TREATMENT OF THE DERANGEMENT SYNDROME

Of all patients with low back pain those having derangement of the intervertebral disc are the most interesting and rewarding to treat. As in dysfunction, it is essential in derangement that from the very first treatment correction of the sitting posture be achieved, but in the early and acute stages of derangement emphasis is placed on the maintenance of lordosis rather than the obtaining of the correct posture. Failure in this respect means failure of what otherwise might be a successful reduction of the derangement. So often it occurs that a patient describes a significant relief from pain and is visibly improved immediately following treatment, but later that same day after sitting for some time he is unable to straighten up on rising from sitting and the symptoms have returned just as they were before treatment. Usually the patient clearly understands the dangers of bending and stooping and carefully avoids these movements. But the hidden dangers of sustained flexion incurred in the sitting position is rarely recognised by patient or therapist.

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Two of every three patients with low back pain have symptoms commencing for no apparent reason. Where there is no recognisable precipitating strain in the production of mechanical back pain, we must assume that the symptoms commenced as a result of the patient’s normal daily pursuits. In other words, in the course of every day living the patient has performed a series of movements or adopted certain positions which have led to mechanical derangement within the lumbar spine. I believe that it is possible to equip the patient with the necessary information and instruct him in the methods required to reverse the mechanical disturbances he unwittingly created and to prevent further episodes of low back pain. This can be achieved if instructions and explanations are given in an adequate but simple manner.

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If the patient adopted a position or performed a movement that damaged the disc mechanism, utilisation of the patient’s movements can reverse that derangement if we understand the mechanism involved.

Where time is a crucial factor in the production of derangement, it must be utilised to its advantage in the reduction of the same. For example, if pain is stated to arise commonly after half an hour of sitting and is caused by derangement, it is unlikely to appear clinically after only two minutes of flexion; and if it takes thirty minutes to produce pain clinically it is unlikely to disappear in two minutes. Throughout the treatment of derangement ample time must be allowed for the distorted nucleus to alter its silhouette and for reversal of the flow of displaced nuclear gel within the disc. In the reduction of derangement, time is obtained by sustaining positions or repeating movements.

READ:   Spinal manipulation techniques

During the course of one treatment session we should not use more than one new procedure; nor should that procedure, if it is a manipulative thrust technique, be performed more than once. Following the application of a new procedure or a manipulation we must wait, if necessary twenty-four hours, to assess the response of the patient.

There are several derangements which commonly occur in the lumbar spine. I realise that my classification of the derangements may oversimplify the true position, but for adequate explanation simplification is necessary. It must be appreciated that many variations of the derangements are possible and not all patients will neatly fit into the system.

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Table of Derangements

Derangement One:

  • Central or symmetrical pain across L4/5.
  • Rarely buttock or thigh pain.
  • No deformity.

Derangement Two:

  • Central or symmetrical pain across L4/5.
  • With or without buttock and/or thigh pain.
  • With deformity of lumbar kyphosis.

Derangement Three:

  • Unilateral or asymmetrical pain across L4/5.
  • With or without buttock and/or thigh pain.
  • No deformity.

Derangement Four:
Unilateral or asymmetrical pain across L4/5.
With or without buttock and/or thigh pain.
With deformity of lumbar scoliosis.

Derangement Five:

  • 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 Six:

  • 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.
READ:   The Derangement Syndrome

Derangement Seven:

  • Symmetrical or asymmetrical pain across L4/5.
  • With or without buttock and/or thigh pain.
  • With deformity of accentuated lumbar lordosis.

I believe that the postero-central and postero-lateral derangements (Derangements One to Six) are all progressions of the same disturbance within the intervertebral disc: commencing with Derangement One, which is the embryonic stage of posterior disc disturbance exhibiting central pain, each successive derangement shows peripheralisation of pain or development of deformity. The principle aim of treatment is to centralise pain and reduce deformity in order to reverse all derangements to Derangement One. Patients with Derangement One are able to treat themselves.

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Under Derangement Seven fall the less common anterior and antero-lateral disc disturbances. The treatment follows a different course than for the posterior derangements, but also here the principle treatment aim is centralisation of pain and reduction of deformity.

In general, the treatment of derangement has four stages:

  1. reduction of derangement.
  2. maintenance of reduction.
  3. recovery of function.
  4. prevention of recurrence.

If possible, the first two stages will be achieved during the initial treatment session. Correction of sitting posture and instruction in a simple means of self-reduction in case of recurrence usually follow. Recovery of function will only be commenced once reduction of derangement has proven to be stable and the patient has been painfree for a few days. Before discharging the patient a full prophylactic programme is given. Self treatment is essential in prophylaxis.

READ:   The Derangements and Their Treatment

Prophylaxis is impossible without self understanding.

Back pain. Predisposing and Precipitating Factors PREDISPOSING FACTORS Sitting posture There are three predisposing factors in the etiology of low back pain that overshadow most others. The first and most important factor is the sitting posture. A good sitting posture maintains the spinal curves normally present in the erect standing position. Postures which reduce or accentuate the normal curves enough to place the ligamentous structures under full stretch will eventually be productive of pain. Such postures are referred to as poor sitting postures. A poor sitting posture may produce back pain in itself without any additional other strains of living. We have all seen patients who entered an airliner, a car, or even a common lounge chair in a perfectly healthy and painfree state only to emerge hours later crippled with pain and unable to walk upright. Alternatively, a poor sitting posture will frequently enhance and always perpetuate the problems in patients suffering from low back pain. By far the great majority of patients comp...
Spine Health. PROCEDURE 13 — FLEXION IN LYING The patient lies supine with the knees and hips flexed to about forty-five degrees and the feet flat on the couch. He bends the knees up towards the chest, firmly clasps the hands about them and applies overpressure to achieve maximum stress. The knees are then released and the feet placed back on the couch. The sequence is repeated about ten times. The first two or three flexion stresses are applied cautiously, but when the procedure is found to be safe the remaining pressures may become successively stronger, the last two or three being applied to the maximum possible. Fig. Flexion in lying. Effects: Flexion in lying causes a stretching of the posterior wall of the annulus, the posterior longitudinal ligament, the capsules of the facet joints, and other soft tissues. As the movement takes place from below upwards the lower lumbar and lumbo-sacral joints are placed on full stretch at the beginning of the exercise as soon as movement is initiated. Thus, the procedure is very i...
TREATMENT OF FLEXION DYSFUNCTION Loss of flexion is the second most common movement loss in the lumbar spine. It manifests itself in several ways, which interfere with either the amount of available flexion or the pathway taken to achieve flexion. This type of dysfunction is commonly seen in patients with an accentuated lordosis. Patients with significant flexion dysfunction are usually unable to sit slouched with a convex lumbar spine. When giving postural instructions to these patients, we must explain that once sitting relaxed they place the lumbar spine on full stretch much sooner than patients with a normal flexion excursion. Fig. Recovery of loss offlexion, using the procedure of flexion in standing. Recovery of pure flexion loss To regain flexion we must, just as in the case of extension dysfunction, explain to the patient the purpose of performing exercises. Again, we must stress the necessity of causing a moderate degree of discomfort or pain with the exercises. Pain produced by stretching of contra...
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 2 — LYING PRONE IN EXTENSION The patient, already lying prone, places the elbows under the shoulders and raises the top half of his body so that he comes to lean on elbows and forearms while pelvis and thighs remain on the couch. In this position the lumbar lordosis is automatically increased. Emphasis must be placed on allowing the low back to sag and the lordosis to increase. Fig. Lying prone in extension. Effects: Procedure 2 is a progression of procedure 1 and merely enhances its effects by increasing extension. Again, in derangement some time must be allowed to affect the contents of the disc and, if possible patients should remain in this position for five to ten minutes. In more acute patients sustained extension may not be well tolerated due to pain, and initially we must rely on the use of intermittent extension.