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.

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.

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.

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.

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.

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.

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.

Prophylaxis is impossible without self understanding.