scarring; and when adherence of the nerve root is thought to be the cause, we must determine whether it is safe at this stage to stretch the nerve root without causing further disc prolapse.
To differentiate between sciatica caused by compression from a disc bulge, or that due to increased root tension from adherence, careful assessment of the flexion test movements is essential. Flexion in standing will enhance the sciatica in both situations — that is, in derangement and in root adherence. The answer to the problem will be found in flexion in lying, which will not enhance sciatica in a patient with an adherent root, but will always enhance it when the disc is in a weakened state. Thus, production or enhancement of sciatica which remains worse as a result of performing flexion in lying indicates that the increase in mechanical deformation is caused by a bulging disc. With such a response to the test movements it is dangerous for the patient to perform flexion exercises in standing as well as in lying, as this may lead to recurrence or increase of derangement.
Should testing of flexion in lying indicate that sciatica is caused by a disc derangement and the disc wall is able to distend during this movement, it is likely that testing of extension in lying will have the opposite effect and reduce the derangement. If this is the case the patient must be placed under the extension principle for a period of twenty-four hours to confirm the diagnosis. If after this time there is a positive response to extension, the extension principle may be continued and the patient must be treated as for Derangement Three. If the response to extension appears to be negative, or if progress appears to be slow, the use of unilateral mobilisation and manipulation procedures is indicated as outlined before (Derangement Three). It will be understood that, once full centralisation is obtained treatment should be continued and progressed exactly as described for Derangement One.
Should the test movements indicate that sciatica is caused by entrapment — root adherence or scarring, the treatment described for this under Derangement Six should be applied. Remember however that the treatment must be considered to be that required for dysfunction. The derangement stage has now passed and the damage repaired.
- Unilateral or asymmetrical pain across L4/5.
- With or without buttock and/or thigh pain.
- With leg pain extending below the knee.
- With deformity of sciatic scoliosis.
Derangement Six clearly is a progression of Derangement Four and Five. The patient commonly exhibits a sciatic scoliosis as well as a reduced lordosis. The sciatica is more likely to be constant and there is little chance of reducing the symptoms by positioning or movement. Often the patient states that movement brings relief of pain; however, movement or a change of position gives a short-lived respite only. Neurological deficit commonly occurs.
If in a patient with Derangement Six and constant sciatica most test movements are found to enhance the leg pain and no movement reduces it, a provisional diagnosis of accomplished disc protrusion can be made provided the presence of neurological deficit and a positive myelogram support this finding. Remember, that at this stage the condition is irreversible using mechanical therapy. Subsequent surgery usually confirms our diagnosis.
Fig. Patient with Derangement Six. This patient shows a similar deformity as the patient with Derangement Four — a primary lateral shift.
If there is no position in which the patient is painfree, we must be careful when sending the patient home on bed rest. It is certainly not desirable that the patient assumes positions which increase the symptoms. Before placing a patient on bed rest we must examine the various positions and their effects on sciatica and low back pain, and advise the patient accordingly. If there is a position which produces significant reduction in leg pain, the patient should be instructed to adopt and maintain that position for long periods at a time.
If no test movements or positions can be found to reduce the pain referred below the knee then, I believe, there are no techniques available which will have a beneficial effect on the derangement. Intermittent traction in the order of twenty minutes a day on an out-patient basis has been described as useful, but if progress is made it is difficult to attribute this to the treatment rather than to the passage of time. Continuous traction in bed is a different matter and often produces good enough results to make the procedure an attractive alternative to surgery.
If test movements indicate that reduction of the derangement is possible, treatment should be commenced following the lines of that for Derangement Four and Five. During the treatment great care should be taken to check regularly if there is a change in peripheral symptoms. Increased tingling or numbness felt in the foot must never be ignored, and if these are present treatment should be modified immediately.
If there is improvement but full centralisation has not yet been achieved, the application of mobilising and manipulation procedures may be indicated.
Techniques outlined previously (Derangement Three) may be utilised, provided pre-manipulative testing is performed to ensure centralisation of symptoms is taking place. If peripheral pain is enhanced in the pre-manipulative testing position, the manipulation should not be performed. Whatever procedure you have in mind, never manipulate a patient without pre-manipulative testing.
Should lateral shift correction produce reduction of the derangement, then progress usually is uncomplicated and treatment should continue as outlined for Derangement Four. The recovery of full flexion or the treatment of any residual flexion dysfunction must be delayed much longer after the resolution of a severe sciatica than is usually the case with pure lumbar pain. I consider eight to ten weeks from the time of onset of peripheral symptoms to be the minimum time before implementing the flexion dysfunction procedures to the maximum.
Stretching of adherent nerve root
Once the acute episode has subsided and the patient is able to attend to his occupation, nerve root adherence as a result of scarring may cause a persistent sciatic reference which, in some cases, may last for years. This disability will not produce neurological deficit if the initial episode has not already done so. It is desirable to reduce the nerve root entrapment or adherence, and in many patients this may be done successfully by using the procedures for flexion dysfunction — that is, the shortened structures should be stretched frequently and firmly every day until the adherence is resolved. To achieve this flexion in lying (Proc. 13) should be regularly performed for one week. This is followed by flexion in standing (Proc. 14) which must be performed often enough to elongate and stretch scarred and adherent tissue without causing further bulging of the disc wall.
Fig. Treatment of adherent sciatic nerve root, using flexion in standing.
When treatment of dysfunction due to an adherent nerve root is commenced it should not be attempted during the first four to five hours of the day. During this time period the disc is likely to be under increased pressure as a result of its nocturnal imbibition and reabsorbtion of fluid. I recommend that in the initial stages of treatment the patient performs ten repetitions of flexion in standing (Proc. 14) from midday on, every three hours until retirement. When the derangement appears stable and the integrity of the disc wall is established, the patient may commence the exercise a little earlier in the day and repeat it every two hours. However, it is inadvisable to perform flexion in standing (Proc. 14) on awaking.
Because flexion in standing (Proc. 14) places stress on the disc wall and forces the disc posteriorly, there are always risks involved in stretching an adherent nerve root, especially in the initial stages. Therefore, flexion in standing (Proc. 14) must always and immediately be followed by extension in lying (Proc. 3), or if this is not possible by extension in standing (Proc. 6).
As the nerve root stretching becomes effective, the patient may perceive the same amount of pain whereas his flexion range has increased. Gradually his fingertips will move closer to his ankles, and where a certain amount of flexion produced significant pain before it may have become painfree now. It will become easier to drive the car and to walk uphill.
It is my belief that intermittent stress applied to joints in this manner strengthens ligamentous structures rather than damages them, while scar tissue will stretch and yield to such stress. However, if a sustained stress is applied damage may occur to both ligamentous and scar tissue.
- Symmetrical or asymmetrical pain across L4/5.
- With or without buttock and/or thigh pain.
- With deformity of accentuated lumbar lordosis.
In Derangement Seven the disturbance within the disc appears to be located in a more antero-lateral or anterior position, which leaves the patient with an accentuated lordosis as the presenting deformity. This type of derangement is not common, but it is easily identified.
The patient with Derangement Seven may exhibit such a gross loss of flexion that in full flexion the lumbar spine remains lordotic. At first sight the condition appears to be the common flexion dysfunction presenting with an accentuated lordosis. However, the patient describes a sudden onset of pain and assures that he was able to touch his toes easily the day before the onset of pain.
Fig. Patient with Derangement Seven. a – Examination of standing posture — accentuated lordosis. b – Flexion loss at commencement of treatment session. c – Recovery of flexion at finish of same treatment session. The remarkable recovery of flexion within a short time period indicates derangement.
If examination shows a marked deviation in flexion, it may be necessary to perform flexion in step standing (Proc. 15) to reduce the lateral component of the derangement. Usually, this procedure rapidly brings the deviation to the midline. As soon as the deviation in flexion is corrected flexion in step standing (Proc. 15) should be discontinued. Correction of deviation in this type of derangement is sometimes very dramatic, and if the procedure is repeated too often the deviation in flexion may change to the opposite side. The treatment should be continued with flexion in lying (Proc. 13).
If there is no deviation in flexion on the test movements, treatment should commence with flexion in lying (Proc. 13), and after a few days flexion in standing (Proc. 14) may be added. Sometimes an intermediate stage of flexion seems indicated. This can be found by performing flexion in the sitting position and is progressed by placing the feet further from the chair as the flexion is performed. Once reduction of the derangement is achieved it is possible to recreate the derangement situation simply by performing extension in lying (Proc. 3). This is exactly the opposite from the previous derangements with a posterior or postero-lateral disc disturbance where recurrence is to be expected as soon as the lordosis is lost following reduction. If there is improvement but the patient has unilateral pain which has not fully centralised, the application of unilateral techniques may be indicated such as sustained rotation (Proc. 11) and rotation manipulation in flexion (Proc. 12).
Because patients with deformity of accentuated lordosis rarely develop extension dysfunction, it is not necessary that extension procedures be included in the treatment of patients with Derangement Seven.