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:   TREATMENT OF EXTENSION DYSFUNCTION

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.

READ:   Spine Health. PROCEDURE 6 — EXTENSION IN STANDING

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:   The Postural Syndrome

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.

READ:   Spine Health. PROCEDURE 12 — ROTATION MANIPULATION IN FLEXION

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:

READ:   Spine Health. PROCEDURE 15 — FLEXION IN STEP STANDING
  • 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.

READ:   The Intervertebral Disc

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:   TYPICAL TREATMENT PROGRESSION — THE POSTURAL SYNDROME

Prophylaxis is impossible without self understanding.

The Derangement Syndrome Of all mechanical low back problems that are encountered in general medical practise, mechanical derangement of the intervertebral disc is potentially the most disabling. It is my belief that in the lumbar spine, if in no other area, disturbance of the intervertebral disc mechanism is responsible for the production of symptoms in as many as ninety-five percent of our patients. Twenty-five years of clinical observation and treatment of lumbar conditions have convinced me that certain phenomena and the various movements which affect them, can occur only because of the hydrostatic properties invested in the intervertebral disc. For thirty years Cyriax has attributed lumbar pain to internal derangement of the intervertebral disc mechanism. He has outlined the cause of lumbago, and proposed that pain of a slow onset is likely to be produced by a nuclear protrusion while that of a sudden onset is caused by a displaced annular fragment. Although at present we are unable to prove either of ...
Spine Health. PROCEDURE 5 — SUSTAINED EXTENSION To apply a sustained extension stress to the lumbar spine an adjustable couch, one end of which may be raised, is a necessary piece of equipment. The patient lies prone with his head at the adjustable end of the couch which is gradually raised, about one to two inches at the time over a five to ten minute period. Once the maximum possible degree of extension is reached, the position may be held for two to ten minutes, according to the patient’s tolerance. When lowering the patient the adjustable end of the couch should slowly be returned to the horizontal over a period of two to three minutes. This must not be done rapidly, for acute low back pain may result. Fig. Sustained extension. Effects: The procedure is predominantly used in the treatment of derangement. The effect is similar to that of the third procedure, but a time factor is added with the graduated increase and the sustained nature of the extension. In certain circumstances a sustained extension stress is preferable...
Intervertebral discs Figure. The adult vertebral column and typical vertebrae in each region, lateral views. There are at least 24 intervertebral discs interposed between the vertebral bodies: six in the cervical, twelve in the thoracic and five in the lumbar region, with one between the sacrum and coccyx. (Additional discs may be present between fused sacral segments.) The discs account for approximately one-quarter of the total length of the vertebral column, and are primarily responsible for the presence of the various curvatures. On descending the vertebral column, the discs increase in thickness, being thinnest in the upper cervical region and thickest in the lower lumbar. In the upper thoracic region, however, the discs appear to narrow slightly. In the cervical region the disc is about two-fifths the height of the vertebrae, being approx-imately 5 mm thick. In the thoracic region the discs average 7 mm in thickness, so that they are one-quarter of the height of the vertebral bodies. The discs in ...
TREATMENT OF EXTENSION DYSFUNCTION By far the most common form of ⚡ dysfunction ⚡ is that involving loss of extension. Having already explained and taught the postural requirements, we must now instruct the patient in the methods required to regain lost extension. We must explain to him the reasons for the need to recover the extension movement. The patient must realise that without an adequate range of extension it is not possible to sit with a lordosis, even when a lumbar support is used. For some patients it is imperative that the range of extension be improved, otherwise they will be unable to sit correctly. It is my experience that, following adequate explanation, patients will co-operate with the treatment and work hard at their recovery. They will perform exercises that cause discomfort or even pain, as long as they understand the reasons for doing so. Fig. Recovery of loss of extension, using the procedure of extension in lying. Exercises In order to systematically stretch the lumbar spine in extension, I...
Spine Health. PROCEDURE 15 — FLEXION IN STEP STANDING In this procedure the patient stands on one leg while the other leg rests with the foot on a stool so that hip and knee are about ninety degrees flexed. Keeping the weight bearing leg straight the patient draws himself into a flexed position, firmly approximating the shoulder and the already raised knee (both being on the same side). If possible the shoulder should be moved even lower than the knee. The patient may apply further pressure by pulling on the ankle of the raised foot. The pressure is then released and the patient returns to the upright position. The sequence is repeated about six to ten times. It is important that the patient returns to neutral standing and restores the lordosis in between each movement. Fig. Flexion in step standing. Effects: This procedure causes an asymmetrical flexion stress on the affected segments. It is applied when there is a deviation in flexion, which may occur in dysfunction as well as derangement. Both in dysfunction and derangement th...