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.

READ:   Spine Health. PROCEDURE 13 — FLEXION IN LYING

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.

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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.
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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 Postural Syndrome

Prophylaxis is impossible without self understanding.

Low Back Pain. Contraindications Although it has been accepted throughout that all patients have received adequate medical screening, occasionally patients with serious pathology or mechanical disorders unsuited to mechanical treatment are encountered during routine examination. If in the examination no position or movement can be found which reduces the presenting pain, the patient is unsuited for mechanical therapy, at least at this time. The existence of serious pathology should be considered when the history states that there has been no apparent reason for the onset of symptoms; that the symptoms have been present for many weeks or months, and have during that time increased in intensity; and that they are constant; and the patient feels that he is gradually getting worse. On examination the pain remains exactly the same, irrespective of positions assumed or movements performed. Usually there is little loss of function if any, and postural deformity is not often seen. In addition to the examination finding, th...
Hyperlordosis: Treatment, Prevention, and More What’s hyperlordosis? Human spines are naturally curved, but too much curve can cause problems. Hyperlordosis is when the inward curve of the spine in your lower back is exaggerated. This condition is also called swayback or saddleback. Hyperlordosis can occur in all ages, but it’s rare in children. It’s a reversible condition. Keep reading to learn about the symptoms and causes of hyperlordosis and how it’s treated. What are the symptoms of hyperlordosis? If you have hyperlordosis, the exaggerated curve of your spine will cause your stomach to thrust forward and your bottom to push out. From the side, the inward curve of your spine will look arched, like the letter C. You can see the arched C if you look at your profile in a full-length mirror. You may have lower back pain or neck pain, or restricted movement. There’s limited evidence connecting hyperlordosis to lower back pain, however. Most hyperlordosis is mild, and your back remains flexible. If the arch in your bac...
Spine Health. PROCEDURE 11 — SUSTAINED ROTATION/MOBILISATION IN FLEXION The patient lies supine on the couch, and the therapist stands on the side to which the legs are to be drawn, facing the head end of the couch. The patient’s far shoulder is held firmly on the couch by the therapist’s near hand, providing fixation and stabilisation. With the other hand the therapist flexes the patient’s hips and knees to a rightangle and carries them towards himself, causing the lumbar spine to rotate. With the patient’s ankles resting on the therapist’s thigh the knees are allowed to sink as far as possible and the legs are permitted to rest in that extreme position. The lumbar spine is now hanging on its ligaments in a position which combines side bending and rotation. By pushing the knees further towards the floor the therapist applies overpressure to take up the remaining slack in the lumbar spine. Depending on the purpose for which the procedure is used, the position of extreme rotation is maintained for a shorter or longer period. Fig. Sustained rotation/mob...
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...
The Dysfunction Syndrome The word ‘dysfunction’ chosen by Mennell to describe the loss of movement commonly known as ‘joint play’ or ‘accessory movement’ seems infinitely preferable to the terms ‘osteopathic lesion’ and ‘chiropractic subluxation’, neither of which means anything and both of which mean everything. ‘Dysfunction’ or ‘not functioning correctly’ at least acknowledges that something is wrong without going through the sham procedure of pretending that only those who belong to the club really understand the terminology. For years osteopaths and chiropractors have claimed that only the people, properly trained in their particular calling, have the necessary knowledge to understand their terminology. There may be some truth in that. Although I believe that the term ‘dysfunction’ as used by Mennel does not strictly cover the loss of movement caused by adaptive shortening, I have chosen to use this term instead of repeatedly referring to ‘adaptive shortening’. Essentially, the mechanism of pain prod...