TYPICAL TREATMENT PROGRESSION — THE DYSFUNCTION SYNDROME

Day one

  • Assessment and conclusion/diagnosis.
  • Explanation of the cause of dysfunction and the treatment approach.
  • Postural correction and instructions, especially regarding sitting; demonstrate the use of a lumbar support.
  • Commence with exercises to recover function — that is, extension in lying, flexion in lying, or side gliding in standing, whatever procedure is indicated.
  • Emphasise the need to experience some discomfort during the exercises, and the importance of frequent exercising during the day.
  • If flexion in lying is recommended, we must warn to stop exercising if the symptoms quickly worsen. We may have overlooked derangement, or commenced the procedure too early following recent derangement.
  • Always follow flexion exercises with some extension.
READ:   The Derangements and Their Treatment

Day two

  • Confirm diagnosis.
  • Check postural correction.
  • Completely repeat’postural correction and instructions.
  • Check exercises. If improving nothing should be changed.
  • If not improving, ensure that exercises are performed far enough into end range, maintained long enough during the last three repetitions, and performed often enough during the day.
  • Warn for ‘new pains’.

Day three

  • Check posture and exercises.
  • If no improvement, commence mobilisation procedures. Several mobilisation treatments may be required.
  • Patient must continue the self-treatment exercises as directed.

Day four and five

  • Check exercises and progress.
  • If in treatment for flexion dysfunction no further progress is possible with flexion in lying, change to flexion in standing, possibly flexion in step standing.
  • Take necessary precautions when starting flexion in standing.
  • Ensure that patient has ‘new pains’.
READ:   Back pain. The Cause of Pain

Further treatments

  • I prefer to see patients in this category three or four days in succession. If progress is adequate and the patient understands the self-treatment
    programme, treatment may change to alternate days and later to twice per week if required.
  • It usually takes ten to twelve treatments, spread over four to six weeks, to successfully treat dysfunction.
  • If towards the middle of the treatment period the patient ceases to improve and especially if the remaining pain is unilateral, then a rotation manipulation may be required. This may have to be repeated two or three times and should be combined with mobilising and exercising procedures already being applied.
  • Before discharge prophylaxis must be discussed in detail.
READ:   Spine Health. PROCEDURE 3 — EXTENSION IN LYING
Spine Health. PROCEDURE 7 — EXTENSION MOBILISATION The patient lies prone as for procedure 1. The therapist stands to one side of the patient, crosses the arms and places the heels of the hands on the transverse processes of the appropriate lumbar segment. A gentle pressure is applied symmetrically and immediately released, but the hands must not lose contact. This is repeated rhythmically to the same segment about ten times. Each pressure is a little stronger than the previous one, depending on the patient’s tolerance and the behaviour of the pain. The procedure should be applied to the adjacent segments, one at a time, until all the areas affected have been mobilised. Fig. Positioning of hands prior to extension mobilisation. Extension mobilisation. Effects: In this procedure the external force applied by the therapist enhances the effects on derangement and dysfunction as described for the previous extension procedures. In general, symmetrical pressures are used on patients with central and bilateral symptoms. Therapist-...
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 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...
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.
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...